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3rd year - Obstetrics and Gynecology > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

Maternal mortality definition

A

Death of women while pregnant or within 42 days of termination of pregnancy from any cause per 100 000 deliveries

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2
Q

Timing of first trimester screening

A

Once, ideally before 12 weeks

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3
Q

What does first trimester screening include

A
  1. IPS testing
  2. Ultrasound for dating
  3. Labs (CBC, blood type, electrophoresis if anemia, infection (gonorrhea, chlamydia, HIV, VDRL, HBsAg, urine culture and sensitivity, Rubella)
  4. PAP test
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4
Q

A mother is not immune to rubella on screening. What action do you take?

A

Must avoid sick contact during pregnancy and immunize postpartum

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5
Q

A mother has gonorrhea, chlamydia, bacterial vaginosis or trichomonad during pregnancy. What do you do?

A

Treat

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6
Q

What can cause a false VDRL reading?

A

Lupus

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7
Q

What is included in 2nd trimester screening

A
  1. Morphology ultrasound at 18-20 weeks (only mandatory ultrasound)
  2. Blood - hemoglobin, ABO, Rh, Rh antibody at 24-28 weeks
  3. Gestational diabetes screen with non-fasting 50g glucose load at 24-28 weeks
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8
Q

Gestational diabetes screening algorithm

A

Tony’s pg 12

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9
Q

3rd trimester screening

A
  1. GBS vaginal and rectal swab at 35-37 weeks
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10
Q

How to interpret symphysial fundal height

A

Distance from pubic bone crest to top of uterus to measure growth

FSH should be roughly equal to gestational age (+/- 2 cm) and increase 1 cm per week

Use starting at 12 weeks

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11
Q

What is crown rump length

A

Longest straight line from outer margin of cephalic pole to rump

Most accurate estimation of gestational age in 1st trimester after 6 weeks

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12
Q

What is a biophysical profile

A

Usually done in high-risk pregnancies in 3rd trimester

U/S evaluation of fetal well-being using Manning’s score system and non stress test

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13
Q

Oligohydramniosis cut off and associations

A

<5

Associated with placental insufficiency and baby in stress

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14
Q

Polyhydroamniosis

A

> 25

Associated with diabetes, chromosomal abnormalities and anatomical abnormalities

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15
Q

Trisomy 18

A

Edwards syndrome

Severe mental retardation and other
<10% survive 1 year

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16
Q

Trisomy 13

A

Patau syndrome

Severe mental retardation and other
5% survive 3 years

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17
Q

Trisomy 16

A

Lethal, often first trimester spontaneous abortions

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18
Q

45,X

A

Turner syndrome

First-trimester spontaneous abortions
Slightly lower IQ

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19
Q

47, XXX; XYY, XXY

A

Klinefelter syndrome

Tall, eunuchoid habitus and small testes

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20
Q

del(5p)

A

Cri du chat syndrome

Severe mental retardation, microcephaly, distinctive facial features, characteristic cat’s cry sound

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21
Q

What birth defect risk does not increase with maternal age

A

Open neural tube defects

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22
Q

What does IPS screen for

A

Risk of Down’s, Edward’s and neural tube defects

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23
Q

What does IPS include

A
  1. Ultrasound (nuchal translucency >3 mm and absence of nasal bone increases risk for Down Syndrome) and PAPP-A (lower in trisomy 21) at 11-14 weeks for Down’s
  2. Maternal serum screening at 15-21 weeks, ideally at 15+3 weeks
    Free beta-hCG - higher in Down’s
    AFP - high in NTD
    uE3 - low in Down’s and Edward’s
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24
Q

Types of pre-natal screening for birth defects

A
  1. Non-invasive – IPS, MSS
  2. Invasive – chorionic villous sampling and amniocentesis

Now instead of IPS can do EFTS (one stop shop mainly meant to rule out Down Syndrome). EFTS has 7% false positive rate vs 10% false positive rate in IPS

NIPT is probably going to start to replace EFTS soon

Amniocentesis will always be the gold standard (performed if positive screening with IPS or EFTS) and is a diagnostic test

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25
Q

Indications for invasive pre-natal screening

A
  1. Positive prior screening test (IPS or maternal serum screening)
  2. Family history of genetic disease
  3. Maternal age >40
  4. Specific u/s finding that need to be f/u
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26
Q

