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4th Year - Management > Obstetrics - Management > Flashcards

Obstetrics - Management Flashcards

1
Q

Minor Pregnancy Problems

A

Reflux

  • Extra pillows and antacids
  • Rule out pre-eclampsia

Constipation

  • Movicol
  • Increase fibre intake

Vaginitis
- Clotrimazole pessary

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2
Q

Hyperemesis Gravidarum - Rx

A

Increase fluid intake

Not tolerating oral

  • Admission and IV Fluids
  • Levomepromazine
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3
Q

Hype. Gravidarum - Complications

A
  • IUGR if >10% weight lose

- Wernicke’s encephalopathy - give pabrinex

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4
Q

Small for Dates

A

<10th centile = doppler UA

Normal - 2 weekly doppler and USS

High Resistance
>37 weeks - CTG and induce
< 37 weeks - UA dopp 2/weekly

Severe
>37 weeks - CTG and deliver
<34 weeks - doppler, steroids, daily CTG

CTG normal = repeat daily
CTG Abnormal= LSCS

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5
Q

Large for Dates - Investigations

A

> 90th centile = GTT

GTT at 24-28 weeks

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6
Q

Large for Dates - Delivery

A

@ 41 weeks

BMI <30/favourable cervix induce at 41+4

BMI >30/unfavourable cervix = induce/LSCS at 41

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7
Q

IUGR - Rx

A

Weekly UA doppler and 2 weekly growth scans

  • Daily CTG if doppler abnormal
  • Delivery at 37 weeks, earlier if compromise
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8
Q

Scan - BPP

A
  • Breathing
  • Movements
  • Fetal tone
  • Amniotic fluid volume

If any decreased/depleted could indicate IUGR as baby not wasting time on moving etc if restricted

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9
Q

Dopplers

A 
Umbilical = placenta -> foetus
Uterine = mum -> placenta
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10
Q

Prolonged Pregnancy

A

> 42 weeks

  • Sweep cervix
  • Daily CTG (if abnormal, deliver)
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11
Q

Bishop’s Score

A

Likelihood of spontaneous labour
> 8 = labour likely

<8 - induction may be required

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12
Q

Reduced Foetal Movements

A

Lie on left side and count kicks for 2 hours

- less than 10: come to MAC

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13
Q

RFM >28 weeks

A

Auscultate foetal heart

  • rapid CTG - abnormal = deliver
  • USS within 24 hours - manage as SGA
  • Normal = reassure
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14
Q

RFM <24 weeks

A

Auscultate foetal heart

- If present, assess for neuromuscular conditions

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15
Q

PROM - Examination

A

Observations - check for infection

  • Sterile speculum
  • Antenatal exam
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16
Q

PROM - Investigations

A

CTG

HV Swab

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17
Q

PROM - Rx

A

90% will deliver in 48 hours, induce after 24 hrs

Infection

  • Broad spec cef and met IV
  • Deliver immediatly
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18
Q

PROM - Neonatal Abx

A

If labour >18 hours

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19
Q

PPROM - Exam

A

Sterile speculum

CTG <26 weeks

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20
Q

PPROM - Rx

A
  • Admit
  • Erythromycin 250mg QDS 10 days

Outpatient

  • Weekly - growth, temp, FBC, CRP
  • Induce at 34 weeks
  • Earlier if RFM or change in discharge/infection

Give steroids 2 x IM betamethason 12mg 24 hours apart

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21
Q

Antenatal Scans

A

Dating
11+2 - 14+1

Anomaly
18-20+6

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22
Q

Bloods

A

8-12 weeks

  • HIV, Hep B
  • Coagulopathies
  • Rhesus and HBO type
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23
Q

Rhesus status

A

If -ve

ANTI D

  • 28 and 24 weeks
  • 72 hours post delivery
  • Vaginal bleed
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24
Q

Combined Screening

A
  1. USS - nuchal translucency

2. Bloods - HCG and PAPPa

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25
Q

Diagnositic tests

A

CVS - from 11 weeks
- 1% risk

Amniocentesis from 15 weeks
- 0.8 % risk

Harmony/Iona
- Non-invasive blood test, private

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26
Q

Quadruple test

A

If >14 weeks

- Blood test for down’s syndrome

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27
Q

HIV in Pregnancy

A

ART

  • Undetectable by 36 weeks (<50 = VD)
  • Breastfeeding 10x chance, only until 6 months

Neonate
- 4 weeks ART

Parter
- Protected sex/abstinence

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28
Q

Hep B

A

Notifiable
- Vaccination x 5 for neonate

  • Safe to breastfeed
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29
Q

Epilepsy - Risks

A

Increase seizures

  • NTD
  • Sodium valproate syndrome
  • Orofacial clefts
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30
Q

Epilepsy - Management

A

Folic acid 5mg
Monotherapy (lamotrigine, levotiricetam)
Oral vit K at 36-40 weeks

