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Obestetrics > Other topics in Obs > Flashcards

Other topics in Obs Flashcards

1
Q

VBAC indication

A

Offered in singleton preg of cehalic pres at 37+wk who have had single lower segment c-section
w or w/o Hx vaginal birth
Consider if 2+ lower segment c-sec

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2
Q

CIs to VBAC

A

Previous uterine rupture
classical c-sec scar
other CI e.g.major praevia

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3
Q

VBAC vs ERCS

A 
VBAC has fewest Cx
VBAC success rate = 75%
Biggest risk of VBAC is emergency c-sec
ERCS a/w placenta praevia/accreta and adhesions
ERCS longer recovery
ERCS risks bowel/bladder inj.
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4
Q

Best indicator of future successful vaginal delivery

A

Hx of vaginal delivery

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5
Q

Risks of VBAC

A

Emergency c-sec
uterine rupture 1:200 (1:100 if syntocinon).
39% req. instrumental
Higher risk w/post-dates, twins, macrosomia
infant: transient morbidity (can happen in ERCS to), still birth v small risk

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6
Q

Intrapartum Mx of VBAC

A

Electronic monitoring throughout
Induced/augmented labour increased risk
Induction with mechanical less likely to rupture scar and PGs

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7
Q

Planning ERCS

A

> 39w
proph. ABx
VTE proph.

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8
Q

Care of c-section scar

A

keep dry
remove sutures 5d
no heavy lifting 6w
no getting pregnant for 12-18m

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9
Q

PACES counselling of VBAC

A

option of VBAC or ERCS
VBAC risks: rupture, emergency c-sec, (75% success rate of VBAC)
ERCS risks: future preg. bleed, infection, clot

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10
Q

Multiple Pregnancy AN Care

A

Obstetric led care

Extra Scan for GA +anomalies+chorionicity

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11
Q

Epi of multiple pregnancy

A

1% natural conception

much higher with IVF

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12
Q

Chorionicity in multiple pregnancy

A

Detect at time of detecting multiple pregnancy
No. placental masses
Lamba and T sign
Assign left and right baby
Refer to senior USS if can’t be assessed
Manage as monochorionic until proven otherwise
If >14w use: membrane thickness, lamba sign, no, masses, and disconcordant foetal sex

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13
Q

General care for multiple pregnancy

A

Lifestyle: same as normal AN, risk of anaemia (FBC 20-24w)

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14
Q

Uncomplicated monochorionic diamniotic care

A

9+ appointments w/HCP
2+ w/ specialist obstetrician
Scan + appointment when CRL 45-84mm and then at:
16,18,20,22,24,28,32,34

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15
Q

Uncomplicated dichorionic

A

8+ appointments
2+ w/ specialist obstetrician
Scan+appointment CRL45-84 and then every 4wks from 20-36

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16
Q

Uncomplicated monochorionic triamniotic or dichorionic triamniotic

A

11+ appointments
2+ w/specialist obstetrician
Scan+appointment every 2wk from 14-34wk

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17
Q

Uncomplicated trichorionic triamniotic

A

7+ scans
2 apps w/ sp. obs
Scan+app every 4wk from 20-34

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18
Q

Summary of monitoring in mono/dichorionic

A

mono: 2wkly growth and doppler from 16w (refer foetal medcine)
di: 4wkly growth and doppler from 20w

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19
Q

Foetal complications of multiple pregnancy (T21)

A

Higher risk T21
Different screening (combined test, consider second trim. screen)
Caclulate risk per bayb in di risk per preg. in mono
Higher false positive rate in multiple preg
Invasive testing more likely
Cx of invasive tests more likely
Possibility of selective foetal reduction

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20
Q

Foetal Cx of multiple pregnancy (NOT T21)

A

Structural ab: as normal AN
TTTS: do not monitor in T1, start from wk16 on 2wkly basis, go to weekly if membrane folding or other signs
IUGR: do NOT use SFH, estimate weight discordance using 2+ biometric measures from 20w, difference >20% can be sign of IUGR

