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ΩΩ 3a Bateman - Obs and Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

cWhat are the different drugs for:

Termination

Ectopic

Miscarriage

A

Termination = Mifepristone

Ectopic = Methotrexate

Miscarriage = Misoprostol

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2
Q

WHAT IS PRE-ECLAMPSIA?

A

Hypertension and proteinuria during pregnancy normally seen after 20 weeks

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3
Q

What are the high risk and moderate risk of developing pre-eclampsia?

A
  • *High risk factors**
  • Hypertensive disease in a previous pregnancy
  • Chronic kidney disease
  • Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
  • Type 1 or type 2 diabetes
  • Chronic hypertension
  • *Moderate risk factors**
  • First pregnancy
  • Age 40 years or older
  • Pregnancy interval of more than 10 years
  • Body mass index (BMI) of 35 kg/m² or more at first visit
  • Family history of pre-eclampsia
  • Multiple pregnancy
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4
Q

What are the prevention methods for pre-eclampsia?

Why is this offered?

When is this offered?

A
  1. Low does aspirin 75mg
  2. >=1 high risk factors
  3. >=2 moderate
  4. Normally commenced at 12 weeks but before 16 weeks
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5
Q

What are the symptoms of pre-eclampsia?

A
  1. Headache
  2. Visual disturbance
  3. Epigastric and right upper quadrant pain
  4. Nausea and vomiting
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6
Q

What is the diagnosis of pre-eclampsia?

A
  1. BP >140/90
  2. FBC - High Hb
  3. Increase urea and creatinine
  4. Increase lactate dehydrogenase
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7
Q

What are the complications of pre-eclampsia?

A
  1. Eclampsia
  2. HELLP
  3. Cerebral haemorrhage
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8
Q

What are the categories of hypertension in pregnancy?

A

Pre-existing hypertension

Pregnancy-induced hypertension
Hypertension, no proteinuria or oedema

Pre-eclampsia
Hypertension, proteinuria and oedema

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9
Q

What is the treatment of pre-eclampsia?

A

>140/90
Oral labetalol hydrochloride
If not tolerated then nifedipine

>160/110
Admit to hospital
IV labetalol hydrochloride

Aiming for 135/85 mmHg

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10
Q

WHAT IS HELLP SYNDROME?

A
  1. Haemolysis
  2. Elevated liver enzymes
  3. Low platelets

Manifestation of pre-eclampsia

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11
Q

What are the symptoms of HELLP syndrome?

A
  1. Nausea & vomiting
  2. Right upper quadrant pain
  3. Lethargy
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12
Q

What is the treatment of HELLP syndrome?

A

Delivery of the baby

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13
Q

What should you do if a woman is past 37 weeks and is showing signs of pre-eclampsia?

A

IV magnesium sulphate and arrange for delivery of the baby

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14
Q

WHAT IS ECLAMPSIA?

A

Presence of tonic-clonic seizures in assocaited with a diagnosis of pre-eclampsia

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15
Q

What is the treatment of eclampsia?

A
  1. Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop
    • Should be given once a decision to deliver has been made
    • In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
    • Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
  2. Respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
  3. Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
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16
Q

When should magnesium treatment be stopped in eclampsia treatment?

A

Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

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17
Q

What is the treatment for respiratory depression caused by magnesium sulfate?

A

Calcium gluconate

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18
Q

What is the best anti-epileptic used in pregnancy?

A

Lamotrigine

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19
Q

WHAT IS ESSENTIAL HYPERTENSION?

A

Hypertension with no secondary cause identified >140/90mmHg

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20
Q

What are the risk factors for essential hypertension?

A

Genetic variation

Aging

Obesity

Salt

Alcohol

Renin

Diabetes

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21
Q

How is essential hypertension diagnosed?

A

Blood pressure readings on 3 different occasions >140/90mmHg

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22
Q

What is the treatment for essential hypertension?

A

Lifestyle changes

  • *<55 years of with type 2 diabetes**
    1. ACE inhibitor - Ramipril, Captopril
    2. Add calcium channel blocker - Amplodipine, Verapamil
    3. Add thiazide-like diuretic e.g. Indapamide
  • *>55 years or black patients of African/Carribean descent**
    1. Calcium channel blocker
    2. Add ACE inhibitor
    3. Add thiazide-like diuretic
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23
Q

What week is hypertension in pregnancy diagnosed?

A

20 weeks

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24
Q

What if an ACE inhibitor is not tolerated e.g. because of a cough

A

Offer angiotensin 2 receptor blocker - Candesartan, Azilsartan

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25
Q

WHAT IS PLACENTA PREVIA?

A

Placenta implants low in the uterus, covering part or all of the cervix

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26
Q

What are the different types of placenta previa?

A

Complete previa
The placenta covers the entire cervical opening

Partial previa
The placenta covers part of the cervical opening

Marginal previa
The placenta borders the cervix

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27
Q

What are the symptoms of placenta previa?

A
  1. Often none
  2. Not painful

Often after 24 weeks presentation

Can be:

  1. Small bleeds before large cramping
  2. Breech position
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28
Q

How is placenta previa diagnosed?

A
  1. Normally found at the routine 20 weeks scan
  2. Ultrasound with colour flow doppler
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29
Q

What is the treatment of placenta previa?

A
  1. Little or no bleeding
    • Bed rest, abstian from sex
  2. Heavy bleeding
    • Admission
    • Blood transfusion
    • C-section at 37 weeks - 38 weeks
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30
Q

WHAT IS PLACENTA ACCRETA?

A

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall).

Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.

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31
Q

What is the cause of placenta accreta?

A

Abnormalities in the lining of the uterus

Typically due to scarring after a C-section or other uterine surgery

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32
Q

What are the symptoms of placenta acreta?

A

Placenta accreta often causes no signs or symptoms during pregnancy

Vaginal bleeding during the third trimester might occur.

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33
Q

What are the complications of placenta accreta?

A

Heavy vaginal bleeding
Can cause disseminated intravascular coagulopathy
Lung failure
Kidney failure

Premature birth

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34
Q

What is the diagnosis for placenta accreta?

A

Normally picked up on the 20 week scan

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35
Q

What is the treatment for placenta accreta?

A
  1. C-section and hyserectomy
  2. Curettage of the uterus, coupled with methotrexate
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36
Q

WHAT IS PLACENTA INCRETA?

A

Placenta invades even more deeply into the myometrium of the uterus

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37
Q

WHAT IS PLACENTAL ABRUPTION?

A

Placental abruption occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery.

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38
Q

What are the risk factors for placental abruption?

A

The cause of placental abruption is often unknown.

  1. Multiparity
  2. Maternal trauma
  3. Increasing maternal age
  4. Polyhydramnios
  5. Proteinuric hypertension
  6. Cocaine use
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39
Q

What are the symptoms of palcental abruption?

A

Placental abruption is most likely to occur in the last trimester of pregnancy, especially in the last few weeks before birth.

Vaginal bleeding, ONLY IN 80% of cases

Abdominal pain (begin suddenly)

Back pain (begin suddenly)

Uterine tenderness or rigidity - WOODY

Uterine contractions, often coming one right after another

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40
Q

What is the diagnosis for placental abruption?

A

Largely clinical

  1. Evidence of shock
  2. Pain
  3. Uterine rigidity
  4. Absent fetal heart sounds
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41
Q

What is the management for placental abruption?

A
  1. Fetus alive and < 36 weeks
    • Fetal distress: immediate caesarean
    • No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
  2. Fetus alive and > 36 weeks
    • Fetal distress: immediate caesarean
    • No fetal distress: deliver vaginally
  3. Fetus dead
    • Induce vaginal delivery
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42
Q

WHAT IS A UTERINE RUPTURE?

