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Year 5 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Give 3 physiological cardiorespiratory changes in pregnancy

A

Increased - RR, HR, SV, CO, plasma volume, preload, O2 consumption, laryngeal oedema
Decreased - SVR, afterload, residual capacity, arterial PO2

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2
Q

When in pregnancy are women with heart disease at greater risk?

A

When CO is high or rapidly changing - early pregnancy, second trimester, immediately postpartum

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3
Q

Give 3 physiological haematological changes in pregnancy

A

Increased - plasma volume causing dilutional anaemia, leukocytosis, transferrin and TIBC, coagulation factors
Decreased - iron

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4
Q

Give 3 physiological urinary tract changes in pregnancy

A

Increased - renal blood flow and GFR, excretion of metabolites, glycosuria, water retention, residual urine volume, UTI risk

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5
Q

Give 3 physiological GI tract changes in pregnancy

A

Increased - bowel transit

Decreased - LOS pressure, gastric peristalsis, gastric emptying

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6
Q

Give 3 physiological skin changes in pregnancy

A 
Hyperpigmentation - umbilicus, nipples, abdominal midline (linea nigra), face (melasma) 
Hyperdynamic circulation and high oestrogen - spider naevi, palmar erythema 
Stretch marks (striae gravidarum)
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7
Q

Give 3 physiological MSK changes in pregnancy

A

Increased ligamental laxity (back pain, pubic symphysis dysfunction)
Exaggerated lumbar lordosis

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8
Q

Outline the timeline of antenatal care appointments for women with no risk factors

A 
Pre-booking - first contact with health professional 
Booking appointment and screening 
18-20 weeks - anomaly scan 
(25 weeks) 
28 weeks 
(31 weeks)
36 weeks
38 weeks
(40 weeks)
41 weeks
42 weeks

(prim patients have additional appointments)

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9
Q

When should a booking appointment take place and what are the aims?

A 
By 10 weeks 
Identify risks (e.g. domestic abuse)
Screen for abnormalities/illness
Obtain initial observations
Determine likely gestation
Develop rapport and encourage future attendance 
Provide key health information (e.g. smoking cessation, dietician, dental care, folic acid, alcohol, food)
Social work involvement if required
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10
Q

How is an estimated date of delivery calculated?

A

Naegele’s rule

EDD = LMP + 1 year - 3 months + 7 days

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11
Q

What risk factors should be considered in pregnant women?

A 
Age <18 or >40 
Para 0 or para 6+
Low or high BMI
Low socioeconomic status
Drug/alcohol misuse
Previous obstetric problems 
Vulnerable groups (e.g. asylum seekers)
Pre-existing medical conditions (e.g. diabetes, hypertension)
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12
Q

What questions should be asked regarding obstetric history at booking appointment?

A 
Miscarriage >14 weeks
Stillbirth 
Neonatal death 
Recurrent miscarriage (>3 consecutive)
Premature birth 
Pregnancy induced hypertension 
Gestational diabetes
Rhesus disease
Antepartum haemorrhage 
Induction of labour 
Operative birth 
Postpartum haemorrhage
Obstetric anal sphincter injury
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13
Q

What screening blood tests are done at booking?

A 
FBC 
Blood group 
Sickle cell and thalassaemia
Rubella
Hep B
Syphilis
HIV
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14
Q

Give 3 types of fetal screening

A

Nuchal translucency (11-14 weeks) - Down syndrome
Fetal anomaly scan (18-22 weeks)
Chorionic villus sampling (from 11 weeks)
Amniocentesis (from 15 weeks)
Non-invasive prenatal testing

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15
Q

When is the first trimester?

A

0-12 weeks

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16
Q

When is the second trimester?

A

12-20 weeks

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17
Q

From what point is the fetal heart auscultated at antenatal appointments?

A

18 weeks

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18
Q

Give 5 common problems in pregnancy and their basic management

A

Nausea and vomiting - admit if severe, antiemetics
Heartburn - antacids, H2 antagonists
Haemorrhoids - avoid constipation
Constipation - increase fluid intake
Pelvic girdle/sciatica/back pain - PT
Anaemia - iron replacement
Carpal tunnel syndrome - exclude pre-eclampsia, PT, splint
Bleeding gums - dental check up
Fatigue - screen for anaemia, physical activity
Itching - consider obstetric cholestasis if >30 weeks
Rashes - antihistamines, steroids
Vaginal discharge - swab

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19
Q

When is the third trimester?

A

20 weeks-term

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20
Q

What should be covered during antenatal appointments?

A

BP, urinalysis, auscultation of fetal heart
Ask about pain and vaginal loss
Ask about common pregnancy problems
Ask about foetal movements
Abdominal examination
Evaluation of fetal growth (from 24 weeks)

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21
Q

How is fetal growth evaluated at antenatal appointments?

A

From 24 weeks

Symphyseal-fundal height - measure fundal height in cm from pubic symphysis to the top of the uterus

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22
Q

Give 3 antenatal complications

A 
Polyhydramnios
Oligohydramnios
Hypertension and pre-eclampsia
Anaemia 
Impaired glucose tolerance 
Mental health problems
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23
Q

Define polyhydramnios

A

Excess of amniotic fluid
Single deepest vertical pool (DVP) >8cm
Amniotic fluid index (AFI) >90th centile for gestation

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24
Q

How does polyhydramnios present?

A

Large for date
Tense abdomen
Unable to feel fetal parts

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25
Q

What are the complications of polyhydramnios?

A 
Placental abruption 
Malpresentation 
Cord prolapse
Large for gestational age 
C-section
Postpartum haemorrhage
Premature birth 
Perinatal death
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26
Q

Define oligohydramnios

A

Deficiency of amniotic fluid

DVP <2cm or AFI <5cm

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27
Q

What are the complications of oligohydramnios?

A 
Poor perinatal outcome
Prolonged pregnancy
Ruptured membranes 
IUGR
Fetal renal congenital abnormalities
Hypoxia (cord compression)
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28
Q

Give 2 symptoms of hypertension in pregnancy which should be asked if there is suspicion of pre-eclampsia

A

Headache
Visual disturbance
Severe upper abdominal pain
Significant facial/hand/ankle oedema

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29
Q

Give 3 risk factors for hypertension and pre-eclampsia

A

Nulliparity
FH
Extremes of maternal age
Obesity
Medical condition - hypertension, renal disease, SLE, diabetes
Obstetric factors - multiple pregnancy, previous pre-eclampsia, hydatidiform mole, hydrops

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30
Q

How is anaemia in pregnancy defined and managed?

A

Hb <105 g/L
Check folate, B12 and ferritin
Oral iron therapy

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31
Q

When should a glucose tolerance test be done in pregnancy?

A

Glycosuria or risk factors

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32
Q

What are the risk factors of impaired glucose tolerance in pregnancy?

A

FH diabetes
High BMI
Previous macrosomic baby
Previous GDM

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33
Q

How are pro-pregnancy and pro-labour factors involved in the initiation of labour?

A

Inhibition of pro-pregnancy - progesterone, NO, catecholamines, relaxin
Activation of pro-labour - oestrogen, oxytocin, prostaglandins, prostaglandin dehydrogenase, CRH, inflammatory mediators

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34
Q

What is the role of NO in labour?

A

Involved in cervical ripening

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35
Q

What is the role of oxytocin in labour?

A

Stimulation of uterine contractility - increases frequency and force

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36
Q

What is the role of prostaglandins in labour?

A

Promote cervical ripening and stimulate uterine contractility

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37
Q

What is the role of inflammatory mediators in labour?

