Obstetrics Pregnancy Pathology Flashcards
Define still birth and what are some risk factors
Still Birth: death after 24 weeks
50% of cases unknown Advanced maternal age Maternal obesity Social deprivation Smoking Non - white ethnicity Domestic violence
What test is done to assess the amount of fetal blood in the maternal blood?
Keilhauer test
How does a still birth usually present?
Lack of fetal movement in the upcoming days to diagnosis
may include:
- Abdominal pain
- Bleeding
What is the investigations should be undertaken for a still birth and outline the management:
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)
What are the different types of breech presentations?
Flexed position / Complete
- cross - legged baby
Extended position / Frank
- feet pointing up (bum first)
Footling
- both or one
What are the complications of a breech presentation?
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
What are some causes to a breech presentation?
Uterine:
- fibroids
- Abnormal Uterus (Septate)
- Placenta previa
Fetal:
- macrosomia
- Twins
- prematurity
- Polyhydramnios
What are the management options for a breech presentation?
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
What are some of the risk factors for placenta previa?
Previous C - section *biggest risk factor
Endometriosis
Curettage to the endometrium from previous miscarriage
High parity
Maternal Age >40
Previous placenta previa
What is the definition of antepartum bleeding?
Bleeding >24 weeks gestation
What question from the history do you want to establish into antepartum bleeding?
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?
What are the maternal and fetal complications of placenta abruption?
Maternal:
Shock
AKI
Sheehan Syndrome
DIC - due to thromboplastic release
Fetal:
- Hypoxia
Contrast placental abruption and placenta previa:
Abruption:
- Painful
- Dark red blood
- Doesn’t stop bleeding
- Fetal distress
- associated with hypertension
Previa:
- Painless
- Bright red
- Stops spontaneously
- Non- fetal distress
What is the definition of post- partum haemorrhage?
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
What are the general causes of PPH?
4 T’s
Tone
- uterine atony
Trauma
- C - section
- Baby passing through birth canal
Tissue
- Placenta arreta
- Cord traction
Thrombin
- clotting abnormalities
What are some of the risk factors for uterine atony?
Excessive stretching of the uterus
- polyhydramnios
- twins
Fatigue
- prolonged labour
Interruption of muscle contraction
- full bladder
What is the management of Uterine atony?
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
What are the typical causes of secondary PPH?
Retained clots or products of conception
What is the definition of a large for gestational age?
Over the >95 percentile
What is the average birth weight?
8 - 10 pounds
3.5kg - 4.5kg
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?
4 mins of unresponsive CRP.
Done if >20 weeks gestational
- improves venous return
- improves oxygenation
- improves ventilation
Other than the 4 H’s and 4 T’s what are additional factors that must be considered in pregnancy?
Pre-eclampsia
Amniotic fluid embolism
Mg 2+ toxicity
What Manoeuvre should be done on a pregnancy woman during CRP?
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
In monozygotic twins, what are the days which will lead to either monoamniotic, monochorionic etc:
< 4 days:
- Diachronic
- Diamniotic
4-9 days:
- Monochronic
- Diamniotic
> 9 days
- Monochronic
- Monoamniotic
> 13 days
- conjoined twins
What signs can be seen on ultrasound to help differentiate between DCDA and MCDA?
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
What are some complications of multiple pregnancies?
Maternal:
- hyperemesis gravida
- pre-eclampsia
- gestational diabetes
- placenta previa
Fetal:
- intrauterine growth restriction
- miscarriage
- congenital abnormalities
- pre-term delivery
How often should multiple pregnancies be scanned?
DZ - every 4 weeks from 24 weeks onwards
MZ - every 2 weeks from 16 weeks onwards
What is the torch screen into still birth?
Toxoplasmosis Other Rubella CMV Herpes
List some complications that can occur with twins during pregnancy?
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
What is the staging of twin to twin transfusion?
Quintero staging
What is the management options of twin to twin transfusion?
Fetoscopy laser ablation of anastomosis
Cord occlusion
What is a major complication of MCMA?
Cord entanglement which can lead to severe accidents.
What are the manoeuvres that can be done during shoulder dystocia?
McRobert’s Manoeuvre
Suprapubic pressure
Rubin manoeuvre
Break clavicle
Zanieinelle Procedure
- forced back into the uterus
When a semen sample is given what analysis is given on the sperm?
Concentration/ Number
Motility
Morphology
What assessments should be done into male infertility?
Semen analysis History testicular examination FSH \+/- Karyotyping if severe oligospermia
What is one of the main treatments for male infertility?
Intracytoplasmic Sperm Injection
How can ovulation to assessed?
Progesterone levels at 21 days (mid-luteal progesterone level)
What are the 1st and 2nd line drugs used in PCOS to treat anovulation?
1st line:
- Clomiphene
A Selective oestrogen receptor modulator
Increased risk of multiple pregnancy and endometrial cancer
2nd line:
- Letrozole
What investigations should be done into tubal infertility?
