repro Flashcards
CPR on pregnant woman?
keep woman supine with let uterine displacement
30 compressions (100-120 bpm) - depth 5-6cm
2 breaths: 30 compressions
if no response to CPR in 4 mins = C-section!!
Shockable rhythms process?
defib adrenaline 1mg after 3rd shock - then every 4 mins
amiodarone 300mg after 3rd shock
non-shockable rhythm process?
adrenaline every 3-5 mins
drugs for VF/VT? opiate overdose? magnesium toxicity? local anaesthetic toxicity?
VF/VT = 300mg amiodarone
opiate = naloxone
Mg = calcium gluconate
LA = intralipid
anaphylaxis ABCDE?
remove allergen
high flow oxygen
IM adrenaline 500mcg every 5 mins and IV crystalloid bolus
chlorohreniramine
20mg IV hydrocortisone
200mg IV salbutamol neb
Diabetic emergencies?
Hypo
* STOP INSULIIN
* glucose <4mmol/l = 50ml of 10% dextrose IV/1mg glucagon IM/glucogel
DKA
* insulin
* fluids - saline
NOTE - CAN BE NORMOGLYCAEMIC IN PREGNANCY
amniotic fluid embolism presentation? Tx?
not predictable or preventable acute presentation
* profound foetal distress
* sudden respiratory distress
* seizure
* DIC
Tx = ITU - supportive
PE s/s preg + postnatal?
symptoms
* dyspnoea
* pain
* cough
* haemoptysis
* collapse
signs
* temp >37
* raised JVP
* enlarged liver
* parasternal heave
* fixed splitting of 2nd heart sound
* cyanosis
* tachycardia
Dx PE preg/postnatal? Tx?
ECG - tachy, RVH (rarely S1Q3T3)
CXR - pleural effusion, raised hemi, wedge collapse
ABG - hypoxia + normal CO2
ECHO - rule out dissection and tamponade
CTPA!!
Tx = thrombolysis!!
stroke Ax pregnancy?
PRE-ECLAMPSIA!!!
thrombosis
amniotic fluid embolism
haemorrhagic infarct - infection, cocaine, vasculitis
cord prolapse risk factors
Tx
breech
preterm labour
2nd twin
AROM
Tx = tocolysis + all 4’s/immediate delivery
shoulder dystocia risk factors? Signs?
obesity
diabetes
macrosomia
prolonged 1st + 2nd stage
instrumental delivery
Signs = turtle sign!
Complications shoulder dystocia? Tx?
Comps
* stillbirth
* hypoxic brain injury
* brachial plexus injury - Erb’s palsy
* fractures
* PPH
Tx = HELPERR
* Help
* Episiotomy
* Legs (McRoberts manouvre)
* Pressure (suprapubic)
* Enter (rotational pringle-can manouvre)
* Remove posterior arm
* Roll patient onto her hands and knees
admission to mother + baby unit when?
rapidly changing mental state
suicidal ideation
significant estrangement from infant
guilt or hopelessness
beliefs of inadequacy as mother
psychosis
bipolar in pregnancy?
50% relapse rate if untreated
baby blues? Tx?
50% women
tearful, irritable, anxiety, poor sleep + confusion
3-10 days
Tx = self-limiting! support + reassurance
puerpueral psychosis? risk factors?
presents within 2 weeks of delivery
* sleep disturbance
* confusion + irrational ideas
* develops into mania, delusions, hallucinations
Risk factors
* bipolar
* previous puerperal psychosis (50%)
* 1st degree relative with history of bipolar
Tx puerperal psychosis? Main complication?
EMERGENCY - needs admission to mother baby unit
Tx
* antidepressants
* antipsychotics
* mood stabilisers
* ECT
25% go on to develop bipolar disorder
postnatal depression symptoms? onset? Tx?
tearful, irritable, anxiety, anhedonia, poor sleep, weight loss - can present with concerns regarding baby and parenting skills
onset = 2-6 weeks postnatally (later than puerpural psychosis and baby blues), lasts weeks to months
Tx = CBT, antidepressants, if very severe consider admission
complication postnatal depression?
70% lifetime risk of depression
bipolar tx pregnancy?
lamitrogine safest in pregnancy?
* valproate gives neural tube defects
* carbamezapine can cause cardiac defects, neural tube defects
* lithium can cause ebstein’s anomaly + heart defects
should bipolar treatment be stopped in pregnancy?
breastfeeding?
no - 50% relapse without Tx
lithium is contraindicated in breastfeeding
shizophrenia Tx pregnancy?
antipsychotics are safe in pregnancy
clozapine contraindicated in breastfeeding!!! - life threatening
avoid anticholingerics in pregnancy!!
risk to foetus if mother is bipolar?
schizophrenic
bipolar = 1 in 7
schizophrenia = 10%
depression Tx in pregnancy?
sertraline first line (pulmonary hypertension is main complication)
venlafaxine = hypertension
paroxetine = cadiac abnormalities
depression meds breastfeeding?
sertraline 1st line
TCAs are ok too
avoid citalopram + fluoxetine (high levels in breast milk)
alcoholism in pregnancy consequences
miscarriage
foetal alcohol syndrome (facial deformities, lower IQ, epilepsy)
maternal Wernicke’s encephalopathy
maternal korsakoff syndrome (permanent)
consequences of drug use (cocaine, ecstasy) in pregnancy
death
teratogenic - microcephaly, heart defects
pre-eclampsia
placental abruption
IUGR + preterm labour
miscarriage
withdrawal
nicotine in pregnancy?
miscarriage
placental abruption
IUGR
stillbirth
antenatal care for substance abuse
methadone program
child protection + social work
breastfeeding contraindicated if alcohol >8, HIV, cocaine
labour plan regarding analgesia
paroxetine in pregnancy?
generally avoided - less safe than other SSRIs (heart defects)
complication of antipsychotics in pregnancy?
they are safe but 2nd gen (olazapine, quetiapine etc) carry risk of gestational diabetes
however, olanzapine and quetiapine have best evidence base
recommendations mood stabilisers in pregnancy?
lamotrigine in pregnancy! (antipsychotics like quetiapine also safe)
valproate and carbamazepine avoided at all costs
lithium - avoid if possible (Ebstein’s anomaly) but consider reintroduction immediately post-partum if not breastfeeding
anxiety Tx pregnancy?
SSRIs first line
avoid benozdiazepines - cleft lip, neonatal withdrawal (floppy baby)
final recommendations for Tx of mental illness in pregnancy
baby blues
reassure patient + breast exam
rate of recurrence = 50% (untreated)
psychiatry, midwife
strong advise to start meds antenatally (mood stabilisers + antipsychotics)
bimanual pelvic exam
one hand on cervix, one hand on abdomen
if mass felt in centre = uterine
fel tlaterally = ovarian
if mass moves in line with cervix = uterine
if mass does not move = adnexae
ovarian cancer Tx?
radiotherapy is NOT USED!!!
tx = chemo + debulking surgery
ovarian cancer makers
CEA: Ca125 ratio?
