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Y4 Reproductive Health > Obstetrics Passmed 2 > Flashcards

Obstetrics Passmed 2 Flashcards

1
Q

How can perineal tears be classified?

A

first degree:
superficial damage with no muscle involvement
do not require any repair

second degree:
injury to the perineal muscle, not involving the anal sphincter
require suturing on the ward

third degree:
injury to perineum involving the anal sphincter
require repair in theatre

fourth degree:
injury to perineum involving the anal sphincter and rectal mucosa
require repair in theatre

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2
Q

Risk factors for perineal tears?

A

primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery

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3
Q

What is placenta accreta? Risk factors?

A

attachment of the placenta to the myometrium, due to a defective decidua basalis

= inc risk of PPH

Risk factors:
previous caesarean section
placenta praevia

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4
Q

What is placenta praevia? How can it be graded?

A

placenta lying wholly or partly in the lower uterine segment

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os

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5
Q

What are the risk factors for placenta praevia?

A

Maternal age >40 years
Previous C section
Multiparity
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Curettage to the endometrium after miscarriage or termination

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6
Q

If low-lying placenta at the 20-week scan:

A

rescan at 32 weeks, no need to limit activity
if still present at 32 weeks then scan every 2 weeks
final ultrasound at 36-37 weeks to determine the method of delivery
elective caesarean section for grades III/IV between 37-38 weeks

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7
Q

Mx of placenta praevia with bleeding?

A

admit
ABC approach to stabilise the woman
if not able to stabilise → emergency caesarean section
if in labour or term reached → emergency caesarean section

in all cases of antepartum haemorrhage, give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative

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8
Q

Factors associated with placental abruption?

A

proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age

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9
Q

How should placental abruption be managed?

A

no fetal distress:
< 36 weeks = observe closely, steroids
> 36 weeks = deliver vaginally

fetal distress: immediate caesarean

fetus dead : induce vaginal delivery

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10
Q

Complications of placental abruption?

A

Maternal:
shock
DIC
renal failure
PPH

Fetal:
IUGR
hypoxia
death

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11
Q

Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery or 1000ml blood loss after C section.

What are the causes of primary PPH?

A

Tone (uterine atony - failure of adequate contractions): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)

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12
Q

Give some risk factors for primary PPH

A

previous PPH
pre-eclampsia
polyhydramnios
prolonged labour
placenta praevia, placenta accreta
macrosomia
increased maternal age
emergency Caesarean section

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13
Q

What is classed as minor v major PPH?

A

minor is under 1000ml blood loss
major is over 1000ml blood loss

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14
Q

How should PPH be managed?

A

escalate to senior staff members immediately

STABILISE:
two peripheral cannulae (14G), bloods including group and save
lie the woman flat
commence warmed crystalloid infusion

MECHANICAL:
palpate the uterine fundus and rub it to stimulate contractions
catheterisation to prevent bladder distension and monitor urine output

MEDICAL:
IV oxytocin (slow IV injection followed by an IV infusion) , ergometrine , carboprost IM (unless there is a history of asthma) , misoprostol sublingual

SURGICAL:
intrauterine balloon tamponade where uterine atony main cause of haemorrhage

other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
hysterectomy is sometimes performed as a life-saving procedure

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15
Q

What is secondary PPH?

A

occurs between 24 hours - 6 weeks

typically due to retained placental tissue or endometritis

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16
Q

Postpartum mental health problems range from the ‘baby-blues’ to puerperal psychosis.

What score can be used to screen for this?

A

The Edinburgh Postnatal Depression Scale
maximum score of 30
score > 13 indicates a ‘depressive illness of varying severity’

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17
Q

What are the key features of baby blues? Mx?

A

3-7 days following birth and is more common in primips, mothers are characteristically anxious, tearful and irritable

Mx: reassurance, support from health visitors

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18
Q

When does postnatal depression usually come on? Mx?

A

Most cases start within a month and typically peaks at 3 months

Mx: CBT, sertraline / paroxetine

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19
Q

What are the key features of puerperal psychosis? Mx?

A

Onset usually within the first 2-3 weeks following birth

Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Mx: admission to mother and baby unit

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20
Q

What are the 3 stages of postpartum thyroiditis?

A
  1. Thyrotoxicosis - give propanolol
  2. Hypothyroidism - give thyroxine
  3. Normal thyroid function (but high recurrence rate in future pregnancies)
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21
Q

What are the potential complications of pre-eclampsia?