A

Contribute to cervical ripening and membrane rupture

Stimulate uterine contraction

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38
Q

What is cervical ripening?

A

Late in pregnancy, the cervix softens, effaces and dilates

Prostaglandins increase ripening by inhibiting collagen synthesis and stimulating collagenase activity

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39
Q

How is cervical ripening assessed?

A

Bishop’s score
0 - <1cm dilation, >2cm length, spines -3, firm, posterior
1 - 1-2cm, 1-2cm, -2, medium, central
2 - 3-4cm, <1cm, -1, soft, anterior

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40
Q

Outline the delivery process

A

Head at pelvic brim in right/left OT position, neck flexed so presenting diameter is suboccipitobregmatic
Head descends and engages
Head reaches pelvic floor and occiput starts to rotate to OA
Complete rotation
Head delivers by extension
Shoulders rotate into AP diameter with continued descent, head follows in external rotation (restitution)
Anterior shoulder delivers with lateral flexion
Posterior shoulder delivers

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41
Q

How is labour diagnosed?

A

Uterine contractions, effacement (thinning) and dilatation

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42
Q

Outline the process of effacement

A

Has occurred when the entire length of the cervix has been ‘taken up’ into the lower segment of the uterus
Begins with the internal os, and proceeds downwards to the external os until the cervical tissue becomes continuous with the uterine walls

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43
Q

What can be seen on speculum examination in a patient with rupture of membranes?

A

Pool of liquor in the posterior vaginal fornix

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44
Q

What is the risk of prelabour rupture of membranes?

A

Ascending infection - chorioamnionitis

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45
Q

How should prelabour ROM be managed?

A

Conservative if mother and baby well

Induction of labour after 24 hours

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46
Q

What is the first stage of labour?

A

From onset of labour until full cervix dilation
Latent phase (cervix effaced and 3-4cm dilated) and active phase (cervix dilated)
8-18 hours in prim, 5.5-12 hours in multi

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47
Q

What is the second stage of labour?

A 
From full dilation (10cm) until head is delivered 
Propulsive phase (until head on pelvic floor) and expulsive phase (from urge to bear down until baby delivered) 
Within 3 hours in prim, 2 hours in multi
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48
Q

What is the third stage of labour?

A

From delivery until expulsion of placenta/membranes
Recognised by cord lengthening and gush of dark blood, controlled traction on cord (30 mins with oxytocin, 1 hour without)

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49
Q

What assessments are conducted throughout labour?

A

History
Maternal HR, BP, temperature, urinalysis, partogram recording
Assessment of length, strength and frequency of contractions
Observe - ROM, meconium, bleeding
Assess fetal movements
Abdominal examination - fundal height, engagement, auscultation of fetal heart
CTG recording
Vaginal examination - every 4 hours ideally by the same person

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50
Q

What is station of the presenting part?

A

Recorded with respect to ischial spines with spines = 0

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51
Q

What positions can the fetal head be in during labour?

A

Right/left occipitoposterior
Right/left occipitotransverse
Right/left occipitoanterior

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52
Q

Define caput

A

Caput succedaneum is oedema of the scalp owing to pressure of the head against the rim of the cervix and is classified arbitrarily as ‘+’, ‘++’, or ‘+++’

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53
Q

Define moulding

A

Describes the change in head shape, which occurs during labour, made possible by movement of the individual scalp bones.
It is classified arbitrarily as ‘+’ if the bones are opposed, ‘++’ if the bones overlap but can be reduced, and ‘+++’ if the bones overlap, but cannot be reduced

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54
Q

When is meconium during labour concerning?

A

Thick pea-soup green meconium - fetal hypoxia or acidosis

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55
Q

What is injected after delivery of the anterior shoulder in the second stage of labour and why?

A

IM oxytocin

Reduce risk of postpartum haemorrhage

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56
Q

What is a partogram?

A

Graph record of clinical findings during labour
Records maternal observations (BP, HR, temp), fetal heart rate, progressive cervical dilatation, descent of the presenting part, strength and frequency of contractions, and colour of amniotic fluid

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57
Q

What is a precipitate labour?

A

Expulsion of the fetus within <2-3 hours of onset of contractions due to uterine overactivity and can lead to fetal distress

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58
Q

What is a slow labour?

A

Cervical dilation of <2cm in 4 hours

Inadequate uterine activity

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59
Q

What is a malpresentation?

A

Any non-vertex position - face, brow, breech, shoulder

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60
Q

Give 3 things associated with breech presentation

A 
Multiple pregnancy 
Bicornate uterus
Fibroids 
Placenta praevia
Polyhydramnios
Oligohydramnios
NTDs
Neuromuscular disorders
Autosomal trisomies
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61
Q

To whom and when should external cephalic version (ECV) be offered?

A

All women with breech presentation at 36/37 weeks

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62
Q

What is malposition? Give an example

A

Abnormal position of the vertex relative to the maternal pelvis
Occipitoposterior - longer labour, may require oxytocin/c-section

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63
Q

Define prolonged pregnancy

A

Pregnancy beyond 42 weeks

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64
Q

What are the risks of prolonged pregnancy and how are they reduced?

A

Intrauterine death and intrapartum hypoxia
Induction of labour is offered at 41-42 weeks (after membrane sweep attempted) - if declined, should do twice weekly CTG and USS

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65
Q

When is induction of labour offered?

A

When risk of continuing pregnancy outweighs risk of delivery
E.g. prolonged pregnancy, maternal diabetes, twin pregnancy, fetal growth restriction, suspected fetal compromise, hypertensive disorders, deteriorating maternal medical condition, maternal request

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66
Q

What are the contraindications to induction of labour?

A

Vaginal delivery contraindicated (e.g. placenta praevia, transverse lie)
Caution in previous c-section/uterine surgery
Risk of hyperstimulation in those with previous precipitate labour

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67
Q

What methods are available for induction of labour?

A 
Unfavourable cervix (Bishop score ≤6) - prostaglandins gel/tablet into posterior fornix, reassess after 6 hours, can repeat, ARM after score >6, can cause GI upset 
Favourable cervix (Bishop score >6) - ARM, synthetic oxytocin (need CTG monitoring)
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68
Q

What are the risks of induction of labour?

A

Hyperstimulation

Increased operative vaginal delivery

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69
Q

What is augmentation?

A

The process of accelerating labour which is already underway

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70
Q

Give 2 non-pharmacological methods of pain relief in labour

A 
Maternal support 
Environment 
Birthing pools
Education 
(Limited evidence - massage, acupuncture, hypnosis, TENS)
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71
Q

Give 2 pharmacological methods of pain relief in labour

A

Inhaled analgesics - entonox (50:50 O2 and NO)
Systemic opioid analgesia - IM diamorphine (avoid in 4 hours before delivery)
Pudendal analgesia (instrumental delivery)
Regional analgesia - epidural, spinal
GA (higher risk)

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72
Q

What are the side effects of entonox?

A

Nausea
Vomiting
Lightheadedness

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73
Q

Give 3 features of epidural anaesthesia for labour

A

Used for labour, can be topped up for instrumental delivery
Maternal request
Extradural catheter placed
Effect may be patchy
Not associated with - prolonged first stage, c-section, long-term backache
Associated with - prolonged second stage, instrumental delivery

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74
Q

Give 2 features of spinal anaesthesia for labour

A

Used for operative delivery/surgical management of postpartum complications
Subarachnoid injection lasting 2-4 hours
Dense and reliable analgesia

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75
Q

Give 3 complications of regional anaesthesia

A 
Dural puncture headache
Hypotension
Local anaesthetic toxicity 
Accidental total spinal block 
Neurological complications
Bladder dysfunction
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76
Q

Why are pregnant women undergoing GA at increased risk

A

Reduced gastro-oesophageal tone
Increased intra-abdominal mass
Reduced gastric emptying
Regurgitation of gastric contents and aspiration (pneumonitis)
Difficult and failed intubation more likely

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77
Q

How are spontaneous perineal tears classified?