A

When the muscular wall of the uterus tears during pregnancy or childbirth

This causes the baby to leek into the abdomen

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43
Q

What are the risk factors for a uterine rupture?

A

A uterine scar from a previous cesarean

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44
Q

What are the symptoms of a uterine rupture?

A
  1. Excessive vaginal bleeding
  2. Sudden pain between contractions
  3. Contractions that become slower or less intense
  4. Abnormal abdominal pain or soreness
  5. Recession of the baby’s head into the birth canal
  6. Bulging under the pubic bone
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45
Q

How is a uterine rupture diagnosed?

A

Often undiagnosed cause the symptoms are often sudden and non specific

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46
Q

What is the treatment of a uterine rupture?

A

Emergency exploratory laparotomy with ceserean delivery

A hysterectomy may be indicated if the woman is bleeding severely

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47
Q

WHAT IS THE CEVICAL SHOW?

A

Also called the bloody show or cervical mucus plug

It is a sign that labour is impending

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48
Q

What is the cervical plug (operculum)?

A

It is a plug which seals the cervical canal during pregnancy, it is formed by a small amount of cervical mucus

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49
Q

Wha is the cervical plug for?

A

Acts a barrier to deter bacteria into the uterus

Contains a mixture of antimicrobial agents, including immunoglobulins and antimicrobial peptides

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50
Q

When does the cervical plug come out?

A

When the cervix beings to dilate before labour

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51
Q

WHAT IS VASA PREVIA?

A

Where some fetal umbilical cord vessels run across the cervix

They are inside membranes and unprotected by the umbilical cord or placenta

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52
Q

What are the symptoms of vasa previa?

A

Often no symptoms at all

  1. Rupture of membranes followed immediately by vaginal bleeding
  2. Sometimes appear in labour, fetal distress (bradycardia and late decelerations) or stillbirth
  3. Sometimes there is vaginal bleeding which is darker than normal since fetal blood has less oxygen than the mother
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53
Q

What are the causes of vasa previa?

A

Velamentous cord
Umbilical cord goes into the membranes, resulting in vessels that are unprotected leading to the placenta

Biobed placenta
Two placentas

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54
Q

How is vasa previa diagnosed?

A

Not normally routinely checked for in pregnancy

If you have certain risk factors then:
Transvaginal ultrasound

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55
Q

What are the risk factors for vasa previa?

A
  1. Placenta previa
  2. Previous C-section
  3. IVF pregnancy
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56
Q

What is the treatment for vasa previa?

A

If picked up on scan then plans can be made to resolve

  1. Sometimes resolves on its own
  2. Pelvic rest
  3. Planned C-section at 35-37 weeks
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57
Q

WHAT IS A POSTPARTUM HAEMORRHAGE?

A

Defined as excessive blood loss after childbirth >500mls

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58
Q

What are the different types of postpartum haemorrhage?

A

Primary
Occurs in the first 24 hours after delivery

Secondary
Occurs between after 24 hours and 6 weeks after delivery

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59
Q

What is the cause of a primary postpartum haemorrhage?

A

4 T’s

Tone: Uterine atony - failure of uterus to contract down after delivery of the placenta

Trauma

Tissue: Retained placenta - placenta remains in the uterus and the vessels continue to bleed

Thromib: Blood clotting disorders - haemophilia, von Willebrand disease

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60
Q

What conditions are more at risk of developing primary postpartum haemorrhage?

A

Placenta previa

Multiple pregnancy

Pre-eclampsia

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61
Q

What is the management of a primary postpartum haemorrhage?

A
  1. IV syntocinon (oxytocin)
  2. IM carboprost
  3. Intrauterine balloon tamponade
  4. B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
  5. If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
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62
Q

How can you prevent primary postpartum haemorrhage?

A
  1. Oxytocin
  2. Misprostol
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63
Q

WHAT IS THE CAUSE OF A SECONDARY POSTPARTUM HAEMORRHAGE?

A

Infection - endometritis

Placental tissue remains in the womb (retained products of conception)

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64
Q

What are the symptoms of a secondary postpartum haemorrhage?

A
  1. Fever
  2. Abdo pain
  3. Vaginal bleeding
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65
Q

What are the investigations for a secondary postpartum haemorrhage?

A
  1. FBC
  2. Blood cultures
  3. Ultrasound - used if RPOC is suspected
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66
Q

What is the management of a secondary postpartum haemorrhage?

A

Sepsis - urgent referral to the hospital

Speculum exam - remove of clots

Endometritis - IV piperacillin/tazobactim

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67
Q

WHAT ARE BABY BLUES?

A

During the first week after childbirth, many women get what’s often called the “baby blues”.

Women can experience a low mood and feel midly depressed at a time when they expect they should feel happy after having a baby.

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68
Q

What is the cause of baby blues?

A

“Baby blues” are probably due to the sudden hormonal and chemical changes that take place in your body after childbirth

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69
Q

What are the symptoms of baby blues?

A

Feeling emotional and bursting into tears for no apparent reason

Feeling irritable or touchy

Low mood

Anxiety and restlessness

All these symptoms are normal and usually only last for a few days.

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70
Q

How long does the baby blues last?

A

3-7 days

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71
Q

What is the treatment for baby blues?

A

Get as much rest as you can.

Accept help from family and friends.

Connect with other new moms.

Create time to take care of yourself.

Avoid alcohol and recreational drugs, which can make mood swings worse.

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72
Q

WHAT IS POSTPARTUM DEPRESSION?

A

Depression after the birth of your baby

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73
Q

What are the symptoms of postpartum depression?

A
  1. Usual features of depression
  2. Fears about baby’s health
  3. Maternal deficiencies
  4. Marital tensions including loss of sexual interest
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74
Q

When does postpartum depression occur?

A

1 month and 3 months

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75
Q

How do you diagnose postpartum depression?

A

Edinburgh scale

Order blood tests to determine whether an underactive thyroid is contributing to your signs and symptoms

Order other tests, if warranted, to rule out other causes for your symptoms

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76
Q

What is the treatment for postpartum depression?

A

Cognitive behavioural therapy may be beneficial.

Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant

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77
Q

WHAT IS POSTPARTUM PSYCHOSIS?

A

Postpartum psychosis (or puerperal psychosis) is a severe mental illness. It starts suddenly in the days, or weeks, after having a baby.

Symptoms vary, and can change rapidly.

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78
Q

What is the cause of postpatrum psychosis?

A

Several things seem to play a part in postpartum psychosis. Your family history and genetic factors are important - you are more likely to have postpartum psychosis if a close relative has had it.

Hormone levels and disturbed sleep patterns may also be involved

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79
Q

What are the symptoms of postpatrum psychosis?

A
  1. Confusion and disorientation
  2. Obsessive thoughts about your baby
  3. Hallucinations and delusions
  4. Sleep disturbances
  5. Excessive energy and agitation
  6. Paranoia
  7. Attempts to harm yourself or your baby
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80
Q

What is the treatment of postpartum psychosis?

A
  1. Urgent admission to hospital
  2. Preferably with the baby
  3. Antipsychotic
  4. ECT
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81
Q

What is the risk of developing postpartum psychosis again after a previous pregnancy with it?

A

25-50%

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82
Q

WHAT IS AN PUERPERAL INFECTION?

A

A puerperal infection occurs when bacteria infect the uterus and surrounding areas after a woman gives birth.

It’s also known as a postpartum infection.

