Obstetrics - Management Flashcards
Minor Pregnancy Problems
Reflux
- Extra pillows and antacids
- Rule out pre-eclampsia
Constipation
- Movicol
- Increase fibre intake
Vaginitis
- Clotrimazole pessary
Hyperemesis Gravidarum - Rx
Increase fluid intake
Not tolerating oral
- Admission and IV Fluids
- Levomepromazine
Hype. Gravidarum - Complications
- IUGR if >10% weight lose
- Wernicke’s encephalopathy - give pabrinex
Small for Dates
<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
Large for Dates - Investigations
> 90th centile = GTT
GTT at 24-28 weeks
Large for Dates - Delivery
@ 41 weeks
BMI <30/favourable cervix induce at 41+4
BMI >30/unfavourable cervix = induce/LSCS at 41
IUGR - Rx
Weekly UA doppler and 2 weekly growth scans
- Daily CTG if doppler abnormal
- Delivery at 37 weeks, earlier if compromise
Scan - BPP
- Breathing
- Movements
- Fetal tone
- Amniotic fluid volume
If any decreased/depleted could indicate IUGR as baby not wasting time on moving etc if restricted
Dopplers
Umbilical = placenta -> foetus Uterine = mum -> placenta
Prolonged Pregnancy
> 42 weeks
- Sweep cervix
- Daily CTG (if abnormal, deliver)
Bishop’s Score
Likelihood of spontaneous labour
> 8 = labour likely
<8 - induction may be required
Reduced Foetal Movements
Lie on left side and count kicks for 2 hours
- less than 10: come to MAC
RFM >28 weeks
Auscultate foetal heart
- rapid CTG - abnormal = deliver
- USS within 24 hours - manage as SGA
- Normal = reassure
RFM <24 weeks
Auscultate foetal heart
- If present, assess for neuromuscular conditions
PROM - Examination
Observations - check for infection
- Sterile speculum
- Antenatal exam
PROM - Investigations
CTG
HV Swab
PROM - Rx
90% will deliver in 48 hours, induce after 24 hrs
Infection
- Broad spec cef and met IV
- Deliver immediatly
PROM - Neonatal Abx
If labour >18 hours
PPROM - Exam
Sterile speculum
CTG <26 weeks
PPROM - Rx
- 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
Antenatal Scans
Dating
11+2 - 14+1
Anomaly
18-20+6
Bloods
8-12 weeks
- HIV, Hep B
- Coagulopathies
- Rhesus and HBO type
Rhesus status
If -ve
ANTI D
- 28 and 24 weeks
- 72 hours post delivery
- Vaginal bleed
Combined Screening
- USS - nuchal translucency
2. Bloods - HCG and PAPPa
Diagnositic tests
CVS - from 11 weeks
- 1% risk
Amniocentesis from 15 weeks
- 0.8 % risk
Harmony/Iona
- Non-invasive blood test, private
Quadruple test
If >14 weeks
- Blood test for down’s syndrome
HIV in Pregnancy
ART
- Undetectable by 36 weeks (<50 = VD)
- Breastfeeding 10x chance, only until 6 months
Neonate
- 4 weeks ART
Parter
- Protected sex/abstinence
Hep B
Notifiable
- Vaccination x 5 for neonate
- Safe to breastfeed
Epilepsy - Risks
Increase seizures
- NTD
- Sodium valproate syndrome
- Orofacial clefts
Epilepsy - Management
Folic acid 5mg
Monotherapy (lamotrigine, levotiricetam)
Oral vit K at 36-40 weeks
Abx for UTI
- Trimethoprim (not in 1st trimester)
- Nitrofurantoin (not in 3rd trimester - haemolysis)
Abx for Chorioamnionitis
- Cefuroxime 1.5mg TDS IV
- Metronidazole 500mg TDS IV
Abx for Endometritis
- Co-amoxiclav 1.2g IV TDS
Penicillin allergy
- Clindamycin and metronidazole
Anticoagulants safe in Pregnancy
LMWH
- unfractionated heparin if eGFR < 30
Warfarin - Dangers
- 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
Safe Analgesia
- Paracetamol
- Opioids (do cause resp depression as cross placenta)
- Entinox
Dangerous Analgesia
NSAIDS
- 1st trimester = miscarriage and malformation
- 3rd trimester = premature closure of PDA
Normal Labour
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
CTG (>26 weeks)
DR - Define Risk
C - Contraction (4 in 10)
BR - Baseline Rate (100-160) A - Accelerations, reassuring VA - Variability >5 D - Decellerations O - overall impression
Non-reassuring CTG
Left lateral side
Give IV fluids
Fetal scalp stimulation
FBS
Fetal Blood Sample
> 7.25 - normal
7.20-7.25 - borderline, repeat in 30 mins
<7.20 - deliver immediately
Analgesia in Labour
- Entinox
- Opiods
- Regional (increased risk of operative delivery)
Complications of Epidural
Failure
Low BP
LA toxicity
Total spinal
Induction Methods
Membrane sweeping
Prostaglandin into posterior fornix (propess 10mg)
Artificial ROM
Oxytocin regime for increase contractions
Complications of Induction
- Fetal distress
- Rapid delivery (trauma and APH)