Ca125, AFP, HCG, LDH
if Ca125>CEA = primary ovarian tumour
if CEA>Ca125 = GI origin
struma ovarii
thyroid tissue in ovary - hyperthyroidism
RMI score
Meig’s syndrome
triad = benign ovarian tumour + ascites + pleural effusion
resolves after resection of the tumour
clinical feature of ovarian torsion?
pain does not settle with analgesia
smear test timing
begins at 25 years
if negative HPV = next test in 5 years (from ages 25-65)
smoking cervical cancer?
nicotine is a co-carcinogen (helps HPV thrive in body)
definitions of bleeding in pregnancy
bleeding in early pregnancy <24 weeks
bleeding in late pregnancy (antepartum haemorrhage) >24 weeks
hormones produced by placenta
HPL + HCG
antepartum haemorrhage (APH)?
commonest causes?
APH = >24 weeks gestation and before second stage of labour (PPH)
placental abruption
placenta praevia
uterine rupture
vasa praevia
local causes: ectoprion, polyp, infection, carcinoma
quantifying APH
pretty sure this should say 500
placental abruption?
pathology?
seperation of placenta too early = bleeding (may be concealed)
blood escapes into amniotic sac OR myometrium (concealed)
interrupts placental circulation causing hypoxia
can result in couvelaire uterus (bruised uterus that doesnt contrast much due to bleeding in myometrium)
placental abruption risk factors?
70% occur in low risk pregnancies
pre-eclampsia/HTN
trauma
smoking, cocaine, amphetamines
thrombophillia (APS)
diabetes
renal disease
polyhydramnios, multiple pregnancy
PRROM
abnromal placenta + previous abruption
symptoms PA?
severe continuous abdominal pain (labour is intermitent)
* continuous backache with posterior placenta
bleeding (may be concealed)
preterm labour - PPROM
may simply present with maternal collapse
signs PA
unwell distressed patient, bleeding may be concealed
uterus tender, woody hard, cannot feel foetal parts
foetal HR = bradycardia/absent
CTG shows irritable uterus (10 contractions/10 mins)
CTG also shows maternal tachycardia, loss of variability, decellerations
PA management?
resuscitate mother
* 2 large bore IV
* bloods - FBC, clotting, LFT U+E, Xmatch, Kleinhauer if resus negative
* Fluids (careful with PET - fluid overload)
* catheter (empty bladder?)
uregent delivery by C/S
complications placental abruption
maternal = hypovolaemic shock, anaemia, PPH (25%), renal failure, infection, thromboembolism
foetal = IUD, hypoxia, prematurity
PA recurrence
10% recurrence - cant really prevent
stop smoking, drug use
APS - LMWH + LDA
placenta praevia?
Placenta praevia = when the placenta lies directly over the internal os
Low-lying placenta = placental edge is <20mm from internal os on TVUS
placenta praevia complication?
risk factors
placenta praveia = 20% APH
risk factors = previous C/S, previous abortion, multiparity, assisted conception, smoking, endometritis, fibroid
placenta praevia screening
foetal anomaly scan
rescan at 32 + 36 weeks (TVUS)
MRI if placenta accreta suspected
placenta praevia symptoms
signs?
painless bleeding >24 weeks
foetal movements present
signs
* uterus soft, non-tender (unlike aburption)
* presenting part high due to placental mass in lower uterus
* may be transvserse, breech
* CTG normal
what must be avoided in placenta praevia
digital exam !!
Dx placenta praevia?
check anomaly scan
confirm by TVUS
MRI to exclude placenta accreta
placenta praevia Tx?
resus mother - large bore IV + assess baby
steroids <36 weeks
MgSO4 <32 weeks
anti-D if rhesus neg
MgSO4 for neuro protection
placenta praevia Tx - not bleeding?
advise patient to attend immeditely if bleeding including spotting or contractions/pain
no sex
placenta praevia delivery?
consider from 34-36 weeks if bleeding
if uncomplicated, consider delivery between 36-37 weeks
(give steroids)
placenta praevia delivery style
C/S if placenta covers os or <2cm from os
vaginal delivery if placenta >2cm from os and no malpresentation
placenta accreta?
risk factors
complictions
placenta abnormally adherent to uterine wall
risk factors = placenta praevia + C/S
complications = severe bleeding, PPH, death
placenta accreta classification
increta = invading myometrium
percreta = penetrating uterus to bladder
mnagement placenta accreta
expect to lose >3L of blood
prophylactic iliac artery balloon
hysterectomy
uterine rupture?
risk factors
full thickness opening of uterus (including serosa)
* if serosa is intact = dehiscence
risk factors = previous C/S or uterine surgery (e.g. myomectomy), multiparity, IOL (prostaglandins, syntocinon), obstructed labour
symptoms uterine rupture?
signs?
severe abdominal pain
shoulder-tip pain
maternal collapse
PV bleeding
signs = loss of contractions, acute abdomen, peritonism, foetal distress/IUD
Tx uterine rupture
urgent resus + surgery
2 large bore IV access
FBC, clotting, Xmatch, LFT U+E, Kleinhauer
IV fluids
anti-D if rhesus neg
vasa praevia?
Dx?
S/s?
unprotected foetal vessels travel below presenting part over internal cervical os
Dx = TVUS
S/s = sudden dark red bleeding and foetal bradycardia/death
types vasa praevia?
risk factors?
type 1 = vessel connected to velamentous umbilical cord
type 2 = connected to accessory lobe
risk factors = bi-lobed or accessory placenta, low-lying placenta, multiple pregnancy, IVF (1 in 300)
Tx vasa praevia?
steroids <36 weeks
deliver C/S by 36 weeks
APH from vasa praevia = emergency C/S
PPH?
types?
blood loss >500ml after birth of baby
primary = within 24 hours of delivery
secondary = after 24 hours (can be up to 6 weeks later)
minor = 500-1000ml (without shock)
major = >1000ml (or signs of shock)
Ax PPH?
4T’s = uterine atony (70%), trauma, tissue, thrombin
risk factors PPH
anaemia, previous CS, placenta praevia/accreta, previous PPH, multiple pregnancy, polyhydramnios, obesity, macrosomia
intrapartum risk factors = prolonged labour, C/S, retained placenta, active management of third stage (syntocinon/syntometrine)
PPH Tx?