A

First degree - vaginal epithelium and vulval skin
Second degree - perineal muscles
Third degree - perineum involving anal sphincter complex
Fourth degree - anal sphincter complex and anal/rectal mucosa

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78
Q

What are the indications for episiotomy?

A 
Rigid perineum preventing delivery 
Large tear thought to be imminent 
Instrumental delivery 
Suspected fetal compromise
Shoulder dystocia
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79
Q

Why is an episiotomy not carried out routinely in uncomplicated vaginal delivery?

A

There is no clear evidence that it reduces the incidence of third or fourth degree tears
A spontaneous tear may be less painful than an episiotomy and may also heal better

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80
Q

How is an episiotomy carried out?

A

Infiltrate local anaesthetic (unless effective regional block)
Make right medio-lateral cut

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81
Q

How is an episiotomy/perineal tear repaired?

A

Infiltrate local anaesthetic (unless effective regional block)
Perform rectal examination to exclude third and fourth degree tears
Use a rapidly absorbable synthetic suture material to carry out continuous, non-locking and sub-cuticular sutures
Analgesia and ice packs
Advise on perineal care and hygiene
No contraindication to PR analgesia

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82
Q

How long does postnatal care extend?

A

6 weeks

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83
Q

What are the advantages of skin-to-skin immediately post-birth?

A

Neonatal thermoregulation, respiratory regulation, increases successful breastfeeding
Maternal stimulation of oxytocin, which increases uterine contractions and milk production

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84
Q

Outline immediate post-birth care of the neonate

A 
Apgar score (1, 5, 10 mins)
Clamp and cut umbilical cord after 1 minute 
Birth weight and temperature 
Physical examination 
Record first micturition and feed 
Vitamin K administration
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85
Q

Outline immediate post-birth care of the mother

A 
Observe vaginal blood loss, palpate fundus to assess contraction
Examine for tears and repair
Support skin-to-skin
Check colour, BP, HR, RR, temperature 
Offer food 
Record first micturition 
Assess VTE risk and commence prophylaxis
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86
Q

Give 3 benefits of breastfeeding for the baby

A 
Reduced infection
Reduced vomiting and diarrhoea
Reduced childhood leukaemia 
Reduced obesity
Reduced CVD
Available on demand 
Strengthens emotional bond
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87
Q

Give 3 benefits of breastfeeding for the mother

A

Reduced breast/ovarian cancer risk
Reduced osteoporosis
Reduced CVD
Reduced obesity

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88
Q

What do midwives cover on home visits?

A

Discuss birth - PTSD
Assess mental health - postnatal depression, suicide
Physical - observations, haemorrhage, anaemia, sepsis, perineum
Discuss contraception
Baby - feeding, changing, safe sleeping, washing

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89
Q

Give 5 postnatal complications

A

Anaemia
Bowel problems - constipation, fear of defecation, reduced mobility
Breast problems - nipple pain/cracks/bleeding, mastitis, abscess, engorgement
Perineal breakdown
Incontinence - compression of pudendal nerve during delivery
Puerperal pyrexia - genital/urinary/breast infection, DVT/PE
Secondary PPH - uterine infection, retained products of conception
VTE - LMWH, early mobilisation
Mental health problems

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90
Q

Define stillbirth

A

Baby delivered with no signs of life that is known to have died after 24 weeks (before this is a miscarriage)

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91
Q

What are the risk factors for stillbirth?

A 
Advanced maternal age
Maternal obesity 
Social deprivation 
Smoking 
Non-white ethnicity 
Domestic violence
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92
Q

What are the causes of stillbirth?

A

Fetal - lethal congenital abnormality, growth restriction, infection, anaemia, haemorrhage, twin to twin transfusion, cord obstruction
Maternal - DKA, pulmonary HTN, antibodies, diabetes
Placental - abruption, pre-eclampsia, maternal renal disease, APL syndrome, thrombophilia, smoking, cocaine use
Structural - uterine abnormality, uterine rupture, placenta praevia, vasa praevia
Intrapartum - asphyxia, trauma

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93
Q

How does stillbirth present?

A

Reduced fetal movements
Bleeding
Abdominal pain
Asymptomatic - unexpected finding at US

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94
Q

What are the signs of stillbirth on USS?

A

Absence of fetal heartbeat
Spalding sign (overlapping skull bones)
Hydrops

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95
Q

Define hydrops

A

Hydrops fetalis, or hydrops, is a condition that occurs when large amounts of fluid build up in a baby’s tissues and organs causing extreme swelling

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96
Q

How is stillbirth managed?

A

Vaginal birth or c-section

Analgesia as required

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97
Q

What aftercare is important for stillbirth?

A

Psychological care
Memory box with photos, hand and footprints
Funeral arrangements, consider cultural practices
Suppression of lactation
Maternal investigations
Post-mortem
Communication with community team
Support groups
A meeting to discuss events surrounding loss at 6-8 weeks postnatal
No clear evidence on when should conceive again
More frequent antenatal visits and regular growth scans for future pregnancies

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98
Q

Define miscarriage, stillbirth and livebirth

A

Miscarriage - any pregnancy loss before 24 weeks gestation
Stillbirth - any fetus born dead at/after 24 weeks
Livebirth - fetus which shows signs of live after delivery at any gestation

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99
Q

How might a miscarriage present in the presence of a positive pregnancy test?

A

Vaginal bleeding - brown, spotting or heavy, tissue
Pelvic discomfort/pain
Asymptomatic

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100
Q

How should suspected miscarriage be investigated?

A 
Speculum examination 
Transvaginal USS 
Examination of products of conception 
Serum hCG tracking 
FBC, group and save
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101
Q

What signs indicate miscarriage on USS?

A 
No fetal heart activity 
>7mm crown-rump length 
Empty sac 
Retained tissue (incomplete)
Empty uterus (complete, too early, ectopic)
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102
Q

How is miscarriage managed?

A

Conservative - review every 1-2 weeks
Medical - misoprostol
Surgical - cervical priming with misoprostol and then electrical vacuum aspiration under GA or manual vaccum aspiration under LA

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103
Q

When is anti-D required in a rhesus negative woman who has miscarried?

A

<12 weeks vaginal bleed and severe pain
<12 weeks medical/surgical management
Any potential sensitising event >12 weeks

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104
Q

Give 5 causes of miscarriage

A 
Unexplained (50%)
Maternal age 
Fetal chromosome abnormality 
Immunological - lupus anticoagulant and antiphospholipid antibodies 
Endocrine - PCOS, poorly controlled DM/thyroid 
Uterine abnormalities 
Infection 
Environmental - smoking, alcohol 
Cervical weakness
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105
Q

How should recurrent miscarriage be managed?

A

Aspirin and LMWH for antiphospholipid antibodies

Supportive care

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106
Q

What is the most common site for an ectopic pregnancy? Give 2 other possible sites

A 
Tubal (95%)
Interstitial
Cervical 
Abdominal 
Infundibular 
Ovarian 
Peritoneal
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107
Q

What are the risk factors for ectopic pregnancy?

