Obstetrikk og Gynekologi Flashcards
Hva er placenta previa?
.
Hva står HELLP for?
.
Hvor lenge varer et gjennomsnittlig svangerskap?
40 weeks, 280 days
– from 1. day of last menstrual period
Hva undersøker man på rutineUL uke 17-18?
- gestational week (bekrefter termin)
- antal fostre
- lokalisasjon av placenta
- Fetal anatomy
Hva er amniocentese?
Og hva undersøker man for?
Fostervannsprøve
Amniocentese foretas i 13.–14. svangerskapsuke når det foreligger risiko for at fosteret kan ha kromosomfeil, «ryggmargsbrokk» eller visse stoffskiftesykdommer. Undersøkelse av fostervannet eller av celler fra fostervannet etter dyrking i laboratoriet kan vise om en slik tilstand foreligger. Amniocentese fører til abort i ca. 1 % av tilfellene.
Tilbys alle kvinner som fyller 38 år det året de har termin.
Evt (• Prior history of fetal abnormality • Family history)
Når gjøres “tidlig ultralyd”
Uke 11
x
• 40 weeks, 280 days – from 1. day of last menstrual period • > 36-37 weeks breech presentation? – referral to specialist care • <37 week delivery; preterm birth – approximately 10% • spontaneous, induced (preeclampsia, diabetes, fetal growth restriction, multiple pregnancy) • > 41 weeks referral to specialist care
x
x
x
x
x
x
x
x
x
x
Effacement
x
Fortynning av cervix
The Three stages of labour
- cervical opening 3-10cm
- passiv + aktiv fase (fra fullstendig dilatert cervix til barnet er ute)
- Fra barnet er ute til placenta er ute.
Obstetrikkens tre P-er
Power
Passage
Passenger
CTG
Cardio Toco Graphy
Clomiphene
x
Tamoxiphene
x
østrogeneffekter
• Endometrium: – proliferation • Endometrium: – proliferation • Cervix: – secretion clear, viscous, – permeable for spermatozoa Vagina: – more flattened epithelium, strengthened connective tissue • Mammary gland: – stimulation of glandular duct growth . Skeleton – increased bone density and strength – stimulation of longitudinal growth, but earlier growth cessation • Liver: – Slightly ↑HDL and ↓LDL – changes in clotting/thrombolytic factors • Other effects: – slight anabolic effects – variable Na+ + water retention • Hypothalamus/piuitary: – negative feedback via GnRH
Østrogenbivirkninger
• Mild effects, e.g.: – nausea,
– waterretention
Oestrogens
• Thrombosis (largely mediated through the liver):
– slightincreaseincertaincoagulationfactors
– smalldecreaseinanticoagulationfactors:prC,prS,AT III
• Hyperplasia or oncogenesis:
– endometrium,
– mammarygland(particularlywhencombinedwith progestin)
Progesteroneffekter
Effects of progestogens
Effects of progestogens • Endometrium: – secretory changes, – inhibition of the proliferative effect of estrogen • Myometrium: – reduced motility • Cervix: – inhibition of the estrogen effect on cervical mucus • Mammary glands: – growth/development of glandular acini (requires estrogen-prepared epithelium) • Placenta: – obligatory role in maintaining the placentar function • Liver: Progestogens • – ↓HDL, ↑LDL (very slight and variable effects, may reflect androgenic effect components) Other effects: – weakandvariableanabolic effects • Hypothalamus/pituitary: – negative feedback via GnRH
Normal labour starst with:
• Regular contractions – 2-3 /10 min
– last for 30-60 sec
• SpontanousRuptureOf Membrans (SROM)?
• Bloodstained mucus? («slimpropp» in Norwegian)
3 stages of labour
- First stage Cervix dilatation
- Second stage Delivery of the baby
- Third stage Delivery of the placenta
First stage of labour – 2 Phases
• Latent phase – Cervix effacement (shortening) – Cervix dialtation 3-4cm • Active phase – 4-10 cm dilatation
• Myometrim contracts from the fundus, effaces «utsletter» the cervix and make the head descent through the birthcanal
Sally is 41 weeks and have regular contractions
What do we ask Sally at admission ?
- Obstetric history
- Pregnancy complications
- Fetal activity
- Ruptured membranes(SROM) – Amniotic fluid colour
- Bleeding or discharge
Examination of Sally at admission
• BP, urine, temperature, puls
• Fetal heart rate
– admissionCTG
• Abdominal examination
– Presentation, engagement, position (Leopold) contractions, uterin tonus
• Vaginal examination
– Cervical dilatation and fetal head descent ( Bishop score) – Amniotic fluid
Bishop score
Cervical dilatation and fetal head descent
Cervical dilation Cervical effacement Cervical consistency Cervical position Fetal station
The Bishop score grades patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6 usually require that a cervical ripening method be used before other methods.
They can be remembered with the mnemonic: Call PEDS For Parturition = Cervical Position, Effacement, Dilation, Softness; Fetal Station.
A score of 5 or less suggests that labour is unlikely to start without induction. A score of 9 or more indicates that labour will most likely commence spontaneously.
0-2 or 0-3p per factor.
Bishop score 2
annen kilde med 0-2 pr faktor. Sjekk opp!