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83
Q

What are the different types of puerperal infections?

A

Endometritis
An infection of the uterine lining

Myometritis
An infection of the uterine muscle

Parametritis
An infection of the areas around the uterus

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84
Q

What are the symptoms of puerperal infections?

A

fever

pain in the lower abdomen or pelvis caused by a swollen uterus

foul-smelling vaginal discharge

pale skin, which can be a sign of large volume blood loss

chills

feelings of discomfort or illness

headache

loss of appetite

increased heart rate

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85
Q

How is a puerperal infection diagnosed?

A
  1. Physical exam
  2. High vaginal swab
  3. Throat swab
  4. Blood culture
  5. Urine analysis
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86
Q

How is a puerperal infection treated?

A
  1. IV Antibitoics in hospital
  2. Clindamycin + Gentamycin
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87
Q

WHAT IS DEFINED AS PUERPERAL PYREXIA?

A

Temp above 38 degrees

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88
Q

What is the cause of puerperal pyrexia?

A

Endometritis: most common cause

Urinary tract infection

Wound infections (perineal tears + caesarean section)

Mastitis

Venous thromboembolism

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89
Q

What is the management of puerperal pyrexia?

A
  1. If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics
  2. Clindamycin and gentamicin until afebrile for greater than 24 hours
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90
Q

WHAT IS VTE IN PREGNANCY?

A

Venous thromboembolism (VTE) refers to the formation of a thrombus within veins

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91
Q

What are the risk factors for a VTE?

A
  1. Age > 35
  2. Body mass index > 30
  3. Parity > 3
  4. Smoker
  5. Gross varicose veins
  6. Current pre-eclampsia
  7. Immobility
  8. Family history of unprovoked VTE
  9. Low risk thrombophilia
  10. Multiple pregnancy
  11. IVF pregnancy
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92
Q

What are the symptoms of a VTE in pregnancy?

A

DVT
Leg pain and discomfort (the left is more commonly affected), swelling, tenderness, oedema, increased temperature and a raised white cell count

PE
Dyspnoea, pleuritic chest pain, haemoptysis, faintness, collapse. The patient may have focal signs in the chest, tachypnoea, a raised jugular venous pressure (JVP) and there may be ECG changes (S1Q3T3)

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93
Q

How do you diagnose a VTE in pregnancy?

A

DVT
Duplex ultrasound scan

PE
Chest X-ray
ECG
Compression duplex ultrasound

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94
Q

What is the treatment for a VTE in pregnancy?

A

Four or more risk factors
Low molecular weight heparin antenatally + 6 weeks postpartum

Three risk factors
Low molecular weight heparin from 28 weeks + 6 weeks postpartum

If DVT diagnosis is made shortly before delivery
Continue LMW Heparin for 3 weeks postpartum

Anti-Xa acitvity to monitor is it’s working

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95
Q

What blood thinners should be avoided in pregnancy?

A

DOAC

Warfarin

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96
Q

WHAT ARE THE TYPES OF ANAEMIA DURING PREGNANCY?

A

Iron-deficiency anemia

Folate-deficiency anemia

Vitamin B12 deficiency

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97
Q

What type of sized anaemia does each anaemia cause?

A

Folate/B12 - macrocytic

Iron deficiency anaemia - microcytic

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98
Q

What are the symptoms of anaemia in pregnancy?

A
  1. Pale skin, lips, and nails
  2. Feeling tired or weak
  3. Dizziness
  4. Shortness of breath
  5. Rapid heartbeat
  6. Trouble concentrating
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99
Q

What are the risks with iron deficiency anaemia in pregnancy?

A

A preterm or low-birth-weight baby

A blood transfusion (if you lose a significant amount of blood during delivery)

Postpartum depression

A baby with anemia

A child with developmental delays

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100
Q

What are the risks with folate deficiency anaemia?

A

Preterm or low-birth-weight baby

Baby with a serious birth defect of the spine or brain (neural tube defects)

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101
Q

What are the tests for anaemia?

A

Hemoglobin test

Hematocrit test

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102
Q

What is the treatment for iron deficiency anaemia?

A
  1. Give oral iron therapy
  2. Different for different times
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103
Q

When should women take folic acid?

A
  1. women should take 400mcg of folic acid until the 12th week of pregnancy
  2. women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
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104
Q

What are the causes of folic acid deficiency?

A
  1. Phenytoin
  2. Methotrexate
  3. Pregnancy
  4. Alcohol excess
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105
Q

Why would you give some women 5mg of folic acid?

A
  1. Either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
  2. The woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
  3. The woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more)
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106
Q

WHAT IS RHESUS/HAEMOLYTIC DISEASE OF THE NEWBORN?

A

Hemolytic disease of the newborn (HDN) is a blood problem in newborn babies.

It occurs when your baby’s red blood cells break down at a fast rate.

It’s also called erythroblastosis fetalis.

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107
Q

What is the cause of haemolytic disease of the newborn?

A

HDN happens most often when an Rh negative mother has a baby with an Rh positive father.

If the baby’s Rh factor is positive, like his or her father’s, this can be an issue if the baby’s red blood cells cross to the Rh negative mother.

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108
Q

What are the symptoms of haemolytic disease of the newborn?

A

Mother

  1. A yellow coloring of amniotic fluid

Baby

  1. Oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
  2. Jaundice, anaemia, hepatosplenomegaly
  3. Heart failure
  4. Kernicterus (brain damage)
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109
Q

How do you diagnose haemolytic disease of the newborn?

A
  1. Blood test
    • Rh positive antibodies in your blood (anti-D IgG)
  2. Percutaneous umbilical cord blood sampling
    • Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
    • Kleihauer test: add acid to maternal blood, fetal cells are resistant
  3. Ultrasound
    • Enlarged organs or fluid buildup in your baby
  4. Amniocentesis
    • Amount of bilirubin in the amniotic fluid
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110
Q

What is the treatment for haemolytic disease of the newborn?

A
  1. Transfusions
  2. Phototherapy
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111
Q

How is haemolytic disease of the newborn prevented?

When is medicine given?

A

If you’re Rh negative and have not been sensitized, you’ll get a medicine called Rh immunoglobulin (RhoGAM)

28 + 34 weeks

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112
Q

WHAT IS A UTI IN PREGNANCY?

A

A UTI occurs when bacteria from somewhere outside of a woman’s body gets inside her urethra (basically the urinary tract) and causes an infection.

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113
Q

What is the cause of UTI in pregnancy?

A

Growing fetus can put pressure on the bladder and urinary tract. This traps bacteria or causes urine to leak.

Ureteral dilation, when the urethra expands and continues to expand until delivery.

Urine to become more still in the urethra. This allows bacteria to grow.

Urine gets more concentrated. It also has certain types of hormones and sugar. These can encourage bacterial growth and lower your body’s ability to fight off “bad” bacteria trying to get in.

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114
Q

What are the symptoms of UTI in pregnancy?

A

burning or painful urination

cloudy or blood-tinged urine

pelvic or lower back pain

frequent urination

feeling that you have to urinate frequently

fever

nausea or vomiting

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115
Q

What complications can UTI in pregnancy cause?

A

Early labour

Small baby

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116
Q

What is the treatment for UTI in pregnancy?

A
  1. First line - Nitrofurantoin
  2. Second line - Amoxicillin or cefalexin
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117
Q

WHAT IS PREMATURE LABOUR?

A

Regular contractions and the opening of your cervix after 20 weeks and before 37 weeks

118
Q

What are the symptoms of premature labour?