A

Previous ectopic pregnancy
Endometriosis
Pelvic infection (chlamydia)
Pelvic surgery (c-section, sterilisation, appendicectomy)
Contraception (progesterone only pill, IUD/IUS)
Assisted conception
Smoking

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108
Q

What is the incidence of miscarriage?

A

20% of all pregnancies

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109
Q

What is the incidence of ectopic pregnancies?

A

1 in 200

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110
Q

How do ectopic pregnancies present (in the presence of a positive pregnancy test)?

A 
Asymptomatic 
Vaginal bleeding 
Pelvic discomfort/pain - localised to one side, referred to shoulder
Pain on opening bowels 
Maternal collapse, hypovolaemic shock
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111
Q

How should suspected ectopic pregnancies be investigated?

A

Assess if they are haemodynamically stable - if not A-E assessment, involve seniors, prepare for theatre
Examination - peritonism, bimanual (cervical excitation, adenexal mass), vaginal swabs
USS
Examination of POC
Serum hCG tracking
FBC and group and save/crossmatch

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112
Q

How is hCG tracking used in ectopic pregnancy?

A

Helpful for pregnancy of unknown location and stable patient, measure hCG 48 hours apart
>66% increase - intrauterine pregnancy
<66% increase/<15% decrease - ectopic pregnancy
>15% decrease - failing ectopic

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113
Q

How are non-emergency ectopic pregnancies managed?

A

Conservative
Medical - methotrexate
Surgical - laparoscopy/laparotomy, salpingostomy/salpingectomy, risk of oophorectomy

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114
Q

When is methotrexate used to manage an ectopic pregnancy?

A

Medical management of non-emergencies
Criteria - pain free, unruptured ectopic, serum hCG low, able to return for follow up, no medical contraindications (e.g. anaemia)

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115
Q

Is anti-D required in rhesus negative patients after ectopic pregnancy?

A

Yes

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116
Q

What is gestational trophoblastic disease?

A

A group of conditions characterised by abnormal proliferation of trophoblastic tissue with production of HCG
Premalignant and malignant forms

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117
Q

What are the 2 types of premalignant gestational trophoblastic disease?

A

Partial hydatidiform mole

Complete hydatidiform mole

118
Q

What is a partial hydatidiform mole?

A

GTD
Triploid - 23 mother + 46 father chromosomes; 2 sperm + 1 egg
Present as failed pregnancy
0.5% risk of malignancy

119
Q

What is a complete hydatidiform mole?

A

GTD
Diploid - 46 father chromosomes, empty ovum
1-2% risk of malignancy

120
Q

What are the 3 types of malignant gestational trophoblastic disease?

A

Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour

121
Q

What are the risk factors for GTD?

A

Extremes of maternal age (<20 years = 3x, >40 years = 10x)
Previous molar pregnancy
Ethnicity (Korea, China)

122
Q

What are the clinical features of GTD?

A 
PV bleeding
Enlarged uterus
Hyperemesis gravidarum
Hyperthyroidism 
Early onset pre-eclampsia
123
Q

How is GTD investigated?

A

USS - snowstorm appearance
Histology (suction curettage)
hCG tracking
Specialist care (Dundee)

124
Q

What is the incidence of nausea and vomiting in pregnancy and what is the likely cause?

A

> 50% in first trimester

Associated with hCG levels (similar to TSH)

125
Q

What is hyperemesis gravidarum?

A

Persistent vomiting in pregnancy causing weight loss (more than 5% of body mass) and ketosis

126
Q

What are the complications of hyperemesis gravidarum?

A 
Wernicke's encephalopathy (thiamine deficiency)
Central pontine myelinolysis (rapid correction of hyponatraemia)
Maternal death (rare)
127
Q

What are the effects of hyperemesis gravidarum on the baby?

A

Intrauterine growth restriction

Significantly smaller at birth

128
Q

How should hyperemesis gravidarum be investigated?

A

Urine - ketones, rule our UTI
Bloods - U&Es, LFTs, TFTs
USS - check for multiple/molar pregnancy

129
Q

How is hyperemesis gravidarum managed?

A 
Oral intake advice/dietician input 
IV fluids (avoid dextrose) 
Regular antiemetics 
Ranitidine/omeprazole 
Thromboprophylaxis 
Vitamin replacement 
Oral steroids 
TPN (extreme)
Psychological support 
Assessment of fetal growth
130
Q

Do women with epilepsy experience an increase in seizure frequency during pregnancy?

A

Yes, 1/3rd of them do

131
Q

Name 2 antiepileptic drugs which are teratogenic

A

Phenytoin
Carbamazepine
Sodium valproate

132
Q

What are the teratogen effects of sodium valproate?

A 
Neurocognitive impairment
Autism spectrum disorders
Attention deficit disorders
Neural tube defects 
Hypospadias
Heart defects
Craniofacial anomalies
Skeletal anomalies
Developmental delay
133
Q

Why are so many antiepileptic drugs teratogenic? What can be done to counteract this?

A

Decrease availability of serum folate - folate 5mg/day at least 1 month prior to conception
Induce fetal hepatic enzyme activity which reduces vitamin K and causes bleeding - neonatal konakion administration

134
Q

How should epilepsy be managed in pregnancy?

A

Pre-pregnancy counselling - monotherapy, folate supplementation
AED dose adjustment/drug monitoring
US/serum screening - abnormalities
Vitamin K - daily for mother from 36 weeks, to neonate IM at birth
Seizure management - diazepam/lorazepam if termination needed
Intrapartum - IV access, continue AEDs, avoid exhaustion, CTG
Post-natal - safety with feeding/bathing, dose modification
Contraception - higher dose may be needed

135
Q

What contraceptive options are most suitable for patients on enzyme inducing AEDs postnatally?

A

Copper IUD
IUS
Medroxyprogesterone acetate injections

136
Q

What AEDs are enzyme inducing?

A

Carbamazepine
Phenytoin
Phenobarbital
Topiramate

137
Q

What AEDs are not enzyme inducing?

A

Sodium valproate
Levetiracetam
Gabapentin
Pregabalin

138
Q

What are the complications of maternal varicella infection?

A

Pneumonia
Hepatitis
Encephalitis
Death

139
Q

What is the risk to the fetus if the mother has been exposed to varicella during pregnancy?

A

Fetal infection is rare (1-2%)
Fetal varicella syndrome - skin scarring, eye defects, limb hypoplasia, neurological abnormalities
Neonatal infection - severe chickenpox, treat with aciclovir

140
Q

What can be given to reduce risk of varicella transmission to the fetus when the mother has been exposed?

A

Varicella zoster immunoglobulin

141
Q

How can risk from varicella exposure in pregnancy be checked?

A

History

Maternal IgG levels

142
Q

How can maternal HIV be transmitted to the baby?

A

During birth (highest risk)
Prenatal possible
Depends on viral load

143
Q

How can transmission of HIV from mother to fetus be reduced?

A

Antiretroviral therapy throughout pregnancy

Keep viral load low

144
Q

How is a delivery plan made for mothers with HIV?

A

Viral load <50 at 36 weeks with no contraindications - vaginal delivery
Viral load >50 at 36 weeks - c-section at 38 weeks

145
Q

How should a newborn of a HIV positive mother be managed after birth?

A

Post-exposure prophylaxis (zidovudine) within 4 hours after birth for 4 weeks
Avoid breastfeeding

146
Q

When should neonatal HIV testing be carried out?

