obstetrics summary Flashcards
preconcepton care
diet - folate
weight - BMI
exercise
smoking/alcohol advice - assess intake and provide advice
pregnancy history - screen for modifyable risk factors
genetic screening - if indicated from personal/family history
medical history
pychosocial screening - DV and mental health screen
environmental screening - work, home
contraception/family planning
infectious screen and vaccinations
breast exmination
first antenatal visit
planned vs. unplanned
LMP and tests to date
obstetric history
gynaecological history
medical history (personal and family)
social history
care options
provide pregnancy health record
antenatal examination
height/weight (BMI)
BP
urinalysis
cardio exam
abdominal examination - fundal height, palpation for lie/presentation (from 28 weeks), FHR auscultation
initial investigations
MSU
rubella
syphilis
antibodies
blood group
chlamydia/gonorhhea
FBC
globinopathies
HIV/HBV/HCV
iron sstudies and immunications
subsequent investigations following antenatal visit
US:
dating - 8-12 weeks
first timester screen 11-14 weeks
anatomy scan 18-20 weeks
OGTT 24-28 weeks
GBS screen 36 weeks
screening test
combined first trimester screening test
non-invasive prenatal testing
triple test
if any are poitive > CVS vs. amniocentesis
rhesus D negative
mother with rhesus negative and foetus with resus positive
risk of maternofoetal haemorrhage
RhD Ig binds Rh positive foetal cells to prevent immune response
preterm labour and birth complications
birth after 20 weeks and before 37 weeks gestation
complications:
- mother - increased risk of obstetic intervention
- neonate - ICH, respiratory support, bowel necrosis, sepsis, death
- child - CP, chronic lung disease, deafness, blindness, developmental delay
- adult - metabolic syndrome, diabetes, heart disease
risk factors for preterm birth
previous pre-term birth, FHx, smoking, extremes of age, stress/anxiety, previous preinatal loss, short cervical length
aetiologies of pre-term birth
spontaneous preterm labour, PPROM, preeclampsia, diabetes, APH, multiple pregnancies, infectons, uterine abnormalities, cervical surgeries
prevention of pre-term birth
optimal control of risk factors (smoking cessation)
measure cervical length ot foetal anatomy + subsequent scans
vaginal progesterone is history of spontenous preterm birth
what to do for short cerrvical length
200mg vagnal progesterone in evening if cervix <25mm
consider cervical cerclage is cervix <10mm
vaginal progesterone is history of spontaneous preterm birth
workup of preterm labour
diagnosis - regular painful contractions and cervical change
history - gestational age, contractions, presence of fluid
examination - temperature, abdominal exmiantion, sterile speculum
investigations in preterm laabour
fFN - foetal fibronectin
MSU
HVS
USS
EFM
management of preterm labour
admit - offer analgesia, baselne investigatons, CTG
tocolysis - <34 weeks gestations nifedpine, IV salbutamol, GTN patch
corticosteroids - 2 doses 11.4mg IM metamethasone 24 hours apart
MgSO4 - foetal neuroprotection in women <30 weeks gestation
antibiotics - ntrapartum benzylpenicillin for GBS prophylaxis
breech ppresentation
c-secton reduced rissk of short tern maternal and foetal complications
risk factors for breech presentation
nullipparity, previous breech, uterine and plecntal abnormalitiess, poly/oligohydramnios, multiple pregnancies, grand multiprity
foetal - extended legs, short umbilical cord, early gestation, foetal abnormality, IUGR
PROM
premature rupture of membranes before labour begins
history - tme, type and colour of fluid, presence of signs indicative of infection (odour, abdominal pain, fever, dysuria, discharge)
exmination and investgations for PROM
examinations - vitals, abdominal examination, sterile speculum
investigations - bloods (FBC, UEC, CRP), MSU LVS, ECS, STI screen, amnicator, USS exmaination
PPROM management
admit and observe - CTG
oral erythromycin
remove cervical cerclage
discharge if >72 hours with no evidence of infection/preterm labour with approprate education
when to do IOL in PPROM
signs of chorioamnionitis/maternal sepsis or foetal compromise
PROM management
expectant managemnt is cepahlic presentation, clear liquor, no sign s of infection, no cervicaal suture, assess temperature 4 hourly/vaginal loss/foetal movements
at 18 hours post ROM commence antibiotics
when to do OIL for PROM
