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Specialities > Obstetrics Pregnancy Pathology > Flashcards

Obstetrics Pregnancy Pathology Flashcards

1
Q

Define still birth and what are some risk factors

A

Still Birth: death after 24 weeks

50% of cases unknown 
Advanced maternal age 
Maternal obesity 
Social deprivation
Smoking 
Non - white ethnicity 
Domestic violence
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2
Q

What test is done to assess the amount of fetal blood in the maternal blood?

A

Keilhauer test

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3
Q

How does a still birth usually present?

A

Lack of fetal movement in the upcoming days to diagnosis

may include:

  • Abdominal pain
  • Bleeding
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4
Q

What is the investigations should be undertaken for a still birth and outline the management:

A

Investigations:
- Ultrasound to establish fetal heartbeat
May see signs of:
- overlapping of cranial bones (Spalding)
- hydrops

Maternal investigations:

  • Keilhauer test - establish any fetal blood in maternal circulation
  • FBC
  • CRP
  • TORCH screen
  • Drug toxicity

Management:
- induce labour - mifepristone + Misoprostol
+
- Cabergoline (dopamine agonist to prevent lactation)

**do this away from other babies and treat fetus as a baby (wrap up etc)

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5
Q

What are the different types of breech presentations?

A

Flexed position / Complete
- cross - legged baby

Extended position / Frank
- feet pointing up (bum first)

Footling
- both or one

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6
Q

What are the complications of a breech presentation?

A

Maternal risk:

  • undergoing Emergancy C section (which carries risks)
  • fatigue
  • Uterine atony - PPH

Fetal:
Cord prolapse

Fetal head entrapment

Premature rupture of membranes

Birth asphyxia

Bruising / damage to the baby passing through canal
- neurological damage

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7
Q

What are some causes to a breech presentation?

A

Uterine:

  • fibroids
  • Abnormal Uterus (Septate)
  • Placenta previa

Fetal:

  • macrosomia
  • Twins
  • prematurity
  • Polyhydramnios
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8
Q

What are the management options for a breech presentation?

A 
External Cephalic Manipulation 
- offered at 36 weeks or 37 for multiparous 
or 
C section 
-always used for footling presentation

Vaginal delivery:

  • Hands off approach
  • Flexing knees
  • Lovsett’s manoeuvre
  • Mauriceau - Smellie -Veit manoeuvre / MSV

*vaginal delivery should not have epidurals because of the decreased ability to push

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9
Q

What are some of the risk factors for placenta previa?

A

Previous C - section *biggest risk factor

Endometriosis

Curettage to the endometrium from previous miscarriage

High parity

Maternal Age >40

Previous placenta previa

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10
Q

What is the definition of antepartum bleeding?

A

Bleeding >24 weeks gestation

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11
Q

What question from the history do you want to establish into antepartum bleeding?

A

How much?

When did it start?

Was it fresh blood or mixed with mucus and clots?

Provoked?
- post coital?

Abdominal Pain?

Fetal movements?

Are there any risk factors for abruption?

Do you know from your ultrasound where the placenta lies?

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12
Q

What are the maternal and fetal complications of placenta abruption?

A

Maternal:
Shock

AKI

Sheehan Syndrome

DIC - due to thromboplastic release

Fetal:
- Hypoxia

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13
Q

Contrast placental abruption and placenta previa:

A

Abruption:

  • Painful
  • Dark red blood
  • Doesn’t stop bleeding
  • Fetal distress
  • associated with hypertension

Previa:

  • Painless
  • Bright red
  • Stops spontaneously
  • Non- fetal distress
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14
Q

What is the definition of post- partum haemorrhage?

A 
Primary PPH defined as: blood loss
-  >500mls following vaginal delivery 
or 
- 1000mls following C - section 
\+/- 
- 10% decrease in haematocrit
within 24 hours of delivery.

Secondary PPH defined as:
- significant blood loss >24 hours - 12 weeks after birth

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15
Q

What are the general causes of PPH?

A

4 T’s

Tone
- uterine atony

Trauma

  • C - section
  • Baby passing through birth canal

Tissue

  • Placenta arreta
  • Cord traction

Thrombin
- clotting abnormalities

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16
Q

What are some of the risk factors for uterine atony?

