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Y4 Reproductive Health > Obstetrics Passmed 1 > Flashcards

Obstetrics Passmed 1 Flashcards

1
Q

Give some of the key causes of abdominal pain during pregnancy

A

Early:
Ectopic pregnancy / Miscarriage

Late:
Labour
Placental abruption
Uterine rupture
Symphysis pubis dysfunction
Pre-eclampsia/HELLP syndrome

Any time:
Appendicitis
UTI

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2
Q

Risk factors for ectopic pregnancy?

A

damage to tubes (salpingitis, surgery)
previous ectopic
IVF (3% of pregnancies are ectopic)

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3
Q

How can an ectopic pregnancy present?

A

female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

lower abdominal pain: usually constant and may be unilateral, due to tubal spasm
vaginal bleeding: usually less than a normal period, may be dark brown in colour

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

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4
Q

How does a threatened miscarriage present?

A

painless vaginal bleeding occurring before 24 weeks
typically occurs at 6 - 9 weeks
cervical os is closed

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5
Q

How does a missed (delayed) miscarriage present?

A

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion

mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear

when the gestational sac is > 25 mm and no embryonic/fetal part can be seen = ‘blighted ovum’ or ‘anembryonic pregnancy’

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6
Q

How does an inevitable miscarriage present?

A

cervical os is open
heavy bleeding with clots and pain
can be complete or incomplete

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7
Q

What happens in an incomplete miscarriage?

A

not all products of conception have been expelled
heavy bleeding and crampy, lower abdo pain
(in complete miscarriage there is less bleeding)

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8
Q

What is placental abruption? Key clinical features?

A

Placental abruption is separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Clinical features:
shock out of keeping with visible blood loss
constant pain
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems

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9
Q

What is symphysis pubis dysfunction?

A

Ligament laxity increases in response to hormonal changes of pregnancy
Causes pain over the pubic symphysis with radiation to the groin and the medial aspects of the thighs
A waddling gait may be seen

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10
Q

Describe the abdominal pain seen in pre-eclampsia

A

epigastric / RUQ pain
associated with hypertension / proteinuria

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11
Q

How does uterine rupture present?

A

Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree

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12
Q

Give some risk factors for uterine rupture

A

Previous caesarean section – this is the greatest risk factor for uterine rupture
Classical (vertical) incisions carry the highest risk

Previous uterine surgery – such as myomectomy

Induction – (particularly with prostaglandins) or augmentation of labour

Obstruction of labour – this is an important risk factor to consider in developing countries

Multiple pregnancy

Multiparity

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13
Q

Describe the location of the abdominal pain seen in appendicitis during pregnancy

A

Location changes depending on gestation

RLQ in the first trimester
umbilicus in the second
RUQ in the third

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14
Q

Alpha-fetoprotein (AFP) is a protein produced by the developing fetus.

Give some causes of a raised AFP

A

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

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15
Q

Give some causes of a low AFP

A

Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

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16
Q

Amniotic fluid emboli occur when fetal cells/ amniotic fluid enter the mothers bloodstream. The majority of cases occur during labour.

What are the symptoms and signs?

A

Symptoms include: chills, shivering, sweating, anxiety and coughing

Signs include: cyanosis, hypotension, tachycardia, bronchospasm, arrhythmia and MI

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17
Q

Key points of mx for antenatal N+V?

A

natural remedies - ginger and acupuncture on the ‘p6’ point (by the wrist)
antihistamines should be used first-line (promethazine)

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17
Q

Risk factors for amniotic fluid embolism?

A

increasing maternal age
induction of labour
C section
multiple pregnancy

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18
Q

How does placenta praevia present?

A

shock in proportion to visible loss
no pain , uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare , small bleeds before large

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19
Q

Why should vaginal examinations not be performed in primary care for suspected antepartum haemorrhage?