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21
Q

Maternal Cx of multiple pregnancy

A 
Hypertension:
- BP and proteinuria every visit
Aspirin 75mg from 12w if any of:
- First preg
- 40+yo
- Pregnancy interval >10y
- BMI >35 at first visit
- FHx pre-eclampsia
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22
Q

Higher Risk of Pre-term birth in multiple pregnancy

A 
multiple preg have higher risk spontaneous birth
do NOT use to determine risk:
foetal fibronectin
home uterine activity
cervical length
If inevitable give corticosteroids
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23
Q

Preventing preterm birth in multiple pregnancy

A 
Do NOT use:
Bed rest at home/hosp
IM or vaginal progesterone
Cerclage
Oral tocolytics
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24
Q

Timing of birth in multiple pregnancy

A

60% of twin preg. will spontaneously birth before 37w
Continuing uncomp. preg >38w a/w risk (36 for triplets)
Offer continuous CTG
?elective birth
If not elective birth offer weekly apps w/sp. obs

25
Q

Elective birth in multiple pregnancy indications

A

IF:
uncomplicated monochorionic twin (from 36w after CS)
Uncomplicated dichorionic twin (from 37w)
Uncomplicated triplet (from 35w after CS)

26
Q

Vaginal birth possible in multiple pregnancy

A

first twin cephalic
5% risk of second twin needing C-sex
Aim for interval <30mins between twins

27
Q

PACES Counselling of multiple pregnancy

A

RF: AMA, Hx, Assisted repro
Risks:
- mat: BP, hyperemesis, GDM
- Feo: monochorionicity, TTTS, defects, prematurity
Scans 2 or 4wkly
Del: 60% before 37w, vaginal if first twin ceph

28
Q

Dx of Monochorionic twin pregnancy

A

All women w/twins offered USS 11-13+6 (CRL 45-84)
Determine chorionicity
Keep photographic record

29
Q

Mono vs dichorionic risks

A

Higher rate of loss in mono (T2 particularly)

?higher risk neurodev. morbidity

30
Q

Screening in monochorionic pregnancy

A 
Triple test if 11-13+6
Quadruple after this
Detailed USS at 18-20+6
USS every 2 weeks from wk16-del.
 - measure liqour (DVP) and UAPI
Calculate EFW using biometrics
31
Q

TTTS in monochorionic pregnancy

A

Advise mother to report sudden increase in abdo size or SOB

EFW differences may be TTTS

32
Q

TAPS in monochorionic pregnancy

A

Screened following fetoscopic laser ablation for TTTS usinf serial MCA peak systolic velocity

33
Q

Screening for selective growth restriction in monochorionic pregnancy

A

at each scan from 20w calc. EFW (2+ biometric)
>20% discordance = perinatal risk
UAD for progonsis and morbidity

34
Q

Mx of TTTS in monochorionic preg

A

Refer FMU
<26w - fetoscopic laser ablation of vascular anastamoses
>26w delivery may be considered
Weekly USS
Del. 34-37w
Expectant Mx
? amnioreduction, septostomy, selective feticide

35
Q

sGR Mx in monochorionic preg

A

Refer FMU
Selective reduction and option if done early
Surveillance scans every 2wks
Abnormal doppler waveforms indicator for delivery in some cases

36
Q

Delivery in monochorionic pregnancy

A

Offer elective del from 36w after CS

MCMA twins high risk of death so c-sec between 32-34w

37
Q

Breech Delivery frequency

A

3-5% at 37w

38
Q

Breech at term women advice

A

Offer ECV

If ECV declined offer planned vaginal or C-sec (generally c-sec)

39
Q

ECV?

