OBSTETRICS Flashcards
What are some causes of antepartum haemorrhage? (think of both dangerous + ‘innocent’ causes)
DANGEROUS = abruption, placenta praevia, vasa praevia
OTHERS =
- cervical polyps/erosions/carcinoma
- cervicitis, vaginitis, vulval varicosities
- placental sinus, circumvalate placenta
What things should you ask in the history of a woman presenting with antepartum haemorrhage?
- Gestational age
- Amount of bleeding
- Associated initiating factors e.g. sex
- Abdominal pain
- Foetal movements
- Prev episode of PV bleed
- Leakage of fluid PV
- Previous pelvic surgery (incl. C section)
- Smoking/Cocaine use
- Blood group + rhesus status
- Prev + current obstetric history
- Position of placenta (if known)
What examination(s)/signs should be done in a woman with suspected antepartum haemorrhage?
Look for signs of haemodynamic compromise
- low BP + tachycardia
- peripheral vasoconstriction
- central cyanosis
- palpate uterus
Do NOT perform PV exam until placenta praevia r/o
- speculum
- digital PV exam to assess cervical ripeness
Foetal assessment = FHR + CTG
How do you initially manage a pregnant woman with APH?
- MATERNAL:
- FBC
- Kleihauer if Rh-ve to determine extent of feto-maternal haemorrhage and if more anti-D is required
- group + save
- coagulation screen if abruption suspected - FOETAL
- USS
- Umbilical artery doppler to assess functioning of placenta
What are the grades/types of placenta praevia?
- Minor (G1+G2) = placenta lies in lower segment close to or encroaching on OS
- Major (G3+G4) = placenta lies OVER cervical OS (=> cervical effacement + dilatation could result in catastrophic bleeding + potential death)
What are the risk factors for developing placenta praevia?
- Previous c section
- Older maternal age
- Structural uterine abnormalities e.g. fibroids
What are the typically clinical features of placenta praevia?
- PAINLESS vaginal bleeding in pregnancy
- Bleeding usually at 26 weeks or more
- May be diagnosed on antenatal USS
What investigation should be performed to diagnose placenta praevia?
TVUSS is the gold standard test
How do you manage a woman with placenta praevia?
- Antenatally advise:
- no intercourse
- avoid vaginal exams + speculums
- USS at 32 weeks to assess placental position, if placenta remains close to os then scan every 2 weeks
- if the placenta is within 2cm of the os then delivery is by caesarean section at 37 weeks
Women with major PP who have bled should be admitted from 34 weeks
What conditions/features are associated with having placental abruption?
- pre-eclampsia
- smoking
- IUGR
- PROM
- Multiple pregnancies
- Polyhydramnios
- Increased maternal age
- Thrombophilia
- Abdominal trauma
- IVF
- Cocaine/amphetamine
- Non-vertex presentation
What is sheehan’s syndrome? What features does it cause?
Women who lose a life-threatening amount of blood in childbirth or who have severe low blood pressure during or after childbirth, this lack of oxygen that causes damage to the pituitary gland
- Hypopituitarism
- Agalactorrhoea
- Amenorrhoea
- Symptoms of hypothyroidism
What are the clinical features of placental abruption?
- Continuous abdominal pain
- Backache if posterior placental abruption
- Uterus tender on palpation. “Woody uterus suggests large haemorrhage.
- PV bleeding - variable and often dark
- Foetal distress is common
What investigations should be performed to diagnose placental abruption?
It is a clinical diagnosis
- perform USS to confirm foetal wellbeing + rule out placenta praevia
How is placental abruption managed?
- Admit all women with PV bleeding + unexplained abdominal pain
- Establish immediate foetal wellbeing with CTG + USS
- Access + bloods
- If foetal distress or maternal compromise = resuscitate + DELIVER
- If no foetal distress and bleeding/pain cease = consider delivery at term
- Anti-D if Rh-ve
- Be wary of PPH
What are some high-risk factors for developing pre-elampsia?
