Obstetrics Pregnancy Flashcards
What are the functions of the placenta?
Organ of respiration
Organ of nutrients transfer and excretion
Organ of hormone synthesis
How can the expectant date be worked out?
Establish regularity of menstrual cycle.
If normal:
+ 7 days. - 3 months (+following year)
or
Ultrasound dating
Where would you expect the uterine growth to be to at 20 weeks gestation?
Umbilicus
What are the trimesters?
1st trimester: <12 weeks
2nd trimester: 12-28 weeks
3rd trimester: > 28 weeks
What is the function of hCG? and where produces it?
Produced by the placenta specifically the trophoblast cells
To maintain Oestrogen and progesterone
What is the effect of progesterone in pregnancy?
Progesterone relaxes the uterus, allowing dilation.
It also relaxes the:
- Lower esophageal sphincter
- Peristalsis
- accounting for gastric reflux and delay in stomach emptying
What are the physiological changes during pregnancy:
Enlargement of pituitary gland
- 50% increase.
- prolactin
Haematological:
- increased clotting factors
- Anaemia - increased use of Iron and increased plasma
Thyroid function
- increased thyroid binding globulin
- increased T4, T3 in response
- free thyroid hormone still same, TSH still same
Uterus
- relaxes
- enlarges
- increased smooth muscle
Cervix:
- Softer
- swollen
Vagina:
- mucosal thickening
- more dilation
Cardiovascular
- increased cardiac output
- drop in blood pressure early pregnancy
Respiratory
- increases slightly
- Increased tidal volumes
- driven by progesterone
Renal:
- renal pelvis and ureter relaxation - Hydronephrosis can occur
- increased GFR - can lead to glucose in urine
- urinary stasis - increased risk of UTIs
G.I:
- Delayed gastric emptying
- Reduced peristalsis (constipation)
What are the aims of the first antenatal clinic and when should be it be arranged by?
Booking appt made by 10 weeks and seen on 12th week.
- Full PMH
- Past obstetric history
- Screening blood tests (FBC, G&S, Syphilis, Rubella, HIV)
- Dating scan for EDD
- identify risks (including domestic violence)
- Screen for abnormalities
- Develop Rapport
- Provide health info
- social work if needed
How is the Due date worked out?
Naegeles Rule:
- (Last menstrual period + 7 days) - 3 months
+ 1 year
So if the LMP was 15th July 2021:
15th + 7 days = 22nd July - 3 months = 22nd April + 1 year:
= 22nd April 2022
**note you need to be careful for womens who menstrual cycle is not the standard 28days. you may need to add less or more than 7 days
What screening can be done into Down’s syndrome?
Triple test: Conducted at 11th-14th week: - Nuchal translucency \+ - PAPP-A (low) \+ - beta - hCG (high)
> 14 weeks: Quadruple test can be done.
- beta - hCG
- AFP
- Inhibin A
- Oestriol
These can be combined to give a score. If high 1/200 then
- amniocentesis can be conducted 15 weeks
- Chorionic villus sampling 11 weeks
What non-invasive Parental testing can be offered?
Cell Free fetal DNA
What key Care is given during the second trimester?
Fetal Anomaly Scan
- 18 - 22 weeks
Antenatal appointments
- BP
- Urinalysis
- Fetal HR - 18 weeks
Assessment of common problems
What key aspects of care/ investigations/ questions are sought in third trimester?
BP/ Urinalysis/ Auscultation of fetal heart rate
Vaginal pain
Enquire about fetal movements
abdominal distention
- inspection
- palpation
- auscultation
Describe the differences between Pregnant and non-pregnant uterus:
Non - pregnant:
- Almost solid
- Approximately 70g
- <10ml
Pregnant:
- Thin walled (1.5cm)
- Approx 10g
- Approx 5L
What are the signs of labour:
Regular painful contractions
Interval between contractions decreasing
Increased pain
Contraction during increasing
Increased cervical dilation
A show
- this mucus formation at the cervix which breaks off. This can occur a few days before. it demonstrates the cervix is softening in preparation for labour
When reading a CTG - how should you interrupt it?
DR C BRAVADO
Define Risk
Contractions
Baseline Rate Variability Accelerations Deaccelerations Overall impression
How is normal labour monitored?
Normally monitored on Partogram:
Vaginal Examination
- 4 hourly
- assess dilatation
Maternal Urine
- 4 hourly
- Ketones
- Protein
Maternal Stats
- temperature
- BP
- HR
Fetal HR
- every 15 mins
- especially after contractions
*if the pregnancy is more high risk then CTG monitoring may be required +/- fetal scalp or electrodes
What is called when a non-natural process is used for third stage of labour and why is there a delay in the cord clamping?
Active third stage management:
- cord traction
- use of syntometrine
- delayed cord clamping
*this reduced PPH and anaemia in baby.
Delay clamping:
- Improves haematocrit
- Reduces need for fetal transfusion
- is done at 1 minute
What drug is given routine to promote uterine contraction? and what does it consist off?
Syntrometrine
- ergometrine (alpha, dopamine, 5HT2 agonist)
- Oxytocin
Name two measures that can be done to prevent preterm:
Pessary progesterone
- prevents uterine contraction
- prevents dilatation of the cervix
Cervical Cerclage
- a stitch put through the cervix to maintain its closure
What are the drugs called that prevent labour progressing? and give an example:
Tocolytics
Nifedipine
What is the management options for preterm labour with intact membranes?