A

Regular or frequent sensations of abdominal tightening (contractions)

Constant low, dull backache

A sensation of pelvic or lower abdominal pressure

Vaginal spotting or light bleeding

Preterm rupture of membranes — in a gush or a continuous trickle of fluid after the membrane around the baby breaks or tears

A change in type of vaginal discharge — watery, mucus-like or bloody

119
Q

What are the risk factors for premature labour?

A

Previous preterm labor or premature birth, particularly in the most recent pregnancy or in more than one previous pregnancy

Pregnancy with twins, triplets or other multiples

Shortened cervix

Smoking cigarettes or using illicit drugs

Certain infections, particularly of the amniotic fluid and lower genital tract

Some chronic conditions, such as high blood pressure, diabetes, autoimmune disease and depression

120
Q

How do you diagnose premature labour?

A

Cervix has begun to soften, thin and open (dilate) before 37 weeks of pregnancy

Pelvic exam - firmness and tenderness of the uterus

Ultrasound - measure the length of the cervix

Uterine monitoring - Tocodynamometers
uterine montior to measure the duration and spacing of contractions

Lab tests - swab for infection and fibronectin

121
Q

What is the treatment for premature labour?

A
  1. Corticosteroids
    • ​​Help develop baby’s lungs maturity, mainly between 23 and 34 weeks
  2. Tocolytics
    • E.g. magnesium sulfate, terbutaline, nifedipine
    • Slow down contractions
  3. Magnesium sulfate
    • Between 24 and 34 weeks to help prevent cerebral palsy
  4. Cervical cerclage - Stitches or tape to reinforce the cervix
    • If short cervix
  5. Progesterone analogue
    • Hydroxyprogesterone caproate if history of premature birth
122
Q

WHAT IS PREMATURE RUPTURE OF THE MEMBRANE (PROM)?

A

Rupture of membranes prior to the onset of labour, in a patient who is at less than 37 weeks of gestation

123
Q

How does prematue rupture of the membranes (PROM) normally present?

A

The mother may give history of a ‘popping sensation’ or a ‘gush’ with continuous watery liquid draining thereafter.

Their underwear or pad may be damp.

124
Q

What are the investigations for premature rupture of the membranes (PROM)?

A

Do not perform a vaginal exam as this will increase the risk of infection!

  1. Seeing amniotic fluid pooling in the vagina as the woman has been lying down for 30 minutes
  2. Sterile speculum examination
  3. Ultrasound for gestation and liquor volume
  4. Temperature for infection
  5. Fetal monitoring
125
Q

What are the risk factors for premature rupture of the membranes (PROM)?

A

Smoking

Previous preterm delivery.

Vaginal bleeding

Lower genital tract infection

Positive amniotic fluid cultures

126
Q

What is the management for prematue rupture of the membranes?

A

Urgent referral to hospital

Antibotic prophylaxis
Erythromycin for 10 days, if contraindicated then penicillin

Antenatal steroids
Prednisolone

Delivery considered at 34 weeks

127
Q

WHAT IS PLACENTAL INSUFFICIENCY?

A

Placenta does not develop properly, or is damaged which fails to deliver proper nutrients to the fetus

128
Q

What are the causes of placental insufficiency?

A
  1. Preeclampsia
  2. Gestational diabetes
  3. Smoking and/or taking illegal drugs
  4. Taking blood thinner medications
  5. Maternal blood clotting
129
Q

What are the symptoms of placental insufficiency?

A
  1. Often no maternal symptoms

They may have:

  1. Smaller uterus than in previous pregnancies
  2. The fetus may also be moving less than expected
130
Q

What are the risks with placental insufficiency?

A
  1. Greater risk of oxygen deprivation at birth (can cause cerebral palsy and other complications)
  2. Learning disabilities
  3. Low body temperature (hypothermia)
  4. Low blood sugar (hypoglycemia)
  5. Too little blood calcium (hypocalcemia)
  6. Excess red blood cells (polycythemia)
  7. Premature labor
131
Q

How is placental insufficiency diagnosed?

A
  1. Pregnancy ultrasound to measure the size of the placenta
  2. Ultrasound to monitor the size of the fetus
  3. Alpha-fetoprotein levels in the mother’s blood (a protein made in the baby’s liver)
  4. Fetal nonstress test
132
Q

What is the treatment for placental insufficiency?

A
  1. Treat underlying risk factors
    Preeclampsia
    Gestational diabetes
  2. Corticosteroids
133
Q

WHAT IS A MISCARRIAGE?

A

The loss of the fetus before 20 weeks of pregnancy

134
Q

What are the causes of recurrent miscarriages?

A
  1. Antiphospholipid syndrome
  2. Endocrine disorders
    • Poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
  3. Uterine abnormality:
    • e.g. uterine septum
  4. Parental chromosomal abnormalities
  5. Smoking
135
Q

What are the risk factors for a miscarriage?

A
  1. Increased maternal age
  2. Smoking in pregnancy
  3. Consuming alcohol
  4. Recreational drug use
  5. High caffeine intake
  6. Obesity
  7. Infections and food poisoning
  8. Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
  9. Medicines, such as ibuprofen, methotrexate and retinoids
  10. Unusual shape or structure of womb
  11. Cervical incompetence
136
Q

What are the symptoms of a miscarriage?

A
  1. Heavy spotting
  2. Vaginal bleeding
  3. Discharge of tissue or fluid from your vagina
  4. Severe abdominal pain or cramping
  5. Mild to severe back pain
137
Q

What are the causes of a miscarriage?

A

Genetic or chromosomal abnormalities
Intrauterine fetal demise
Blighted ovum
Molar pregnancy

Underlying conditions and lifestyle habits
Poor diet
Alcohol and drug use
Maternal age

138
Q

What are the different types of miscarriage?

A

Complete miscarriage: All pregnancy tissues have been expelled from your body

Incomplete miscarriage: You’ve passed some tissue or placental material, but some still remains in your body

Missed miscarriage: The embryo dies without your knowledge, and you don’t deliver it

Threatened miscarriage: Bleeding and cramps point to a possible upcoming miscarriage, cervix is closed

Inevitable miscarriage: The presence of bleeding, cramping, and cervical dilation indicates that a miscarriage is inevitable

Septic miscarriage: An infection has occurred within your uterus

139
Q

How is a miscarriage diagnosed?

A
  1. Ultrasound
    • ​​Empty uterus
  2. Blood test - HCG
  3. Tissue tests
140
Q

What is the treatment for a miscarriage?

A
  1. Threatened miscarriage
    • Rest until the fetus passes
  2. Expectant miscarriage
    • Let it pass naturally
  3. Medical treatment
    • Vaginal Misoprostol
  4. Surgical treatment
    • Dilation and curettage (D&C)
    • Vaccum aspiration
141
Q

What is the criteria for a miscarriage be diagnosed?

A

No cardiac activity and:

The crown-rump length is greater than 7mm OR

The gestational sack is greater than 25mm

142
Q

WHAT IS GESTATIONAL DIABETES?

A

Gestational diabetes is diabetes that develops during pregnancy

143
Q

What are the risk factors for gestational diabetes?

A
  1. BMI of > 30 kg/m²
  2. Previous macrosomic baby weighing 4.5 kg or above
  3. Previous gestational diabetes
  4. First-degree relative with diabetes
  5. Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
144
Q

What are the symptoms of gestational diabetes?

A

For most women, gestational diabetes doesn’t cause noticeable signs or symptoms.

Increased thirst and more-frequent urination are possible symptoms.

145
Q

What are the complications with gestational diabetes?

