Obstetrics Summary Flashcards
What is gravidity?
Number of pregnancies in total including any miscarriages or pregnancies lost before 24 weeks - including current pregnancy.
What is parity?
Number of potentially viable pregnancies beyond 24 weeks delivered - not including the current pregnancy - and including stillbirths and livebirths.
What is multiparous?
Delivered live or potentially viable babies >24 weeks gestation
What is nulliparous?
Never delivered a live or potentially viable baby >24 weeks gestation
What do you want to know in an obstetric history about pregnancies >24 weeks?
- Gestation - preterm labour
- Mode of delivery - SVD, assisted vaginal or CS
- Birth weight - a previous SGA increases risk of subsequent SGA
- Complications: pre-eclampsia, third/fourth degree tears, PPH
- Assisted reproductive therapies - ovulation induction with clomiphene, IVF
- Care providers - mid-wife led or obstetrician led
What do you want to know in an obstetric history for non-viable pregnancies (<24 weeks)?
- Gestation - early or late miscarriage
- Miscarriage management
- Termination management
- Identified causes of miscarriage/stillbirth - foetal anomaly
- If ectopic - the site and management
Which women need a higher dose of folic acid?
DOCTer NTDs
- Baby previously with NTD
- Have a NTD or their partner does
- FH of NTD
- Taking anti-epileptic medication
- Have diabetes
- Obesity BMI>30
- Have bowel disease
What is the dose for folic acid?
400 micrograms to be taken 3 months before conception and 3 months into pregnancy. Higher dose is 5mg.
What are high risk factors for pregnancy?
- Advanced maternal age >40
- Low maternal age <20
- Previous major surgery
- Medical history
- IVF treatment
- Previous CS
- Previous problems in pregnancy e.g. pre-eclampsia, growth restriction etc.
What are they key points for a pregnant abdomen examination?
- Ensure mother has emptied bladder before examination as it can add 2-3cm to measurement of symphysis-fundal height (SFH)
- The higher point of the uterus may not always be in the midline
- If height is inconsistent with normal growth chart, then refer mother for USS to determine foetal estimated weight
What are sensitising events?
- spontaneous miscarriage
- placental abruption
- traumatic events
What is done to prevent sensitising events?
- Prophylactic anti-D (1500iu dose): Given at 28 weeks & 34 weeks.
- Kleihauer-Betke test: Detects presence of foetal red cells in maternal circulation.
- If >5ml estimated, then another dose of anti-D needed.
- Baby’s blood is tested at birth.
What patients would you do screening for GDM?
- BMI >30
- Previous baby >4.5kg
- Previous GDM
- Family history (1stdegree)
- Ethnic origin–South Asian, black Caribbean, Middle Eastern
What is the target glucose ranges in pregnancy?
- For glucose monitoring in pregnancy, the aim is a fasting glucose of 3.5-5.5mmol/L (though NICE just says <5.5),and 1-hour post meal glucose<7.8 (TCD says <7.1, NICE says <7.8), pre-meal (or any other time) should be 4-7mmol/l
- Diagnosis of diabetes - fasting glucose>5.6, 2h post-GTT>7.8
How do you manage diabetes in pregnancy?
- Continue taking insulin and metformin in pregnancy
- Lifestyle factors
- 5mg folic acid OD
- Screening (retinopathy and nephropathy) if not carried out in last 6 months
- If urinary PCR ration >30mg/mmol and eGFR <45 refer to nephrologist
- If pre-existing diabetes - seek help if unwell or hyperglycaemia due to risk of DKA
- Aspirin 75mg OD (reduces pre-eclampsia risk) - start before 12 weeks and continue to birth
What antenatal checks are done in pregnancy with diabetes?
USS appts:
- Routine dating scan = 11-13/40 wks
- Routine anomaly ~ 20/40 wks
- Serial growth scans = every 4wks from 28/40 onwards - check for foetal size, macrosomia, polyhydroamnios
- And consider other abnormalities for anaesthetic assessment by 3rd trimester
What is the intrapartum care for mothers with diabetes?