- HTN in previous pregnancy
- CKD
- Autoimmune e.g. SLE, antiphospholipid
- T1DM/T2DM
- chronic HTN
What are some moderate risk factors for developing pre-eclampsia?
- 1st pregnancy
- aged over 40
- BMI over 35
- pregnancy interval over 10 yrs
- FHx of pre-eclampsia
- multiple pregnancy
- low PAPP-A
- uterine artery notching at 22-24 wks
When would you give mothers preventative treatment for pre-eclampsia? What do you give?
If they have 1 high risk factor or 2 moderate factors
- give aspirin 75mg OD from 12 weeks
What risks do pre-eclampsia pose to the mother?
Risk of maternal morbidity/mortality from:
- cerebral haemorrhage
- eclampsia
- multi-organ failure
- HELLP syndrome
- ARDS
What risks do pre-eclampsia pose to the foetus?
- IUGR
- premature delivery (risk of foetal lung immaturity)
What levels of BP + protein are significant for pre-eclampsia?
BP over 140/90 mmHg
Proteinuria over 300mg/24hrs (PCR over 30)
What investigations should you perform in pre-eclampsia?
- FBC
- raised Hb (haemoconcentration)
- thrombocytopenia
- anaemia if haemolysis occurs - Coag screen - mildly prolonged PT + APTT
- Biochemistry
- raised urate
- raised AST/ALT
- raised urea + creatinine
- raised lactate
- proteinuria over 300mg/day
When can you manage pre-eclampsia as an outpatient?
Only if:
- BP under 160-110mmHg
- No or low proteinuria
- asymptomatic
How do you manage mild-moderate pre-eclampsia?
ADMIT
- 4-hourly BP
- 24h urine collection
- daily urinalysis
- Daily CTG
- Bloods every 2-3 days
- Regular USS
- Antihypertensives
- 1st = labetolol (use nifedipine if asthma) - IOL performed at 37-38 wks
- magnesium sulphate given during labour + 24h post-partum to prevent seizures
What is the definition of ‘significant’ pre-eclampsia?
sBP of over 160 mmHg or dBP over 110mmHg in the presence of significant proteinuria (over 1g/day) or significant maternal complications
What is the ideal treatment for significant pre-eclampsia?
DELIVERY
- can be delayed if less than 34wks gestation
- if less than 34wks, give corticosteroids + manage pregnancy expectantly unless complications occur
What is eclampsia?
tonic clonic seizures + pre-eclampsia
44% occur post-natally!
How do you manage eclampsia?
- Obstetric 2222
- ABCDE - continually monitor maternal BP + SpO2
- Magnesium sulphate 4g IV over 5-10 mins
- followed by 1g every 24h - Diazepam for repeated seizures
- Monitor: urine output, obs, FBC, U+E, LFT, clotting
- STOP Mg if RR under 12, tendon relfexes lost, urine output less than 20ml/hr
- Calcium gluconate if Mg toxicity causes respiratory depression
- Monitor foetal HR with CTG
- Deliver once mother stable (LSCS preferred). Manage 3rd stage with oxytocin only.
What is HELLP syndrome?
Severe variant of pre-eclampsia consisting of
- Haemolysis
- elevated liver enzymes
- low platelets
How do you manage HELLP syndrome?
- Delivery is indicated
2. Regional anaesthetics CI if platelets below 80
What are risk factors for ectopic?
- hx of infertility/IVF
- hx of PID
- endometriosis
- tubal surgery
- prev ectopic
- IUCD in situ
- smoker
What investigations should be performed in suspected ectopic pregnancy?
- TVUSS
- Serum progesterone - identifies whether pregnancy is failing
- Serum hCG - repeat after 48h + look at rate of rise
- rise of more than 66% indicated IUP - Laparoscopy = GOLD STANDARD
How do you manage an ectopic pregnancy?
- EXPECTANT
- must be medically stable. No FHR + EP less than 3cm - MEDICAL - IM methotrexate STAT + 3 months contraception
- measure hCG at 4+7 days to determine if second dose required
- Must be unruptured, no pain, no FHR, hCG less than 1500 - SURGICAL - salpingectomy via laparotomy