A
  1. Excessive birth weight
  2. Early (preterm) birth
  3. Serious breathing difficulties
  4. Low blood sugar (hypoglycemia). Severe episodes of hypoglycemia may cause seizures in the baby.
  5. Obesity and type 2 diabetes later in life.
  6. Stillbirth.
146
Q

What is the diagnosis for gestational diabetes?

A

FIRST LINE - Oral glucose tolerance test (OGTT)
Done around 24 to 28 weeks

Fasting glucose is >= 5.6 mmol/l

2-hour glucose is >= 7.8 mmol/l

147
Q

What is the treatment for gestational diabetes?

A

< 7 mmol/l
Trial of diet and exercise should be offered
If glucose targets are not met within 1-2 weeks
Altering diet/exercise metformin should be started
If glucose targets are still not met
Short-acting Insulin should be added to diet/exercise/

>= 7 mmol/l
SHORT ACTING Insulin ONLY should be started

6-6.9 mmol/l
Evidence of complications such as macrosomia or hydramnios, insulin should be offered

148
Q

What additional checking should a previous gestational diabetic woman recieve in her next pregnancy?

A

OGTT immediately after bookimng, and at 24-28 weeks

149
Q

WHAT IS GROUP B STEPTOCOCCUS INFECTION?

A

Group B strep (streptococcus) is a common bacterium often carried in the intestines or lower genital tract.

The bacterium is usually harmless in healthy adults. In newborns, however, it can cause a serious illness known as group B strep disease.

150
Q

What is the causative organism for group B streptococcus disease?

A

Streptococcus agalacticae

151
Q

What are the symptoms of group B streptococus disease?

A

During pregnancy, many women experience symptomatic vaginal discharge, which may prompt health professionals to take a swab for culture

Usually no signs or symptoms

  1. A strong, persistent urge to urinate
  2. A burning sensation or pain when urinating
  3. Passing frequent, small amounts of urine
  4. Urine that appears red, bright pink or cola colored — a sign of blood in the urine
  5. Pelvic pain
152
Q

What babies are at risk of developing group B streptococus disease?

A
  1. Prematurity
  2. Prolonged rupture of the membranes
  3. Previous sibling GBS infection
  4. Maternal pyrexia e.g. secondary to chorioamnionitis
  5. The mother previously delivered an infant with group B strep disease
153
Q

What prevention is given to mothers when at risk of delivering a group B streptococus baby?

A
  1. IV antibiotics (Benpen or erthyromycin) during labour
  2. No point giving it before as has a chance of coming back
154
Q

How is group B streptococus diagnosed?

A

Swab between 35 and 37 weeks of pregnancy

155
Q

What is the treatment for group B strepococus?

A
  1. IV antibiotics
  2. Benzylpenicillin
156
Q

WHAT IS AN ECTOPIC PREGNANCY?

A

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

157
Q

What are the risk factors for an ectopic pregnancy?

A
  1. Damage to tubes (pelvic inflammatory disease, surgery)
  2. Previous ectopic
  3. Black race
  4. Age >35 years
  5. Endometriosis
  6. IUCD
  7. Progesterone only pill
  8. IVF (3% of pregnancies are ectopic)
158
Q

What are the symptoms of an ectopic pregnancy?

A
  1. Light to heavy vaginal spotting or bleeding
  2. Sharp waves of pain in the abdomen, pelvis, shoulder, or neck
  3. Severe pain that occurs on one side of the abdomen
159
Q

Where is the place most likely for an ectopic pregnancy to attach?

Where is most likely to bleed?

A

Ampulla

160
Q

How is a ectopic pregnancy diagnosed?

A
  1. A pregnancy test will be positive.
  2. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
161
Q

What are the different types of management for an ectopic pregnancy?

A
  1. Expectant (watchful waiting)
  2. Medical
    Methotrexate
  3. Surgical
    • ​​Laparoscopic Salpingectomy
    • Open salpingectomy if ruptured and haemodynamically unstable
    • Also have to give anti-D if mother negative
162
Q

What is the criteria for expectant management of an ectopic pregnancy?

A
  1. An unruptured embryo
  2. <35mm in size
  3. Have no heartbeat
  4. Be asymptomatic
  5. Have a B-hCG level of <1,000IU/L and declining
163
Q

What is the criteria for medical management of an ectopic pregnancy?

A
  1. Size <35mm
  2. Unruptured
  3. No significant pain
  4. No fetal heartbeat
  5. Serum B-hCG <1,500IU/L
164
Q

What is the criteria for surgical management of an ectopic pregnancy?

A
  1. Size >35mm
  2. Can be ruptured
  3. Pain
  4. Visible fetal heartbeat
  5. Serum B-hCG >1,500IU/L
165
Q

WHAT IS SHOUDLER DYSTOCIA?

A

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body

166
Q

What are the complications with shoulder dystocia?

A
  1. Maternal
    • Postpartum haemorrhage
    • Perineal tears
  2. Fetal
    • Brachial plexus injury
    • Neonatal death
167
Q

What nerve roots are involved with Erb’s palsy?

A

C5-C6

168
Q

What are the risk factors for shoulder dystocia?

A
  1. Fetal macrosomia
  2. High maternal body mass index
  3. Diabetes mellitus
  4. Prolonged labour
169
Q

What are the symptoms of shoulder dystocia?

A

Difficulty in delivery of the fetal head or chin.

Failure of restitution – the fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’.

‘Turtle Neck‘ sign – the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell.

170
Q

What is the treatment for shoulder dystocia?

A

McRoberts’ manoeuvre should be performed.

This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery

Episiotomy

171
Q

WHAT IS MALPRESENTATION?

A

Malpresentation is the situation where a foetus within the uterus is in any position that is not cephalic - i.e. head down.

172
Q

What are some examples of malpresentations?

A
  1. Face
  2. Brow
  3. Breech
  4. Shoulder
173
Q

What are the different types of breech presentation?

A
  1. Complete breech - feet presenting but flexed hips and knees
  2. Frank breech - hips flexed and legs extended over anterior surface of body
  3. Footling breech
    • At least 1 extended fetal hip
    • ​Contraindication to labor
174
Q

What are the risk factors for a breech presentation?

A
  1. Uterine malformations, fibroids
  2. Placenta praevia
  3. Polyhydramnios or oligohydramnios
  4. Fetal abnormality (e.g. CNS malformation, chromosomal disorders)
  5. Prematurity (due to increased incidence earlier in gestation)
175
Q

What is more common in breech presentations?

A

Cord prolapse

176
Q

What is the management for a breech presentation?

A

If < 36 weeks
Many fetuses will turn spontaneously

**36 weeks**
Externalcephalic version (ECV)

if the baby is still breech
Planned caesarean section or vaginal delivery

177
Q

What are the contraindications for an ECV?

A

Where caesarean delivery is required

Antepartum haemorrhage within the last 7 days

Abnormal cardiotocography

Major uterine anomaly

Ruptured membranes

Multiple pregnancy

178
Q

What are the reasons for bleeding in each trimester?

A
179
Q

What are the different types of multiple pregnancies?

A

Dichorionic diamniotic (DCDA)
If two eggs are fertilised or if one egg splits soon after fertilisation, each baby has its own placenta with its own outer membrane called a ‘chorion’ and its own amniotic sac

Monochorionic diamniotic (MCDA)
If the fertilised egg splits a little later, the babies share a placenta and chorion but they each have their own amniotic sac; these babies are always identical

Monochorionic monoamniotic (MCMA)
Much less commonly, the fertilised egg splits later still and the babies share the placenta and chorion and are inside the same amniotic sac; these babies are always identical; this is rare and carries additional risks.