A

Excessive stretching of the uterus

  • polyhydramnios
  • twins

Fatigue
- prolonged labour

Interruption of muscle contraction
- full bladder

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17
Q

What is the management of Uterine atony?

A

ABCDE - resuscitation of patient. Major Haemorrhage

Fundal massage
Empty bladder - very important

  • Ergometrine (Alpha/ 5HT/ Dopamine agonist)
    or
    +/-
  • Carboprost / Misoprostol (prostaglandin)

Surgical:

  • Uterine tamponade (balloon) (a fist can be used in Emergancy situation)
  • B Lynch suture
  • Ligation of uterine arteries
  • Hysterectomy
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18
Q

What are the typical causes of secondary PPH?

A

Retained clots or products of conception

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19
Q

What is the definition of a large for gestational age?

A

Over the >95 percentile

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20
Q

What is the average birth weight?

A

8 - 10 pounds

3.5kg - 4.5kg

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21
Q

How long should CRP in a pregnant women be conducted for before carrying out an Emergancy C - section? At what gestational age can this be done and what are the benefits of it?

A

4 mins of unresponsive CRP.

Done if >20 weeks gestational

  • improves venous return
  • improves oxygenation
  • improves ventilation
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22
Q

Other than the 4 H’s and 4 T’s what are additional factors that must be considered in pregnancy?

A

Pre-eclampsia
Amniotic fluid embolism
Mg 2+ toxicity

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23
Q

What Manoeuvre should be done on a pregnancy woman during CRP?

A

Left lateral displacement
- two hands moving the uterus over to the left

improves flow and venous return by removing pressure off the SVC and aorta

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24
Q

In monozygotic twins, what are the days which will lead to either monoamniotic, monochorionic etc:

A

< 4 days:

  • Diachronic
  • Diamniotic

4-9 days:

  • Monochronic
  • Diamniotic

> 9 days

  • Monochronic
  • Monoamniotic

> 13 days
- conjoined twins

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25
Q

What signs can be seen on ultrasound to help differentiate between DCDA and MCDA?

A

Lamda Sign / twin peak sign
- this is a triangular appearance on the placenta demonstrating two placentas thus: DCDA

T sign/ Absence of the Lamda sign and when two fetus can be seen telling you it is at least a monochorionic pregnancy
- MCDA

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26
Q

What are some complications of multiple pregnancies?

A

Maternal:

  • hyperemesis gravida
  • pre-eclampsia
  • gestational diabetes
  • placenta previa

Fetal:

  • intrauterine growth restriction
  • miscarriage
  • congenital abnormalities
  • pre-term delivery
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27
Q

How often should multiple pregnancies be scanned?

A

DZ - every 4 weeks from 24 weeks onwards

MZ - every 2 weeks from 16 weeks onwards

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28
Q

What is the torch screen into still birth?

A 
Toxoplasmosis 
Other 
Rubella 
CMV 
Herpes
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29
Q

List some complications that can occur with twins during pregnancy?

A

Twin transfusion
- death of one twin which steals blood

Twin to twin transfusion
- anastomosis where one twin receives more blood than the other

Twin reversed arterial perfusion sequence (TRAP sequence)
- acardiac monster

30
Q

What is the staging of twin to twin transfusion?

A

Quintero staging

31
Q

What is the management options of twin to twin transfusion?

A

Fetoscopy laser ablation of anastomosis

Cord occlusion

32
Q

What is a major complication of MCMA?

A

Cord entanglement which can lead to severe accidents.

33
Q

What are the manoeuvres that can be done during shoulder dystocia?

A

McRobert’s Manoeuvre

Suprapubic pressure

Rubin manoeuvre

Break clavicle

Zanieinelle Procedure
- forced back into the uterus

34
Q

When a semen sample is given what analysis is given on the sperm?

A

Concentration/ Number
Motility
Morphology

35
Q

What assessments should be done into male infertility?

A 
Semen analysis 
History 
testicular examination 
FSH 
\+/- 
Karyotyping if severe oligospermia
36
Q

What is one of the main treatments for male infertility?

