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PACES Mx > Obstetrics Mx > Flashcards

Obstetrics Mx Flashcards

1
Q

Diet and Exercise advice in GDM (4)

A 
􏰅 Self-monitoring of BG w/glucometer
􏰅 Diet - Refer ALL to dietician
􏰅 Exercise - 30mins walking/day until just
breathless
􏰅 Target: Fasting BG - 5.3 but >4 to
prevent hypoglycaemia
1hr BG - 7.8 or 2hr BG - 6.4
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2
Q

Neonatal side effects of VZV in pregnancy

A

<28 weeks: Congenital varicella syndrome (IUGR, microcephaly, limb hypoplasia, chorioretinitis)

28-36 weeks: Shingles (dermatomal distribution rash) in first few years of life

> 36 weeks: Neonatal chickenpox infection (especially if birth within 7 days of rash) and premature delivery

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3
Q

Mx of SGA

A

Screen infections: CMV, toxoplasmosis, syphilis
Umbilical artery doppler

Karyotyping may be offered
Steroids+deliver where there are neonatal facilities

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4
Q

Mx of retained product of conception

A

Elective curettage with antibiotic cover may be required.

Surgical measures should be undertaken if there is excessive
or continuing bleeding, irrespective of ultrasound findings.

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5
Q

Endometritis Mx

A

IV antibiotics if there are signs of severe sepsis.

If less systemically unwell – oral treatment may be sufficient

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6
Q

Endometritis risk factors

A 
Caesarian
Prolonged rupture of membranes
Severe meconium staining in liquor
Manual removal of placenta
Extreme maternal ages
Prolonged surgery
Retained products of conception
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7
Q

Classification of pre-eclampsia

A

Mild: Proteinuria + mild/mod HTN

Moderate: Proteinuria + severe HTN + no Cx

Severe: Proteinuria + HTN <34 or maternal Cx

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8
Q

Mx of pre-eclampsia?

A

Mild: 6 hourly BP, don’t deliver before 34 weeks

Moderate/severe: Oral labetalol , nifedipine and hydralazine can also be used
AVOID ACEi (teratogenic, reduced fetal urine output), ARB diuretic

MgSO4 to prevent/treat seizures

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9
Q

Pre-eclampsia questions (5)

A 
Headache, vision
Sudden swelling of hands/feet
Abdo pain/tenderness
Vomiting
Bleeding
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10
Q

3 or more miscarriages Mx

A

Antiphospholipid syndrome antibody screen
Give asprin & LMWH

Karyotype both parents􏰄Give donor or PGS of IVF
Pelvic USS􏰄Give IVF

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11
Q

Miscarriage Questions?

A

Colour, Clotting, Amount

Pain, Shoulder tip pain

RFs: Infection, trauma

PMH: DM, connective tissue disease, uterine abnormalities

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12
Q

Neonatal Tx if HIV in pregnancy

A

PO Zidovudine if viral load <50/ml
Triple ART if viral load >50/ml

Therapy continued for 4-6 weeks
Do NOT breastfeed

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13
Q

HIV in pregnancy Mx

A

Start ART 28-32 weeks and continued intrapartum

Zidovudine monotherapy: If viral load is <10,000/ml + if willing to deliver by prelabour caesarean section

HAART if viral load >10,000/ml

Vaginal if viral load <50
Zidovudine started 4 hours before Caesarian

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14
Q

Mx of miscarriage

A

Expectant (wait 2-6 weeks)

Medical: Misoprostol (prostaglandin) +/- mifepristone (anti-progesterone)

Surgery: Evacuation of retained products (ERCP) under anaesthetic

If RH -ve & >12 weeks OR medical/surgical: Give anti-D

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15
Q

VTE Mx

A

Graduated stockings for 2 years, elevate leg.
LMWH 1mg/kg BD for remainder of pregnancy. At least 6w postnatally

After delivery, choose to stay on LMWH or switch to warfarin.
Offer thrombophilia screening if strong personal or FH of VTE

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16
Q

PE Ix

A
  • ECG, ABG
  • Baseline investigations: FBC, coagulation screen, U&E, LFT
  • Perform compression duplex ultrasound if DVT symptoms.
  • CXR

CTPA or V/Q

17
Q

PE Mx

A
  1. ABCDE, senior involvement
  2. Urgent CTPA
  3. IV unfractionated heparin until PE excluded. LMWH 1mg/kg BD for remainder of pregnancy. At least 6w postnatally.
  4. Graduated stocking and mobilisation

“When you go home you should continue injecting yourself daily with the medication we give”

18
Q

Hyperemesis gravidarum Mx

A

Bland meals low in carbohydrates but high in protein, can try ginger.
PO cyclizine
Review in 1 week

Can switch to PO metoclopramide (max 5d)

Rehydrate if needed with 0.9% saline + KCL
Thiamine if needed

Serial growth scans if it continues into 2nd trimester

19
Q

When to admit with hyperemesis gravidarum

A 
Weight loss >5%, 
Ketonuria, 
Very dark urine (or no urination >8hrs)
Inability to keep food or fluids down for 24hrs 
Symptoms of pre-eclampsia
20
Q