- Uncomplicated T1/2DM - offer elective CS between 37-38+6/40 - either by LSCS or induction of labour
- Offer delivery before 37/40 if woman has maternal/foetal complications
- Offer delivery before 40+6 in women with GDM
- Diabetic macrosomia pregnancies and EFW of >4.5kg, offer elective LSCS as alternative to VD due to concerns regarding shoulder dystocia
- For non-diabetics consider elective delivery if EFW >5kg
- Women with T1DM or who cannot maintain BMs within target (4-7mmol/l) in labour then start insulin sliding scale
- Encourage breastfeeding - ideally feed within 30mins of birth and baby’s blood sugars checked every 2-4hrs, aim to maintain >2mmol/l
What is the post-partum care for diabetes?
- Post-delivery - don’t need as much insulin
- Women with GDM usually stop all glucose reducing agents immediately after delivery
- If pre-existing diabetes - restart pre-pregnancy dose (reduced by 25-40% if they’re breastfeeding)
What is the risk of T2DM with GDM?
- Women who had GDM - check plasma glucose 6-12 weeks post-birth for T2DM
- Women who test negative for diabetes at their postnatal review - offer annual screen for diabetes
- Can reduce risk of having GDM recurrence in future pregnancies by diet and weight control
What are the hypertensive disorders in pregnancy?
- Pregnancy induced hypertension: hypertension after 20 weeks without proteinuria
- Pre-eclampsia: hypertension after 20 weeks with proteinuria (PCR >30)
- NICE recommends aspirin daily to reduce pre-eclampsia risk (if high risk)
What is the treatment for hypertensive disorders in pregnancy?
- BP: Keep < 160 systolic (risk of cerebral accidents), abetalol, nifedipine (labetalol 1st line, but give nifedipine if they have asthma), hydralazine (vasodilator)
- Fluid balance: very important, restrict fluid due to risk of pulmonary oedema
- Prevention of fits: magensium sulphate infusion
- Management of HELLP is supportive: blood transfusion to treat low platelelts and RBCs, treat BP and give Mg
- Only cure is delivery of placenta - IOL, CS
What are the haematological changes in pregnancy?
- Physiological anaemia of pregnancy: plasma volume increase by 50%, red cells increase by 25-30% therefore Hb conc. falls
- Gestational Thrombocytopenia:
10% healthy pregnant women have platelet count below 150x10^9/L - Increased thrombotic risk: factor VIIIc + plasma fibrinogen (coagulation factors) increased, protein S (anti-coagulant factor) reduced
What is SGA and FGR?
- SGA: foetus born with birth weight below 10th centile
- FGR: failure of foetus to reach pre-determined growth potential due to pathology
What are minor risk factors for SGA?
- Maternal age >/= 35yrs
- IVF singleton pregnancy
- Nulliparity
- BMI <20
- BMI 25-34.9
- Smoker
- Low fruit intake
If >3 risk factors (RF); Uterine Artery Doppler at 20 week scan: normal – single scan in 3rd trimester, abnormal – serial scans from 28 weeks
What are major risk factors for SGA?
- Maternal age >40yrs
- Smoker
- Paternal or maternal SGA
- Cocaine use
- Daily vigorous exercise
- Previous SGA baby
- Previous stillbirth
- Chronic HTN
- Diabetes with vascular disease
- Renal impairment
- Antiphospholipid syndrome
If one or more RF, serial scans from 28 weeks: if patient unsuitable for monitoring of growth by SFH measurements (BMI >35 or fibroids), do serial scans from 28 weeks
What are the absolute contraindications to ECV?
Manoeuvre of baby from breech to cephalic presentation.
- Woman needs C-section
- Antepartum haemorrhage within last 7 days
- Abnormal CTG
- Major uterine issue
- Ruptured membranes
- Multiple pregnancy
What are the risk factors for breech presentation?
- Placenta praevia
- Polyhydramnios/oligohydramnios
- Foetal abnormality
- Prematurity
What are the types of breech presentation?
- Frank breech - bum first, with legs up
- Complete breech - baby in position but bottom first
- Footling breech - one/two leg out in pelvic inlet