Purpose of invasive pre-natal screening

A

Test for other genetic and birth defects outside of Down’s, Edward’s and NTD

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27
Q

Chorionic villous sampling

A
  1. Done at 11-13 weeks
  2. Sample taken from placental villi
  3. 1% miscarriage rate (higher than amniocentesis)
  4. Results come back in 2-3 weeks
  5. Do not detect NTD so AFP need to be done at 15-20 weeks
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28
Q

Amniocentesis

A
  1. Done at 15-22 weeks
  2. Sample taken from amniotic fluid
  3. <1% miscarriage rate
  4. Results come back within 3 weeks (rapid aneuploidy 1 week, conventional chromosome study 2-3 weeks)
  5. Can detect NTD
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29
Q

Cordocentesis

A

Done at >18 weeks

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30
Q

Normal placenta

A
  1. Discoid
  2. 500 grams, 15-20 cm in diameter, 2-3 cm thick
  3. Situated in upper uterine segment in fundal portion of uterus
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31
Q

Trimesters in weeks

A

1- end of 12 - 1st trimester
13- end of 26 - 2nd trimester
27 onward - 3rd trimester

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32
Q

3rd trimester bleeding differential diagnosis

A
  1. Pregnancy related
    Placenta - placental abruption, placenta previa, vasa previa
    Uterus - uterine rupture
    Cervix - cervical insufficiency (thin cervix), cervical friability, cervical cancer
    Vagina - laceration of trauma
    Physiologic - bloody show associated with labour
2. Non-pregnancy related cause 
PALM COEIN 
Polyps
Adenomyosis
Leiomyoma
Malignancy (including trophoblastic disease) 
Coagulopathy
Endometrial dysfunction
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33
Q

NIPT

A

Non invasive prenatal testing
Replacing amniocentesis because of risk of miscarriage
Measures fetal cells in maternal serum
Results in 10 days

Not currently covered by the ministry unless maternal age 40+

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34
Q

HIV contraindications for pregnancy and childbirth

A

No ergot if post partum hemorrhage
No instrumentation/vacuum
No breastfeeding

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35
Q

Degrees of shock and associated signs and symptoms

A

Mild - <20% - cool extremities, increased cap refill

Moderate - 20-40% - tachycardia, tachypnea, postural hypotension, oliguria

Severe - >40% - hypotension, agitation/confusion, hemodynamic instability

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36
Q

Limit of neonatal viability

A

22 weeks

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37
Q

4 main causes of preterm births

A

Spontaneous

  • preterm labour with intact membranes
  • PPROM

Indicated

  • maternal or fetal complications requiring early delivery
  • Twins or high-order multiples
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38
Q

Pre term labour risk factors

A

SES
Genetic factors (maternal race, history, age)
Increased uterine distension (polyhydramnios, multifetal gestation)
Multifetal gestation
Infection (UTI, periodontal, bacterial vaginosis) —> treat even if asymptomatic in pregnancy
Behavioural (low maternal weight, substance abuse, smoking)
Short inter-pregnancy interval (delivery <12 months)
Vaginal bleeding (T2>T1)
Cervical surgery
Uterine congenital malformations: bicornuate/didelphys

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39
Q

Pathogensis of preterm labour

A

Stress response via HPA axis

  • Increased maternal cortisol or fetal ACTH by fetal adrenals
  • Increases CRH production by placenta/membranes and decidua
  • Estrogen conversion of adrenal DHEA leads to increased myometrial receptivity

Inflammation/infection -

Decidual hemorrhage

Uterine Stretch

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40
Q

Prevention for preterm labour

A

Not very successful
Screening in women with risk factors (cervical length 10th centriole <26 mm, bacterial vaginosis swab first trimester)

Interventions:
Modifying behavioural risks - alternating positions (strict bedrest not shown to be of any benefit)
Progesterone in women with previous PTB or short cervix once there is change in cervix

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41
Q

Pre term labour diagnosis

A

Painful contractions
Pelvic pressure
Back pain
Bleeding

Signs: 
Palpable contractions
Short cervix 
Open cervix on spec 
Dilated cervix on digital exam
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42
Q