ABCDE
oxygen
2 large bore IV
FBC, Xmatch, LFT U +E, clotting (fibrinogen)
if DIC/coagulopathy = FFP, cryoprecipitate, platelets
stop the bleeding
* uterine massage
* 5 units IV syntocinon stat
* empty bladder
* Bakri or Rusch balloon
if still bleeding = ergometrine (not in HTN), carboprost, misoprostol, tranexamic acid
if STILL bleeding = surgery
secondary PPH?
main causes?
>24 hours
RPOC + infection
(exclude RPOC with USS)
thing to remember APH?
Kleihauer, anti-D and steroids
common viral infections in pregnancy?
rubella, measles, mumps, influenzae, chicken pox, CMV
Rubella?
S/s?
Maternal infection?
viral infection transmitted by direct contact/droplet
s/s = fever, rash, lymphadenopathy, poluarthritis
maternal infection can cause miscarriage, stillbirth, birth defects (CRS)
congenital rubella syndrome?
triad = cataract + cardiac abnormalities (PDA) + deafness
outcome of maternal rubella infection?
Management
dependent on gestation - worse early on
Tx
* blood IgM within 10 days of exposure
* IgG can be detected after natural infection or vaccination
* if patient not immune consider TOP
* supportive Tx = rest, fluids, paracetamol, avoid contact with other pregnant women
measles?
S/s?
maternal infection?
Tx
caused by paramyxovirus = highly contagious!!
S/s = fever, white spots in mouth (koplik’s spots), runny nose, cough, red eyes, rash
usually non teratogenic but can cause IUGT, microcephaly, miscarriage, preterm birth
Tx = supportive
chicken pox?
S/s?
Tx?
varicella zoster - spread via droplet
s/s = fever, malaise, vesicular rash
Tx
* check VZV immunity
* offer VZ immunoglobulin within 10 days of exposure
* if >10 days = aciclovir?
* aciclovir also given if >20 weeks gestation
* avoid other pregnant women
severe chicken pox?
Tx?
severe infection = hepatitis, encephalitis, pneumonia
Tx - hospitalisation + IV aciclovir
foetal varicella syndrome?
occurs form 7-28 weeks gestation:
hypoplasia of limbs
IUGR
cataracts
microcephaly
cutaenous scarring
commonest congenital infection?
significance?
complications?
CMV
leading non-genetic cause for sensorineural deafness
comps = miscarriage, stillbirth, IUGR, microcephaly, thrombocytopenia, mental retardation, deafness
maternal infection CMV?
unlike rubella, chance of congenital infection increases later on in pregnancy
Dx CMV?
Tx CMV pregnancy?
Dx = amniocentesis + guage how symptomatic foetus is via MRI foetal brain
valacyclovir
immunoglobulin
parvovirus?
maternal infection?
complications?
slapped check syndrome/fifth disease
maternal infection is self limited
foetal complications = mainly affects erythroid precursors
* aplastic anaemia, congenital heart failure, hydrops foetalis + foetal death
Dx + Tx parvovirus in pregnancy?
Dx = virus specific IgM
Tx = self-limiting
mumps?
Symptoms?
RNA virus - no ill effects on pregnancy or foetus
symptoms = fever, headache, no rash, swollen salivary glands
MMR vaccine pregnancy?
live vaccine so contraindicated
influenza pregnancy
prophylaxis?
Tx?
if infection super virulent = can cause miscarriage + preterm labour
vaccine safe during pregnancy + breastfeeding
Tx = antivirals
zika virus?
complications?
prophylaxis?
mosquito bite
comps = microcephaly, brain defects, deafness + blindness, epilepsy, developmental delay
no vaccine so only way to avoid is to not travel to Zika affected area
if returning from Zika affected area do not try to coneive for 6 months
HSV in pregnancy?
if genital lesions near time of delivery = C/S
HIV pregnancy
comps?
Tx?
routinely screened for alongside syphillis + hep B
comps = IUGR, miscarriage (maternal mortility and morbidity not increased)
management
* screen for CMV, TB and toxoplasmosis
* HAART treatment
* prophylactic antibiotics
* elective C/S reduced risk of transmission by 50% (zidovudine infusion commenced 4 hours prior to CS)
* DO NOT BREASTFEED
HIV delivery?
C/S recommended
however if viral load <50 copies/ml (on HAART), vaginal delivery can be considered
toxoplasmosis pregnancy?
complications
treatment
toxoplasmosis = from raw/undercooked meat or cat faeces
comps = hydrocephalus, chorioretinitis, cerebral calcifications, microcephaly, mental retardation
Tx = self-limiting
acute toxoplasmosis in pregnancy = spiramycin
listerosis?
symptoms?
complications pregnancy?
Tx?
listeria monocytogenes = eating infected food
symptoms = headache, diarrhoea, abdominal pain, nausea
complications = neonatal death, neonatal sepsis, preterm labour, stillbirth
Tx = amoxicillin + gentamicin
(co-trimoxazole if allergic)
co-trimox also known as trimethorpim-sulfamethoxazole
prevention listeriosis in pregnancy?
avoid unpasturised milk, soft cheese, refrigerated smoked seafood (salmon etc)
group B strep pregnancy Tx?
if chorioamnionitis?
IV penicillin
chorioamnionitis = broast spectrum antibiotics
* gentamicin + metronidazole
* s/s = tender abdomen, foul-smelling discharge
puerperium?
physiological changes
from end of 3rd stage of labour to 6 weeks postpartum
uterus contracts immediately after delivery, not palpable after 10 days
cervical os closed by 10 days
lochia - blood stained for up to 14 days (rubra), then yellow then white (sera, alba)
menstruation resumes at 6 weeks if not breastfeeding
cardio = CO and PV return to normal in a week, oedema up to 6 weeks, BP normal within 6 weeks
GFR decreases to normal over 3 months
blood = U+E’s return to normal, Hb and HCT rise again, WCC falls, platelet and clotting factors fall but hypercoagulable state can persist for up to 6 weeks
perineal tears
1st degree = skin
2nd degree = skin and muscle
(can both be repaired by midwife, as can episiotomy)
3a = <50% external anal sphincter
3b = >50%
3c = involves internal anal spincter
4th degree = involves anal or rectal mucosa
VTE post-partum?
prophylaxis?
hypercoagulable state
low risk = hyration + mobilisation
mod risk = 10 days prophylactic LMWH
high risk = 6 weeks prophylactic LMWH
endometritis risk factors?
Ax?
Tx?
risk factors = prologed labour, prolonged ROM, forceps delivery, RPOC, C/S
Ax = GBS!!!, staph, E.coli, anaerobes
Tx = broad spectrum antibiotics (co-amox/clinamycin if allergic + matronidazole + gentamicin)
seocndary PPH Ax?
Tx?
endometritis (infection) + RPOC
Tx = antibiotics, evacuation of RPOC
urinary retention women tx?
catheterise - treat underlying cause
trial without catheter after 48 hours
vesico-vaginal fistula?
caused by prolonged obstructed labour
(common in 3rd world countries)
puerpeural psychosis recurrence?
