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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
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
26
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
27
How often should multiple pregnancies be scanned?
DZ - every 4 weeks from 24 weeks onwards | MZ - every 2 weeks from 16 weeks onwards
28
What is the torch screen into still birth?
``` Toxoplasmosis Other Rubella CMV Herpes ```
29
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
30
What is the staging of twin to twin transfusion?
Quintero staging
31
What is the management options of twin to twin transfusion?
Fetoscopy laser ablation of anastomosis Cord occlusion
32
What is a major complication of MCMA?
Cord entanglement which can lead to severe accidents.
33
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
34
When a semen sample is given what analysis is given on the sperm?
Concentration/ Number Motility Morphology
35
What assessments should be done into male infertility?
``` Semen analysis History testicular examination FSH +/- Karyotyping if severe oligospermia ```
36
What is one of the main treatments for male infertility?
Intracytoplasmic Sperm Injection
37
How can ovulation to assessed?
Progesterone levels at 21 days (mid-luteal progesterone level)
38
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
39
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
40
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
41
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
42
What is the biggest cause of death from pre-eclampsia?
Sub-arachnoid
43
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
44
What are the complications of pre-eclampsia?
Maternal: - SAH - Eclampsia - Uterine rupture - HELLP syndrome - AKI - DIC Fetal - Prematurity - Intrauterine growth restriction - Oligohydramnios - Fetal death
45
What is the prevention of pre-eclampsia:
>2 more moderate risk factors or >1 more high risk factor = aspirin 75mg from 12 weeks
46
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
47
What important medical history should be ascertained when treating someone for pre-eclampsia?
If they are asthmatic or not
48
What charts are used to monitor pregnant women with pre-eclampsia in HDU?
Maternity Early Warning Score Charts - MOEWS
49
What drug should be used to treat eclampsia?
Magnesium Sulphate
50
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
51
What is the data collecting system used into maternal deaths?
MBRRACE - UK
52
What are some of the causes of polyhydramnios?
Idiopathic Swallowing defects Duodenal atresia Fetal Hydrops Chromosomal abnormalities Macrosomia Maternal Diabetes
53
What are the complications of Polyhydramnios?
Preterm labour Malpresentation - more room for baby to move Cord Prolapse Post partum haemorrhage
54
What two different types of US techniques can be used to diagnose polyhydramnios?
Amniotic Fluid Index Maximum Pool Depth
55
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
56
What clinical signs may you find in an ectopic pregnancy?
Cervical excitation Abdominal tenderness Adnexal mass Shoulder tip pain - if rupture
57
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
58
What is the definition of Antepartum Haemorrhage?
Bleeding from the vaginal tract >24 weeks until end of second stage of labour
59
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
60
What are some risk factors for a PPH?
Uterine distension: - Macrosomia - Multiple pregnancies - Polyhydramnios Prolonged labour Fibroids APH
61
What is the general management of PPH?
1. Call for help 2. ABC 3. Identify cause 4. Control bleeding 5. Replace blood loss
62
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
63
What is the general management for pre-term labour?
1. Assess maternal well being and resolve potential causes - Emergancy Section if compromised - usually resolving things like infection can stop the labour 2. - Tocolysis - nifedipine - steroids IM - Magnesium sulphate - Antibiotics .3 . Special care unit - delayed cord clamping
64
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
65
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
66
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
67
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
68
What signs may be present in pre-eclampsia?
Hypertension and proteinuria Hyperreflexia Clonus Oedema Papilledema Haemolytic anaemia Serum creatinine rise Low platelets
69
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
70
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

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