Onset of labour- Hormonal factors
• Maternal changes:
– Progesteron receptors decrease
– Oestrogen increases
– Oxytocin increase
– Prostaglandin increase
• Increase intracellular calcium myometrial cells
– Corticoid releasing hormone increases
• Fetal changes:
– Cortisol from fetus might contribute to conversion of progesterone to oestrogenOnset of labour- Myometrium
• Uterin pacemaker?
• Gap-junction formation increase between myometrial cells
• Retraction of myometrium starts in upper part of uterus
• Lower segment thinner and cervix taken into it
• Labour contractions – Last for 30-60 sec
– Every 2-3 minutes
Onset of labour- Cervix
• In pregnancy
– Muscle cells and fibroblasts
– Collagen, fibronectin and dermatan sulphate keeps the cervix rigid and closed
• Labour
– Prostaglandin and humoral mediators increase proteolytic activity and collagen turnover
– Increased water content of the cervix- softens
Fetal assessment during normal labour
• Amniotic fluid during labour
• Intermittent auscultation FHR (pinard, doppler)
– Fetal heart rate: 110-150/min
• Continues external fetal monitoring (CTG) • Fetal scalp blood sampling /STAN
Engagement of the fetal head
- Transverse lie of the head
- If more than 2/5 of the head is palpable abdominally, the head is not engaged
- Engaged at the start of labour in most nulliparous but not multiparous
The cardinal movements of labour
- Flexion
- Internal Rotation
- Extension
- External Rotation
Episiotomy
x
Puerperal fever
x
Puerperium
- 6 weeks after delivery
- Physiological changes
- Psycologicaly vulnerable
What is a normal labour?
– Spontanous onset, cephalic presentation, 37-42 weeks, no artificial interventions, spontanous delivery
Indications for operative delivery
Passage: Cephalopelvic disproportion Placenta previa Passenger: Excessive fetal size Abnormal fetal lie / presentation Multiple gestations Fetal distress (asphyxia) Power: Inadequate uterine contractions Prolonged stages 1-2
Maternal factors:
Repeated previous cesareans Chorioamnionitis
Necessary with rapid delivery
Chorioamnionitis
x
Operative vaginal delivery
Forceps
Vacuum
Obstetric anal sphincter injuries (OASIS)
x
The 4 steps for perineal protection at the end of second stage of delivery
- One hand slowing down the delivery of the head
- The other hand protecting perineum
- Mother NOT pushing when head is crowning
- EPISIOTOMY by indication
Placenta percreta, increta, accreta?
x
Medical abortion
• Medical prenancy termination
– 200 mg (1 tablet) mifepristone (Mifegyne) orally at the hospital
Anti-progesterone. Blocks progesterone receptors in the endometrium
• 36-48 hours after mifepristone treatment
– 4 tbl. misoprostol (Cytotec) vaginal administration. May be administered at
home
Prostaglandin-analog. Uterine contractions
1 x Paralgin Major supp. and/or 400 mg ibuprofen (or other NSAID)
Medical abortion, follow up:
- Vaginal bleeding up to 3 weeks after the termination
- Menstruation usually returns after 4-6 weeks
- hCG detection in urine after 4 weeks by the patient herself
- If the urine hCG test is positive, serum hCG concentrations should be measured
- At serum hCG > 500 IU/mL the patient should be referred to hospital
Surgical termination of pregnancy
• 0,6 mg misopostol (cytotec) vaginally prior to surgery
Surgery
Pregnancy termination after pregnancy week 12
- Mifegyne orally at the hospital, outpatient treatment
* 36-48 hours later: admission to hospital for delivery/termination
Causes of preterm birth
- Hemorrhage in pregnancy
- Eclampsia/pre eclampsia
- Cervical insufficience
- Infections in mother and fetus • Multiples
- Premature rupture of amniotic fluid • Stress/ hard physical labour (?)
- Genes
- Unknown
Pre-eclampsia
Pre-eclampsia (new onset of hypertension and proteinuria after gestational week 20)
GUTCH og graviditet
x
Blodgass under graviditet
x
andre verdier enn normverdier.
Behandning av Gonoré
• Ceftriaxone (Rocefalin) 500 mg i.m. injection • Azitromycin 2g orally
Endometritis post partum
x
UVI i svangerskap (asymptomatisk bakteriuri)
- Pregnant women are predisposed to UTI
- Asymptomatic bacteriuria:
- 5-10% pregnant women
- 20-40% of these will develop pyelonephritis • Riskofpretermbirth
- Asymptomatic bacteriuria should be treated
Listeriolyse
fra myke oster, upasteuriserte
Haptoglobin
x
Hvordan regne termin
Et år legges til første dag i siste mens (v jevne menssykluser) Trekker fra tre mnd. Legger til en uke.
Cyklokapron
Stopper bløding. Kan fikse tung mens.
Abort, terminologi
Threatened abortion Vaginal bleeding, cervix closed, signs of viable pregnancy on ultrasound
Missed abortion
No viable signs on ultrasound
with and without symptoms, cervix closed
Incomplete abortion
Vaginal bleeding
cervix dilated /products of conception in
Complete abortion
uterine cavity
Cervix has closed, uterus small, scant bleeding