60% recurrence
mastitis?
Tx
staph infection - presents with fever and breast tenderness
Tx = continue breastfeeding + antibiotics
(may progress to breast abscess req surgical drainage)
Contraception methods
barrier methods
oral hormonal = POP, COCP
injectable progestogen
LARC = nexplanon, IUD (copper or Mirena IUS)
sterilisation
likely diagnosis?
endometritis
could also be wound infection, UTI, chest infection, thrombophlebitis, mastitis/breast abscess, viral infection
SOB after delivery?
PE until proven otherwise
suspected PE Tx?
LMWH until VQ scan/CTPA result
inhaled meconium?
black streaky lungs
foetal shunts?
how does foetal circulation work
ductus venosus
formaen ovale
ductus arteriosus
oxygenated blood in IVC in foetus
deoxygenated blood in umbillical arteries
foetal preparation for birth
surfactant production (type 2 pneumocytes)
accumulation of glycogen - liver, muscle, heart
accumulation of brown fat - between scapulae and internal organs
swallow amniotic fluid + inhale it = helps lungs grow (severe oligohydramnios can result in hypoplastic lungs)
how is amniotic fluid in lungs absorbed?
vaginal delivery squeezes lungs
baby absorbs rest by crying
foetal cardiovascular changes following birth?
failure of this process?
pulmonary resistance drops
systemic vascualr resistance increases
ducts/shunts close (DA becomes ligamentum arteriosus, DV becomes ligamentum teres)
patent foramen ovale
persistent ductus arteriosus
persistent pulmonary hypertension of the newborn
persistent pulmonary hypertension of the newborn?
Dx?
Tx?
shunts remain (PFO + DA)
Dx
branches that supply right upper limb are always preductal so Dx = pre and post-ductal saturations
right hand will have more oxygenation than left leg
Tx = oxygen, nitric oxide (vasodilation of pulomary arteries so lowers pulmonary resistance), inotropes to aid CO
if all this fails = ECMO
transient tachypnoea of the newborn?
s/s?
tx?
seen in big healthy babies born by C section
no vaginal “squeeze” so take longer to absorb amniotic fluid
s/s = tachypnoea, grunting
self-limiting but screen for infection
thermoregulation newborn?
main source of heat production is non-shivering thermogenesis (cannot physiclly shiver as a baby)
breakdown of brown fat
need hats, skin to skin contact, blanket, clothes
Ax hypoglycaemia newborn?
unwell
premature (low glycogen stores)
maternal diabetes
hyperinsulinism
physiological jaundice of newborn?
unconjugated bilirubin (breakdown of foetal Hb)
Common STIs
describe blood film
likely diagnosis - this is from urethral disharge swab
gram negative coccus
neisseria gonorrhoea
(can’t be chlamydia because chlamydia does not gram stain - use NAAT instead)
PCR testing for gonorrhoea and chlamydia?
NAATS
more sensitive test
Tx gonorrhoea?
ceftriaxone
if allergic to penicillin = ??
gram appearance?
likely diagnosis given history is: vaginal discharge, intense itch, vulva red and inflammed, thick white discharge
gram +ve cocci
candida!! - large gram +ve round
Tx vaginal candida albicans?
1st line = topical clotrimazole
2nd line = oral fluconazole
non-albicans candida?
less likely to respond to fluconazole
Tx trichomonas vaginalis?
important to remember?
metronidazole
with metronidazole, not not drink alcohol (2 days before and 2 dys after) - disulfiram reaction
treat partners too - as very difficult to diagnose
Dx HSV-2 genital lesions?
Tx?
PCR from de-roofed vesicle
Tx = aciclovir
differentials?
Tx?
DDx painless lesion = syphillis + LGV
Tx syphillis = IM benzylpenicillin (if allergic = doxycycline or azithromycin)
syphillis Dx?
Test of treatment effectiveness?
RPR (rapid plasma reagin) used to test response to treatment - want it to decrease
transabdominal ultrasound req?
advantags vs disadvatages?
bladder must be full
advantages = safe, readily available, no radiation
disadvantages = difficult in obese patients + gaseous distension
..
which vessel is ovary next to?
external iliac
TVUS req?
therefore if need to do TAUS and TVUS
TVUS needs empty bladder
so do TAUS first, let patient urinate then do TVUS
..
acute abdomen Ix?
1st line = USS
2nd line = CT
hysterosalpingography (HSG)?
x-ray real time imaging
for assessment of tubal patency in pateints with infertility
endometrial cancer Dx?
TVUS!
MRI to assess degree of myometrial invasion
CT to look for datnt metastases
TORCH screen?
toxoplasmosis, rubella, CMV, herpes simplex, HIV
first line test for analysing foetal chromosomes
what does it do?
foetal chromosome microarray
has higher resolution but only detects chromosomal imbalance (insertions/deletions)
technique for balanced translocations = karyotype
answer = A
women with PET can have severe foetal grwoth restriction
differential diagnosis vulval itch
lichen sclerosis?
Ax?
Epidemiology?
Symptoms?
inflammatory, scarring dermatosis of ano-genital skin
Ax = unknown
Epidemiology = women>men, pre-pubescent children + post-menopausal women, associated with other autoimmune diseases
symptoms = itch, pain, dyspareunia, constipation (esp children)
lichen sclerosis O/E?
white papules + plaques - figure of 8 pattern
ecchymosis, erosions + fissures
DDx lichen sclerosis?
S/s?
Associated with?
lichen planus
however will affect mucosal membranes (mouth), nails, hair
S/s lichen planus = itch, pain, dyspareunia, discharge
associated with vitiligo, pemphigoid, morphoea
complication lichen sclerosis?
Tx?
SCC - esp in smokers
Tx = good genital skin care + super potent topical steroid (dermovate)
Dx?
tx?
genitourinary syndrome of the memopause
* pallor of vestibule
* urethral caruncle
* loss of vaginal rugae
* inside vagina = pallor with petechial haemorrhages
tx = vaginal oestrogen
vulval pain DDx
vulvodynia?
tx?
burning vulval pain occuring in absence of visible findings
Tx
* localised provoked pain = lidocine ointment, physio
* unprovoked pain = tricyclics, gabepentin/pregabalin
* psychosexual interventions
FGM types
must report FGM?
100% - offense for failing to proect a girl at risk of FGM
Tx FGM?
type 3 = de-infibulation
painful genital lesion DDx?
history = painful lesion
Dx?
vulval epithelial neoplasia
HPV-related, VIN similar to CIN
s/s = itchy/painful
pregnnancy trimesters?
1st trimester = week 1 to week 12
2nd = week 13 to week 26
3rd = week 27 to end of pregnancy
types of ovarian cyst?