A

During the first 48 hours and prior to hospital discharge
2 weeks post cessation of infant prophylaxis (6 weeks of age)
2 months post cessation of infant prophylaxis (12 weeks of age)
HIV antibody testing for seroreversion should be performed at age 18 months

147
Q

Outline how rhesus isoimmunisation occurs

A

Rh+ father
Rh- mother
Rh+ fetus
Rhesus antigens from the developing fetus can enter the mother’s blood during delivery, in response to which the mother will produce anti-Rh antibodies
If a second pregnancy is Rh+, the mother’s anti-Rh antibodies will cross the placenta and damage fetal RBCs

148
Q

What are the antenatal and postnatal consequences of haemolytic disease of the newborn?

A

Antenatal - polyhydramnios, thickened placenta, hydrops, in-utero demise
Postnatal - jaundice, hepatosplenomegaly, pallor, kernicterus, hypoglycaemia

149
Q

How is risk of rhesus disease assessed?

A

Maternal blood group and titres

Fetal blood group amniocentesis and free fetal DNA (paternal blood group)

150
Q

How can rhesus disease be prevented?

A

Blood transfusion vigilance

Anti-D prophylaxis

151
Q

When is anti-D required in a Rh- mother?

A

After management of ectopic pregnancy
After management of molar pregnancy
Therapeutic termination of pregnancy
<12 weeks vaginal bleed which is heavy, repeated or associated with severe pain
<12 weeks medical or surgical management of miscarriage
Potentially sensitising event >12 weeks

152
Q

What can be done after delivery to determine anti-D requirements

A

Test cord blood

Test maternal blood

153
Q

Give 3 physiological skin changes seen in pregnancy

A 
Hyperpigmentation 
Striae gravidarum 
Hair and nail changes 
Angiomas and spider naevi 
Greasier skin 
Pruritis
154
Q

Give 3 common skin diseases in pregnancy

A 
Atopic eruption of pregnancy
Acne vulgaris or rosacea
Psoriasis 
Infections (candida, viral warts, varicella)
Infestations (scabies)
Autoimmune (SLE, pemphigus)
155
Q

Give 2 specific dermatoses of pregnancy

A

Atopic eruption of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis
(Obstetric cholestasis)

156
Q

What is the most common pregnancy rash, when is its onset and what are the 2 types?

A

Atopic eruption of pregnancy
Early (before 3rd trimester)
Eczematous and prurigo

157
Q

How is atopic eruption of pregnancy managed?

A

Emollients
Aqueous cream and menthol
Topical steroids
Antihistamines

Narrow band UVB
Oral steroids

158
Q

When is polymorphic eruption of pregnancy most likely to occur and what pattern does the rash follow?

A

3rd trimester or postpartum, mostly primigravid

Lower abdomen affected with umbilical sparing

159
Q

How is polymorphic eruption of pregnancy managed?

A

Symptomatic treatment

Emollient, topical steroids, antihistamine

160
Q

When is pemphigoid gestationis most likely to occur, what does it look like and what is the pathophysiology?

A

2nd/3rd trimester or pureperium
Urticarial lesions, wheals and bullae
Binding of IgG to skin basement membrane

161
Q

What are the risks of pemphigoid gestationis?

A

Premature delivery
Fetal growth restriction
Transient infant blistering
Secondary infection which can cause scarring

162
Q

How is pemphigoid gestationis managed?

A

Refer to dermatology and obstetrics
Topical steroids and antihistamines
Additional antenatal surveillance
Oral steroids if severe

163
Q

Define chronic hypertension in pregnancy

A

HTN before 20 weeks in absence of hydatidiform mole or persistent HTN beyond 6 weeks postpartum

164
Q

What are the types of gestational hypertension?

A

Gestational hypertension without proteinuria
Gestational proteinuria without hypertension
Gestational proteinuric hypertension (pre-eclampsia)

165
Q

Define pre-eclampsia

A

Hypertension after 20 weeks gestation with 1 or more of: proteinuria, maternal organ dysfunction or fetal growth restriction

166
Q

What are the potential forms of maternal organ dysfunction in pre-eclampsia?

A

Renal insufficiency - creatinine >90 micromol/L
Liver involvement - elevated transaminases (2x normal) and RUQ pain
Neurological complications - eclampsia, altered GCS, blindness, stroke, hyperreflexia, clonus, headache)
Haematological - thrombocytopaenia, DIC, haemolysis

167
Q

Define eclampsia

A

Generalised tonic-clonic convulsions in women with pre-eclampsia, if the seizures cannot be attributed to any other causes (epilepsy, cerebral infarction, tumour, ruptured aneurysm)

168
Q

What are the 2 phases of pre-eclampsia pathophysiology?

A

Phase 1 - abnormal placentation

Phase 2 - endothelial dysfunction

169
Q

How does placentation occur in normal pregnancy?

A

Trophoblast invasion of maternal spiral arteries causes diameter increase 5x converting high resistance low flow to low resistance high flow

170
Q

How does abnormal placentation occur in pre-eclampsia?

A

Inadequate trophoblast invasion which causes inadequate placental perfusion

171
Q

Outline the pathophysiology of endothelial dysfunction in pre-eclampsia

A

Widespread dysfunction due to oxidative stress from ischaemic placenta which promotes platelet adhesion and thrombosis and disturbs vascular tone
Exaggerated maternal inflammatory response

172
Q

What are the risk factors for pre-eclampsia?

A

First pregnancy
FH
Extremes of maternal age
Obesity
Medical - pre-existing HTN, renal disease, diabetes, antiphospholipid antibodies, inherited thrombophilia, CTD
Obstetric - multiple pregnancy, previous pre-eclampsia, hydrops, hydatidiform mole, >10 years since last pregnancy

173
Q

Give 3 symptoms of pre-eclampsia

A 
Severe headache 
Severe RUQ/epigastric pain 
Sudden face/hands/feet swelling 
Visual disturbance - blurring, flashing, scotoma 
Vomiting 
Restlessness/agitation
174
Q

Give 3 signs of pre-eclampsia

A 
Hypertension 
Proteinuria
Hyperreflexia
Raised creatinine 
Reduced platelets 
Clonus 
Haemolytic anaemia
Raised liver enzumes 
Retinal haemorrhages 
Papilloedema
175
Q

How is pre-eclampsia investigated?

A

BP
Urinalysis
Bloods - FBC (low platelets, low Hb, haemolysis on film), LFTs (high ALT/AST), U&Es (low urine output, high urate/urea/creatinine), coagulation (prolonged)
Fetal assessment - symphyseal-fundal height, USS (growth, liquor, umbilical artery doppler), deliver if compromised

176
Q

What is HELLP and what are its complication?

A

Severe pre-eclampsia variant requiring delivery
Haemolysis, elevated liver enzymes and low platelets
DIC, placental abruption, acute renal failure, stroke, haemorrhage

177
Q

How can pre-eclampsia be prevented?

A

Low dose aspirin (75mg) from 12 weeks inhibits thromboxane A2

178
Q

How is pre-eclampsia managed?

A 
Control BP 
Assess fluid balance 
Prevent eclampsia - magnesium sulphate 
Consider delivery 
Optimise postnatal care
179
Q

What are the indications for delivery in pre-eclampsia?

