OG Flashcards
Itchy Hands and Feet During Pregnancy
Obstetric Cholestasis
induction of labour at 37 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
Acute SOB, Hypotension. Then CVS Failure and Coagulopathy and then convulsions, leading to coma and death in unmanaged. Happens in the end stages of labour
Amniotic Fluid Embolism
140/90 BP. RUQ pain, headaches, blurry vision, oedema and nausea. If they have convulsions…then it is..
Pre-Eclampsia. Then it is eclampsia if not managed
Painless PV Bleeding during pregnancy
Placenta Praevia
Abdominal pain, PV bleeding and woody hard uterus
Placental Abruption
Acute severe abdominal pain during labour, PV bleed, maternal hypotension and foetal hypoxia
Uterine Rupture
Turtle sign, failure of delivery of the foetus after head comes out.
Shoulder Dystocia
Cord Presentation vs Cord Prolapse
Presentation is when cord descends below with membranes intact. Prolapse is when cord presents after rupture of membranes
Blood loss within first 24 hours of birth
Primary PPH. Can be minor (500-1000) or major (>1000)
Blood loss within 24 hours and 12 weeks of birth
Secondary PPH. Often due to retained products of conception or endometritis
LIF pain in a young fertile woman
Ectopic unless proven otherwise
Shouldertip pain, pelvic pain, PV bleeding. Maybe a collapse in a young fertile woman
Ruptured ectopic
Severe pelvic pain with hypovolaemic shock. Not Pregnant
Ovarian Cyst Torsion/Rupture
Abnormal uterine bleeding, especially post coital and inter menstrual must rule out
Cervical Carcinoma
Post menopausal bleeding, must rule out
Endometrial Carcinoma
Non-specific symptoms of abdo pain, weight loss, flaws, distension. Management
Ovarian Carcinoma. Surgery and Chemo
PV Discharge, pelvic pain fever, abnormal bleeding in a young woman
PID
Thick curdy cheese like discharge. Diagnosis and management
Candida Albicans. Do a high vaginal swab. Give clotrimazole
Fishy discharge, clue cells, abnormal pH, whiff test positive
BV, gardnerella vaginosis, Do a high vaginal swab, treat with metronidazole
Asymptomatic intracellular gram negative pathogen. Most common STI
Chlamydia Trachomatis, endocervical swab, give doxycycline. Azithromycin in pregnancy
Asymptomatic gram negative diplococci
Neisseria Gonorrhoea, endocervical swab, give ceftriaxone
Smears first age 3 yearly dates 5 yearly dates How to do smear Risk factors for cervical cancer
- Uses liquid based cytology to collect cells from transformation zone of the cervix.
25-49 is 3 yearly and 50-64 is 5 yearly
Get patient exposed from the waist down, lie down on the table, legs up to bum and let them drop to the side. Insepction, then pull vulva apart with right hand, insert speculum with left. Make sure it is inserted sideways then turn it up. Open it and lock it. Use brush to take sample rotating around 10 times clockwise at cervical area. Remove it all. Thank the patient etc..
Risk factors include HPV, smoking, sexual activity, COCP and immunodeficiency
Stress incontinence management
Weight loss, stop smoking, pelvic floor exercises
Urge incontinence management
Avoid caffeine, bladder training, maybe oxybutynin.
Prolapse management
Conservative: Pelvic floor exercises, possible pessary.
Surgical: Fixation of ligament to prevent prolapse
Dr C BraVADO
Define Risk, Contractions, Baseline rate, Variability, Accelerations, Deceleration, Overall
Post Natal Depression Scale
Edinburgh Depression Scale. Mother should fill it herself without discussing with others. Scored out of 30
Small for dates cuases
Pre-eclampsia, Oligohydroamnios, Smoking, Drugs, Maternall Illnesses, IUGR which can be symmetrical or Asymmetrical
Large for dates causes
Polyhydroamnios, Diabetes
Combined Test
11-14 weeks: PAPP-A and b-hCG and nuchal translucency
Triple Test
14-20 weeks: AFP, hCG and oestriol.
Quadruple Test
14-20 AFP, b-HCG, osteriol and inhibin A
Antepartum Haemorrhage and management
Placenta Praevia, Vasa Praevia, Placental Abruption
Management: ABCDE approach
Give oxygen, fluids, analgesia if required. Then do baseline obs and abdominal examination.
Bloods include FBC, U+E, LFT, TFT, CRP, ESR, G+S/Cross-match.
Imaging include TVUS for diagnosis.
Admit patient and monitor regularly. May require a cesarean section
Preterm labour. Diagnosis and management
Before 37 weeks.
