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RHCN > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What are the 3 main appointments during pregnancy

A
  1. booking visit at 8-11 weeks
  2. dating scan at 12 weeks
  3. foetal anomaly scan at 20 weeks
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2
Q

What is placenta praevia

A

When the placenta is blocking the internal Os (cervix) - this prevents delivery of the baby and likely to cause haemorrhage

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3
Q

What is perinatal

A

Any time from when you become pregnant through pregnancy and delivery until 1 year postpartum

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4
Q

What is the classic sign of placental abruption

A

Firm, ‘woody’ feeling uterus

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5
Q

Symptoms of placental abruption

A

Pain
Fresh PV bleeding
If blood from abruption is trapped and forms a haematoma, may present with old blood during delivery instead (when dislodged)

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6
Q

What are the stages of labour

A

1st - contractions infrequent, <4cm cervical dilation
2nd - divided into latent and active, contractions more regular and active pushing may begin, 4-10cm dilation
3rd - delivery of placenta

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7
Q

Distinguishing between baby blues and postnatal depression in terms of timeframe

A

Baby blues = in first 2 weeks postpartum, peaks within 5 days due to hormone flux
Postnatal depression = up to 1 year postpartum, depressive symptoms must be present for at least 2 weeks

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8
Q

Medical treatment options for postpartum haemorrhage

A 
Bimanual compression 
Oxytocin 5 units slow IV
Ergometrine 0.5mg slow IV/IM
Carboprost (Hemabate) 0.25mg IM up to 8 doses
Misoprostol 1000mg PR
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9
Q

Surgical treatment options for postpartum haemorrhage

A 
Balloon tamponade
Haemostatic brace suturing
Bilateral ligation of uterine  or internal iliac arteries
Selective arterial embolisation 
Hysterectomy
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10
Q

Mechanism of action of Carboprost (Hemabate)

A

Synthetic prostaglandin (F2 alpha) stimulates the uterus to contract to provide haemostasis

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11
Q

Mechanism of action of Oxytocin in PPH

A

Peptide hormone causes uterine contraction to provide haemostasis

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12
Q

Mechanism of action of Misoprostol in PPH

A

Synthetic prostaglandin (E1) causing contraction of the uterus and reduces cervical tone

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13
Q

What is the definition of pre-eclampsia

A

New onset hypertension after 20 weeks gestation (also up to 6 weeks postpartum) and proteinuria with or without oedema

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14
Q

Moderate risk factors for PET

A

First pregnancy, maternal age over 40, maternal BMI over 35, FHx PET, pregnancy intervals of greater than 10 years, multiple pregnancy

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15
Q

High risk factors for PET

A

Hx HTN/eclampsia/PET, CKD, autoimmune disease e.g. SLE or APS, T1/2DM, chronic HTN

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16
Q

Differential diagnoses for PET

A
  1. essential hypertension (before 20 weeks gestation)
  2. pregnancy-induced hypertension (after 20 weeks gestation without proteinuria)
  3. eclampsia (seizures + PET)
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17
Q

What is classified as significant proteinuria

A

> 300mg protein in 24hr urine sample OR >30mg/mmol PCR

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18
Q

What BP level is classed as HTN

A

Systolic >140 or diastolic >90

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19
Q

Classification of pre-eclampsia and relevant thresholds

A 
Mild = BP 140/90 - 149/99
Moderate = BP 150/100 -  159/109
Severe = BP > 160/110 (with proteinuria) or BP >140/90 with proteinuria + SYMPTOMS
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20
Q

Symptoms of pre-eclampsia

A

Frontal headaches
Visual disturbance (diplopia, flashing lights)
Epigastric pain
Sudden onset oedema (facial or peripheral)
Vomiting

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21
Q

Signs of pre-eclampsia

A

Altered mental status
Dyspnoea
Clonus (hyper-reflexia)
Oedema

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22
Q

Maternal complications of pre-eclampsia

A 
HELLP syndrome
DIC
Eclampsia
ARDS
Cerebrovascular haemorrhage
Death
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23
Q