24 hours following ROM or if criteria for expectant management not met
early pregnancy loss
spontaneous interuption of established pregnancy <20 weeks gestation
risk factors for early pregnancy loss
AMA, medical conditions (diabetes/coagulopathies/APS), uterine abnormalities, SLE, infections, drugs, smoking, cevicaal incompetance, prevous spontaneous miscariage
presentation of early pregnancy loss
PV bleeding/spotting , suprapubic cramping, lower abdominal/back pain
workup for early pregnancy loss
abdominal examination, speculum examination, B HCG, FBC, blood group and antbodies, USS
types of miscarrage
threatened
inevitable
incomplete
complete
missed
management options for early preganancy loss
expectant
medical - PV misopristol, approppriate analgesia
surgical - dilatation and curettage, haaemodynamicaally stable, failure of medical Mx
hypertensve disorders of pregnancy
genstational HTN
Chronic HTN
pre eclampsia
pre eclampsia superimposed on chronic hypertension
eclampsia
new onset hypertension post 20 weeks gestation management
BP, ECG, spit urine PCR, FBC, UEC, LFT, US to assess foetal growth, AFI, dopplers,
CTG if > 30 weeks
if features of pre-eclampsia are present
MSU urinalysis (protein/urine microscopy)
investigations for DIC/haemolysis if presence of thrombocytopaenia or falling Hb
management of acute severe hypertension
> 170/110
nifedipine 10mg PO
labetolol 20-80mg IV
hydralazine 5-10mg IV
management of maintenance therapy of hypertension
BP > 140/90
methydopa or labetolol
hydralazine, nifedipine, prazosin
definitive management of pre-eclampsia
delivery
indiications of delivery for pre-eclampsia
gestational age >37 weeks
inability to control hypertension
deteriorating platelet count, liver function, renal function
placental abruption
peristent neurological symptoms/eclampsia
APO
severe FGR/non-reasurring foetal status
management of eclampsia
resus - IV access, secure aairway, oxygen by mask
if seizure is extended give IV midazolam
MgSO4
after acute manaagement of eclampsia
continue MgSO4 pot resus to prevent further seizures
contorl HTN to below 160/100
arrange c-section
gestational diabetes define
any degree of lgucoe intolerance wtih onset, or first recogntion during pregnancy
includes pregnant women with previous diabetes not diagnosed until pregnancy
screening for gestational diabetes
OGTT for all women at 24-28 weeks
ealrier OGTT if higher risk
diagnosis of gestational diabetes
fasting > 5.1 mmol/L
1 hour BG > 10 mmol/L
2 hour BG > 8.5 mmol/L
symptoms of gestational diabetes
frequent urination
blurrred vision
thrist
weakness
monitoring and management
BGL monitoring
serial USS/umbilical artery doppler - 34 weeks (macrosomia/PH)
glycaemic control
birth planning
foetal complications of gestational diabetes
macrosomia
hypoglycaemia
reppiratory disstrress
preterm birth
jaaundice
overweight/obesity
dysglycaemia
dyslipidaemia
hypertension
antepartum haemorrhage causes
placental abruption
partial orr complete seperaation of the placenta from the utuerus prior to delivery
placenta praevia
placenta is inserted wholly or in part into the lower segment of the uterus
major if lying over internal cervical os
minor/partial if leading edge of placenta is in the lowerr uterine segment but not covering cervical os
vasa praevia
fetal vessels coursing through membraanes over internal cervical is and below fetal presenting part, unprotected by placental tissue or umbilical cord
Symptoms of placental abruption
lower abdominal pain
vaginal bleeding
rigid uterus, tenderness
fetal distress
antepartum aemorrhage workup
history - blood loss, pain assessment, presence of contractions, triggers, presence of foetaal movements, risk assessment
examination - maternal vitals (haemodynamic stability), abdominal exmination, foetal observations, spec exam)
investigations of antepartum haemorrhage
kleihhauer test
FBC, G+H, cross match
coagulation screen
UEC
LFT
USS
management of antepartum haemorrhage
A-E assessment
rule out obvious causes of external bleedings
consider need for blood transfusion, delivery, corticosteroids
anti D if Rh -ive
management of post partum haemorhage
assess A-E - vitals, 4Ts, extent of bleeding, labour
resus - IV access, investigations, O2, fluid replacement, tranexamic acid
arrest - fundal massage, bimanual compression, IDC insertion, uterotonics (oxytocin +/- ergometrine), oxytocin infusion, carboprost IM 15 minutely