Consider tocolytics and steroids to develop lungs.
As well as Abx for PPROM.
Magnesium Sulphate IV considered for foetal brain development
PPROM
Abx for 10 days, do GBS swab, may go home if labour doesn’t start within 48 hours. Strict safety netting. So any pain, discharge, bleeding, foetal distress needs to come back
Risks of prematurity to foetus
Intraventricular Haemorraghe, RDS, Necrotising Enterocolitis, Hypothermia, Hypoglycaemia
Reduced foetal movements History, Diagnosis and Management
Consider risk of stillbrithy and IUGR. May require emergency cesarean. Ask about GDM, Smoking, Alcohol, Drugs, Screening for abnormalities
Primary PPH Cause, Management and 4T’s
Uterine Atony is the most common cause Cross-match bloods and do FBC for possible transfusion Uterine massage Examination for retained products or tears Oxytocin Ergometrine Carboprost Balloon tamponade Ligation of the uterine artery B-lynch suture Emergency life-saving hysterectomy
4 T’s are Tone, Tissue, Trauma, Thrombin
Breech Presentation at 37 weeks
ECV, advice on planned cesarean if ECV fails. Ideally avoid breech vaginal delivery
Pre-eclampsia Management
Labetalol
Nifedipine and Methyldopa to be considered
Regular follow ups to monitor BP and Urine
Regularly do LFT’s and U+E’s
Monitor foetal growth regularly
Consider induction of pregnancy at 37-38 weeks or cesarean
Gestational Diabetes Management
Cut off for GDM
OGTT test
Regularly self monitor
Diet and exercise
Metformin, Insulin
Plan to induce at around 38 to 40
Feed baby soon after they’re born as higher risk of hypoglycaemia
Cut off is fasting 5.6 and 2 hour OGTT 7.8
Target fasting glucose is 5.3. Start metformin or insulin.
Increased folic acid dose
Ectopic Pregnancy Management
Expectant: May resolve itself, but needs monitoring
Medical: Methotrexate, avoid pregnancy for 3months
Surgical: Laparoscopy salpingotomy or salpingectomy. with anti-D prophylaxis
Vaginal Discharge Causes
Ectropion, Physiological, Neoplasia, STI, Foreign Body, PID
Cesarean Section Risks
Risks to mother: Infection of the wound, poor healing, increased blood loss, DVT, damage to bladder
Risks to baby: Some minor bruising and TTN
Future pregnancies: Placenta preavia, increased stillbrith risk, placenta accreta/increta/percreta
Also may require thromboembolic prophylaxis so consider LMWH and Ted stockings.
Vaginal Birth Risks
Also VBAC
May require instrumental delivery and episiotomy, maternal blood loss, PPH, tears in the peineal region, may require emergency cesarean anyway, bladder incontinence
VBAC is not a problem for most women, but risks of uterine rupture, blood loss, and may require a cesarean anyway
Hyperemesis Gravidarum Management
ABCDE: If severe, admit with fluids and correct electrolyte imbalances. Give pabrinex as they may be deficient. If being admitted, also thromboprophylaxis so TED stockings and consider LMWH
Small bland meals that are frequent,
Some people say ginger and acupuncture helps, can try
Medication: Pyridoxine, Doxylamine which are OTC. Can be prescribed Metoclopramide or Promethazine
HIV in Pregnancy
Screen for HIV
Start on anti-retroviral therapy (ziduovudine)
Specialist referral
Advise C-section if viral load not controlled
Neonatal ART, give infusion during labour period if needed
No breast feeding
Secondary Amenorrhoea
Pregnancy Hypothalamic amenorrhoea (e.g. Stress, excessive exercise) Polycystic ovarian syndrome (PCOS) Hyperprolactinaemia Premature ovarian failure Thyrotoxicosis* Sheehan's syndrome Asherman's syndrome (intrauterine adhesions)
Dysmenorrhoea Causes and Management
Primary: Mefanemic acid or ibuprofen
Secondary: Due to endometriosis, adenomysosis, PID, IUD and fibroids. Treat underlying cause
Menorrhagia Causes
Dysfunctional Uterine Bleeding Anovulatory Cycles Fibroids Hypothyroidism IUD Progesterone Contraception Bleeding Disorders
Menorrhagia Investigations and Management
Baseline Obs
Bloods: FBC, CRP, LFT, TFT, CA125
Imaging: TVUS
Management: IUS (first), COCP (second), Tranexamic Acid (if contraception not needed)
Fibroids Diagnosis, Investigations and Management
Presents as menorrhagia, dysmenorrhoea, with urinary/GI symptoms and subfertility
USS
Medical: IUS, COCP, Tranexamic acid, consider GnRH agonists short term to shrink