Foetal complications of pre-eclampsia

A

Prematurity
Intrauterine growth restriction
Placental abruption
Intrauterine foetal death

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24
Q

What is HELLP syndrome

A

Haemolysis
Elevated liver enzymes
Low platelets

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25
Q

Suggested pathophysiology of pre-eclampsia

A
  • incomplete remodelling of spiral arteries
  • muscular integrity of arteries is maintained
  • leads to high resistance/low flow circulation to the placenta
  • results in poor perfusion
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26
Q

Prevention of pre-eclampsia

A

Aspirin 75-150mg OD from 12 weeks until delivery

Lifestyle and exercise advice - address modifiable risk factors and diabetes management

27
Q

Management of pre-eclampsia

A 
Only cure is delivery
VTE prophylaxis (LMWH)
Antihypertensives:
- Labetalol 
- Nifedipine 
- Methyldopa
Consider early delivery if severe/unresponsive to treatment/complications
Monitor BP initially postpartum
28
Q

Difference between primary and secondary PPH

A 
Primary = loss of >500ml within 24 hours of delivery
Secondary = abnormal bleeding from 24 until six weeks postpartum
29
Q

Antenatal risk factors for PPH

A 
Antepartum haemorrhage 
Placenta praevia
Placental abruption
Multiple pregnancy
Pre-eclampsia/HTN
Previous PPH
Maternal obesity
Maternal age over 40
30
Q

Delivery related risk factors for PPH

A 
C section
Retained placenta
Mediolateral episiotomy
IOL
Labour longer than 12 hours
Macrosomic baby
31
Q

Maternal haemorrhagic conditions which are risk factors for PPH

A

Factor 8 deficiency (haemophilia A carrier)
Factor 9 deficiency (haemophilia B carrier)
Von Willebrand’s disease

32
Q

4 T’s of PPH

A

Tone - uterine atony
Trauma - lacerations of uterus/cervix/vagina
Tissue - retained placenta or clots
Thrombin - coagulopathy

33
Q

4 components of PPH management

A
  1. communication to relevant team members
  2. resuscitation
  3. monitoring and investigation
  4. measures to stop bleeding
34
Q

Physical methods of managing PPH secondary to uterine atony

A

Bimanual uterine compression (bladder emptied)

35
Q

Pharmacological methods of managing PPH secondary to uterine atony

A
  1. oxytocin 5 units by slow IV
  2. ergometrine 0.5mg slow IV
    oxytocin + ergometrine = syntometrine
  3. carboprost 0.25mg IM (x8 doses max)
  4. misoprostol 1000mg PR
36
Q

Surgical methods of managing PPH secondary to uterine atony

A

Balloon tamponade
Bilateral ligation of uterine or internal iliac arteries
Hysterectomy

37
Q

5 complications of PPH

A
  1. hypovolaemic shock
  2. disseminated intravascular coagulation
  3. AKI
  4. liver failure
  5. acute respiratory distress syndrome
38
Q

2 most common causes of secondary PPH

A
  1. endometritis

2. retained products of conception

39
Q

Risk factors for endometritis

A 
C section
Prolonged ROM
Severe meconium
Long labour with multiple examinations
Manual removal of placenta
Low socioeconomic status
Maternal anaemia
Prolonged surgery
GA
40
Q

Symptoms of endometritis

A 
Fever
Abdo pain
Offensive smelling discharge (lochia)
Abnormal PV bleeding/discharge
Dyspareunia
Dysuria
General malaise
41
Q

Signs of endometritis

A

Fever, rigors, tachycardia
Tenderness of suprapubic area and adnexae
Elevated fundus which feels boggy (RPOC)

42
Q

Management of endometritis

A

If septic - fluids, oxygen, antibiotics (tazocin)