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31
Q

Abx for UTI

A
  • Trimethoprim (not in 1st trimester)

- Nitrofurantoin (not in 3rd trimester - haemolysis)

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32
Q

Abx for Chorioamnionitis

A
  • Cefuroxime 1.5mg TDS IV

- Metronidazole 500mg TDS IV

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33
Q

Abx for Endometritis

A
  • Co-amoxiclav 1.2g IV TDS

Penicillin allergy
- Clindamycin and metronidazole

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34
Q

Anticoagulants safe in Pregnancy

A

LMWH

  • unfractionated heparin if eGFR < 30
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35
Q

Warfarin - Dangers

A
  • Still birth, prematurity, bleed, ocular defects

Foetal Warfarin Syndrome

  • Nasal hypoplasia
  • hypoplasia of the extremities
  • developmental delay

EXCEPTION

  • Mechanical heart valve
  • Only between 12-36 weeks
36
Q

Safe Analgesia

A
  • Paracetamol
  • Opioids (do cause resp depression as cross placenta)
  • Entinox
37
Q

Dangerous Analgesia

A

NSAIDS

  • 1st trimester = miscarriage and malformation
  • 3rd trimester = premature closure of PDA
38
Q

Normal Labour

A

1st stage

  • 4-10cm dilated
  • mobilistation in low risk women

2nd stage

  • Passive (allow 2 hours)
  • Active (1 hour of active pushing)

3rd stage

  • Placenta delivery
  • Delayed cord clamping (until stopped pulsing)
  • IM syntocinon
39
Q

CTG (>26 weeks)

A

DR - Define Risk
C - Contraction (4 in 10)

BR - Baseline Rate (100-160)
A - Accelerations, reassuring
VA - Variability >5
D - Decellerations 
O - overall impression
40
Q

Non-reassuring CTG

A

Left lateral side
Give IV fluids
Fetal scalp stimulation

FBS

41
Q

Fetal Blood Sample

A

> 7.25 - normal
7.20-7.25 - borderline, repeat in 30 mins
<7.20 - deliver immediately

42
Q

Analgesia in Labour

A
  • Entinox
  • Opiods
  • Regional (increased risk of operative delivery)
43
Q

Complications of Epidural

A

Failure
Low BP
LA toxicity
Total spinal

44
Q

Induction Methods

A

Membrane sweeping

Prostaglandin into posterior fornix (propess 10mg)

Artificial ROM

Oxytocin regime for increase contractions

45
Q

Complications of Induction

A
  • Fetal distress
  • Rapid delivery (trauma and APH)
  • Uterine hypertonia and rupture
  • Amniotic fluid embolus
46
Q

Contraindications of Induction

A
  • Unstable lie
  • Acute fetal compromise
  • Placenta praevia
  • Previous LSCS
47
Q

Malposition

A

Optimal = OA

OP = back to back
OT = head sideways in birth canal
Brow = forehead first, wider part to deliver
48
Q

Complications of Malposition

A
  • Longer delivery
  • Increase pain
  • Increased intervention (LSCS, Forceps)
49
Q

Breech - Exam

A

HR above umbilicus

Head at top of uterus

50
Q

Breech - USS

A

Check at 36 weeks
Full = bum first
Partial/Footling = knees/feet first (must be LSCS)

51
Q

ESV

A 
37 weeks (35-50% successful)
- May cause transient fetal bradycardia
- Monitored before and after (CTG, USS)
- Need Anti D 
Risks - hypoxia, PROM, Labour

10% will revert

52
Q

Transverse/Unstable

A

Admit due to increased risk of cord compression
- Discharge if moves to longitudinal and stays for 38 hours

If transverse at 36 weeks - LSCS

53
Q

Twin Classification

A

DCDA - 1-3, own placenta, own sac
MCDA - 4-8, same placenta, own sac
MCMA - 8-13, same placenta, same sac

54
Q

Risks of Twin Pregnancy

A
  • Premature labour
  • Pre-eclampsia
  • Twin to Twin if MC, treat with laser
55
Q

Twin Delivery

A

DCDA

  • 37 weeks
  • Vaginal delivery if presenting twin cephalic

MCDA

  • 34-37 weeks
  • Vaginal Delivery if presenting twin cephalic

MCMA

  • 34 weeks
  • LSCS due to risk of entanglement
56
Q

Shoulder Dystocia - Mx

A

CALL FOR HELP

McRobert’s Manouvre

  • Flexion and adduction of hips
  • Knees to abdo
  • Suprapubic pressure

Episiotomy to make access for internal manouvers

57
Q

Delay in First Stage

A

<2cm in 4 hours for primip

<2cm in 4 hours or slowing in multip

AROM, oxytocin, LSCS

58
Q

Forceps Indication

A
  • 1 hour active pushing in second stage
  • Fluids
  • 4 in 10 contractions
  • Good condition of baby`
59
Q

Forceps Pros and Cons

A

Pros - 95% success rate

Cons - Painful, increased risk of tear, require episiotomy

60
Q

Venteuse Pros and Cons

A

Pros - Gentle?