STI investigations
Pelvis ultrasound
hysteron- salpingo- gram
- dye inserted and monitored via x-ray
Laparoscopic & blue dye test
What is eligibility criteria for IVF?
Co-habiting for > 2 years
<42 years old
BMI between 18.5 - 30
Non - smokers
No previous children of one partner
Outline the investigations that should be done into a couple who are struggling with fertility:
History/ exam
Male:
- Semen analysis
Female:
- Transvaginal scan
- Ovulation testing
- Tubal patency testing
What is the biggest cause of death from pre-eclampsia?
Sub-arachnoid
What is the definition of pre-eclampsia? how does this differ from pregnancy related hypertension?
Pre-eclampsia is:
- New onset hypertension >20 weeks
+
- Proteinuria
Pregnancy associated hypertension:
- New onset hypertension >20 weeks
with no proteinuria
What are the complications of pre-eclampsia?
Maternal:
- SAH
- Eclampsia
- Uterine rupture
- HELLP syndrome
- AKI
- DIC
Fetal
- Prematurity
- Intrauterine growth restriction
- Oligohydramnios
- Fetal death
What is the prevention of pre-eclampsia:
> 2 more moderate risk factors
or
1 more high risk factor
= aspirin 75mg from 12 weeks
What is the management of pre-eclampsia?
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
What important medical history should be ascertained when treating someone for pre-eclampsia?
If they are asthmatic or not
What charts are used to monitor pregnant women with pre-eclampsia in HDU?
Maternity Early Warning Score Charts - MOEWS
What drug should be used to treat eclampsia?
Magnesium Sulphate
What are the signs of Magnesium Sulphate, and how is it treated?
Signs:
- loss of deep tendon reflexes
- Respiratory depression
- Respiratory arrest
- Cardiac arrest
Management:
- Call for help
- Stop Mg2+ Sulphate
- IV Calcium Gluconate
- Intubate
What is the data collecting system used into maternal deaths?
MBRRACE - UK
What are some of the causes of polyhydramnios?
Idiopathic
Swallowing defects
Duodenal atresia
Fetal Hydrops
Chromosomal abnormalities
Macrosomia
Maternal Diabetes
What are the complications of Polyhydramnios?
Preterm labour
Malpresentation
- more room for baby to move
Cord Prolapse
Post partum haemorrhage
What two different types of US techniques can be used to diagnose polyhydramnios?
Amniotic Fluid Index
Maximum Pool Depth
What bedside test can be done to diagnose premature rupture of the membranes?
Sterile speculum Examination
- fluid in posterior fornix of vagina
- Leakage through cervix
Nitrazine paper test
What clinical signs may you find in an ectopic pregnancy?
Cervical excitation
Abdominal tenderness
Adnexal mass
Shoulder tip pain
- if rupture
What are the symptoms of an ectopic pregnancy?
Lower Pelvic pain
- may become generalised if peritonitis
- Unilateral usually
Early pregnancy bleeding
- Less than normal period
- Dark
Amenorrhoea
What is the definition of Antepartum Haemorrhage?
Bleeding from the vaginal tract >24 weeks until end of second stage of labour
What are some differentials for APH?
Uterine-placental causes:
- Placenta abruption
- Placenta previa
- Uterine rupture
Cervical lesions
- Cervical erosion
- Cervicitis
- Cervical polyp
- Cervical cancer
Vaginal infections
Vasa Praevia
What are some risk factors for a PPH?
Uterine distension:
- Macrosomia
- Multiple pregnancies
- Polyhydramnios
Prolonged labour
Fibroids
APH
What is the general management of PPH?
- Call for help
- ABC
- Identify cause
- Control bleeding
- Replace blood loss
What are the major causes for secondary PPH? and what investigations are done?
Endometritis
Retained products of conception
- Examination and stats
- Endocervical swabs and vaginal swabs
- TVS
What is the general management for pre-term labour?
- 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
Why might there be the need for induction of labour?
Post estimated delivery date:
Utero-placenta insufficiency
- reduced fetal movement
- oligohydramnios
Previous intrauterine restriction
Multiple pregnancy
Maternal complications
- gestational diabetes
- essential hypertension
What investigations should be done into suspected miscarriage?
Refer to early pregnancy Assessment Unit
Bloods:
- BhCG
- FBC
- G&S
Imaging:
- TVS
- repeat scans 1 week later should be done
What are the different types of Gestational trophoblastic diseases that can occurs, and what are the initial symptoms?
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
What is the management of molar pregnancies?
Uterine evacuation - suction
Follow up at GTD clinic for hCG level measurements
- London
- Sheffield
- Dundee
Chemotherapy if further treatment is needed
What signs may be present in pre-eclampsia?
Hypertension and proteinuria
Hyperreflexia
Clonus
Oedema
Papilledema
Haemolytic anaemia
Serum creatinine rise
Low platelets
Define miscarriage and the different types:
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
What is the management of a woman diagnosed with pre-eclampsia?
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