A

Maternal - gestation >37 weeks, failure to control BP, deteriorating liver/renal function, progressive fall in platelets, neurological complications
Fetal - abnormal heart rate, deterioration

180
Q

What drugs can be used to treat HTN in pregnancy? Give a side effect of each

A

Methyldopa - drowsiness
Labetalol - postural hypotension, fatigue
Hydralazine - hypotension
Nifedipine - flushing, headaches

181
Q

Give 3 maternal complications of pre-eclampsia

A 
Placental rupture
DIC
HELLP (10-20%)
Pulmonary oedema
Aspiration
Eclampsia (1%)
Liver failure
Stroke
Death
Long term cardiovascular morbidity
182
Q

Give 3 fetal complications of pre-eclampsia

A 
Pre-term delivery
IUGR
Hypoxia-neurological injury
Perinatal death
Long term cardiovascular morbidity (associated with low birth weight)
183
Q

What is the future risk to mothers with HTN/pre-eclampsia in pregnancy?

A

Increased risk of high BP in later life/gestational HTN in future pregnancies/pre-eclampsia in future pregnancies

184
Q

Outline the physiology of glucose in pregnancy

A

Increasing insulin resistance in pregnancy
Insulin production doubles from 1st to 3rd trimester
Ketosis and glycosuria common

185
Q

How is hyperglycaemia driven by placental hormones in pregnancy?

A

Placenta produces lactogen and somatomammotrophin -> increased insulin resistance and production -> if insulin resistance without capacity to produce insulin, hyperglycaemia/gestational diabetes occurs

186
Q

What are the effects of high glucose in pre-existing diabetes on the fetus?

A

Increased rate of fetal congenital abnormalities - cardiac defects, NTDs, renal abnormalities

187
Q

What is the pathophysiology of macrosomia?

A

Glucose crosses placenta but insulin does not
Fetus produces insulin from 10 weeks
Increased maternal glucose -> increased fetal glucose -> increased fetal insulin production -> macrosomia

188
Q

What are the complications of macrosomia?

A

Intrauterine death

Shoulder dystocia

189
Q

How do insulin requirements change with gestation?

A

1st trimester - static/decrease
2nd trimester - increase
3rd trimester - increase/slight decrease towards term

190
Q

What are the obstetric complications of diabetes?

A

UTI
Operative delivery
Pre-eclampsia
Polyhydramnios - pre-term labour, malpresentation

191
Q

What are the risks of pre-existing/gestational diabetes in pregnancy?

A

Pre-existing - miscarriage, congenital malformation, stillbirth, neonatal death
Gestational - neonatal hypoglycaemia, perinatal death
Both - fetal macrosomia, birth trauma, c-section, induction, transient neonatal morbidity, obesity/diabetes in baby’s later life

192
Q

What are the risks to the fetus in maternal diabetes?

A 
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia/  polycythemia
Idiopathic RDS
Delayed lung maturity
Prematurity
Predisposition to obesity and diabetes in later life
193
Q

Why is pre-conception care important in women with diabetes? What should this involve?

A

Good glycaemic control prior to conception is ideal

Risks and how to reduce them, diet/weight/exercise, management of diabetes, retinal and renal assessment, timing of contraception cessation, frequency of appointments and support

194
Q

What should pre-pregnancy glucose targets be?

A

Fasting - 5-7 mmol/L

HbA1c - <48 mmol/L

195
Q

What antenatal care will be required for pregnant women with diabetes?

A

Folic acid - 5mg pre-conception to 12 weeks
Early booking appointment
Obstetric review - 4 weekly until 28 weeks, 2 weekly until 36 weeks, weekly until delivery
Monitor fetal growth
Serum screening and detailed anomaly scan
Retinal and renal screening - booking and 28 weeks
Planned delivery between 37 and 38+6 weeks

196
Q

What are the risk factors for gestational diabetes? What should be done about them?

A

BMI above 30 kg/m2
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
Minority ethnic family origin with a high prevalence of diabetes

If any one factor identified at booking offer testing for GDM at 24-28 weeks using 2 hour 75g OGTT

197
Q

How is gestational diabetes diagnosed?

A

2 hour 75g OGTT

A fasting plasma glucose level of 5.6 mmol/litre or above or
a 2-hour plasma glucose level of 7.8 mmol/litre or above

198
Q

How is gestational diabetes managed?

A

Antenatal - diet and exercise, metformin and insulin, delivery no later than 40+6
Intrapartum - glucose between 4-7 mmol/L
Postpartum - stop all treatment, 6 week fasting glucose, annual review

199
Q

Outline the role of thyroid hormones in pregnancy

A

Fetal thyroxine obtained from mother as thyroid gland becomes functional at 12 weeks
Iodide is lost through urine and placenta to cause deficiency which mean pregnant women require additional iodine
Thyroid hormones are increased in pregnancy (peak at mid-gestation)

200
Q

What are the complications of untreated thyroid disease in pregnancy?

A

Abnormal neuropsychological development
Miscarriage
Stillbirth
Placental abruption, prematurity

201
Q

How does pregnancy mimic hyperthyroidism and what are the best discriminators?

A

Mimics - heat intolerance, palpitations, palmar erythema, goitre, emotional lability, tachycardia, increased T4, suppressed TSH
Discriminators - weight loss, eye signs, pretibial myxoedema, tremor

202
Q

What treatments are available for hyperthyroidism in pregnancy?

A 
Anti-thyroid drugs - carbimazole, PTU 
Beta-blockade - propranolol 
Serial biochemical monitoring 
Requirements reduced in pregnancy 
Check neonatal TFTs if breast feeding mother on high dose 
Surgery (rare)
Radioiodine (contraindicated)
203
Q

What is postpartum thyroiditis?

A

Occurs 1-3 months postpartum
Presentation - transient hyperthyroidism -> subsequent hypothyroidism (may be confused with postnatal depression) -> often remits with resolution after 1 year

204
Q

What are the risk factors for twin pregnancy?

A

Assisted conception
Advanced maternal age
West African ethnic origin
Family history

205
Q

Define zygosity, chorionicity and amnionicity

A

Zygosity - number of fertilised eggs
Chorionicity - number of placentas
Amnionicity - number of sacs

206
Q

What is the most common multiple pregnancy type?

A

Dizygotic twins

207
Q

Define dizygotic twins

A

2 eggs, 2 sperm

Not identical

208
Q

Define monozygotic twins

A

1 egg, 1 sperm
Identical
May be any combination of di/mono chorionic/amniotic

209
Q

What signs on USS can show if twins are dichorionic or monochorionic?

A

Lamda sign - dichorionic

T sign - monochorionic

210
Q

What are the maternal risks of multiple pregnancy?

A

Antenatal - all risks increased; hyperemesis gravidarum, pre-eclampsia, gestational diabetes, placenta praevia
Intrapartum
Postpartum - haemorrhage, depression, anxiety, relationship difficulties

211
Q

What are the fetal risks of multiple pregnancy?

A

Miscarriage (one or both)
Congenital anomaly
Growth restriction (regular USS)
Preterm delivery

212
Q

What are the fetal risks of multiple pregnancy in monochorionic twins and why?

A

Acute transfusion, twin-twin transfusion syndrome, twin reversed arterial perfusion
Commnication between circulations via placental anastomoses

213
Q

What options are available for prenatal diagnosis?

A

Bloods - screening, free fetal DNA
USS - chorionicity, nuchal translucency
Invasive - amniocentesis, CVS

214
Q

What is the median gestation at delivery for multiple pregnancy?

A

Twins - 37 weeks

Triplets - 34 weeks

215
Q

When and how should delivery be planned for in multiple pregnancy?

A

Elective delivery - aim for vaginal but risk of c-section, may request elevtive c-section
DCDA - 37 weeks
MCDA - 36 weeks

216
Q

What management should be used in delivering multiple pregnancy?