A

progression to eclampsia

altered mental status, blindness, stroke, clonus, severe headaches

liver involvement (elevated transaminases)

haemorrhage: placental abruption, intra-abdominal, intra-cerebral

cardiac failure

fetal complications (intrauterine growth retardation, prematurity)

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22
Q

What features might severe pre-eclampsia present with?

A

hypertension: typically > 160/110 mmHg
proteinuria: dipstick ++/+++
headache , visual disturbance, papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

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23
Q

What preventative tx can be given to women at moderate or high risk of developing pre-eclampsia?

A

aspirin 75-150mg daily from 12 weeks gestation until the birth

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24
Q

When should women be treated for anaemia in pregnancy? What is the treatment?

A

First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L

oral ferrous sulphate, continued for 3 months after correction

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25
What are the risks of CTPA and VQ scanning in pregnancy?
CTPA - slightly increased risk of maternal breast cancer VQ - slightly increased risk of childhood cancer
26
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery. How does it present?
headache abdominal pain, N+V jaundice hypoglycaemia severe disease may result in pre-eclampsia ALT raised on investigation
27
How should obesity be managed in pregnancy?
5mg of folic acid, rather than 400mcg all obese women should be screened for gestational diabetes with OGTT at 24-28 weeks if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist
28
Risks of smoking in pregnancy?
Increased risk of miscarriage, pre-term labour and stillbirth IUGR Increased risk of sudden unexpected death in infancy
29
How does fetal alcohol syndrome present?
learning difficulties characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly IUGR & postnatal restricted growth
30
What are the risks of cocaine use in pregnancy?
Maternal risks hypertension in pregnancy including pre-eclampsia placental abruption Fetal risk prematurity neonatal abstinence syndrome
31
What are the risks of premature delivery?
intraventricular haemorrhage (brain bleed) retinopathy of prematurity hearing problems respiratory distress syndrome necrotizing enterocolitis (inflamed SI) chronic lung disease, hypothermia, feeding problems, infection, jaundice
32
How should preterm prelabour rupture of the membranes (PPROM) be confirmed?
a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
33
How should PPROM be managed?
admission regular observations to ensure chorioamnionitis is not developing oral erythromycin should be given for 10 days antenatal corticosteroids
34
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. What are the main causes?
endometritis: most common cause UTI wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
35
How should endometritis be managed?
patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
36
How should shoulder dystocia be managed?
McRoberts' manoeuvre should be performed: this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen
37
What are the potential complications of untreated shoulder dystocia?
Maternal – 3rd or 4th degree tears (3-4%), post-partum haemorrhage (11%) Fetal – humerus or clavicle fracture, brachial plexus injury (2-16%), hypoxic brain injury
38
The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres. What is the normal range?
should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
39
A nuchal US scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include:
Down's syndrome congenital heart defects abdominal wall defects
40
Causes of hyperechogenic bowel on USS of a foetus:
cystic fibrosis Down's syndrome cytomegalovirus infection
41
Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia. What are the main risk factors?
prematurity polyhydramnios multiparity multiple pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie 50% of cord prolapse occurs after artificial rupture of membranes
42
How should cord prolapse be managed?
the presenting part of the fetus may be pushed back into the uterus to avoid compression if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm the patient is asked to go on 'all fours' until emergency C section tocolytics may be used to reduce uterine contractions (e.g. terbutaline)
43
What is the treatment of choice for VTE prophylaxis in pregnancy?
LMWH Avoid DOACs!!!
44
What is Twin-to-twin transfusion syndrome (TTTS)?
relatively common complication of monochorionic twin pregnancies The two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the 'donor' receives a lesser share of the placenta's blood flow than the other twin, the 'recipient'.
45
What diagnosis would you consider for a patient under 20 weeks with hypertension and minimal proteinuria?
chronic hypertension - existent before pregnancy
46
What can be done in an antenatal clinic as an informal method of induction?
membrane sweep
47
At what stage of an uncomplicated pregnancy should women be offered induction?
41-42 weeks
48
What is the most common explanation for short episodes (< 40 minutes) of decreased variability on CTG?
foetus is asleep
49
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler, what should be offered?
immediate USS
50