- Uterine hypertonia and rupture
- Amniotic fluid embolus
Contraindications of Induction
- Unstable lie
- Acute fetal compromise
- Placenta praevia
- Previous LSCS
Malposition
Optimal = OA
OP = back to back OT = head sideways in birth canal Brow = forehead first, wider part to deliver
Complications of Malposition
- Longer delivery
- Increase pain
- Increased intervention (LSCS, Forceps)
Breech - Exam
HR above umbilicus
Head at top of uterus
Breech - USS
Check at 36 weeks
Full = bum first
Partial/Footling = knees/feet first (must be LSCS)
ESV
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
Transverse/Unstable
Admit due to increased risk of cord compression
- Discharge if moves to longitudinal and stays for 38 hours
If transverse at 36 weeks - LSCS
Twin Classification
DCDA - 1-3, own placenta, own sac
MCDA - 4-8, same placenta, own sac
MCMA - 8-13, same placenta, same sac
Risks of Twin Pregnancy
- Premature labour
- Pre-eclampsia
- Twin to Twin if MC, treat with laser
Twin Delivery
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
Shoulder Dystocia - Mx
CALL FOR HELP
McRobert’s Manouvre
- Flexion and adduction of hips
- Knees to abdo
- Suprapubic pressure
Episiotomy to make access for internal manouvers
Delay in First Stage
<2cm in 4 hours for primip
<2cm in 4 hours or slowing in multip
AROM, oxytocin, LSCS
Forceps Indication
- 1 hour active pushing in second stage
- Fluids
- 4 in 10 contractions
- Good condition of baby`
Forceps Pros and Cons
Pros - 95% success rate
Cons - Painful, increased risk of tear, require episiotomy
Venteuse Pros and Cons
Pros - Gentle?
Cons - increased failure rate (15-20%)
LSCS - Maternal Risk
- Infection
- VTE
- Bleeding
More than 3 C sections
- bleeding/hysterectomy
- Damage to bladder/bowel
- Placenta accreta
- Still birth
LSCS - Fetal Risk
- SCBU
- Cut
- Asthma
- High BMI
LSCS - Indications
- Maternal choice
- Fetal distress
- Malpresentation
- MCMA Twins
- 2 previous LSCS
Pre-Term Labour (<34 weeks)
- Betamethasone 12mg x2 over 24 hours
- Tocolytics to allow steroids to work
- Abx in labour
Placenta Praevia - Mx
- 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
Placenta Abruption - Mx
- Admission
- IV Fluids
- Group and Save, Cross match 4 units, FBC
- Anti D if Rh-ve
- CTG
Placenta Abruption - Delivery
> 37 weeks
- Induce
- Urgent LSCS if fetal distress
<34 weeks
- Steroids
Monitor on ward if no distress and minor bleed
Chronic Hypertension
Labetalol 100mg BD
Target <150/100
Monitor urine dip
Pregnancy Induced Hypertension
> 140/90 after 20 weeks with no proteinuria
Pre-Eclampsia - Monitoring
- BP and Urine Dip
- Serial FBC, UEs, LFTs, clotting
- UA doppler, daily CTG if abnormal
Pre-Eclampsia - Mx
> 150/100 = labetalol
> 160/100 = urgent admission
Symtoms of pre-eclampsia: headaches, visual disturbance, epigastric pain
= urgent admission
Pre-Eclampsia - Delivery
Maternal complications - deliver
Mild - by 37 weeks
Mod-severe - 34-46 weeks
Prophylactic Magnesium Sulphate
VTE - Mx
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
PPH - Atonic Uterus Mx
ABCDE Approach
- Ergometrine IV bolus
- Suntocinon infusion
- Prostaglandins
- EUA/laparotomy
PPH - Trauma Mx
Repair
VTE - Acute Mx
ABCDE
- LMWH as soon as suspected
CXR
V/Q Scan
What is H.E.L.L.P Syndrome?
Haemolysis
Elevated liver enzymes,
Low platelets
HELLP - Mx
IV Magnesium Sulphate
IV Labetalol
Deliver when stable
Gestational Diabetes - Risks
Maternal
- DKA in type 1, labile sugars, pre-eclampsia, eclampsia
Fetal
- Sudden IUD, neonatal hypoglycaemia, shoulder dystocia
GDM - Mx
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)
Endometritis - RF
LSCS HIV +ve Prolonged ROM Meconium Prolonged Labour Retained products
Contraception
Breastfeeding <6 weeks
- LAM
- PoP
- Implant
Breastfeeding <6 months
- PoP
- Depo
- Implant
- IUD/IUS
- COCP (UK MEC 2
Lactation - Benefits
- Increased immunity
- Bonding
- Supply and demand
- Free
- Weightloss
- Protective against breast Ca
Post-Partum Depression
< 1 year PP
Down, depressed or hopeless in past month?
Anhedonia?
Post-Partum Depression - Mx
Mild - mod: self help
Mild with depression Hx: SSRI
Mod-severe:
- CBT
- SSRI (Caution in breastfeeding)
Puerperal Psychosis
In 2 weeks PP
Screen for delusions/hallucinations
Assess risk to baby self partner public
Admit to Mother and Baby unit if psychotic
