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RISHI Year 5 PACES 2 (Val edit) > Obstetrics Investigations and Management > Flashcards

Obstetrics Investigations and Management Flashcards

1
Q

Investigations for suspected hyperemesis gravidarum

A
  • Examination => signs of dehydration
  • Basic observations => reduced BP, high HR, weight and calculate BMI
  • Urine dipstick à ketones
  • Bloods:
    • FBC => increased hct
    • U&Es => dehydration
  • PUQE score
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2
Q

Mx of hyperemesis gravidarum

A
  • Consider admission for the following patients:
    • Women unable to keep oral anti-emetics down
    • Continued N&V associated with ketonuria +/- >5% weight loss despite oral anti-emetics
    • Confirmed/suspected co-morbidity e.g. UTI
  • IV fluid resuscitation and correction of electrolyte abnormalities (usually with KCl)
  • IV antiemetics
    • 1st line = Cyclizine or promethazine
    • 2nd line = metoclopramide/ondansetron
  • Thiamine supplementation
  • Offer VTE prophylaxis with LMWH
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3
Q

Associations for hyperemesis

A
  • multiple pregnancies
  • trophoblastic disease
  • hyperthyroidism
  • nulliparity
  • obesity

Smoking associated with decreased risk

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4
Q

Ddx for pre eclampsia

A
  • Pre-eclampsia
  • Gestational HTN
  • Essential HTN
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5
Q

Mx of eclampsia

A
  • ABC approach
  • Labetalol + IV Magnesium sulphate
    • Prevent seizures in severe pre-eclampsia
    • Treat seizures once they develop
  • 4g loading dose
  • 1g/hour infusion 24hrs after last fit
  • Recurrent fits => further 2-4g over 5-15 mins
  • Monitor urine output, reflexes, RR and oxygen sats

labetalol: 1V 50 MG BOLUS (max of 4) CAN ALSO GIVE 200mg PO

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6
Q

First-line treatment for magnesium sulphate induced respiratory depression

A

Calcium gluconate

10% 10mls over 10mins

Measure sats, RR , ECG

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7
Q

RF for pre eclampsia

A

High Risk Factor:

  • HTN during previous pregnancy
  • CKD
  • Autoimmune SLE/antiphospholipid
  • T1DM/T2DM
  • Chronic HTN

Moderate Risk Factor:

  • First pregnancy
  • >40 years,
  • Pregnancy interval 10+ years
  • BMI 35+ at booking
  • FH of pre-eclampsia
  • Multiple pregnancy
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8
Q

Mx of HELLP

A
  • ABC approach
  • 1st line in confirmed HELLP is to deliver
  • IV Magnesium sulphate
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9
Q

How is high-risk Pre eclampsia managed?

A
  • 75 mg OD aspirin from 12 weeks until birth
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10
Q

For a patient with pre-eclampsia when would you consider delivery?

A
  • Uncontrollable BP despite 3+ antihypertensive classes at full dose
  • Maternal sats <90%
  • HELLP
  • Neuro features
  • Placental abruption
  • Reversed end-diastolic flow in umbilical artery doppler
  • Non-reassuring CTG
  • Stillbirth
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11
Q

Ix for suspected Obstetric cholestasis

A
  • Examination => jaundice, excoriation marks, SFH
  • Basic observations => BP, HR, temp
  • Urine dipstick
  • Bloods:
    • LFTs
    • Bile acids
    • WCC
    • Clotting screen – prolonged PT
  • CTG
  • Abdo USS
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12
Q

Mx of Obstetric cholestasis

A
  • Conservative:
    • Topical emollients
    • Wear loose fitting clothing
  • Medical:
    • Ursodeoxycholic acid
    • Vit K supplementation
  • Monitoring:
    • Obstetrician led care
    • Regular LFTs and more frequent scans
    • Safety net about reduced fetal movements
    • Offer induction at 37 weeks
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13
Q

Differentials for PV bleeding in pregnancy

A
  • Placenta praevia
  • Placental abruption
  • Vasa praevia
  • Bloody show
  • Cervical ectropion
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14
Q

Ix for PV bleeding

A
  • A to E approach
  • Examination – signs of anaemia, tense and tender abdomen
  • Basic observations – haemodynamic stability
  • CTG
  • TVUSS
  • Bloods:
    • FBC
    • Group and save
    • Coagulation profile à DIC
    • Kleihauer test
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15
Q