Follicular e.g. polycystic ovaries
Luteal (corpus luteum)
Endometriod (2* to endometriosis)
Epithelial
Mesothelial
commonest type of ovarian cyst?
Ax?
Tx?
follicular cyst - thin walled, lined by granulosa cells
form when ovulation doesn’t occur e.g. PCOS
Tx = usually resolve over a few months
endometriosis?
S/s?
Sites?
endometrial glands and stroma found outside uterine body
(in myometrium called andenomyosis)
Pain, pelvic inflammation, infertility
sites = ovary “chocolate cyst”, pouch of douglas, cervix, bladder, bowel etc
ovarian enodmetriosis macroscopic? Microscopic?
complications?
macroscopic = peritoneal spots, fibrous adhesions, chocolate cysts
microscopic = endometrial glands and stroma
complicatons = pain, cyst formation, adhesions, infertility, ectopic pregnancy, malignancy (endometrioid carcinoma)
endometriosis - endometrial spots
chocolate cyst endometriosis
types of ovarian tumour
Epithelial (most common)
Germ cell
Sex chord/stromal
Metastatic
epithelial ovarian tumours?
Serous (most common)
Mucinous
Endometrioid
Clear cell
Brenner
serous ovarian carcinoma types?
how are serous carcinoma of ovary and uterus linked?
High grade:
precursor = serous tubal intraepithelial carcinoma (STIC)
Low grade:
Precursor = serous borderline tumour
serous carcinoma of uterus + ovary both have TP53 mutation
classification ovarian tumour?
Benign = no cytological abnormalities, no stromal invasion
Borderline = cytological abnormalities, no stromal invasion
Malignant = stromal invasion
endometrioid and clear cell carcinoma of ovary associations?
associated with endometriosis of the ovary + lynch syndrome
brenner tumour of the ovary?
transitional epithelium in the ovary
usually benign!
germ cell tumours in the ovary?
teratoma
immature teratoma
dysgerminoma (most common malignant germ cell tumour)
yolk sac tumour
choriocarcinoma
most common malignant germ cell tumour ovary?
histological appearance?
dysgerminoma (equivalent to seminoma in testes)
large primitive germ cells surrounded by lymphocytes
most common benign germ cell tumour?
rare variant?
teratoma (dermoid cyst)
contain sebum, hair, skin, GI, thyroid tissue etc
immature teratoma (embryonic tissues) is very rare
sex chord/stromal ovarian tumours?
fibroma/thecoma (benign) - can produce oestrogen causing uterine bleeding
granulosa cell tumour (malignant) - also produce ostreogen
sertoli-leydig tumours - produce androgens
commonest origins of ovarian metastatic tumours?
when to suspect?
Stomach
Colon
Breast
Pancreas
suspect when tumours are bilteral and small
FIGO staging ovarian cancer
1A = tumour in 1 ovary
1B = both ovaries
1C = burst through ovary
2A = uterus/fallopian tube
2B = pelvic organs like bowel/bladder
3A = lymph nodes (para-aortic) or microscopic peritoneal extrapelvic involvement
3B = macroscopic peritoneal metastasis <2cm
3C = macroscopic peritoneal metastasis >2cm
4 = distant metastasis
pathology of fallopian tubes?
Inflammation - salpingitis due to infection
Cysts and tumours
Serous tubal intraepithelial carcinoma
Endometriosis
Ectopic pregnancy
ectopic pregnancy?
commonest site?
complication?
when to suspect
ectopic pregnancy = implantation of conceptus outside endometrial cavity
commonest site = ampulla of fallopian tube
major complication = can rupture and cause haemorrhage (hypovolaemic shock)
suspect in any female of reproductive age with amenorrhoea and acute hypotension + acute abdomen
Ax cervical cancer?
risk factors
presentation?
HPV 16 + 18
risk factors = smoking, early intercourse, “high risk” male, OCP, multiple partners
presentation
* at screening
* post-coital bleeding/IMB/PMB
* acute renal failure
staging cervical cancer
1a - microscopic
1b - visible lesion
2a - vaginal involvement
2b - parametrial involvement
3 - lower vagina or pelvic sidewall
4 - bladder/rectum or metastases
Tx cervical cancer
surgery - LLETZ (fertiliy sparing), Wertheim (radical hysterectomy)
radiotherapy
chemotherapy - cisplatin, barboplatin/paclitaxol
Ax endometrial cancer?
S/s?
Tx?
obesity, oestrogens (HRT/Tamoxifen), Lynch syndrome HNPCC
s/s = post-menopausal bleeding
Tx = TAH-BSO
side effects chemo?
Fatigue
Hair loss
Anaemia
bleeding/bruising
Nausea + vomiting
neoadjuvant vs adjuvant chemo
Neoadjuvant = before main treatment to reduce the size of a tumor
Adjuvant = after main treatment to destroy remaining cancer cells
symtpoms ovarian cancer
bloating
early satiety/loss of appetite
pelvic/abdominal pain
increased urinary frequency/urgency
red flag ovarian cancer?
new onset IBS >50 y/o
Dx ovarian cancer?
bloods - ca125
if ca125 >35 IU/ml = USS of abdomen + pelvis
large for dates?
Ax?
symphyseal-fundal height >2cm for gestational age
Ax
* Wrong dates
* Foetal macrosomia
* Polyhydramnios
* Diabetes
* Multiple pregnancy
foetal macrosomia?
risks?
USS EFW >90th centile (>4.5kg), abdominal circumference >97th centile
risks = obsructed labour, shoulder dystocia (esp diabetes), PPH
Tx macrosomia?
exclude diabetes
in absence of any other conditions, induction of labour should NOT be carried out simply because of macrosomia
discuss C/S?
Dx?
criteria?
Ax?
polyhydramnios = excess amniotic fluid
criteria: AFI >25cm, deepest pool >8cm
Ax
* diabetes
* GI atresia/cardiac/tumours
* monochorionic twin pregnancy
* hydrops foetalis
* viral infection (erythrovirus B19, toxo, CMV)
symptoms polyhydramnios?
signs?
Dx?
Ix?
Tx?
symptoms = abdominal discomfort, PROM, preterm labour, cord prolapse
signs = LFD, malpresentation, tense shiny abdomen, inability to feel foetal parts
Dx = AFI >25cm, deppest pool >8cm
Ix = OGTT, serology (toxo, CMV, parvovirus), US foetal survery (GI tract, heart)
Tx = IOL by 40 weeks
complications polyhydramnios?
malpresentation
preterm labour + PROM
cord prolapse
PPH
risk factors multiple pregnancy?