A

Intracytoplasmic Sperm Injection

37
Q

How can ovulation to assessed?

A

Progesterone levels at 21 days (mid-luteal progesterone level)

38
Q

What are the 1st and 2nd line drugs used in PCOS to treat anovulation?

A

1st line:
- Clomiphene
A Selective oestrogen receptor modulator
Increased risk of multiple pregnancy and endometrial cancer

2nd line:
- Letrozole

39
Q

What investigations should be done into tubal infertility?

A

STI investigations

Pelvis ultrasound

hysteron- salpingo- gram
- dye inserted and monitored via x-ray

Laparoscopic & blue dye test

40
Q

What is eligibility criteria for IVF?

A

Co-habiting for > 2 years

<42 years old

BMI between 18.5 - 30

Non - smokers

No previous children of one partner

41
Q

Outline the investigations that should be done into a couple who are struggling with fertility:

A

History/ exam

Male:
- Semen analysis

Female:

  • Transvaginal scan
  • Ovulation testing
  • Tubal patency testing
42
Q

What is the biggest cause of death from pre-eclampsia?

A

Sub-arachnoid

43
Q

What is the definition of pre-eclampsia? how does this differ from pregnancy related hypertension?

A

Pre-eclampsia is:
- New onset hypertension >20 weeks
+
- Proteinuria

Pregnancy associated hypertension:
- New onset hypertension >20 weeks
with no proteinuria

44
Q

What are the complications of pre-eclampsia?

A

Maternal:

  • SAH
  • Eclampsia
  • Uterine rupture
  • HELLP syndrome
  • AKI
  • DIC

Fetal

  • Prematurity
  • Intrauterine growth restriction
  • Oligohydramnios
  • Fetal death
45
Q

What is the prevention of pre-eclampsia:

A

> 2 more moderate risk factors
or
1 more high risk factor
= aspirin 75mg from 12 weeks

46
Q

What is the management of pre-eclampsia?

A

Pharmacological treatment when: >150/100

Frequent monitoring:

  • BP
  • Urine analysis
  • Fetal scan with CTG to assess for fetal growth

Non- Asthmatic:

  • labetalol 200mg- repeat dose at 30mins if no improvement
  • IV infusion of labetalol

Asthmatic:

  • Nifedipine - repeat dose
  • IV hydralazine

+
- VTE prophylaxis
+
Careful fluid monitoring - aim for 80mls/ hour to avoid overload.

Fetus:

  • Steroids
  • IV magnesium sulphate
47
Q

What important medical history should be ascertained when treating someone for pre-eclampsia?

A

If they are asthmatic or not

48
Q

What charts are used to monitor pregnant women with pre-eclampsia in HDU?

A

Maternity Early Warning Score Charts - MOEWS

49
Q

What drug should be used to treat eclampsia?

A

Magnesium Sulphate

50
Q

What are the signs of Magnesium Sulphate, and how is it treated?

A

Signs:

  • loss of deep tendon reflexes
  • Respiratory depression
  • Respiratory arrest
  • Cardiac arrest

Management:

  • Call for help
  • Stop Mg2+ Sulphate
  • IV Calcium Gluconate
  • Intubate
51
Q

What is the data collecting system used into maternal deaths?

A

MBRRACE - UK

52
Q

What are some of the causes of polyhydramnios?

A

Idiopathic

Swallowing defects

Duodenal atresia

Fetal Hydrops

Chromosomal abnormalities

Macrosomia

Maternal Diabetes

53
Q

What are the complications of Polyhydramnios?

A

Preterm labour

Malpresentation
- more room for baby to move

Cord Prolapse

Post partum haemorrhage

54
Q

What two different types of US techniques can be used to diagnose polyhydramnios?

A

Amniotic Fluid Index

Maximum Pool Depth

55
Q

What bedside test can be done to diagnose premature rupture of the membranes?

A

Sterile speculum Examination

  • fluid in posterior fornix of vagina
  • Leakage through cervix

Nitrazine paper test

56
Q

What clinical signs may you find in an ectopic pregnancy?