A

women with placenta praevia may haemorrhage

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20
Q

Define antepartum haemorrhage

A

bleeding after 24 weeks

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21
Q

How should antepartum haemorrhage be investigated?

A

FBC
Clotting profile, Group and Save & Cross-match
Kleihauer test if the woman is Rhesus negative (to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required)

U&Es and LFTs
to exclude pre-eclampsia and HELLP syndrome, and any other organ dysfunction

Assess Fetal Wellbeing using CTG in women above 26 weeks gestation

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22
Q

Give some maternal complications of APH

A

anaemia
coagulopathy
maternal shock
infection
renal tubular necrosis
prolonged hospital stay
psychological sequelae

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23
Q

Give some fetal complications of APH

A

hypoxia
SGA and growth restriction
prematurity
fetal death

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24
Causes of vaginal bleeding in the 1st trimester?
Spontaneous abortion Ectopic pregnancy Hydatidiform mole
25
Causes of vaginal bleeding in the 2nd trimester?
Spontaneous abortion Hydatidiform mole Placental abruption
26
Causes of vaginal bleeding in the 3rd trimester?
Bloody show Placental abruption Placenta praevia Vasa praevia
27
How does Hydatidiform mole present?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis Uterus may be large for dates and serum hCG is very high
28
How does Vasa praevia present?
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
29
Mx of nipple candidiasis?
miconazole cream for the mother and nystatin suspension for the baby
30
Mx of mastitis?
treat 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection' Oral fluclox 10-14 days, continue breastfeeding
31
How does Raynaud's disease of the nipple present? Mx?
intermittent pain present during and immediately after feeding blanching of the nipple followed by cyanosis and/or erythema Mx: minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking
32
Which abx should be avoided in breastfeeding?
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
33
Which psychiatric drugs should be avoided in breastfeeding mothers?
lithium, benzodiazepines
34
What techniques can be used to suppress lactation?
stop the lactation reflex i.e. stop suckling/expressing supportive measures: well-supported bra and analgesia cabergoline
35
What is the difference between a frank and footling breech presentation?
A frank breech is the most common presentation = hips flexed and knees fully extended A footling breech = one or both feet come first with the bottom at a higher position, rarer but carries a higher perinatal morbidity
36
What are the main risk factors for breech presentation?
uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality prematurity
37
How should breech presentations be managed?
if < 36 weeks: many fetuses will turn spontaneously > 36 weeks (or 37 weeks if multiparous) :external cephalic version (ECV) if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
38
What are the contraindications to ECV (pressure applied to abdomen to try and turn the baby)?
where caesarean delivery is required antepartum haemorrhage within the last 7 days abnormal cardiotocography major uterine anomaly ruptured membranes multiple pregnancy
39
What are Category 1 C sections?
an immediate threat to the life of the mother or baby examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia delivery of the baby should occur within 30 minutes of making the decision
40
What are Category 2 C sections?
maternal or fetal compromise which is not immediately life-threatening delivery of the baby should occur within 75 minutes of making the decision
41
What are Category 3 and 4 C sections?
3 = delivery is required, but mother and baby are stable 4 = elective
42
What are the 2 main types of C section?
lower segment caesarean section: most common classic caesarean section: longitudinal incision in the upper segment of the uterus
43
What is Cardiotocography (CTG)?
used to record pressure changes in the uterus using internal or external pressure transducers
44
What is normal fetal heart rate?
100-160 / min
45
What is fetal baseline bradycardia?
Heart rate < 100 /min Causes: Increased fetal vagal tone, maternal beta-blocker use
46
What is fetal baseline tachycardia?
Heart rate > 160 /min Causes: Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
47
What are early decelerations?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction Usually indicates head compression
48
What are late decelerations?
Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction Indicates fetal distress e.g. asphyxia or placental insufficiency
49
What are variable decelerations?
Independent of contractions May indicate cord compression
50
What are the features of fetal varicella syndrome?
skin scarring, eye defects (microphthalmia), microcephaly, limb hypoplasia and learning disabilities
51
How should chickenpox exposure in pregnancy be managed?
if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies if <20 weeks gestation and not immune to varicella: given varicella-zoster immunoglobulin (VZIG) as soon as possible if > 20 weeks gestation and not immune to varicella then either VZIG or antivirals (aciclovir) should be given days 7 to 14 after exposure
52
How should diagnosed chickenpox in pregnancy be managed?
oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
53
What is Chorioamnionitis? Mx?
ascending bacterial infection of the amniotic fluid / membranes / placenta major risk factor is the premature rupture of membranes which expose the normally sterile environment of the uterus to potential pathogens Mx = prompt delivery and IV abx
54
How does Down's syndrome present in antenatal testing?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
55
What is pre-eclampsia?
condition seen after 20 weeks gestation triad: pregnancy-induced hypertension (140/90) proteinuria oedema eclampsia is pre-eclampsia + seizures
56
How should pre-eclampsia be managed?
arrange emergency secondary care assessment oral labetalol is first-line, nifedipine (e.g. if asthmatic) and hydralazine may also be used women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
57
How should eclampsia be managed?
in eclampsia an IV bolus of magnesium sulphate (4g over 5-10 minutes) should be given followed by an infusion of 1g / hour urine output, reflexes, respiratory rate and oxygen saturations should be monitored during tx tx should continue for 24 hours after last seizure or delivery
58
What is the first-line treatment for magnesium sulphate induced respiratory depression?
calcium gluconate
59
What are the risks of sodium valproate and phenytoin in pregnancy?
sodium valproate: associated with neural tube defects phenytoin: associated with cleft palate
60
How can neural tube defects be prevented during pregnancy?
all women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
61
Which women should take more folic acid?
M = Metabolic conditions e.g. T1DM, coeliacs O = Obesity (BMI>30) R = Relative (PMHx) E = epilepsy (on anti-epileptics)
62
Causes of placental abruption?
A = Abruption previously B = Blood pressure (i.e. hypertension or pre-eclampsia) R = Ruptured membranes, either premature or prolonged U = Uterine injury (i.e. trauma to the abdomen); P = Polyhydramnios T = Twins or multiple gestation I = Infection in the uterus, especially chorioamnionitis O = Older age (over 35 years old) N = Narcotic use
63
What is a galactocoele?
cystic lesion in the breast caused by a build up of milk usually painless
64
Give some risk factors for gestational diabetes
BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
65
What is used to screen for gestational diabetes?
OGTT women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal women with risk factors: 24-28 weeks
66
What is diagnostic for gestational diabetes?
fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L
67
How should gestational diabetes be managed?
fasting plasma glucose level < 7 mmol/l = a trial of diet and exercise should be offered - if glucose targets not met within 1-2 weeks metformin should be started - if glucose targets are still not met insulin should be added (short-acting) if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
68
What are the fetal complications of GD?
Macrosomia – this can cause complications during labour, such as shoulder dystocia, obstructed/delayed labour, and/or higher rates of instrumental deliveries Organomegaly (particularly cardiomegaly) Erythropoiesis (resulting in polycythaemia) Polyhydramnios Increased rates of pre-term delivery
69
How should pre existing diabetes be managed in pregnancy?
weight loss for women with BMI of > 27 kg/m2 stop oral hypoglycaemic agents (bar metformin) and commence insulin, ensure tight glycaemic control folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts treat retinopathy as can worsen during pregnancy
70
What is a hydatidiform mole?
Benign tumour of trophoblastic material occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, all 46 chromosomes are of paternal origin
71
Benzylpenicillin is the antibiotic of choice for Group B Strep intrapartum antibiotic prophylaxis (IAP). Who should be offered it?