43
Q

Management of RPOC

A

Elective curettage with antibiotic cover

44
Q

Indications for IOL

A 
Post-term
Foetal compromise
Maternal request
Pre-eclampsia
Pre-labour ROM past 37/40
Intra-uterine death (maternal permission)
45
Q

Contraindications for IOL

A

Placenta praevia
Transverse foetus
Bishop score <4

46
Q

What is the Bishop score

A

Cervix score, pre-labour scoring system to determine whether IOL is required
>8 favours IOL
<6 IOL not ideal

47
Q

Methods to induce labour

A
  1. membrane sweep/cervical sweep

2. vaginal prostaglandin E2 (PGE2) as a pessary or gel

48
Q

What is a membrane sweep

A

Doctor/midwife inserts fingers through the cervix to rotate against the wall of the uterus. Separates the amniotic membrane to promote labour.

49
Q

Definition of antepartum haemorrhage

A

Bleeding from 24 weeks until birth of the baby

50
Q

Common causes of antepartum haemorrhage

A 
Unknown (50%)
Placenta praevia
Placental abruption
Vulval/cervical infection
Uterine rupture
Partner violence
51
Q

What is placental abruption

A

Placenta detaches from the lining of the uterus, causing rupture in the spiral arteries leading to massive haemorrhage

52
Q

Risk factors for placental abruption

A

Pre-eclampsia/HTN
Smoking
Trauma
Multiparity

53
Q

What is placenta praevia

A

Placenta is positioned blocking the cervix and therefore blocking the outflow tract for the foetus during labour - delivery cannot be vaginal unless far enough away from the cervical os

54
Q

Management of antepartum haemorrhage

A

Admit to hospital for assessment and management
If foetal distress, immediate delivery is necessary irrespective of gestation
FBC, group and save, clotting, crossmatch, U&E, LFT

55
Q

What is rhesus disease

A

Haemolytic disease of the foetus and newborn (HDFN)
Mother with rhesus negative blood who has previously been sensitized to rhesus positive (i.e. previous rhesus positive pregnancy) + further rhesus positive pregnancy. Mother has antibodies against RhD positive blood (anti-D antibodies) from previous pregnancy which leads to haemolytic disease in the second RhD positive pregnancy.

56
Q

Risk factors for gestational diabetes

A 
Previous hx of GD
Previous macrosomic baby (>4.5kg)
BMI >30
Ethnic origin: black Caribbean, middle Eastern, south Asian
FHx diabetes
PCOS
Smoking
57
Q

Foetal implications of gestational diabetes

A

Foetal hyperglycaemia - glucose is transported across the placenta but insulin isn’t therefore foetus increases its own insulin supplies (hyperinsulinaemia). After birth, maternal glucose supply is no longer therefore foetus becomes hypoglycaemic.

58
Q

Investigation for gestational diabetes

A

Oral glucose tolerance test
Diagnosis if:
- fasting glucose >5.6mmol/L
- postprandial (after 75g glucose drink) glucose >7.8mmol/L

59
Q

When should glucose tolerance test be offered

A

At 24-28 weeks gestation to women with risk factors

At booking for women with previous GD

60
Q

Management of gestational diabetes

A

Lifestyle - diet, exercise, measurement of glucose levels 4x day
Metformin, insulin
Additional growth scans at 28, 32 and 36 weeks
Aim to deliver baby at 37-38 weeks

61
Q

Postnatal care for gestational diabetes

A

Stop all anti-diabetic medication immediately after delivery
Blood glucose measured before discharge to ensure levels are normal
Fasting glucose test at 6-13 weeks postpartum

62
Q

Risks of gestational diabetes to mother

A 
Miscarriage
Pre-eclampsia
Preterm labour
Diabetic retinopathy
Stillbirth
Perinatal mortality
63
Q

Risks of gestational diabetes to foetus

A 
Congenital malformations
Macrosomia
Postnatal hypoglycaemia
Organomegaly
Erythropoiesis 
Polyhydramnios
64
Q

When does the booking visit take place

A

8-12 weeks gestation

RHCN (5 decks)

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