180
Q

What are the complications of multiple pregnancies?

A
  1. Anaemia
  2. Pre-eclampsia
  3. A higher chance of bleeding more heavily than normal after the birth
  4. A higher chance of needing a caesarean section or assisted vaginal delivery to deliver your babies
181
Q

What are the complications of monoamniotic monozygotic twins?

A
  1. Increased spontaneous miscarriage, perinatal mortality rate
  2. Increased malformations, IUGR, prematurity
  3. Twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
    • Regular checks at 16 and 24 weeks
182
Q

What increases your chance of having twins?

A

Previous twins

Family history

Increasing maternal age

Multigravida

Induced ovulation and in-vitro fertilisation

Race e.g. Afro-Caribbean

183
Q

What is the management of multiple pregnancies?

A
  1. Ultrasound for diagnosis + monthly checks
  2. Additional iron + folate
  3. More antenatal care (e.g. weekly > 30 weeks)
  4. Precautions at labour (e.g. 2 obstetricians present)
  5. 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
184
Q

WHAT ARE THE DIFFERENT TYPES OF LIE?

A
  1. Longitudinal lie (99.7% of foetuses at term)
  2. Transverse lie (<0.3% of foetuses at term)
  3. Oblique (<0.1% of foetuses at term)
185
Q

How is an abnormal lie detected?

A

Abnormal foetal lie will be detected during routine antenatal appointments with a midwife during abdominal examination.

Abdominal examination
The head and buttocks are not palpable at each end of the uterus. The foetus can be felt to be lying directly across the uterus.

Ultrasound scan
Allows direct visualisation of the foetal lie. Foetal heart rate is also auscultated to assess for distress.

186
Q

What are the complications of a transverse lie?

A
  1. Pre-term rupture membranes (PROM)
  2. Cord-prolapse (20%)

If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK.

187
Q

What is the management for a transverse lie?

A

Before 36 weeks gestation
no management required.

After 36 weeks gestation

Perform external cephalic version (ECV) of the foetus. This can be performed late in pregnancy and even early labour if the membranes have not yet ruptured
Contraindications include maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality. Success rate is around 50%

Elective caesarian section

188
Q

What are the different types of caesarean section?

A

Lower segment caesarean section: now comprises 99% of cases

Classic caesarean section: longitudinal incision in the upper segment of the uterus

189
Q

What are the contraindications to a vaginal birth after a caesarean section?

A

Previous uterine rupture or classical caesarean scar

190
Q

WHAT IS OLIGOHYDRAMNIOS?

A

Oligohydramnios refers to a low level of amniotic fluid during pregnancy.

191
Q

What are the causes of oligohydramnios?

A
  1. Premature rupture of membranes
  2. Fetal renal problems e.g. renal agenesis
  3. Intrauterine growth restriction
  4. Post-term gestation
  5. Pre-eclampsia
192
Q

What are the symptoms of oligohydramnois?

A

No maternal symptoms other than a sense of decreased fetal movement

Uterine size may be less than expected based on dates.

193
Q

How do you diagnose oligohydramnois?

A
  1. Investigation of placental function
  2. Ultrasound examination of the foetal kidneys and urogenital system
194
Q

What is the management for oligohydramnios?

A

Before term:
Expectant management
Ongoing antepartum surveillance
Continuous fetal heart rate monitoring during labour

At term:

Delivery is often the most appropriate management.

After term:

Isolated oligohydramnios in the post-term patient has no greater risk for caesarean delivery and there is insufficient evidence to support induction for women with oligohydramnios

195
Q

What is the measurement to be defined as oligohydramnios?

A

AFI <5

Or fluid <500ml

196
Q

What is the measurement to be defined as polyhydramnios?

A

AFI >24cm

Or fluid > 2000ml

197
Q

WHAT ARE THE RENAL CHNAGES IN PREGNANCY?

A
  1. Reduced urea
  2. Reduced creatinine
  3. Increased urinary protein loss
198
Q

WHAT IS DONE 8 - 12 WEEKS GESTATION IN THE ANTENATAL CHECK?

A

Booking visit

  1. General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
  2. BP, urine dipstick, check BMI

Booking bloods/urine

  1. FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
  2. hepatitis B, syphilis
  3. HIV test is offered to all women
  4. urine culture to detect asymptomatic bacteriuria
199
Q

What is done 10 - 13 +6 weeks gestation in the antenatal check?

A
  1. Early scan to confirm dates
  2. Exclude multiple pregnancy
200
Q

What is done 11 - 13+6 weeks gestation in the antenatal check?

A

Down’s syndrome screening including nuchal scan

201
Q

What is done 16 weeks gestation in the antenatal check?

A
  1. Information on the anomaly scan in week 18-20+6weeks
  2. Blood results from booking 8-12 weeks visit
  3. If Hb < 11 g/dl consider iron
  4. Routine care: BP and urine dipstick
202
Q

What is done 18 - 20+6 weeks gestation in the antenatal check?

A

Anomly scan

  1. Anencephaly
  2. Open spina bifida
  3. Cleft lip
  4. Diaphragmatic hernia
  5. Gastroschisis
  6. Exomphalos
  7. Serious cardiac abnormalities
  8. Bilateral renal agenesis
  9. Lethal skeletal dysplasia
  10. Edwards’ syndrome, or T18
  11. Patau’s syndrome, or T13
203
Q

What is done 25 weeks gestation in antenal checks?

A

Routine care:

  1. BP
  2. Urine dipstick
  3. Symphysis-fundal height (SFH)
204
Q

What is done 28 weeks gestation in the antenatal check?

A
  1. Routine care: BP, urine dipstick, SFH

Blood stuff

  1. Second screen for anaemia and atypical red cell alloantibodies.
  2. If Hb < 10.5 g/dl consider iron
  3. First dose of anti-D prophylaxis to rhesus negative women
205
Q

What is done 31 weeks gestation in the antenatal check?

A
  1. Routine care: BP, urine dipstick, SFH
  2. Second screen for anaemia and atypical red cell alloantibodies.
  3. If Hb < 10.5 g/dl consider iron
206
Q

What is done 34 weeks gestation in the antenatal check?

A
  1. Routine care: BP, urine dipstick, SFH
  2. Second dose of anti-D prophylaxis to rhesus negative women*
  3. Information on labour and birth plan
207
Q

What is done 36 weeks gestation in the antenatal check?

A

Routine care as above

Check presentation - offer external cephalic version if indicated

Information on breast feeding, vitamin K, ‘baby-blues’

208
Q

What is the symphysis-fundal height?

A

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres

209
Q

How do the symphysis-fundal height and gestational age match?

A

It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

210
Q

What is the lady had a diffent symphysis-fundal height to date?

A

Ultrasound

211
Q

WHAT IS CAPUT SUCCEDANEUM?

A

Caput succedaneum is a subcutaneous, extraperiosteal, collection of fluid that collects as the result of pressure on the baby’s head during delivery

212
Q

What is a cephalhaematoma?

A

A cephalhaematoma is a haemorrhage between the skull and periosteum.

Because the swelling is subperiosteal, it’s limited by the boundaries of the baby’s cranial bones.

213
Q

What is a chignon?

A

A chignon is a temporary swelling left on an infant’s head after a ventouse suction cap has been used to deliver him or her

214
Q

What is a carbuncle?

A

A carbuncle is a red, swollen, and painful cluster of boils that are connected to each other under the skin.

215
Q

WHAT INFECTIOUS AGENTS ARE SCREENED FOR IN ANTENATAL SCREENING?