Diagnosis of PTL

A

Fetal fibronectin

  • Glycoproteins in cervicovaginal secretions, swab for these in posterior fornix
  • Marker for impending preterm labour
  • Poor sensitivity in asymptomatic women
  • Negative predictive value 98%, PPV 30%
  • Useful 24-34 weeks with intact membranes
  • Can not have had internal examination within 24h
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43
Q

When to avoid doing a digital exam

A

If you are unsure of the location of the placenta (have not gotten 2nd trimester morphology screen)
Do speculum exam instead

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44
Q

Management of PTL

A
  1. Determine fetal presentation
  2. Celestone
  3. Tocolytics?
  4. Antibiotics for GBS prevention
  5. Transfer to tertiary center
  6. Paediatric consultation
  7. Neuroprotection (MgSO4)
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45
Q

What’s the deal with antenatal steroids?

A

Betamethasone 12 mg IM q 24h x 2 doses
<34 weeks
Activates fetal surfactant production to decrease RDS
One course good for each pregnancy

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46
Q

Risk factors for PPROM

A 
Antepartum bleeding 
Previous cervical surgery 
Smoker 
Low SES 
Cervical incompetency (cervix opens without contractions, presents with pressure, discharge)
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47
Q

PPROM diagnosis

A
  1. Pooling
  2. Cough test
  3. Nitrazine - pH (amniotic fluid basic, vagina acidic)
    - false positive with blood, sperm, BV, alkaline urine
  4. Ferning - false positive 20% (sperm, cervical mucous), false negative 40%
    - Swab in the fornix, not in the cervix because mucous will can false positive

Obstetrical ultrasound

  1. Fetal position
  2. Amount of amniotic fluid
  3. Dating
  4. Fetal well being
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48
Q

PPROM complications

A

Maternal

  1. Infection (chorioamniotis, endometriosis, Baxter Emma)
  2. Increased risk of CS

Fetal

  1. Infection
  2. Preterm delivery (50% deliver in first 24h, 70-80% in following week)
  3. Cord prolapse
  4. Abruption
  5. Pulmonary hypoplasia
49
Q

PPROM Management

A
  1. Confirm diagnosis
  2. Ensure maternal and fetal well being
  3. Address underlying cause that needs management (ex. Abruption, chorio)
  4. Avoid digital exam unless in labour (push up bacteria each time)
  5. GBS swabs
  6. Ultrasound
  7. Decide on expectant vs active management
50
Q

Indications for induction

A
  1. Weight gains in maturity against infection risk
  2. Earlier PPROM more likely to gain significant time
  3. After 34 weeks gain in time smaller
  4. Most will induce after 35 weeks
51
Q

Expectant management

A 
<34 weeks 
Goal is to increase latency period 
Antibiotic prophylaxis 
Maternal and fetal monitoring 
Antenatal steroids 
Possible transfer to tertiary center
52
Q

Infertility definition

A

1 year of unprotected intercourse without conception

53
Q

2 most important factors for natural conception rate

A
  1. Female age

2. Duration of infertility

54
Q

What past medical history would be concerning for tubal injury?

A

Ruptured appendix

55
Q

What are some screening tests available to predict fertility potential

A

Day 3 FSH, LH, Estradiol
Antral follicle Count (AFC) - most reliable early in cycle
Anti-Mullerian Hormone (AMH)- don’t need to time in cycle, but not covered by OHIP

56
Q

Femal einfertility management class 1

A

Weight gain
GnRH pump
Gonadotropins
IVF

57
Q

Class II Female management

A 
1st line - Weight loss 
1st line med - Femara or Letrizole 
Aromataste inhibitors 
Insulin-sensitizing agents (ex. Metformin) 
Laparoscopic ovarian drilling 
Gonadotropins 
IVF
Bromocriptine or other dopamine agonist (only in cases of hyperprolactinemia and anovulation)
58
Q

Class III Infertility Management

A

Expectant management
?Gonadotropins/IVF
Donor egg - best treatment option to have pregnancy
Adoption