A

Maternal - BP, IV access, fluids, ranitidine

Fetal - continuous CTG, abdominal and fetal scalp electrode

217
Q

What 3 factors contribute to increased risk of postpartum haemorrhage in multiple pregnancy?

A

Tone - large floppy uterus
Tissue - 2x placentas
Trauma - 2 babies

218
Q

What is acute transfusion (multiple pregnancy)?

A

Death of one twin in utero leads to increased risk of hypoxic-ischaemic injury in survivor due to acute transfusion from healthy to dying twin
Risk of exsanguination of healthy twin into dying twin, therefore double IUD

219
Q

How is acute transfusion managed?

A

Increased monitoring of survivor for anaemia and transfusional brain injury
Delivery not indicated unless near term

220
Q

What is twin to twin transfusion syndrome?

A

Chronic net shunting from one twin to the other
Donor twin - growth restricted, oliguric, anhydramnios
Recipient twin - polyuric, polyhydramnios, cardiac problems, hydrops

221
Q

How does twin to twin transfusion syndrome present and how is it diagnosed?

A

16-25 weeks, different liquor volumes

USS - liquor volume, bladder visualisation, cord dopplers, oedema/ascites

222
Q

Outline the staging used for twin to twin transfusion syndrome

A

Quintero staging

  1. Discordant liquor volumes
  2. Bladder not seen in donor
  3. Abnormal dopplers
  4. Fetal hydrops
  5. Death of one or both twins
223
Q

How is twin to twin transfusion syndrome managed?

A

Fetoscopic laser ablation of anastomoses
Cord occlusion
Management in quaternary centre (London)

224
Q

What is the prognosis for twin to twin transfusion syndrome?

A

2/3rds of fetuses die or are brain damage

225
Q

What is twin reversed arterial perfusion syndrome?

A

2 cords linked by a large arterio-arterial anastomosis which allows retrograde perfusion - pump twin and perfused twin

226
Q

How is twin reversed arterial perfusion syndrome managed?

A

Ablation of anastomosis

227
Q

What are the risks of monoamniotic twins?

A

Cord entanglement

Placental anastomoses

228
Q

What are the associations of breech presentation?

A 
Multiple pregnancy 
Bicornuate uterus 
Fibroids 
Placenta praevia 
Polyhydramnios
Oligohydramnios 
Fetal anomaly - NTD, NMD
229
Q

What is the incidence of breech presentation through pregnancy?

A

20 weeks - 40%
32 weeks - 25%
Term - 3-4%

230
Q

What are the 3 breech birth positions?

A

Flexed
Footling
Extended

231
Q

What are the risks of vaginal delivery in breech presentation?

A 
Intracranial injury 
Widespread bruising 
Damage to internal organs 
Spinal cord transection 
Umbilical cord prolapse 
Hypoxia
232
Q

What are the risks of c-section in breech presentation?

A

Surgical morbidity and mortality

233
Q

What is an ECV?

A

External cephalic version

Attempting to manually turn a breech baby from buttocks/foot first to head first

234
Q

When should ECV be offered, what is the success rate and what monitoring should be done?

A

All women with breech presentation at term (36 weeks in nulliparous, 37 weeks in multiparous)
Success rate 50%, 5% recurrence
CTG before and after procedure

235
Q

Give 3 absolute contraindications to ECV

A

When CS required regardless (e.g. placenta praevia)
Antepartum haemorrhage within the last 7 days
Abnormal CTG
Major uterine anomaly
Ruptured membranes
Multiple pregnancy (except delivery of second twin)
Absence of maternal consent

236
Q

Give 3 relative contraindications to ECV

A 
Nuchal cord
Fetal growth restriction
Proteinuric pre-eclampsia
Oligohydramnios
Major fetal anomalies
Hyperextended fetal head
Morbid maternal obesity
237
Q

How should preterm breech presentation be managed?

A

Decision should be based on stage of labour, type of breech, fetal well-being, availability of physician skilled in vaginal breech delivery

238
Q

Define preterm, preterm labour, preterm prelabour rupture of membranes and low birth weight

A

Preterm - gestation <37 weeks
Preterm labour - regular contractions + effacement and dilatation of cervix at 20-37 weeks
PPROM - rupture of fetal membranes <37 weeks and before labour
Low birth weight - <2501g

239
Q

What are the causes of preterm birth?

A

Spontaneous labour, unknown cause
Elective delivery (e.g. due to maternal hypertension, fetal growth problems or haemorrhage)
Preterm premature ruptured membranes
Multiple pregnancy

240
Q

What causes preterm labour?

A

Unknown

Infection may be implicated - inflammation of chorioamniotic membranes causes prostaglandin release

241
Q

What is the baby’s chance of survival following pre-term delivery?

A 
<22 weeks: close to zero
22 weeks: 10%
24 weeks: 60%
27 weeks: 89%
31 weeks: 95%
34 weeks: equivalent to baby born at full term
242
Q

What complications are associated with preterm delivery?

A 
Mortality 
Lung disease 
Cerebral palsy 
Blindness
Deafness
Developmental/behavioural problems
243
Q

What is the role of maternal steroids in preterm delivery and how are they administered?

A

Increase pulmonary surfactant production by type II pneumocytes to reduce risk of RDS
Also reduces risk of intraventricular cerebral haemorrhage, neonatal death, necrotising enterocolitis and ICU admission
IM dexamethasone in divided doses over 24 hours

244
Q

How is antepartum haemorrhage classified?

A

Minor - <50ml
Major - 50-1000ml
Massive - >1000ml +/- hypovolaemic shock

245
Q

What are the causes of antepartum haemorrhage?

A

Local - vulva, vagina, cervix (ectropion, polyp, carcinoma), labour show
Placental - placenta praevia, placental abruption
Unexplained

246
Q

Define placenta praevia

A

Placenta encroaches upon the lower segment of the uterus, with the lower segment arbitrarily defined by ultrasound scanning as extending 5 cm from the internal cervical os

247
Q

What is the main risk factor for placenta praevia?

A

Previous c-section

248
Q

How is placenta praevia classified?

A

Minor (I and II) - encroaches lower uterine segment, reaches internal os
Major (III and IV) - covers part of internal os, completely covers internal os

249
Q

What are the delivery options for minor placental praevia and how is this decided?

A

Vaginal delivery may be possible
Assess engagement of the presenting part, and actual distance of the placenta from the internal (by ultrasound) – must be >2cm

250
Q

Does a low lying placenta at 20 week scan confirm placenta praevia? Why?

A

No
As the uterus grows from the lower segment upwards, the placenta appears to move upwards with advancing gestation
Low placenta at 24 weeks - 2% will be low lying at term

251
Q

What are the complications of placenta praevia?

A

Sudden unpredictable major haemorrhage
Major haemorrhage at c-section due to inefficient lower uterus contraction
Morbidly adherent placenta (abnormally invasive or placenta accreta)

252
Q

How is placenta praevia managed?

A

Admit from 30-32 weeks until delivery if bleeding

Elective delivery at 38-39 weeks unless haemorrhage occurs sooner

253
Q

What is an abnormally invasive placenta?

A

Placenta invades the myometrium and cannot be readily separated from the uterus following delivery
Usually diagnosed with ultrasound antenatally to evaluate the presence and degree of invasion

254
Q

What are the risks of an abnormally invasive placenta?

A

Massive PPH

Requirement for hysterectomy

255
Q

What is placental abruption?