A
  1. Hepatitis B
  2. HIV
  3. Syphillis
216
Q

WHAT IS SECONDARY AMENORRHOEA?

A

Cessation of menstruation for 3–6 months in women with previously normal and regular menses, or for 6–12 months in women with previous oligomenorrhoea.

217
Q

What are the causes of secondary amenorrhea?

A
  1. Pregnancy
  2. Hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
  3. Polycystic ovarian syndrome (PCOS)
  4. Hyperprolactinaemia
  5. Premature ovarian failure
  6. Thyrotoxicosis*
  7. Sheehan’s syndrome
  8. Asherman’s syndrome (intrauterine adhesions)
218
Q

WHAT IS A CORD PROLAPSE?

A

Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus

219
Q

What happens if cord prolapse is not treated?

A

Fetal hypoxia

Irreversible damage or death

220
Q

What are the risk factors for cord prolapse?

A
  1. Transverse and oblique lie
  2. A breech presentation
  3. Disproportion
  4. Multiple pregnancy
  5. Polyhydramnios
  6. Pelvic tumours
  7. A pre-term rupture of membranes
  8. Placenta praevia
221
Q

When is cord prolapse mostly diagnosed?

A

The majority of cord prolapses occur at artificial rupture of the membranes.

222
Q

How is a cord prolapse diagnosed?

A

Fetal heart rate becomes abnormal

Cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

223
Q

What is the management of a cord prolapse?

A
  1. The presenting part of the fetus may be pushed back into the uterus to avoid compression.
  2. Tocolytics (e.g Terbutaline, Indomethacin, Nifedipine, Magnesium Suldate) may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.
  3. The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out
  4. Retrofilling the bladder with 500-700ml of saline may be helpful
224
Q

WHAT IS HYPEREMESIS GRAVIDARUM?

A

Nausea and vomiting of pregnancy’ (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.

225
Q

Why does hyperemesis gravidarum happen?

A

Elevated levels of Beta hCG

226
Q

When does hyperemesis gravidarum happen?

A

Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks

227
Q

What are the associations with hyperemesis gravidarum?

A
  1. Multiple pregnancies
  2. Trophoblastic disease
  3. Hyperthyroidism
  4. Nulliparity
  5. Obesity
228
Q

What is the triad of symptoms in hyperemesis gravidarum?

A
  1. 5% pre-pregnancy weight loss
  2. Dehydration
  3. Electrolyte imbalance
    • Low chloride
    • Low sodium
    • Elevated urea
    • Raised ketones
229
Q

What is the management for hyperemesis gravidarum?

A
  1. Thiamine

First line - Antihistamines

  1. Promethazine
  2. Cyclizine

Second line - Antiemetics

  1. Ondansetron
  2. Metoclopramide

Ginger and P6 (wrist) acupressure

Admission may be needed for IV hydration

230
Q

What are the complications of hyperemesis gravidarum?

A
  1. Wernicke’s encephalopathy
  2. Mallory-Weiss tear
  3. Central pontine myelinolysis
  4. Acute tubular necrosis
  5. Fetal: small for gestational age, pre-term birth
231
Q

What scoring system can be used to evaluate the severity of systems in hyperemesis gravidarum?

A

Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP

232
Q

What are the pathologies of jaunduce in the first 24 hours after birth?

A

Jaundice in the first 24 hrs is always pathological

Causes of jaundice in the first 24 hrs

  1. Rhesus haemolytic disease
  2. ABO haemolytic disease
  3. Hereditary spherocytosis
  4. Glucose-6-phosphodehydrogenase
233
Q

What are the causes of prolonged jaunduce in a newborn?

A
  1. Biliary atresia
  2. Hypothyroidism
  3. Galactosaemia
  4. Urinary tract infection
  5. Breast milk jaundice
  6. Congenital infections e.g. CMV, toxoplasmosis
234
Q

UP TO WHEN CAN A WOMAN TERMINATE A PREGNANCY?

A

24 weeks

235
Q

Who must sign off on an abortion and who can perform it?

A

Two registered medical practitioners must sign a legal document (in an emergency only one is needed)

Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

236
Q

What are the methods for abortion?

A
  1. Less than 9 weeks
    ORal Mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
  2. Less than 13 weeks
    Surgical dilation and suction of uterine contents
  3. more than 15 weeks
    Surgical dilation and evacuation of uterine contents OR late medical abortion (induces ‘mini-labour’) - INFECTION RISK
237
Q

What is used for the management of intrahepatic cholestasis in pregnancy?

A
  1. Induction of labour at 37-38 weeks is common practice but may not be evidence based
  2. Ursodeoxycholic acid - again widely used but evidence base not clear
  3. Vitamin K supplementation
238
Q

Up to how long can a woman show a positive pregnancy test after an abortion?

A

4 weeks

239
Q

How is rubella in pregnancy diagnosed?

A

Significant rise in rubella IgG antibodies

IgM also deteced within 4-6 weeks after contact

240
Q

What is the risk to the fetus after catching rubella?

A

In first 8-10 weeks risk of damage to fetus is as high as 90%

Damage is rare after 16 weeks

241
Q

What are the features of the fetus if the mother contracts rubella?

A
  1. sensorineural deafness
  2. congenital cataracts
  3. congenital heart disease (e.g. patent ductus arteriosus)
  4. growth retardation
  5. hepatosplenomegaly
  6. purpuric skin lesions
  7. ‘salt and pepper’ chorioretinitis
  8. microphthalmia
  9. cerebral palsy
242
Q

What is the management for rubella in pregnancy?

A
  1. Non-immune mothers should be offered the MMR vaccination in the post-natal period
  2. MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
  3. Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
  4. Since 2016, rubella immunity is no longer routinely checked at the booking visit
  5. If a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
243
Q

What is the nuchal scan to check for?

A
  1. Down’s syndrome
  2. Congenital heart defects
  3. Abdominal wall defects
244
Q

When can chorionic villous sampling be done?

A

Between 11 and 13 weeks

245
Q

What are the causes of hyperechogenic bowel?

A
  1. Cystic fibrosis
  2. Down’s syndrome
  3. Cytomegalovirus infection
246
Q

What is Lochia?

A

Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.

247
Q

What should you do if there are no fetal movements between 24 and 28 weeks?

A

If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.

248
Q

What should you do if no fetal movements have been felt below 24 weeks but fetal movements have been felt before?

A

If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.

249
Q

What should you do if no fetal movements have been felt by 24 weeks?

A
  1. Handheld doppler
  2. Ultrasound scan
  3. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
250
Q

What is the Kleihauer test?

A
  1. A Kleihauer test is a test for Fetomaternal Hemorrhage (FMH)
  2. Detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin.
  3. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.
251
Q

What are the indications for a forceps delivery?

A
  1. Fetal distress in the second stage of labour
  2. Maternal distress in the second stage of labour
  3. Failure to progress in the second stage of labour
  4. Control of head in breech deliver
252
Q

What are the side effects of SSRIs in pregnancy?

A

Use during the first trimester gives a small increased risk of congenital heart defects

Use during the third trimester can result in persistent pulmonary hypertension of the newborn

Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

253
Q

What is contained within the combined test?

When is it offered?

A
  1. Nuchal translucency measurement
  2. Serum B-HCG
  3. Pregnancy-associated plasma protein A (PAPP-A)

These tests should be done between 11 - 13+6 weeks

254
Q

What are the results of the combined test which lead to a diagnosis of Down’s?

What conditions is it similar to?

A

Down’s syndrome is suggested by:

  1. ↑ HCG
  2. ↓ PAPP-A
  3. Thickened nuchal translucency

Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

255
Q

What is contained in the triple test and quadruple test?