59
Q

Tubal etiology infertility investigations

A

Hysterosalpingogram (HSG)
SonoHSG
Laparoscopy

60
Q

Tubal factor infertility treatment

A

IVF

Consider tubal surgery if due to tubal ligation or do not want IVF

61
Q

Hirsutism definition

A

Excess facial and body hair caused by excess androgen production

Unwanted

62
Q

Virilization definition

A

Clitoromegaly, depending of voice, balding, body habitus changes
…

63
Q

Whole blood contents

A

RBCs, plasma, fibrinogen

No platelets

64
Q

Packed RBCs

A

RBCs only

No fibrinogen, no platelets

65
Q

Fresh Frozen Plasma FFP

A

Colloid, fibrinogen

No platelets

66
Q

Cryoprecipitate

A

Fibrinogen, other clotting factors

No platelets

67
Q

Placental abruption risk factors, pathophysiology, presentation, complications, diagnosis, treatment

A

Risk factors

  1. Maternal - AMA, prior abruption, prior CS, multi-parity, comorbidity, cocaine
  2. Current pregnancy - multiple gestation, short umbilical cord, PPROM, Prolonged ROM, polyhydramnios, trauma

Pathophysiology
- placental lining separated from uterus, bleeding from maternal side of placenta
Marginal, partial or complete

Clinical presentation

  1. Bleeding per vagina with painful uterine contraction
  2. Tenderness and hard uterus or back pain
  3. Fetus distress as shown by fetal heart rate monitoring

Complications
Fetal complication usually followed by maternal
- fetal distress
- premature delivery
- fetal hypotension, anemia, CP and developmental problem
- couvelaire uterus (penetration of blood into uterine myometrium and into peritoneal cavity)
- Maternal hypovolemic shock and end organ damage
- Maternal DIC

Diagnosis

  • Clinically based on vaginal bleeding, abdo tenderness and/or fetal distress
  • Trans abdominal or vaginal u/s to rule out placenta previa and detect large abruption

Treatment
- Stabilize and deliver (unless premature and no fetal distress, then consider close observation)

68
Q

Placenta previa risk factors, pathophysiology, clinical presentation, complication, investigation, diagnosis, treatment

A

Risk factors

  1. Maternal factors
    - AMA, prior placenta previa, multiparity >5, previous uterus surgery
    - illicit drugs, smoking
  2. Current pregnancy factors
    - multiple gestation

Pathophysiology
Placenta inserted in lower uterine segment such that it is near or partially covers or completely covers the internal cervical os
Grade 1 - low lying, placenta within 5 cm of internal cervical os
Grade 2 - marginal, placenta reaches margin of os but does not cover
Grade 3 - Partial previa, placenta partially covers os
Grade 4 - Complete previa, placenta completely covers os

Clinical Presentation
- Painless bright red vaginal bleeding during 2nd half of pregnancy

Complication

  • Maternal hypovolemic shock
  • Preterm delivery

Investigation

  • Blood work including Kleihauer-Betke stain, HIV, Hepatitis B
  • TA or TV U/S

Diagnosis
- definitive diagnosis with TA/TV U/S

Treatment
Definitive treatment delivery by C-section

69
Q

Vasa Previa risk factors

A
  1. Pregnancy achieved with assisted reproductive technology

2. Placenta - resolved placenta previa, bilobed or succinturiate lobed placenta

70
Q

Vasa previa pathophysiology

A

Fetal vessels unsupported by umbilical cord that overlie the cervix or lies between cervix and fetal presenting part

71
Q

Vasa previa clinical presentation

A

Classic triad

  1. Membrane rupture
  2. leading to painless vaginal bleeding
  3. and fetal bradycardia (or sinusoidal pattern)

Pelvic exam - rarely, pulsating vessel in membrane overlying cervical os

72
Q

Vasa previa diagnosis

A

Pre-natally - identification of membranous fetal vessel passing internal cervical os on ultrasound

May be diagnosed clinically based on presentation of triad

73
Q

Vasa previa treatment

A

Definitive treatment is delivery by C section

74
Q

Definition and classification of hypertension in pregnancy

A

Hypertension in pregnancy diagnosed based on blood pressure 9mean of at least 2 measurements taken at least 15 minutes apart using same arm)