women with a previous baby with GBS disease women in preterm labour women with a pyrexia during labour (>38ºC) women who've had GBS detected in a previous pregnancy should be offered (IAP) OR testing in late pregnancy and then antibiotics if still positive
72
What is HELLP syndrome? How should it be managed?
Hemolysis, Elevated Liver enzymes, and a Low Platelet count Features: nausea & vomiting right upper quadrant pain lethargy Mx = delivery of the baby
73
What techniques can be used to reduce vertical transmission of HIV?
maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)
74
What modes of delivery are available to mothers with HIV?
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended a zidovudine infusion should be started four hours before beginning the caesarean section
75
What neonatal antiretroviral therapy is offered to babies of mothers with HIV?
zidovudine orally if maternal viral load is <50 copies/ml Otherwise triple ART should be used Therapy should be continued for 4-6 weeks
76
Define hypertension in pregnancy
systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
77
How should pregnancy induced hypertension (htn after 20 weeks with no oedema or proteinuria) be managed?
oral labetalol is now first-line oral nifedipine (e.g. if asthmatic) and hydralazine
78
Indications for induction of labour?
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes maternal medical problems intrauterine fetal death
79
How can the Bishop Score be interpreted?
a score of < 5 = labour is unlikely to start without induction a score of ≥ 8 = cervix is ripe, or 'favourable' - high chance of spontaneous labour, or response to interventions made to induce labour
80
What is the membrane sweep?
involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
81
What is the NICE guidance on methods used to induce labour?
if the Bishop score is ≤ 6: vaginal prostaglandins or oral misoprostol (balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean) if the Bishop score is > 6: amniotomy and an intravenous oxytocin infusion
82
What is uterine hyperstimulation?
prolonged and frequent uterine contractions - sometimes called tachysystole the main complication of induction of labour may cause fetal hypoxemia and acidemia or rarely uterine rupture stop the infusion!!!
83
How should intrahepatic cholestasis of pregnancy be managed?
induction of labour at 37-38 weeks and ursodeoxycholic acid - both widely used but evidence base not clear vitamin K supplementation
84
What is intrahepatic cholestasis of pregnancy?
when outflow of bile acids is reduced, causing them to build up in the blood thought to be due to increased oestrogen and progesterone levels
85
how does intrahepatic cholestasis of pregnancy present?
pruritus (hands and feet) jaundice fatigue dark urine pale greasy stools
86
What are the 3 stages of labour?
stage 1: from the onset of true labour to when the cervix is fully dilated stage 2: from full dilation to delivery of the fetus stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
87
Complications of obstetric cholestasis?
maternal - increased risk of gallstones and liver disease fetal - increased risk of passing meconium during labour, prematurity and stillbirth
88
What monitoring should be provided in labour?
FHR monitored every 15min (or continuously via CTG) Contractions assessed every 30min Maternal pulse rate assessed every 60min Every 4 hours: Maternal BP and temp VE should be offered Maternal urine should be checked for ketones and protein
89
What are the 2 phases of stage 1 of labour?
latent phase = 0-3 cm dilation, normally takes 6 hours active phase = 3-10 cm dilation, normally 1cm/hr
90
What are the 2 phases of stage 2 of labour?
'passive second stage' refers to the 2nd stage but in the absence of pushing active second stage' refers to the active process of maternal pushing
91
What are the options if stage 2 of labour lasts for longer than 1 hour?
Ventouse extraction, forceps delivery or caesarean section
92
Indications for a forceps delivery?
fetal / maternal distress in the second stage of labour failure to progress in the second stage of labour control of head in breech delivery
93
Define lochia
vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth if it persists beyond 6 weeks an USS is indicated
94
In oligohydramnios there is reduced amniotic fluid (less than 500ml at 32-36 weeks). What can cause this?
premature rupture of membranes Potter sequence (bilateral renal agenesis + pulmonary hypoplasia) intrauterine growth restriction post-term gestation pre-eclampsia

Y4 Reproductive Health (13 decks)

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