Surgical: Myomectomy
Early Pregnancy PV Bleed
Miscarriage Stuff Molar Pregnancy Ectopic Pregnancy Fibroids Polyps PID Hyperplasia Malignancy If non-pregnant: IUD and progesterone pills and atrophic vaginitis
Endometriosis Investigations and Management
Laparoscopy is the gold standard diagnosis
Management with NSAIDs, then COCP or progesterone contraception. GnRH analogues are next
Surgical management may help. Laser ablation
PE in Pregnancy
ABCDE approach
VQ scan, CTPA if VQ scan is not possible
LMWH throughout pregnancy until 6 weeks post natally
Atrophic Vaginitis Management
Rule out sinister causes
Management with lubricant cream and moisturizers , consider oestrogen cream
Post Coital Bleeding Causes
Idiopathic Ectropion PID Polyps Trauma Hyperplasia Malignancy
Intermenstrual Bleeding Causes
Physiological Vaginitis PID Polyps Ectropion Fibroids Adenomysosis Endometritis Trauma Drug Induced Malignancy
Contraception
Contraindications
Barrier: Condoms, male and female
Hormonal: COCP or Progesterone pills and injection
Implants: IUS, IUD, Implants
Natural: Using body temperature kit in accordance with cycle to estimate ovulation
Emergency: Levonestrogel (3 days), Ullipristal (5 days) and IUD (up to 5 days after ovulation date)
Avoid all hormonal methods in cancers, avoid COCP if UKMEC 4 such as migraine, thromboembolic disease, HTN, age over 35 and smoking over 15 a day, up to 6 weeks post partum, CVD, Liver Disease and poor diabetes control.
Epilepsy in Pregnancy
Lamotrigine seems to be the best one from data.
Risks of uncontrolled epilepsy is generally greater than the risks of harm to the baby.
Increase folic acid dose
Valproate- Neural Tube Defects, development delay
Phenytoin- Cleft palate
Breast feeding is generally safe
Specialist referral and monitoring
Asthma in Pregnancy
No problems with medication during pregnancy or breast feeding.
Avoid triggers, don’t smoke,
Risks of medicine are quite small and the risks of a poorly controlled asthma are higher and linked to SGA
Bartholin’s Cyst Management
Self help measures initially if not problematic. Soak in warm water, analgesia.
If unsuccessful, may require drainage of the cyst. Abx if abscess is formed.
Surgical: Referral to surgery to stitch the glands so they can’t get inflammed (marsupialisation).
Lichen Sclerosus
White plaques in genital area, steroid cream, emollients and barrier creams help, good hygiene so loose clothes, etc.. Recurrence is common
Premenstrual Syndrome
Lifestyle management so good diet, exercise, avoid stress and cut down on alcohol and smoking
Medical management: COCP, CBT and consider Mefanemic acid if pain is key symptom
Specialist referral if still not managed
Post Menopausal Bleeding
Atrophic Vaginitis Endometrial Atrophy Polyps Hyperplasia Trauma Drug Induced Malignancy
COCP Contraindications
Migraine with aura 35 and smoking over 15 Thromboembolic disease HTN (160/100) CVD 6 weeks post partum Diabetes badly controlled Breast cancer Messed up liver full on
HRT
Hot flushes, mood swings, tiredness, poor concentration, dry vagina,
Increased cancer risk of endometrial, ovarian, colorectal, increased risk of VTE, increased risk of strokes, increased risk of fractures
Miscarriage Diagnosis and management
Early pregnancy PV bleed. Can be painful or painless. Do an abdominal exam and then a speculum exam to visualise cervical os and USS to monitor foetus status. ABCDE approach first as always.
If threatened miscarriage, say to get some rest and stuff and come back if anything happens.
If complete miscarriage, then same
If incomplete miscarriage, can do expectant management or give misoprostol vaginally. May require surgical evacuation of retained products of conception.
Consider counselling for patient if planned pregnancy or difficulty conceiving
If recurrent, then investigations for anti-phospholipid syndrome, check diabetes, PCOS, other endocrine conditions and smoking
Smoking in Pregnancy Diagnosis and Management
Diagnosis is from history, baby is often SGA, there is chances of IUGR so baby won’t reach it’s full growth potential. There’s increased risks of problems with their breathing. Increased risk of complications in the pregnancy, increased risks of stillbirth/SGA/premature babies.