  • SBP 140+ and or/ DBP 90+
  • Severe hypertension 160+ SBP or 100+ DBP

Classification:
1. Pre-existing (chronic) hypertension less than 20 weeks GA
2. Gestational hypertension that develops 20+ weeks GA
Both of these are defined as hypertension with resistance, proteinuria, adverse condition or severe complications

75
Q

Pathophysiology of preeclampsia and eclampsia syndrome

A
  1. Decidual immune cell and extravillous trophoblast interactions cause invasion and uteroplacental artery remodelling
    Interaction can be precipitated by
    - Immune factors causing antigen exposure such as primi-gravidity, primi-paternity, donor gametes
    - Genetic factors including epigenetic, familial risks
    - Lowered threshold from metabolic syndrome, chronic infection or inflammation, CKD, diabetes
  2. Interactions of decidual cells and extravillous trophoblast result in inadequate placentation and uteroplacental mismatch, resulting in release of mediators (intervillous soup)
    Intervillous soup includes placental debris, innate immune activation, oxidative stress, eicosanoids, cytokines
  3. Intervillous soup results in endothelial cell activation and dysfunction within vulnerable multi-organ systems, resulting in systemic effects
76
Q

What are the symptoms, signs, lab tests and diagnostic methods for gestational hypertension

A

Investigations:
Pre-existing hypertension/early
- CBC, lytes, Cr, fasting blood glucose
- Urine analysis (protein without RBCs or casts)
Suspected pre-eclampsia
- O2 sat (<97% in pre-eclampsia)
- CBC (anemia in HELLP, thrombocytopenia in pre-eclampsia), film (RBC framgentation in micro-angiopathy), Cr (renal failure), uric acid (increased) glucose, AST, ALT, bilirubin (liver dysfunction), albumin (decreased due to liver dysfunction), LDH, INR, aPTT (increased in DIC), fibrinogen (decreased in DIC)

Fetal testing

  • Monitoring
  • Deepest amniotic fluid pocket (oligohydramnios)
  • Uterine artery doppler velocimetry (uni or bilateral notching, elevated plurality or resistance index suggestive of placental insufficiency)
  • Fetal growth (IUGR)
  • Umbilical artery doppler (increased resistance, absent or reversed end diastolic flow in pre-eclampsia)
  • Ductus venous doppler (increased resistance, absent or reversed A wave in pre-elclampsia)
  • MCA doppler (cerebral redistribution with decreased resistance or brain sparing effect)
77
Q

Gestational hypertension prevention and management

A

Prevention - calcium, folic acid, lifestyle
- High risk (history, abnormal uterine artery Doppler before 24 weeks gestation) - low dose aspirin, L-arginine, rest, prostaglandin precursor, Mg supplementation, heparin to prevent VTE, LMWH

Management
1. Lifestyle

  1. BP control
    No comorbidity target - SBP 130-155 and DBP 80-105
    Comorbidity target - SBP 130-139 and DBP 80-89
    1st line - Methyldopa (but makes moms dopey), lebatalol, nifedipine XL
    2nd line - BB except atenolol, HCT, hydralazine
  2. Manage non severe pre-eclampsia (inpatient)
    a) <24 weeks GA
    - counselling about delivery within days
    b) 24-34 weeks
    - expectant management
    - consider ante-natal corticosteroid for fetal maturation
    c) 34-37 weeks
    - expectant management or immediate delivery
    - consider ante-natal CS if CS delivery
    d) 37+ weeks
    - immediate delivery
  3. Manage severe pre-eclampsia
    - Vitals monitoring, investigations
    - BP control 1st line - Nifedipine, Hydrazine, Labetalol
    Refractory treated with sodium Nitroprusside IV
    - Prophylaxis against eclampsia with MgSO4 4g IV loading dose followed by 1g/h (can also treat existing eclampsia)
    - HELLP treated with FFP transfusion or plasma exchange
    - Consult OB
    - Delivery is the only definitive intervention to resolve pre-eclampsia, thus all severe pre-eclampsia are OB emergencies and require immediate delivery regardless of GA
  4. Post-partum management within 6 weeks
    - Continuous monitoring and labs
    - Control BP with anti-hypertensives according to CHEP guidelines
  5. Post partum long term management after 6 weeks
    - Screen for pre-existing HTN, renal disease
    - Address CVD risk factors
78
Q

Maternal and fetal complications of gestational hypertension, and signs and symptoms of each