Fetal monitoring - CTG
<4cm dilated:
- Steroids
- tocolysis (to allow steroids to take effect)
- Contact neonate team
> 4cm dilated:
- Steroids
- IV magnesium if <30 weeks
- IV steroids
- plan for delivery (they’ve entered active stage there isn’t much stopping now)
Give some indications for induction:
Induction is done when the risk of continuing pregnancy is greater than the risk of labour. Anything that falls into that will be an indication for induction. Some include:
> 12 days post term
Pre-eclampsia
Macrosomia
Premature rupture of membranes
Reduced fetal movements
What are the options for inducing labour:
A membrane sweep is often conducted prior to the induction. Membrane sweep greatly increases the chances of labour without need for induction.
Induction:
Bishop score:
<8:
- Vaginal Pessary of prostaglandins
> 8:
- Artificial rupture of membranes + Oxytocin
Mifepristone + Misoprostol
- used if fetus death
By what stage are people considered a late booker?
24 weeks
- at 24 weeks the EDD may be inaccurate
What week is the fetal abnormality scan conducted?
20 week scan
How many follow up appointments should pregnant women have?
10 for primigravida
7 for parous women
Which week is Anti - D prophylaxis given to Rh Negative women?
IM injection at 28 weeks
What are the top complaints of pregnant women during pregnancy?
G.I
- N&V
- Heartburn
- Constipation
- Haemorrhoids
Urinary
- Frequency
- UTIs
General
- Fatigue
- oedema
MSK
- backpain
- Symphysis pubis dysfunction
Breast tenderness
What is the definition of labour?
Process by which the contents of the uterine cavity are expelled following 24 weeks of pregnancy.
- regular contraction
- painful contractions
- Progressive cervical dilatation
What are the top 5 analgesic methods used in pregnancy?
Non - pharmacological
- bath
- birthing pool
Entonox
Diamorphine IM
Epidural
Pudendal and Perineal infiltration
What are the top reasons for elective Lower uterine segmental caesarean Section?
- Previous E LUSCS
- Breech presentation
- Multiple pregnancy with non cephalic presentation
- Placenta previa
- Previous traumatic delivery
What are some of the reasons for an Emergancy lower uterine caesarean section?
Fetal Distress in labour
Malpresentation
Cord prolapse
Prolonged second stage
Maternal:
- cardiac arrest
- Bleeding
- Cephalopelvic disproportion
What are the screening tests for Down’s syndrome?
Combined test at 10-14 weeks - Nuchal ultrasound scan \+ - Beta hCG (raised) - PAPP- A (lowered)
If the window at 10-14 weeks is missed then:
- AFP
- Unconjugated oestriol
- inhibin A
- Beta hCGH
If score >1/150 then chorionic villous samplying or amniocentesis can be conducted
What is the most common type of skin condition induced by pregnancy?
Prurigo Eruption of pregnancy
- Eczematous type
- Prurigo type
Involves trunk and arms.
Early pregnancy
20% history of eczema before
Treatment:
- emollients
- topical steroids
- antihistamine
- UVB
- Oral steroids
What is a condition that causes itchy skin rash on the stomach and what are some clinical features?
Polymorphic eruption of pregnancy
- pruritic skin eruption of lower abdomen
- Stria skin formation
- Sparing of umbilicus
What is a skin pathology that develops in pregnancy that leads to blister formation? and what are some clinical findings?
Pemphigoid gestationis
- urticarial lesions
- Wheals
- bullae
- Umbilical area
Why is the pH of the mother and fetus important during labour?
Usually the fetus will be 1 unit below the mothers pH.
therefore if the mother has a high pH and the fetus pH is ‘normal’ it is in fact not normal and should be investigated.
Stage 2 of labour is when the baby is passed, in order for this to occur successfully there are 3 important factors - what are they?
Pelvis
Power
Passenger
List several ways the fetus can adapt to a chronic hypoxic and low nutrient environment:
Spend less:
- reduced fetal movement
- Reduced growth
Spend wisely:
- Brain
- Heart
- Kidney prioritised
Gain more:
- Polycythaemia
- Increased extraction of oxygen
At 32 weeks how much fetal movements should a mother be feeling when lying on her side?
> 5 kicks in an hour
or
10 in 2 hours
What blood tests would you offer at first antenatal appointment?
FBC ABO and Rh status HIV status Hep B screening Syphilis screening Rubella Antibody screening
What dietary advice should be given to pregnant women?
400micrograms of Folic acid
- prior to pregnancy and first trimester
Avoid:
- unpasteurised milk (listeria)
- soft cheese (listeria)
- raw meats/ undercooked meat (toxoplasmosis)
- Alcohol
- Vitamin A
Eat plenty of greens
List several common minor complaints during pregnancy:
N&V
Backache
Constipation
Heartburn
Varicose veins
Carpal tunnel
Urinary frequency
What are the risk associated with IUGR?
Hypoxia
Death
- both antenatally and during delivery
Hypoglycaemic (poor glycogen stores)
Hypothermia (poor fat stores)
Jaundice (polycythaemia)
Small weight (future life implications)
What topics should be discussed with a mother in the third trimester:
How to recognise onset of labour
Where they want the baby/ and any risk associated with that
Pain management plan:
- epidural?
- local LA
Future contraception/ plans