Assisted conception - clomid, IVF (UK limits to 2 embryos)
Race - African
FHx
Increased maternal age
Increased parity
Tall women > short women
types of multiple pregnancy?
monozygotic (splitting of 1 egg), dizygotic (fetilisation of 2 ova by 2 sperm)
chorionicity = 1 or 2 placentas
dizygous = always DCDA
monozygous = MCMA, MCDA, DCDA, conjoined
determining chorionicity?
why is this important?
USS lambda sign - strongly suggests dichorionic
important to determine as MCMA at very high risk of complications
symptoms multiple pregnancy?
signs?
symptoms = excessive sickness/hyperemesis gravidarum
signs = high AFP, large for dates, multiple foetal poles, USS confirmation at 12 weeks
multiple pregnancy complications?
Higher perinatal mortality (6 x higher than singleton)
Foetal = congenital abnormalities (e.g. acardiac twin), IUD + IUGR (single/both), preterm birth, cerebral palsy, twin to twin transfusion (oligohydramnios + polyhydramnios)
Mother = hyperemesis gravidarum, anaemia, pre-eclampsia, antepartum haemorrhage (placental abruption), placenta praevia, preterm labour, cesarean section
Tx multiple pregnancy?
USS (every 2 weeks MC, 4 weeks DC)
500mcg folic acid
delivery = C/S for triplets or MCMA
complications monochorionic twins?
Single foetal death
Selective growth restriction (SGR)
Twin-to-twin transfusion syndrome (TTTS)
Twin anaemia-polycythaemia sequence (TAPS)
Absent EDV (AEDV) or revered (REDV)
if one foetus dies, risk to twin?
Death (15%)
Neurological abnormality (26%)
(so need MRI foetal brain 4 weeks post death of co-twin)
TTTS?
complications?
Dx?
Tx?
artery-vein anastomosis (donor twin perfuses recipient twin)
compication = 90% mortality with no treatment
Dx = oligohydramnios-polyhydramnios (oly-poly)
Tx
* <26 weeks = laser ablation (can cause TAPS)
* >26 weeks = amnioreduction septostomy
delivery before 36 weeks
delivery of twins?
delivery method?
risk?
MCMA = C/S by 34 weeks
MCDA = by 36 weeks
DCDA = by 38 weeks
MCMA = cesarean section
for others, vaginal delivery can be considered
* continuous foetal monitoring
* syntocinon after twin 1 (prevents haemorrhage)
* intertwin delivery time <30 mins
remember risk of PPH
complications diabetes in pregnancy (T1, T2 + GD)?
Congenital abnormalities
Miscarriage + Intrauterine death
Worsening diabetic complications e.g. retinopathy, nephropathy
Pre-eclampsia
Polyhydramnios
Macrosomia
Shoulder dystocia!!
Neonatal hypoglycemia
pre-pregnancy counselling type 1 + 2 diabetes
aim for HbA1c <48 mmol
stop embryopathic medication = ACE-I, statins, sulphonylureas
folic acid 5mg (3 months before conception to 12 weeks gestation)
Tx gestational diabetes?
metofrmin + insulin
folic acid 5mg (3 months before conception –> 12 weeks preg)
low dose aspirin from 12 weeks (PET)
regular eye checks for retinopathy
growth scans 4 weeks from 28 weeks
counsel about shoulder dystocia
deliver at 38 weeks (earlier if complications)
risk factors gestational diabetes
Previous GDM
Obesity BMI >30
FH: 1st degree relative
Ethnicity: South Asia (India/Pakistan/Bangladesh), Middle Eastern, Black Caribbean
Previous big baby or current big baby
Polyhydramnios
diabetogenic hormones in pregnancy?
human placental lactogen (HPL) + cortisol
previous GDM recurrence risk?
50% recurrence risk
screening GDM?
Dx?
risk factors at boking
OGTT 24-28 weeks
fasting >5.6
2 hour > 7.8
how often check blood glucose in gestational diabetes?
normal values?
Check BG minimum 4 times a day (premeals)
1 hour post-meal + once before bed
3.5-5.5 mmol/l premeals
1 hour post-meal = <7.8 mmol/l
timing of delivery GDM + pregestational DM?
mode of delivery?
pregestational = 38 weeks
GDM = generally 38 weeks
C-section if EFW >4.5kg
GDM risk of developing T2DM?
follow-up?
70%
fasting blood sugar 6-8 weeks postnatally
small for gestational age?
foetal growth restriction?
SGA = birth weight <10th centile (<2.5kg)
AC + EFW <10th centile
FGR = failure to achieve genetic growth potential
* AC/EFW <3rd centile or <10 centile with evidence of placental dysfunction (abnormal uterine artery doppler)
Ax small for gestational age?
placental = infarcts, abruption, pre-eclampsia!! (common)
foetal infection = rubella, CMV, toxo (can caus epolyhydramnios so LFD but SGA?)
congenital abnormalities (renal agenesis)
chromosomal abnormalities (Downs syndrome)
maternal lifestyle = smoking, alcohol, drugs
complications SGA and FGR?
IUD/stillbirth
hypoxia + effects of chronic apsphyxia (neurodevelopment)
hypoglycaemia
hypothermia
polcytheamia
hyperbilirubinemia
Iatrogenic preterm birth (39 weeks)
single measurement <10th centile?
SGA = referral for serial growth scans
major risk factors SGA?
>40 y/o
smoking
cocaine
daily vigorous exercise
previous SGA
APS
low PAPP-A
BMI >35 or <20
large fibroids
whats this?
uterine artery notching
major risk factor for FGR and pre-eclampsia
management SGA?
serial growth scans
150mg aspirin from 12 weeks for women at risk of PET
mod vs major risk factors SGA
Ix SGA?
Consider offering genetic testing (Downs)
Consider offering infection screening (rubella, CMV, toxo)
Use of umbilical artery doppler (PET)
advanced doppler studies SGA?
middle cerebral artery + ductus venosus
MCA = change to low resistance vessel suggests foetus diverting blood flow to head
DV = abnormalitie suggest foetal acidaemia
delivery SGA?