A 
Recurrence of pre-eclampsia 
Chronic hypertension 
TIIDM, metabolic syndrome 
CKD
Premature CVD including CAD, CVD, PVD
79
Q

Pre-eclampsia definition

A

Hypertensive disorder of pregnancy defined as SBP 140+ and/or DBP 90+ with 1+ of the following:

  1. New proteinuria >300 mg/24h
  2. 1+ Adverse condition
  3. 1+ severe complication

Severe pre-eclampsia is pre-eclampsia with 1+ severe complication

80
Q

What is HELLP syndrome

A

Type of severe pre-eclampsia

Hemolysis, Elevated Liver enzymes, Low Platelets

81
Q

What is eclampsia

A

Generalized tonic clonic convulsive seizure, which is a complication of pre-eclampsia

82
Q

What does expectant management for pre-eclampsia entail?

A

IV access (no volume expansion)
Administration of anti-hypertensives
CS for fetal lung maturation
Daily bio-physical profile and fetal assessment
Daily maternal pre-eclampsia labs
Daily clinical assessment of mother and fetus

83
Q

Indication for hospitalization with maternal hypertension

A

Severe hypertension >160/110
or
Severe pre-eclampsia

84
Q

Normal post partum blood pressure pattern

A

Drop PP day 1-2
Peak PP day 2-7
Decline after PP day 7
Normalize by 3 months

85
Q

Anti-hypertensives acceptable for use during breast feeding

A 
Nifedipine 
Labetalol
Methyldopa 
Captopril 
Enalapril

Dopey Ned took some ace inhibitors and beta blocker

86
Q

Ectopic pregnancy risk factors

A
  1. Demographics: older women, African descent
  2. Uterine structural abnormality: fibroids, adhesions, abn anatomy
  3. Ob/Gyn history: prior ectopic, IUD, PID, salpingitis, infertility
  4. Surgery: abdo, pelvic, IVF
  5. Medication: clomiphene citrate
87
Q

Ectopic pregnancy signs and symptoms

A

Pain, vaginal bleeding

Missed menstrual period, Chadwick’s sign, Hegar’s sign, fever, peritoneal signs, cervical motion tenderness, palpable adnexal mass, tenderness on bimanual

88
Q

Ectopic pregnancy labs and diagnostic tests

A

Serial beta-hCG

  • <8 weeks gestation normally doubles ever 2 days
  • Non viable has slower rise, plateau or decreasing before 8 weeks

U/S (tubal ring on TVUS)
- visible on u/s when b-hCG >1500 for TVUS and >6000 for TAUS

Laparoscopy

Diagnosis – elevated b-hCG and visualization on U/S or laparoscopy

89
Q

Ectopic pregnancy management

A
  1. Stabilize
  2. Abortion (medical or surgical, similar success rate)
    a) Surgical - linear salphingostomy (preserve tube) or salpingectomy (remove tube)
    b) Medical - methotrexate IM
90
Q

Ectopic pregnancy implications for fertility

A

With surgical abortion 40-60% of cases will be fertile and become pregnant again after surgery

With medical abortion 80% preserve Fallopian tube patency

91
Q

Most common site for ectopic pregnancy

A

Fallopian tube (98%) specifically in the ampulla (70%)

92
Q

Indications for surgical abortion

A
  1. > 3.5 cm ruptured ectopic pregnancy
  2. Fetal heart rate present
  3. b-hCG >5000
  4. Liver or renal or hematological disease
  5. Poor compliance, unable to follow up

Indication for salphingectomy - damaged tube, recurrent ipsilateral ectopic

Indication for salpingostomy - if no indication for salphingectomy

93
Q

Indications for medical abortion

A
  1. <3.5 cm ruptured ectopic pregnancy
  2. Fetal heart rate absent
  3. b-hCG <5000
  4. No liver, renal, hematological disease
  5. Good compliance, able to follow up
94
Q

Clinical presentation of spontaneous abortion

A

Abdominal cramping, vaginal bleeding, ROM, passage of tissue and clots

95
Q

Spontaneous abortion definition

A

non-induced embryonic or fetal death or passage of products of conception before 20 weeks GA