Cons - increased failure rate (15-20%)

61
Q

LSCS - Maternal Risk

A
  • Infection
  • VTE
  • Bleeding

More than 3 C sections

  • bleeding/hysterectomy
  • Damage to bladder/bowel
  • Placenta accreta
  • Still birth
62
Q

LSCS - Fetal Risk

A
  • SCBU
  • Cut
  • Asthma
  • High BMI
63
Q

LSCS - Indications

A
  • Maternal choice
  • Fetal distress
  • Malpresentation
  • MCMA Twins
  • 2 previous LSCS
64
Q

Pre-Term Labour (<34 weeks)

A
  • Betamethasone 12mg x2 over 24 hours
  • Tocolytics to allow steroids to work
  • Abx in labour
65
Q

Placenta Praevia - Mx

A
  • Scan at 36 weeks to confirm
  • Admit (delay until 37 weeks if no symptoms)
  • IV Access and blood available
  • Rh-ve women - Anti D
  • Steroids <34 weeks

LSCS at 39 weeks

66
Q

Placenta Abruption - Mx

A
  • Admission
  • IV Fluids
  • Group and Save, Cross match 4 units, FBC
  • Anti D if Rh-ve
  • CTG
67
Q

Placenta Abruption - Delivery

A

> 37 weeks

  • Induce
  • Urgent LSCS if fetal distress

<34 weeks
- Steroids

Monitor on ward if no distress and minor bleed

68
Q

Chronic Hypertension

A

Labetalol 100mg BD
Target <150/100

Monitor urine dip

69
Q

Pregnancy Induced Hypertension

A

> 140/90 after 20 weeks with no proteinuria

70
Q

Pre-Eclampsia - Monitoring

A
  • BP and Urine Dip
  • Serial FBC, UEs, LFTs, clotting
  • UA doppler, daily CTG if abnormal
71
Q

Pre-Eclampsia - Mx

A

> 150/100 = labetalol

> 160/100 = urgent admission

Symtoms of pre-eclampsia: headaches, visual disturbance, epigastric pain
= urgent admission

72
Q

Pre-Eclampsia - Delivery

A

Maternal complications - deliver

Mild - by 37 weeks

Mod-severe - 34-46 weeks

Prophylactic Magnesium Sulphate

73
Q

VTE - Mx

A

Previous VTE - LMWH until 6 weeks PP
>4 risk Factors - LMWH until 6 weeks PP

On warfarin
-Replace with VTE until 6 weeks PP

BMI >40 or 2 Risk factors
- LMWH for 10 days PP

74
Q

PPH - Atonic Uterus Mx

A

ABCDE Approach

  • Ergometrine IV bolus
  • Suntocinon infusion
  • Prostaglandins
  • EUA/laparotomy
75
Q

PPH - Trauma Mx

A

Repair

76
Q

VTE - Acute Mx

A

ABCDE
- LMWH as soon as suspected

CXR
V/Q Scan

77
Q

What is H.E.L.L.P Syndrome?

A

Haemolysis

Elevated liver enzymes,

Low platelets

78
Q

HELLP - Mx

A

IV Magnesium Sulphate
IV Labetalol
Deliver when stable

79
Q

Gestational Diabetes - Risks

A

Maternal
- DKA in type 1, labile sugars, pre-eclampsia, eclampsia

Fetal
- Sudden IUD, neonatal hypoglycaemia, shoulder dystocia

80
Q

GDM - Mx

A

Insulin

  • Folic Acid 5mg until 12 weeks
  • Aspirin 75mg from 12 weeks

Scans

  • Growth and fluid: 28, 32, 36, 40 weeks
  • Anomaly/cardiac USS

Urine PCR every 4 weeks (proteinuria)

81
Q

Endometritis - RF

A 
LSCS
HIV +ve
Prolonged ROM
Meconium
Prolonged Labour
Retained products
82
Q

Contraception

A

Breastfeeding <6 weeks

  • LAM
  • PoP
  • Implant

Breastfeeding <6 months

  • PoP
  • Depo
  • Implant
  • IUD/IUS
  • COCP (UK MEC 2
83
Q

Lactation - Benefits

A
  • Increased immunity
  • Bonding
  • Supply and demand
  • Free
  • Weightloss
  • Protective against breast Ca
84
Q

Post-Partum Depression

A

< 1 year PP

Down, depressed or hopeless in past month?
Anhedonia?

85
Q

Post-Partum Depression - Mx

A

Mild - mod: self help

Mild with depression Hx: SSRI

Mod-severe:

  • CBT
  • SSRI (Caution in breastfeeding)
86
Q

Puerperal Psychosis

A

In 2 weeks PP

Screen for delusions/hallucinations

Assess risk to baby self partner public

Admit to Mother and Baby unit if psychotic

4th Year - Management (11 decks)

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