A

External cephalic version
50-60% success rate
risks: distress needing emergency c-sec or labour
CI: c-section to be performed, APH last 7d, abnormal CTG, uterine anomaly, ROM, multiple preg

40
Q

C-section for breech at term

A

benefits: small reduction in perinatal mortality, planned vaginal higher risk of low apgar and early morbidity but late outcomes same
Risks: small risk of Cx (less than emergency c-sec which happens in 40% of breech PVD), increases risk in future pregnancy

41
Q

Antenatal assessment of Breech delivery

A

Suggestive of high risk vaginal birth:
- hyperextended neck, high/low EFW, footling presentation, AN compromise
Women near or in active 2nd stage should not be routinely offered c-section
Induction not generally recommended (augmentation using oxytocin possible)
Continuous foetal monitoring

42
Q

Breech Delivery itself:

A 
V. dangerous if footling
Hands off approach (ideally baby will deliver itself)
Manoeuvres
Forceps
Make sure theatre ready 
(bloods e,g G+S X-Match)
43
Q

Summary of breech delivery

A 
<36w: many will turn spontaneously
36w ECV (37 for multip)
44
Q

PACES Counselling of Breench Delivery

A

RF: uterine malf., fibroids, praevia, poly/oligohydramnios
Dx: feet down
Offer ECV
Vaginal vs C-section

45
Q

Unstable lie

A

RF: Multip, praevia, uterine anomalies, polyhydramnios, multiple pregnacny
Risks: cord presentation or prolapse, uterine rupture
USS to conform
80% revert to longitudinal before labour
If mechanical eg praevia LSCS
Admit >37w
consider ECV ARM LSCS

46
Q

Mastitis in pregnancy

A

Ix: clinical, consider USS, aspiration, cytology

Encourage continue bf

47
Q

Treating mastitis in pregnancy

A

If systemically unwell, nipple fissure, if Sx not improved after 12-24h
Fluclox 10-14 (clindamycin if allergic)
Continue bf in treatment

48
Q

Breast abscess Mx

A

Surgery

IV/PO ABx (fluclox, cefalexin, doxy, clindamycin) non b-lactam if MRSA

49
Q

Nipple thrush in pregnancy Mx

A

Clinical fx: pain in both nipples after feed, pain up to 1hr, creamy spots in baby mouth
Mx: miconazole topical oral nystatin for bby

50
Q

High dose folic acid in pregnancy

A 
5mg
Previous child w NTD
DM
AED
Obesity
HIV taking co-trimox
sickle cell disease
51
Q

Perineal tear

A

1st deg: superficial damage no muscle
2nd deg: perineal muscle not anal sphincter
3rd deg: involving anal sphincter complex (E/IAS)
3a: <50% EAS, b: >50% EAS, c:IAS tear
4th deg: sphincter complex and rectal mucosa

52
Q

Edinburgh post-natal depression scale

A

10-items max score 30
how mother has felt in the last week
>13 suggests depressive illness
Mx: sertraline and paroxetine for bf

53
Q

Bf CI drugs

A 
ABx: cipro, tetracycline, chloramphenicol, sulphonamides
Psych: Li, benzos
Aspirin
Carbimazole
MTX
Sulphonylureas
Cytotoxics
Amiodarione
54
Q

Req. for Instrumental delivery

A

Fully dilated cervix
OA (OP possible w/some forceps +ventouse)
Ruptured membranes
Cephalic presenation
Engaged presenting part
Pain relief
Sphincter (bladder empty req. cath usually)

55
Q

Preparing for an elective C-section

A 
around 39w
Pre-ass w/midwife:
blood: G+S
MRSA swabs
Ranitidine night before and morning of operation
Fast 8 hours before c-section
56
Q

AN corticosteroids how are they given?

A

2x12mg IM betamethasone
24hrs apart
benefit window from 24hr after first dose to 7d

57
Q

Pregnancy and flying

A

Most airlines say no after 37w (32 for twins)
Discuss w GP
Reduce VTE risk by hydration and activity

58
Q

Depression in pregnancy

A

Discuss concerns
Mild to mod: refer for facilitated self help
Mild w/Hx of severe: consider Mx (SSRI, SNRI, TCA)
Mod-Sev: CBT, consider TCA, SSRI, SNRI,
If therapy req. refer urgently
If a woman decides to stop taking her pre-existing meds ask why and offer alternatives
Post natal: treat as normal pop. offer sertaline/paroxtine

Obestetrics (21 decks)

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