96
Q

Threatened abortion definition

A

Vaginal bleeding with closed cervix and viable fetus, which can resolve or progress to spontaneous abortion

97
Q

Inevitable abortion

A

Dilated cervix, but conception products have not been expelled, will progress to spontaneous abortion

98
Q

Incomplete abortion

A

Some, but not all of conception products have been passed, retained products may include fetus, placenta or membrane

99
Q

Complete abortion

A

All conception products have been passed without need for surgical or medical intervention

100
Q

Missed abortion

A

Fetal demise but no uterine activity to expel conception products

101
Q

Septic abortion

A

Spontaneous abortion complicated by intra-uterine infection

102
Q

Most common fetal cause of spontaneous abortion

A

Chromosomal abnormalities in 50% of cases

103
Q

Cause of recurrent spontaneous abortions

A

MAKE ID
Mechanical uterine anomalies including congenital septate uterus, leiomyoma, endometrial polyps, intra-uterine adhesions
Autoimmune factors including anti-phospholipid syndrome
Karyotype including aneuploidy, chromosomal rearrangement
Endocrinopathy including thyroid disease, DM, PCOS
Maternal infection including TORCH, listeria
Drugs including smoking, illicit drugs and other environmental factors

104
Q

Complication of spontaneous abortion and presentation

A

Septic spontaneous abortion, which presents with fever, hypotensive shock, abdo pain and leukocytosis

105
Q

Management of spontaneous abortion with retained products

A
  1. Watch and wait
  2. Misoprostol
  3. D&C +/- Oxytocin
106
Q

Vaginal bleeding in 1st and 2nd trimester

A
  1. Physiologic - implantation of placenta
  2. Abortion
  3. Abnormal pregnancy - ectopic, gestational trophoblastic disease
  4. Trauma
  5. Genital lesion - polyps, cancer
107
Q

What are the only non-pharmacological pain relief methods that have been shown to have some benefit in relieving pain

A

Vertical position during 1st stage of labour
Continuous support
Acupuncture

108
Q

Types of opioids that can be used in intermittent bolus parenteral method of pain control, and the pros and cons of each

A
  1. fentanyl - fastest onset, shortest duration, lower effect re neonatal respiratory depression
  2. Meriperine - slowest onset
  3. Morphine - longest duration
  4. Nalbuphine - longest duration, lower effect re neonatal respiratory depression
109
Q

Indication for intermittent bolus parenteral opioid administration

A
  • 3rd line

- Early labour or very late stage labour where epidural is not an option

110
Q

Patient controlled analgesia types of opioids used

A
  • Fentanyl most commonly

- Remifentanil

111
Q

Disadvantage of Patient controlled analgesia

A

Requires continuous O2 sat monitoring and one-on-one nursing

112
Q

PCA indication

A
  • 2nd line pain control
  • Epidural refused on contraindicated
  • Intrauterine fetal demise or termination of pregnancy
113
Q

Inhalation nitrous oxide (entonox (50NO: 50 oxygen) indication

A

Usually used before or in conjunction with opioids or epidural

114
Q

First line pain management in labour option

A

Epidural

115
Q

Epidural contraindications

A

Absolute

  • Patient must be able to sit still for procedure
  • Patient refusal
  • Increased intra-cranial pressure
  • Infection at site of injection
  • Systemic infection
  • Coagulopathy

Relative

  • Uncorrected maternal hypovolemia
  • Active neurological disorder
  • Inadequate training or equipment
116
Q

Epidural procedure steps

A
  1. Needle inserted at L2-L5 (usually L3-4) between vertebrae midline into epidural space just beyond the ligamentum flavum
  2. Catheter inserted through needle and left in-situ
  3. Local (bupivicaine or ropivicaine) +/- opioids are inserted via catheter
117
Q

Role of local anesthesia in epidural

A
  1. Block nerve endings bathed in epidural space innervating the birth canal
  2. Ideally blocks only sensory component (motor intact)
  3. 15-20 minutes to take effect
118
Q

What is the effect of epidural analgesia on labour?

A
  1. Prolong 2nd stage of labour, but not clinically significant
  2. Epidural analgesia does not increase risk of C section
  3. Does not increase risk of back pain postpartum

3rd year - Obstetrics and Gynecology (7 decks)

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