39 weeks even if everything else is normal (unlike macrosomia)
FGR (i.e. below <3rd centile) = 37 weeks
if doppler normal = IOL vaginal delivery
if abnormal = C-section
what is folic acid?
deficiency in pregnancy?
recommended dose?
vitamin B9
deficiency = spina bifida, heart/limb defects, anaemia
dose = 400mg for most women
when do you give high dose folic acid 500mg?
previous pregnancy with spina bifida
woman/partner has spina bifida
AEDs
coeliac disease
diabetes
BMI >30
sickle-cell or thalassaemia
folic acid deficiency
vitamin D pregnant women?
higher dose?
daily dose of 10mg
higher dose in:
darker skin
BMI >30
diet low in vitamin D-rich foods (eggs, meat, cereal)
autumn/winter
importance of vit D in pregnancy?
deficiency can cause:
maternal = osteomalacia, pre-eclampsia, gestational diabetes
foetal = SGA, neonatal hypocalcaemia, asthma, rickets
listeriosis complications pregnancy?
reducing risk?
complications = miscarriage, stillbirth, preterm labour
avoid unpasturised milk, soft cheese (camembert, brie, blue), paté, undercooked food, deli meat
reducing risk of toxoplasmosis in pregnancy?
wash all fruit and veg, including ready-prepared salads
avoid undercooked meat
wash hands thoroughy after handling soil
avoid contact with cat faeces
pregnancy complications iron deficiency?
tiredness
SOB
preterm labour
stillbirth
IUGR/SGA
placental abruption
PPH
neurodevelopmental delay
iron rich foods?
red meat (beef, lamb, pork)
pulses (beans, peas + lentils)
fresh leafy greens (cabbage, spinach, parsley)
prunes, raisins, figs
fish (no more than 4 cans/week)
nuts
Dx + Tx iron defieincy pregnancy
important to remember with Tx?
Dx = FBC at booking + 28 weeks
Tx = diet, iron tablets (take with vitamin C)
caffiene and tea reduce absorption of iron tablets
foods to avoid in pregnancy?
soft cheeses
undercooked meat
tuna
raw eggs
patè
liver (high vitamin A neurotoxic to foetus)
fish oil supplements
risks low BMI in pregnancy?
low BMI = <18.5
IUGR + low birthweight
preterm labour
maternal and foetal risks obesity?
Obseity = BMI >30
maternal = miscarriage, gestational diabetes, pre-eclampsia, PE, labour/shoulder dystocia, PPH
foetal = IUD/stillbirth, macrosomia, foetal anomalies
Tx obesity in pregnancy
folic acid 500mg til 12 weeks
LDA from 12 weeks til delivery (PET)
vitamin D 10mg
OGTT 28 weeks
USS growth from 28 weeks
postpartum = fragmin (PE)
initiation of labour?
change in oestrogen/progesterone ratio
progesterone keeps uterus settled
oestrogen makes uterus contract + promotes prostagaldnin production
oxytocin initiates and sustains contractions (also promotes porstaglandin release)
Bishop score?
position, consistency, effacement, dilation + station in pelvis
determines whether ssafe to induce labour
stages of labour?
1st stage
* latent phase = 3-4cm
* active stage = 4-10cm
2nd stage = delivery of baby
3rd stage = delivery of placenta
prolonged 2nd stage?
Tx?
nulliparous = 2 hours (3 hours with epidural)
multiparous = 1 hour (2 hours with epidural)
Tx = episiotomy, instrumental delivery, C/S
duration of 3rd stage of labour?
approx 10 mins but can last up to 30 mins
after 1 hour must be removed under GA
Braxton Hicks?
false labour
can start from 6 weeks gestation
irregular, do not increase in frequency or intensity (relatively painless)
frequency of contractions?
duration?
normal = 3-4 in 10 mins
10-15 seconds long, max 45 seconds (builds up)
types of female pelvis?
gynaecoid = most suitable shape
anthropoid = pelvis inlet has larger OA diameter than transverse
android pelvis = triangular or heart-shaped
analgesia options birth?
paracetamol/co-codamol
entonox
diamorphine
epidural
spinal anaesethetic
remifentanyl
pudenal nerve block
7 cardinal movements of foetus during labour?
1 - engagement (3/5ths in pelvis, 2/5ths felt abdominally)
2 - descent
3 - flexion
4 - internal rotation
5 - crowning and extension
6 - external rotation
7 - expulsion (anterior shoulder first)
vaginal examinations normal labour?
approx every 4 hours
delayed cord clamping?
once pulsations have stopped or up to 3 minutes after expulsion
active management of 3rd stage?
syntometrine (only given in 3rd stage)
or oxytocin (if hypertension i.e. ergometrine CI)
+ controlled cord traction
normal blood loss labour?
normal = <500mls
PPH = >500mls
significant PPH = >1000mls
lactation initiation?
decrease in oestrogen + progesterone
increase in prolactin
oxytocin triggers lactation via nipple stimulation
observations during labour?
30 mins - 60 mins = contractions
Hourly pulse
4 hourly temp and BP - pre-eclampsia or sepsis
Frequency of passed urine
Vaginal examination 4 hourly
foetal monitoring labour?
intermittent = 1 min after contraction every 15 mins in 1st stage, 5 mins in 2nd stage
continous = CTG
delay first stage labour?
<2cm in 4 hours
PPH Tx
empty bladder
uterine massage
uterotonic drugs
IV fluids
HCG produced by?
Function?
placenta
signals corpus luteum to keep producing progesterone
placenta function?
oxygen transport (umbilical vein) + CO2 removal
nutrient + waste transport
hormone secretion
hormone changes in pregnancy?
importance?
HCG increases (doubles every 48 hours in first few weeks)
* ectopic (static or slow rising)
* failing pregnancy (falling)
* ongoing viable pregnancy (doubling)
HPL = acts like a grwoth hormone, decreases insulin sensitivty in mother
progesterone + oestrogen increase as pregnancy progresses
side effects HCG?
high levels?
complication?
side effects = nausea + vomiting
high levels = multiple or molar pregnancy
can cause hyperthryroidism (HCG same effect as TSH)
physiological changes pregnancy
CO increases (HR increases)
BP drops (lowest point in 2nd trimester)
anaemia as RBC and PV increases (Hb diluted)
resp rate increases
GFR increases
hypercoagulable state due to increased fibrinogen and clotting factors
anaemia in pregnancy values?
1st trimester Hb <110g/L
2nd + 3rd trimester Hb <105g/L
2 metabolic phases pregnancy?
1st - 20th week = anabolic phase
Small demands of foetus
lipogenesis, growth of breats, uterus, weight gain
21-40th week (esp. Last trimester) = catabolic phase
High metabolic demands of foetus
Accelerated starvation of mother (insulin resistance + lypolysis)
what hormone stimulates milk production?
prolactin
Naegele’s rule?
due date = LMP + 9 months + 7 days
what is done at every antenatal appointment?
BP
urinalysis (UTI, asymptomatic bacteruria, PET, diabetes)
macrosomia/IUGR
if placenta low lying at anomaly scan when is it re-checked?
32 weeks
trisomy screening for which conditions?
process?
Down’s syndrome T21, edwards syndrome T18, Patau’s syndrome T13
1st trimester = NT combined with HGC + PAPP-A
if high risk = NITP
if NITP positive = CVS/amniocentesis
2nd trimester screening for trisomy?
i.e. if missed 1st trimester screening
AFP
HCG
unconjugated oestradiol (UE3)
inhibin A (high)
(everything down in Downs except those that are HI (HCG and inhibin A)
what is NIPT?
why is it useful?