Mx of PV bleeding

A
  • A to E approach (IV access and fluid resuscitation)
  • Admit until bleeding stops for 24 hours
  • <34 weeks administer steroids and consider tocolytics (not in abruption)
  • Anti-D prophylaxis
  • Continuous fetal monitoring
  • EMCS if fetal distress/mother remains haemodynamically unstable
  • If low-lying placenta at 32 weeks then repeat TVUSS at 36 weeks
  • Deliver:
    • If uncomplicated PP: ELCS at 36 weeks onwards
    • If placenta accrete spectrum: ELCS at 35 weeks onwards
    • Abruption/vasa praevia with fetal or maternal compromise: EMCS
    • Stable abruption >34 weeks: consider ELCS or vaginal delivery with active mx of 3rd stage of labour
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16
Q

Ddx for abdo pain

A
  • Placental abruption
  • Premature labour
  • Braxton-Hick’s contractions
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17
Q

Ix for abdo pain

A
  • A to E approach
  • Examination – signs of anaemia, tense and tender abdomen
  • Basic observations – haemodynamic stability
  • CTG
  • TVUSS
  • Bloods:
    • FBC
    • Group and save
    • Coagulation profile à DIC
    • Kleihauer test
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18
Q

Ix for suspected VTE in pregnancy

A

DVT

  • GE: Unilateral lower limb oedema, erythema, tenderness, low grade pyrexia
  • Duplex USS

PE

  • GE: tachycardia, tachypnoea, low grade pyrexia, reduced O2 saturation, cardiorespiratory collapse
  • Chest auscultation: reduced air entry, creps
  • Cardiovascular: Loud P2
  • ABG: hypoxia and hypocapnia
  • ECG (sinus tachy + S1Q3T3) + CXR
  • If DVT suspected also duplex USS
  • If CXR abnormal à CTPA in preference to V/Q
  • If V/Q or CTPA normal but clinical suspicion high repeat or use alternative Ix
  • Bloods: FBC, U&Es, LFT, Clotting
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19
Q

Risk of CTPA or V/Q scan in pregnancy

A
  • V/Q has slightly increased risk of childhood cancer
  • CTPA has higher risk of maternal breast cancer
  • In both situations, the absolute risk is very small
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20
Q

Mx of VTE in pregnancy

A
  • LMWH (enoxaparin) titrated against booking weight
    • Treat upon clinical suspicion whilst awaiting results
    • If USS negative then discontinue but repeat USS on day 3 and 7
    • Continue for the rest of pregnancy
    • Discontinue 24 hrs before delivery
    • Do not give until 4 hours after spinal
    • Continue 6/52 after delivery or until 3 months Tx in total
    • Monitor platelets and peak anti-Xa levels
  • Massive PE
    • A to E approach
    • MDT
    • IV unfractionated heparin
    • Consider thrombolysis/thrombectomy
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21
Q

Ix for DM in Preganancy

A
  • Examination – SFH, signs or pre-eclampsia, BP, HR
  • Urine dip => glucose, proteinuria
  • Bloods:
    • FBC
    • Fasting blood glucose/OGTT à followed by capillary glucose monitoring
    • TFTs
    • LFTs
  • Monitoring:
    • CTG
    • Serial USS scans for growth and liquor volume
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22
Q

Management of Chronic HTN in pregnancy

A
  • Aim for target BP 135/85
  • Switch from ACEi/ARBs to labetalol
  • 2nd line = Nifedipine
  • 3rd line = Methyldopa (stop within 2 days after birth)
  • Placental growth factor testing 20-35 weeks
  • Anti-hypertensive review 2 weeks post delivery
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23
Q

Management of Gestational HTN

A
  • Aim for target BP 135/85
  • BP monitoring twice a week and dipstick proteinuria tests
  • Placental growth factor testing if pre-eclampsia suspected 20-35 weeks
  • Labetalol or nifedipine if contra-indicated
  • Reduce anti-HTN if BP<130/80 post-natally
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24
Q

Management of previous diabetes

A
  • Preconceptual:
    • Optimisation of glucose control
    • Folate 5mg
  • Medical:
    • Optimise diet
    • Consider converting oral hypoglycaemic to insulin
    • Likely to require increasing doses of insulin
  • Pregnancy:
    • Capillary blood glucose monitoring (monthly HbA1c is offered)
    • Monitor for pre-eclampsia à aspirin 75mg OD from 12 weeks
    • Serial USS for foetal growth
  • Delivery:
    • Sliding scale in labour (38 weeks)
    • MDT – if large then recommend C-section
  • Postpartum:
    • Return to pre-pregnancy doses of medications immediately to avoid hypos
    • Start feeding neonate within 30 mins and fed frequently to prevent hypoglycaemia
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25
Q