Management
Stop smoking, support with stopping smoking, refer to a specialist midwife who can help with that,
If partner is smoking, support with him stopping too
Follow up on patients attempts to stop too
If she declines, be impartial, but say the offer is always open
NHS Stop Smoking Service, and also a NHS in Pregnancy Smoking Service, they will probably give CBT and stuff like that.
Nictoine replacement therapy can be used if you can’t stop without it.
Even an e-cigarette is better than cigarettes, but none is best of course.
PCOS Diagnosis and Management
Presents as subfertility, hirsutism, acne, oligomenorrhoea and typically obese.
Investigations: Raised LH, raised FSH, USS shows cysts, testosterone and prolactin may be mildly elevated
Management
Conservative: Lose weight, stop smoking, so lifestyle
Medical: COCP for hirsutism and acne if not aiming for fertility. If aiming for fertility, clomifene or metformin
Will have to have regular sex for 2 years before trying IVF and stuff
Termination of Pregnancy Management
Assess competence
Check legal requirements are met (by 24 weeks)
2 registered medical practitioners must sign a document confirming abortion. Also rule out STI’s as they can increase complications
Before 9 weeks: Mifepristone and then misoprostol after 48 hours to initiate contractions
After 9 weeks: Surgical evacuation which is surgical dilation and suction. Early surgical is local, late surgical may require general
Complications:
Infection, bleeding, failure of termination, poor wound healing, trauma to cervix or uterus, small chance of fertility
PE/DVT in Pregnancy
Can present as chest pain, radiating to the back, or may be an emergency with fluids. May have had a history of a swelling in the legs prior.
Management is via ABCDE. Ensure patient is stable so give oxygen, fluids, analgesia if appropriate. Do VQ scan and then give LMWH for the remainder of the pregnancy and for four to six weeks after delivery.
Also lifestyle stuff, stay hydrated, move around enough, .
Delivery shouldn’t be in birthing centre and should be done in the labour ward
STI/PID Diagnosis and Management
STI can be asymptomatic, if not, can be present with pain, dysuria, discharge and maybe bleeding.
Investigations include doing endocervical swab and microscopy to look for suspected organism and give antibiotics accordingly.
If PID, they will more likely have pain, urine, discharge, bleeding symptoms. Also may have a fever and dyspareunia. May present as infertility due to previous STI’s. Will need more Abx. Ceftriaxone, Metronidazole and Doxycycline
If they have IUS or IUD, may require removal. Counsel patient on safe sex behaviour
Acute Gynae Pain Differentials, Diagnosis and Management
ABCDE approach, ensure patient is table
Give oxygen, fluids, analgesia as required
Bloods for cross-match or G+S if needed
Differentials include ectopic pregnancy, miscarriage, PID, ovarian torsion, ruptured ovarian cyst, ruptured fibroid, appendicitis
Investigations: Bloods, Imaging
Management: Depends on underlying cause, give Abx if needed and surgical management mostly.
Infertility Differentials and Management
In history, ask about all the symptoms, rule out fibroids, endometriosis, PCOS, PID, male factor, blocked tubes, premature ovarian failure
Investigations: FSH and LH (day 3), progesterone levels 7 days before the end of period, prolactin levels, TFT’s, FBC, U+E, LFT’s, do USS to check ovaries and tubes, do STI screen, semen analysis, Hysterosalpingography
Substance Abuse in Pregnancy and Management
Take a good through history. Ask about all drugs. Ask about social situation, ask about the father.
Management is focused on specialist referral. Antenatal care should be consultant led, look at social support for the patient herself if it is poor. Also involve a specialist substance abuse midwife. Patient should have a key worker that can follow up on them throughout the pregnancy and afterwards. Take an MDT approach.
Regular monitoring of foetus, and at birth, will likely require admission to a neonatal unit NICU/SCBU.
How to take blood pressure
Explain that you’ll be doing the BP
Put cuff around
Place diaphragm over brachial artery
Inflate cuff until you can’t hear anything. Then slowly deflate it until you hear something. That is systolic
Then you keep deflating until the sound disappears, that is the diastolic blood pressure.
How to examine the pregnant abdomen
Inspect the abdomen: Signs include linea nigra, striae gravidarum and striae albicans
Palpation of the abdomen
Fetal lie (can be longitudinal, oblique or transverse)
Fetal presentation (can be cephalic or breech)
Measure symphysio-fundal height
Fetal engagement
Use pinard stethoscope to measure heart or doppler
Secondary PPH
Most common cause is endometritis, can just be infection
ABCDE approach, fluids, oxygen, analgesia as required.
Give antibiotics, lots of them, consider the best ones if in doubt. May require examination under anaesthesia with surgical evacuation of retained products
May require iron supplementation or transfusion depending on the severity