A

Triple test
Alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin

Quadruple test
Alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A

256
Q

What are the different degrees of vaginal tears?

A
  1. 1st degree = tear within vaginal mucosa only
  2. 2nd degree = tear into subcutaneous tissue
  3. 3rd degree = laceration extends into external anal sphincter
  4. 4th degree = laceration extends through external anal sphincter into rectal mucosa
257
Q

What conditions is increased alpha-feta protein in?

A
  1. Neural tube defects
    • Meningocele
    • Myelomeningocele
    • Anencephaly)
  2. Abdominal wall defects
    • Omphalocele
    • Gastroschisis
  3. Multiple pregnancy
258
Q

What conditions is decreased alpha-feta protein

A
  1. Down’s syndrome
  2. Trisomy 18 (Edward’s)
  3. Maternal diabetes mellitus
259
Q

What layers do you need to cut through in a caesarean section?

A
  1. Superficial fascia
  2. Deep fascia
  3. Anterior rectus sheath
  4. Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
  5. Transversalis fascia
  6. Extraperitoneal connective tissue
  7. Peritoneum
  8. Uterus
260
Q

What medication can be used to suppress lactation?

A

Cabergoline

261
Q

HOW DO YOU INVESTIGATE GONORRHOEA IN PREGNANCY?

A

Endocervical swabs

262
Q

What is the treatment for gonorrhoea in pregnancy?

A
  1. Ceftriaxone IM

Tetracyclines and fluoroquinolones should be avoided in pregnancy

263
Q

What are the effects of gonorrhoea on pregnancy?

A

Nomally little effect, sometimes:

  1. Prematurity
  2. Intrauterine growth retardation
264
Q

WHAT IS A TREFOIL PELVIS?

A

Deformity of the pelvis as a result of osteomalacia

265
Q

WHAT IS OBSTRUCTED LABOUR?

A

No progress despite strong uterine contractions.

266
Q

What are the causes of obstructed labour?

A

Powers

  1. Hypotonic contraction

Passage

  1. Small pelvis

Passenger

  1. Size of baby
  2. Malposition
267
Q

What are the causes of malpresentation?

A

Maternal factors:

  1. Pelvic inflammation
  2. Pelvic tumour / fibroid
  3. Arcuate or septate uterus
  4. Oligohydramnios
  5. Placenta praevia

Foetal factors:

  1. Prematurity
  2. Multiple pregnancy
  3. Fetal malformation e.g. hydrocephalus
  4. Intrauterine death
268
Q

WHAT ARE THE COMPLICATIONS OF MULTIPLE PREGNANCY IN PREGNENCY?

A
  1. Prematurity
  2. Intrauterine growth retardation
  3. Pregnancy induced hypertension
  4. Anaemia
  5. Polyhydramnios
  6. Congenital malformations
269
Q

What are the complications of multiple pregnancy in labour?

A
  1. Malpresentation
  2. Postpartum haemorrhage
  3. Cord prolapse
270
Q

What is the management for multiple pregnancy?

A
  1. Supplementation of iron and folic acid
  2. Regular monitoring of haemoglobin levels
  3. Increased level of review in antenatal clinic
  4. Booking of the birth into a specialist unit
271
Q

WHAT IS POLYHYDRAMNIOS?

A

Volume of amniotic fluid >1500ml

272
Q

What are the causes of polyhydramnios?

A

Foetal causes:

  1. Twin pregnancy, especially uniovular twins
  2. Anencephaly interferes with foetal swallowing
  3. Oesophageal or duodenal atresia prevents foetal swallowing
  4. Spina bifida

Maternal causes:

  1. Poorly controlled maternal diabetes results in foetal polyuria
  2. Multiple pregnancy
273
Q

What are the complications of polyhydramnios?

A
  1. Malpresentation and malposition
  2. Umbilical cord prolapse on membrane rupture
  3. Postpartum haemorrhage
  4. Placental abruption
  5. Premature labour
274
Q

What are the investigations for polyhydramnios?

A

Largely clinical

  1. Tense uterus
  2. Difficulty in palpation of fetal parts
  3. Difficulty in hearing fetal heart sounds
275
Q

What is the management for polyhydramnios?

A

Slow release of amnitotic fluid via a transabdominal needle

276
Q

WHAT ARE THE DIFINITION OF EACH PERINEAL TEAR?

A
  1. First degree
    • Superficial damage with no muscle involvement
  2. Second degree
    • Injury to the perineal muscle, but not involving the anal spincter
  3. Third degree
    • Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter
  4. Fourth degree
    • Injury to perineum involving the anal sphincter complex and rectal mucosa
277
Q

What repair does each perineal tear require?

A
  1. First degree
    • Do not require any repair
  2. Second degree
    • Require suturing on the ward by a suitably experienced midwife or clinican
  3. Thirs degree
    • Require repair in theatre by a suitably trained clinician
  4. Fourth degree
    • Require repair in theatre by a suitably trained clinician
278
Q

What is the primary anti-emetic used in pregnancy?

A

Antihistamine e.g. promethazine

279
Q

What foods should be avoided in pregnancy?

A
  1. Liver - High levels of vit A
  2. Listeriosis
    • Avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
  3. Salmonella
    • Avoid raw or partially cooked eggs and meat, especially poultry
280
Q

WHAT ARE THE INVESTIGATIONS FOR CHICKENPOX IN PREGNANCY?

A

If there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies

281
Q

If a lady is pregnant and below 20 weeks what is the treatment for chickenpox expsoure?

A
  1. if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
  2. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
282
Q

What if a lady is pregnant and above 20 weeks what is the treatment after chickenpox exposure?

A
  1. if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
283
Q

WHAT IS INTRAHEPATIC CHOLESTASIS OF PREGNANCY?

A
  1. Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK.
  2. It is associated with an increased risk of premature birth + stillbirth
284
Q

What are the features of intrahepatic cholestasis of pregnancy?

A
  1. pruritus - may be intense - typical worse palms, soles and abdomen
  2. clinically detectable jaundice occurs in around 20% of patients
  3. raised bilirubin is seen in > 90% of cases
285
Q

What is the management for intrahepatic cholestasis of pregnancy?

A
  1. Induction of labour at 37-38 weeks is common practice but may not be evidence based
  2. Ursodeoxycholic acid - again widely used but evidence base not clear
  3. Vitamin K supplementation
286
Q

WHEN DO WOMEN REQUIRE CONTRACEPTION AFTER BIRTH?

A

21 days

287
Q

WHAT ARE THE INDICATIONS FOR A FROCEPS DELIVERY?

A
  1. fetal distress in the second stage of labour
  2. maternal distress in the second stage of labour
  3. failure to progress in the second stage of labour
  4. control of head in breech deliver
288
Q

WHAT IS THE TREATMENT FOR A BABY BORN FROM A HEPATITIS B POSITIVE WOMAN?

A

Hep B vaccine and 0.5 ml of HBIG within 12 hours with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

289
Q

WHAT IS AN AMNIOTIC FLUID EMBOLSIM?

A

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction

290
Q

What is the clinical presentation of amniotic fluid embolism?

A
  1. The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
  2. Symptoms include: chills, shivering, sweating, anxiety and coughing.
  3. Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
291
Q

WHAT ARE THE SYMPTOMS OF CHORIOAMNIONITIS?

A
  1. Maternal pyrexia
  2. Maternal tachycardia
  3. Fetal tachycardia

ΩΩ 3a Bateman - Obs and Gynae (6 decks)

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