A

Cervical excitation

Abdominal tenderness

Adnexal mass

Shoulder tip pain
- if rupture

57
Q

What are the symptoms of an ectopic pregnancy?

A

Lower Pelvic pain

  • may become generalised if peritonitis
  • Unilateral usually

Early pregnancy bleeding

  • Less than normal period
  • Dark

Amenorrhoea

58
Q

What is the definition of Antepartum Haemorrhage?

A

Bleeding from the vaginal tract >24 weeks until end of second stage of labour

59
Q

What are some differentials for APH?

A

Uterine-placental causes:

  • Placenta abruption
  • Placenta previa
  • Uterine rupture

Cervical lesions

  • Cervical erosion
  • Cervicitis
  • Cervical polyp
  • Cervical cancer

Vaginal infections

Vasa Praevia

60
Q

What are some risk factors for a PPH?

A

Uterine distension:

  • Macrosomia
  • Multiple pregnancies
  • Polyhydramnios

Prolonged labour

Fibroids

APH

61
Q

What is the general management of PPH?

A
  1. Call for help
  2. ABC
  3. Identify cause
  4. Control bleeding
  5. Replace blood loss
62
Q

What are the major causes for secondary PPH? and what investigations are done?

A

Endometritis

Retained products of conception

  • Examination and stats
  • Endocervical swabs and vaginal swabs
  • TVS
63
Q

What is the general management for pre-term labour?

A
  1. Assess maternal well being and resolve potential causes
    - Emergancy Section if compromised
    - usually resolving things like infection can stop the labour
    • Tocolysis - nifedipine
    • steroids IM
    • Magnesium sulphate
    • Antibiotics

.3 . Special care unit
- delayed cord clamping

64
Q

Why might there be the need for induction of labour?

A

Post estimated delivery date:

Utero-placenta insufficiency

  • reduced fetal movement
  • oligohydramnios

Previous intrauterine restriction

Multiple pregnancy

Maternal complications

  • gestational diabetes
  • essential hypertension
65
Q

What investigations should be done into suspected miscarriage?

A

Refer to early pregnancy Assessment Unit

Bloods:

  • BhCG
  • FBC
  • G&S

Imaging:

  • TVS
  • repeat scans 1 week later should be done
66
Q

What are the different types of Gestational trophoblastic diseases that can occurs, and what are the initial symptoms?

A

Pre-malignant:

  • Partial molar pregnancy (69 chromosomes)
  • Complete molar pregnancy (46 chromosomes)

Malignant:

  • invasive molar pregnancy
  • Choriocarcinoma
  • Placental site trophoblastic tumour

Symptoms:

  • Vaginal bleeding/ discharge
  • Large for due date
  • Hyperemesis
  • Abdominal pain
  • hyperthyroidism
  • haemoptysis

Findings:

  • Snowstorm appearance
  • small bunch of grapes
67
Q

What is the management of molar pregnancies?

A

Uterine evacuation - suction

Follow up at GTD clinic for hCG level measurements

  • London
  • Sheffield
  • Dundee

Chemotherapy if further treatment is needed

68
Q

What signs may be present in pre-eclampsia?

A

Hypertension and proteinuria

Hyperreflexia

Clonus

Oedema

Papilledema

Haemolytic anaemia

Serum creatinine rise

Low platelets

69
Q

Define miscarriage and the different types:

A

Loss of pregnancy <24 weeks.

  • threatened
  • Cervix is closed
  • Spot bleeding
  • *75% of these will self resolve
  • Inevitable
  • cervix is open
  • more bleeding
  • Incomplete
  • products of concept retained
  • heavy bleeding
  • missed
  • Cervix open/closed
  • products of conception +/- there
  • lack of fetal HR
  • complete
  • lack of product of conception
  • cervix closed
70
Q

What is the management of a woman diagnosed with pre-eclampsia?

A

All should be admitted at diagnosis for observation as deterioration of the disease can occur.

  • Blood pressure management
  • Monitoring of fluid balance
  • Magnesium sulphate to reduce seizure risk - given at labour
  • Timely delivery if appropriate

**remember careful monitoring is needed post-partum especially in first 72 hours when seizure risk is still very high

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