Which antiepileptics are known to have the smallest effects on the developing foetus?
Lamotrigine, carbamazepine and levetiracetam
51
What layers does an obstetrician have to go through when performing a C section?
FART EPU Superficial Fascia, deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
52
What is the Wood's screw manoeuvre?
putting a hand in the vagina and rotating the foetus 180 degrees in attempt to 'dislodge' the anterior shoulder from the symphysis pubis only done after McRobert's has been attempted
53
Course of action for patient with raised blood pressure above 160/100 mmHg combined with the significant proteinuria?
emergency hospital admission for monitoring
54
What is the most appropriate immediate action while preparing a patient with a prolapsed cord for a caesarian section?
Retrofilling the bladder with 500-700ml of saline
55
late decelerations in the context of foetal bradycardia =
deliver ASAP! instrumental delivery or C section depending on level of dilation
56
Which additional measure can aid the effectiveness of McRobert's manoeuvre?
applying supra pubic pressure
57
Management of patients on methotrexate trying to conceive?
must be stopped at least 6 months before conception in both men and women
58
What is Fetal fibronectin (fFN)?
a protein that is released from the gestational sac Having a high level has been shown to be related with early labour
59
What further options are available for Down's syndrome screening for patients determined to be at higher risk on the combined test?
non-invasive prenatal screening test (NIPT) - least risk of harm to baby amniocentesis chorionic villous sampling (CVS)
60
Down's syndrome: quadruple test result?
↓ AFP ↓ oestriol ↑ hCG ↑ inhibin A
61
What is Sheehan's syndrome?
complication of severe PPH in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan's syndrome is a lack of postpartum milk production and amenorrhoea following delivery.
62
When does the early scan to confirm dates and exclude multiple pregnancy occur?
10 - 13+6 weeks
63
When is the booking visit?
8 - 12 weeks (ideally < 10 weeks)
64
When is the Down's syndrome screening including nuchal scan?
11 - 13+6 weeks
65
When is the anomaly scan?
18 - 20+6 weeks
66
When is anti-D prophylaxis given to rhesus negative women?
28 and 34 weeks
67
At what gestation would a referral to the maternal fetal medicine unit be warranted for a mother not having experinced fetal movements?
24 weeks
68
How should premature labour be managed?
Admit and administer tocolytics and steroids
69
Mx if a breastfed baby loses > 10% of birth weight in the first week of life?
referral to a midwife-led breastfeeding clinic may be appropriate
70
SSRIs of choice in breastfeeding women?
Sertraline or paroxetine
71
Test results for molar pregnancy?
High beta hCG, low TSH, high thyroxine (imagine beta HCG acts like TSH)
72
What terminology is used to describe the head in relation to the ischial spine?
station
73
Risk factors for pre-eclampsia?
40 years or older Nulliparity Pregnancy interval of more than 10 years FMH/PMH of pre-eclampsia BMI > 30 Pre-existing vascular disease/ renal disease Multiple pregnancy
74
recurrence rate of postnatal psychosis?
25-50%
75
The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS:
Fully dilated cervix OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known Ruptured Membranes Cephalic presentation Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally Pain relief Sphincter (bladder) empty this will usually require catheterization
76
A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch. What is the diagnosis?
Ectopic pregnancy
77
Sepsis in the neonate can broadly be divided into early-onset (<48 hours since birth) and late-onset (>48 hours from birth). What are the causative organisms?
Early-onset sepsis is associated with micro-organisms from the mothers birth canal e.g. Group B Strep Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.
78
What approach should be taken if a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension?
this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review
79
A hepatitis B serology positive woman gives birth to a healthy baby girl. The mother is surface antigen positive. What treatment should be given to the baby?
Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months
80
Indications for continuous CTG monitoring in labour?
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour
81
How would you calculate a patient's Bishop Score?
Cervical position : Anterior = +2 Cervical consistency : Soft= +2 Cervical effacement : 60-70% = +2 Cervical dilation : 3-4cm = +2 Fetal station : 0 = +2
82
What is uterine inversion? How does it present?
a rare complication of birth where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out typically presents with large PPH
83
How can uterine inversion be managed?
Johnson manoeuvre - hand pushes it back up hydrostatic methods - filling vagina with fluid surgery
84
Complications of amniotic fluid embolism?
Prolonged respiratory failure with adult respiratory distress MI, Cardiomyopathy, CCF Renal failure Prolonged coagulopathy Liver failure Seizures
85
Key points of mx for antenatal N+V?
natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) antihistamines should be used first-line (promethazine)

Y4 Reproductive Health (13 decks)

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