Management of GDM

A
  • Medical:
    • Diet/exerecise control for 2 weeks
    • Metformin +/- insulin
    • > 7 fasting start insulin immediately
    • Glibenclamide should only be offered for women who cannot tolerate metformin
  • Pregnancy/delivery: As for pre-existing
  • Postpartum: Stop insulin after delivery, fasting blood glucose measured at 6/52 postpartum
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26
Q

Risk Factors for GDM

A
  • previous baby >4.5kg
  • BMI >30
  • Race
  • Polyhydramnios
  • previous GDM
  • previous unexplained stillbirth
  • 1st degree relative with DM
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27
Q

Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)

A
  • Fasting: 5.3 mmol/l
  • 1 hour after meals: 7.8 mmol/l
  • 2 hour after meals: 6.4 mmol/l
28
Q

Complications of GDM

A
  • Foetus: hyperglycaemia can affect development (NTD, hyperinsulinemia, shoulder dystocia, macrosomia (more than 8 pounds), polyhydramnios due to increased urination.
  • Neonatal: hypoglycaemia can occur when born due to change in glucose in its environment.
  • Mother: increased insulin requirement, UTI and wound infection postpartum, increased risk of C-section, increased risk of preterm delivery
29
Q

Types of breech presentation

A
  • Frank breech
  • Complete or flexed breech
  • Footling breech
30
Q

RF for breech presentation

A
  • Maternal: multiparity, uterine fibroids, previous breech, placenta praevia
  • Foetal: preterm delivery, oligohydramnios, foetal macrosomia, multiple pregnancy
31
Q

Contraindications for ECV

A
  • If C-section is required
  • Abnormal CTG
  • Ruptured membranes
  • Multiple pregnancy
32
Q

Sensitising events for which you give anti-D immunoglobulin

A
  • ECV
  • Surgical management of miscarriage or ectopic pregnancy
  • Abdominal trauma
  • Amniocentesis or chorionic villus sampling
  • Antepartum haemorrhage
33
Q

Causes of IUGR

A
  • Infection
  • Smoking
  • Drinking
  • Genetic problems with the baby
  • Pre-existing medical problems (e.g. hypertension, kidney disease)
34
Q

How do you date scans in pregnancy?

A
  • CRL: 10-14 weeks
  • Head Circumference: 14-20 weeks
35
Q

How can you induce a labour?

A
  • Membrane sweep (to try and stimulate labour)
  • Propess (24 hour pessary)
  • Prostin gel (may be used 6 hourly to further ripen the cervix)
  • Artificial rupture of membranes
36
Q

IUGR: Concerning sign-on doppler?

A

Absence or reversal of end-diastolic flow

37
Q

Investigations for PROM

A
  • Examination – temp, HR, BP, uterine tenderness
  • Urine dip and MC&S
  • Sterile speculum examination
    • Offensive discharge
    • Pooling of amniotic fluid
  • If no pooling: swab for:
    • insulin-like growth factor-binding protein-1 (IGFBP-1) or
    • placental alpha micro-globulin-1 (PAMG-1)
  • Bloods:
    • FBC – raised WCC
    • CRP
  • CTG
38
Q

Management of PROM

A
  • Admit for monitoring (48-72 hours)
  • Antenatal steroids
  • Abx: erythromycin 250mg QDS for 10 days or until established labour => penicillin if not tolerated
  • Offer MgSO4 if 24-29 weeks
  • Monitor temperature (4 hours)
  • Aim to deliver after 34 weeks or earlier if infection
  • Consider rescue cervical cerclage between 16-28 weeks with dilated cervix an unruptured fetal membranes
  • Do not offer if PV bleeding, infection or uterine contractions
  • 23> weeks then consider termination of pregnancy
39
Q

Complications of PROM

A
  • Complications for mother: sepsis and placental abruption
  • Foetal: chorioamnionitis, cord prolapse. PTL, pulmonary hypoplasia, limb contractures, death
40
Q

Examples of tocolytics

A
  • Nifedipine
  • Atosiban
41
Q

What screening test can be used if you are unsure about whether a patient is in labour or not?

A
  • Foetal fibronectin
42
Q

What might be used as neuroprotection in a preterm delivery?

A

MgSO4

43
Q

What are the stages of labour?

A
  • Stage 1: onset of regular contractions to full dilatation of the cervix
  • Stage 2: full dilatation to delivery of the baby
  • Stage 3: from delivery of the baby to delivery of the placenta and membranes
44
Q

Causes of prolonged labour

A
  • Malposition
  • Epidural analgesia
  • Obstructed labour (e.g. CPD)
45
Q

How can you actively manage the third stage of labour?

A
  • IM syntocinon/ergometrine injection
  • Controlled cord traction
  • Should last < 30 mins
46
Q

How do you induce labour?