GDM Mx

A
  1. Fasting glucose <7mmol/L, offer 2-week trial of diet and exercise. If targets of fasting<5.3mmol/L and 2hr glucose<6.4mmol/L are not met, offer metformin 500mg OD for 1w then 500mg BD for 1w then 500mg TDS.
    • Fasting glucose >7mmol/L, offer rapid-acting insulin (aspart, lispro) ± metformin and lifestyle changes.
    • Fasting glucose 6-6.9mmol/L, consider immediate insulin ± metformin and lifestyle changes.
  2. If metformin is insufficient, offer insulin.
  3. Offer 75mg aspirin daily until delivery
21
Q

GDM Ix

A

OGTT: 75g 2hr at booking and another at 24-28w if the first is negative and they have RFs. Offer review at diabetes antenatal clinic within 1w and contact GP.
• Fasting glucose> 5.6mmol/L
• 2hr glucose>7.8 mmol/L

22
Q

GDM counselling

A

Diabetes-antenatal clinic every 2 weeks
Test fasting, pre-meal, 1hr post-meal and bedtime glucose
Advise on hypoglycaemia Sx

Offer retinal assessment immediately and at 28w
Recommend elective birth by induced labour or caesarean from 37 to 38+6.

23
Q

Define pre-eclampsia

A
  • 140/90mmHg on 2 occasions 4hrs apart after 20w

* 30 mg/mmol protein:creatinine ratio

24
Q

Pre-eclampsia antenatal and postnatal Mx

A

US for foetal growth and umbilical artery doppler every 2-4 weeks
Measure FBC, LFT and U&E twice weekly
Initiate birth from 37 weeks

BP measured hourly intrapartum

Postnatal: measure BP 4 times a day, every 2 days up to 2 weeks after if on anti-hypertensives
Urine dip 6-8 weeks
GP follow up at 2 weeks

25
Q

Pre-conception counselling if on antihypertensives

A

Lifestyle changes

• Discontinue ACEi and ARBs and offer alternative antihypertensives

26
Q

HSV in pregnancy Mx

A

FIRST/SECOND TRIMESTER: acyclovir 400mg TDS 5d. Give acyclovir from 36w until delivery. Avoid vaginal delivery for 6w.

THIRD TRIMESTER: acyclovir 400mg TDS until delivery. Give IV if disseminated. Caesarean section indicated.
If vaginal delivery chosen, ROM and invasive procedures should be avoided. IV acyclovir intrapartum.

27
Q

Prevention of Pre-term labour

has history of spontaneous preterm birth or cervical length <25mm

A
  • Consider prophylactic vaginal progesterone between 16+0 and 24+0 until 34w.
  • Consider prophylactic cervical cerclage between 16+0 and 24+0 with previous PPROM or cervical trauma.
  • Consider rescue cerclage between 16+0 and 27+6 with dilated cervix and unruptured membranes.

• Do NOT offer rescue cerclage in infection, active PV bleed or uterine contractions.

28
Q

Mx of preterm labour with rupture of membranes

A
  1. Sterile speculum.
  2. Measure IGF binding protein 1
  3. Prophylactic erythromycin 250mg QDS 10d or until labour
  4. Test CRP, WCC, CTG to diagnose intrauterine infection.
  5. Offer maternal steroid up to 33+6. Consider up to 35+6.
  6. Offer 4g IV magnesium sulphate bolus over 15 mins with IV infusion 1g/hr until birth or 24hrs at 24-29+6. Consider at 30-33+6. Monitor HR, BP, RR, UO.
  7. Consult senior obstetrician about fetal monitoring 23-25+6.
29
Q

Mx of preterm labour with intact membranes

A
  1. Sterile speculum followed by digital examination.
  2. Offer nifedipine for 24+0 to 25+6. Consider up to 33+6.
  3. Under 29+6, manage as above.
  4. Over 30+0, consider TVUSS measurement of cervical length. If >15mm, consider discharge and safety netting. If <15mm, manage as above.
  5. Over 30+0 consider fetal fibronectin to support treatment if TVUSS is not available or acceptable
30
Q

Contraindications to VBAC

A
  • Previous uterine rupture
  • Classical caesarean scar
  • Absolute contraindications to vaginal birth that apply irrespective of scar eg major placenta praevia
31
Q

Counselling for VBAC vs ERCS

A
  • The advantages of VBAC are that if it is successful, you will have a shorter hospital stay and recovery. It also means that you have a good chance of successful future VBACs. However, there is a small risk of HIE to the baby during delivery and there is a 1 in 200 risk of uterine rupture. The absolute risk of birth-related death with VBAC is comparable to first time mums delivering vaginally.
  • The advantages of ERCS are the smaller risk of HIE and the no risk of anal sphincter injury as you will not be pushing. There is no risk of uterine rupture but there is increased risk of placental problems and adhesion formation. ERCS also means that you are likely to require caesareans in future.
  • If you choose to have a VBAC and don’t go into labour by 39w, your obstetrician will probably recommend a ERCS to minimise the risk of complications

PACES Mx (4 decks)

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