A

Retroplacental haemorrhage (bleeding between the placenta and the uterus) which usually involves some degree of placental separation - results in a reduced area for gas exchange between the fetal and maternal circulations predisposing to fetal hypoxia and acidosis

256
Q

Give 3 risk factors for placental abruption

A 
Previous abruption 
Hypertension/pre-eclampsia 
Thrombophilia
Premature rupture of membranes 
Multiple pregnancy 
Folic acid deficiency 
Cocaine 
Smoking 
Social deprivation
257
Q

What is the importance of concealed abruption?

A

‘Revealed’ blood (bleeding from the vagina) may not reflect the total blood loss and a woman may have considerable retroplacental bleeding without any external loss at all – a ‘concealed abruption’, the most hazardous type of abruption

258
Q

How is placental abruption managed?

A

Light bleeding - inpatient observation and surveillance of growth
Major haemorrhage - urgent delivery

259
Q

How is a concealed abruption inferred?

A

Degree of pain
Uterine tenderness
Evidence of hypovolaemic shock

260
Q

How is intrauterine fetal death managed?

A

Vaginal delivery unless systemic maternal risks are such that waiting for vaginal delivery over c-section will be disadvantageous

261
Q

What are the complications of vaginal delivery for intrauterine fetal death?

A

Major blood loss
Hypovolaemic shock
Multisystem organ failure
DIC

262
Q

How do women presenting with placenta praevia differ from those with placental abruption?

A

Praevia - usually painless bleeding, with non-engaged presenting part, soft uterus
Abruption - usually painful bleeding, with hard “woody” uterus (‘couvelaire’ uterus)

263
Q

What should be asked/checked in a patient with suspected APH?

A

Ask - when bleeding started? how much blood has been lost? when did the baby last move?
Observe - is the mother in pain? (suggests abruption or labour) is there blood on the bed, her legs or the floor? is the mother pale? are there signs of hypovolaemic shock? (low blood pressure, tachycardia)

264
Q

What examinations should be done in suspected APH?

A

General inspection and observations
Abdominal examination
USS - determine placental site, assess fetal wellbeing
CTG - if gestation >26 weeks, fetal heart doppler if <26 weeks
Speculum can be carried out, if placenta not low

265
Q

How is APH managed?

A

Admit until bleeding stops
Anti-D if rhesus -ve
If major haemorrhage/fetal compromise - maternal resuscitation and consider delivery

266
Q

What is the role of MBBRACE UK?

A

Surveillance of maternal deaths
Confidential enquiries into maternal deaths during and up to 1 year after pregnancy
Confidential enquiries into cases of serious maternal morbidity
Surveillance of perinatal death (including late fetal loss, stillbirth and neonatal death)
Confidential enquires into stillbirths, infant deaths and serious infant morbidity

267
Q

In relation to maternal deaths, define direct, indirect, coincidental and late

A

Direct - consequence of a disorder specific to pregnancy (e.g. haemorrhage)
Indirect - resulting from existing disease/disease developed during pregnancy (e.g. psychiatric)
Coincidental - incidental/accidental death not due to or aggravated by pregnancy (e.g. RTA)
Late - occurring >42 days but <1 year after pregnancy

268
Q

What are the most common causes of maternal mortality?

A 
Heart disease 
Blood clots 
Epilepsy and stroke 
Sepsis
Mental health conditions 
Bleeding 
Cancer 
Pre-eclampsia
269
Q

What inequalities are evident from maternal mortality data?

A

Ethnic group - black women 5x higher risk of death
Age
Deprived

270
Q

What is the role of the PROMPT Maternity Foundation?

A

Reduce preventable harm for mothers and their babies

271
Q

What are non-technical skills?

A

Cognitive and interpersonal skills that complement practical and technical competencies - situational awareness, decision making, leadership, communication and team working

272
Q

Give 5 emergencies in obstetrics

A

Obstetric cause - PPH, APH (placenta praevia, vasa previa, abruption, uterine rupture), eclampsia, amniotic fluid embolus, uterine inversion, intra-abdominal bleeding, genital tract haematoma, fetal malpresentation, fetal distress
Incidental causes - massive VTE, ruptured hepatic/splenic/aortic aneurysm, ruptured liver/spleen, MI, cardiac arrythmia/failure, CVA, anaphylactic/septic shock, substance abuse

273
Q

Define postpartum haemorrhage

A

Any bleeding from or in to the genital tract following delivery of the infant
Primary – occurring within 24 hours of delivery
Secondary – occurring between 24 hours and 12 weeks postnatally

274
Q

Give 2 antenatal risk factors for PPH

A

Placental abruption
Placenta praevia
Multiple pregnancy
Pre-eclampsia/gestational hypertension

275
Q

Give 2 intrapartum risk factors for PPH

A 
C-section 
Induction of labour
Retained placenta 
Mediolateral episiotomy 
Operative vaginal delivery 
Prolonged labour (>12 hours)
Large baby (>4kg)
Pyrexia in labour 
Age >40
276
Q

How is PPH managed?

A

Call for help - midwife, obstetrician, anaesthetist, haematology, blood transfusion lab
Assess using A-E - oxygen, fluid balance, blood transfusion, blood products, keep patient warm
Bloods - FBC, coagulation, U&Es, LFTs, crossmatch, bedside Hb
Weigh all swabs to estimate blood loss
Treatment - bimanual uterine compression, empty bladder, oxytocin, ergometrine, carpoprost, misoprostol

277
Q

How can uterine contractility be promoted medically?

A

Syntocin (injection & infusion)
Ergometrine (injection)
Carboprost (IM injection)
Misoprostol (suppository)

278
Q

How can PPH be managed in theatre?

A

Examine to check if uterus is contracted
Intrauterine balloon tamponade, brace suture, interventional radiology
Surgery - bilateral uterine/internal iliac artery ligation, hysterectomy, uterine artery embolisation
HDU/ICU care

279
Q

What are the 3 severities of abnormal placentation?

A

Accreta
Increta
Percreta

280
Q

How is secondary PPH managed?

A

Removal of retained tissue/treat infection

Consider balloon tamponade

281
Q

Define maternal collapse

A

An acute event involving the cardiorespiratory systems and/or brain, resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to six weeks after delivery

282
Q

How is maternal collapse managed?

A

ALS

283
Q

What manoeuvre may be useful to reduce aortocaval compression in CPR of a pregnant woman?

A

Manual left lateral uterine displacement

284
Q

When should a perimortem c-section be performed?

A

No response to CPR after 4 minutes and uterus approximately 20 week size
Aim to deliver in 5 minutes

285
Q

What does perimortem c-section aim to do?

A 
Primarily to save mothers life
Increases venous return
Improves ease of ventilation
Allow CPR in supine position
Reduced O2 requirement following delivery
286
Q

In addition to the 4H’s and 4T’s of cardiac arrest, what 2 other conditions should be considered in pregnant women?

A

Eclampsia (including magnesium toxicity)

Amniotic fluid embolism

287
Q

What is the most common cause of death from pre-eclampsia?

A

Intracranial haemorrhage secondary to uncontrolled hypertension

288
Q

When should magnesium sulphate be considered in pre-eclampsia?

A

Primary prophylaxis - women with severe pre-eclampsia where birth is planned within the next 24 hours
Secondary prophylaxis - after eclamptic fit
Should be continued for 24 hours from time of commencement or for 24 hours after delivery

289
Q

What monitoring is necessary for patients on magnesium sulphate?

A

Urine output
Deep tendon reflexes
Respiratory rate

290
Q

Give 2 signs of magnesium sulphate toxicity and how it can be treated

A

Loss of deep tendon reflexes, respiratory depression, respiratory arrest, cardiac arrest
IV calcium gluconate

Year 5 (10 decks)

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