A
  • Membrane sweep
  • Propess (24 hours)
  • Prostin (can be given 6 hourly)
  • ARM
  • Syntocinon
47
Q
A
48
Q

Management of cord prolapse

A
  • The presenting part of the fetus may be pushed back into the uterus to avoid compression
  • Tocolytics 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.
  • Patient on all fours
49
Q

Featurs of pre eclampsia

A
  • hypertension: typically > 170/110 mmHg and proteinuria as above
  • proteinuria: dipstick ++/+++
  • headache
  • visual disturbance
  • papilloedema
  • RUQ/epigastric pain
  • hyperreflexia
  • platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
50
Q

When should a woman take 5mg of folic acid?

A
  • either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
  • the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
  • the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
51
Q

Management of uterine atony

A
  • bimanual uterine compression to manually stimulate contraction
  • intravenous oxytocin and/or ergometrine
  • intramuscular carboprost
  • intramyometrial carboprost
  • rectal misoprostol
  • surgical intervention such as balloon tamponade
    • Other: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
52
Q

RF for PPH

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydramnios
  • emergency Caesarean section
  • placenta praevia, placenta accreta
  • macrosomia
  • ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
53
Q

Definition of PPH

A
  • Primary PPH: >500 ml in 24 hours
  • Secondary PPH: 24 hours - 12 weeks
    • due to retained placental tissue or endometritis
54
Q
A
55
Q

What is the combined test and when is it offered?

A

Consists of:

  • Nuchal translucency measurement
  • Serum B-HCG
  • Pregnancy-associated plasma protein A (PAPP-A)

Result:

  • Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
  • trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

Offered:

  • 11 - 13+6 weeks
56
Q

What is the alternative to the combined test?

A

If women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks

Triple test:

  • human chorionic gonadotrophin
  • alpha-fetoprotein
  • unconjugated oestriol

Quadruple test:

  1. Human chorionic gonadotrophin
  2. alpha-fetoprotein
  3. unconjugated oestriol
  4. inhibin-A
57
Q

What is the difference between amniocentesis and CVS?

A
58
Q

What is meant by SGA? What is IUGR?

A

The weight of the fetus is less than the tenth centile for age

IUGR: doesn’t live up to its growth potential. These can often be SGA babies

59
Q

Common causes of SGA

A
  • Constitutional factors
  • Idiopathic
  • Maternal disease, e.g. pre-eclampsia Smoking
  • Multiple pregnancy
60
Q

Investigations for SGA/ IUGR

A
  • History
  • Examination
    • General
    • Abdo
    • SFH
    • BP and urinanalysis
  • Imaging
    • CTG
    • USS
    • UmbA doppler (can see how healthy the blood flow is to the baby)
    • Foetal middle cerebral artery doppler (for cardiovascular distress, fetal anaemia and fetal hypoxia)
61
Q

Causes of IUGR

A

We measure this by looking at the abdominal circumference of the foetus

Symmetrical (<20 weeks of gestation)

  • Chromosomal
  • Congenital Anomalies (NTD, CHD)
  • Congenital infections

Asymmetrical (Mama, Made, Poor, Uterus) (>20 weeks)

  • Maternal HTN
  • Maternal APS
  • Placental Insufficiency
  • Uterine anomalies
  • Substance abuse
62
Q

When can ECV be managed?

A
  • 36 weeks for nullips
  • 37 weeks for multips
63
Q

Investigations for APH

A
  • Bloods
    • Full blood count
    • Group and cross-match
    • Coagulation screen
    • Urea and electrolytes
  • Cardiotocography (CTG) (immediate)
  • Ultrasound scan (USS) to determine placental site/fetal viability

Management

  • If heavy bleed: catheterize and record hourly urine output
64
Q

Definition and investigations for reduced foetal movement

A

Less than 10 movements within 2 hours (>28 weeks)

If the patient is past 28 weeks:

  • Handheld doppler to confirm fetal heartbeat
    • Not detectable, ultrasound should be offered immediately
    • Heartbeat was detected, CTG should be used for 20 minutes to monitor the heart rate.
65
Q

Investigations for PROM

A
  • Sterile speculum (look for pooling in the posterior vaginal wall)
  • Test for the following if no pooling:
    • Insulin-like growth factor binding protein‑1 (IGFBP-1)
    • Placental alpha-microglobulin 1 (PAMG-1)
66
Q

Oligohydramnios definition and causes

A
  • < 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile

Causes

  • premature rupture of membranes
  • fetal renal problems e.g. renal agenesis
  • intrauterine growth restriction
  • post-term gestation
  • pre-eclampsia

RISHI Year 5 PACES 2 (Val edit) (5 decks)

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