Cell free foetal DNA (cffDNA) - also known as non-invasive prenatal testing (NIPT)
Improved accuracy means fewer women will have to have invasive diagnostic test (CVS/amniocentesis) when their baby does not have downs syndrome
(predictive value >90%)
diagnostic tests trisomy?
Amniocentesis
performed after 15 weeks
Carries miscarriage rate of 1%
Chorionic villus sampling (riskier procedure)
performed after 11-12 weeks
Carries miscarriage rate of <2%
high risk vs moderate risk pre-eclampsia Tx?
high risk = HTN previous pregnancy, CKD, SLE or APS, T1/T2DM, chronic HTN
150mg aspirin from 12 weeks
mod risk = first pregnancy, >40 y/o, pregnancy intrval >10 years, BMI >35, FH pre-eclampsia, multiple pregnancy
75mg aspirin from 12 weeks
conditions screened for at booking?
20 weeks?
28 weeks?
haemoglobinopathies (thalassemia, HbS), hep B, HIV, syphillis, rhesus state, anaemia, trisomy screening offered
20 weeks = anomaly scan
28 weeks = rhesus, OGTT, anaemia
chest pain pregnancy?
All women with chest pain should have ECG
palpitations pregnancy?
physiological = common, occur at rest/lying down
ectopic beats = common, relived by exercise
sinus tachy = part of normal pregnancy
SVT = usually predates pregnancy
hyperthyroidism
phaemchromocytoma = headache, sweating, hypertension (24 hour catecholamines)
breathlessness pregnancy?
very common in 3rd trimester
improves with exertion (different from anaemia)
asthma in pregnancy?
continue treatment as normal
inhaled B2-agonists do not ipair uterine activity or delay onset of labour
where do most DVTs arise in pregancy?
90% in left leg
when to give LMWH in pregnancy?
previous VTE
thrombophillia (APS)
co-morbidities: cancer, heart failure, SLE, IBD, CKD, T1DM, sickle cell, OHSS
LMWH examples?
enoxaparin, daletparin (fragmin), tinzaparin
symptoms + signs DVT?
Dx?
swelling (oedema)
leg pain
tenderness
increased leg temp
elevated white cell count
Dx = duplex ultrasound
if iliac vein thrombosis suspected (whole leg swollen + back pain) = MRI venography
symptoms PE
signs?
Dx?
symptoms = dyspnoea, pleuritic chest pain, collapse, haemoptysis
signs = raised JVP
Dx = CTPA
why are LMWHs used in pregnancy?
warfarin is teratogenic!!!!!
are anticoagulants contraindicated in breastfeeding?
both herparin and warfarin are safe in breastfeeding
recommence warfarin 5th post-natal day (remember CI in pregnancy)
CTD drugs that are safe in pregnancy?
contraindicated?
safe = steroids, azathioprine, sulphasalazine, hydroxychloroquine, aspirin, biologics
unsafe = NSAIDs, cyclophosphamide, methotrexate, chlorambucil, gold, penicillamine, leflunamide
APS s/s?
Dx?
clinical Dx?
s/s: thrombosis, recurrent early pregnancy loss, late preganancy loss (preceded by FGR), placental abruption, severe early onset pre-eclampsia, severe FGR
Dx = anticardiolipid (aCL) + lupus anticoagulant (LA)
(must be 2 x 6 weeks apart - LA and aCL can be transiently raised in infection)
clinical Dx
>3 miscarriages <10 weeks old
>1 foetal loss >10 weeks (morphologically normal foetus)
>1 preterm birth due to PET
Tx APS pregnancy?
LDA + LMWH
epilepsy Tx pregnancy?
All women with epilepsy (WWE) should take 5mg/day folic acid
Lowest effective dose of most appropriate AED should be used (AVOID sodium valproate)
if seizure = benzodiazepines (lorazepam)
Tx seizures in pregnancy?
if no history of epilepsy = MgSO4
if history of epilepsy = IV lorazepam
enzyme inducing AEDs
preterm birth?
post-term?
preterm = <37 weeks
post-term = >42 weeks
commonest type of breech?
most dangerous?
other types?
commonest = Frank breech
most dangerous = footling
other types = complete breech, transverse (shoulder/arm), face + brow presentations
complications epidural?
Hypotension
Dural puncture - CI IN COAGULOPATHY
Headache
High block e.g. higher than T11/T12 (can be associated with breathing problems)
Atonic bladder (40%)
complications obstructed labour?
Sepsis
Uterine rupture (more common in 2nd/3rd pregnancy or previous Cesarean section)
Obstructed AKI
PPH
Fistula formation
Foetal asphyxia
signs of labour obstruction?
Moulding (bones of baby’s head)
Caput (oedema in the scalp)
Anuria
Haematuria
Vulval oedema
partogram used for?
what does it monitor
partogram = assess progression of labour
monitors: foetal heart, amniotic fluid, cervical dilation, descent, contractions, obstruction (moulding), meternal observations
risk factors foetal hypoxia?
small foetus
pre/post dates
antepartum haemorrhage
HTN/PET
diabetes
meconium
epidural
VBAC
PROM >24 hrs
sepsis
IOL
causes of foetal hypoxia?
acute = uterine hyperstimulation, cord prolapse, uterine rupture, abruption, regional anesthesia, vasa praevia
chronic = pre-eclampsia (placental insufficiency)
CTG interpretation
DR C BRAVADO
determine
risk
contractions
baseline
R
ate
variability
accelerations
decelerations
overall impression
Low risk
Heartrate normal
Baseline rate = 120
Accelerations present
Approx 3 contractions 10 minutes
Normal
High risk pregnancy
At least 4 contractions in 10 mins
Baseline rate high - 170
No accelerations
Variability reduced
Late decelerations - beyond peak of contraction
management abnormal CTG?
Change maternal position (all 4s)
IV fluids
Stop syntocinon
Scalp stimulation
Consider tocolysis - terbutaline 250 micrograms s/c
Consider foetal blood sampling (FBS - acidosis)
Operative delivery (category 1 delivery)
foetal blood sampling interpretation?
indications for operative delivery?
failure to progress (stage 2 >2 hours)
foetal distress
severe PET
umbilical cord prolapse stage 2
breech
causes of maternal collapse?
head = eclampsia, epilepsy, CVA
heart = MI, arrythmias, peripartum cardiomyopathy (orthopnoea)
hypoxia = asthma, PE, anaphylaxis
haemorrhage = abruption, uterine rupture, trauma, uterine inversion
whole body = hypoglycaemia, amniotic fluid embolism, sepsis
reversible causes of cardiac arrest?
+ pregnancy
4 H’s and 4T’s (reversible causes of cardiac arrest)
4H’s = hypoxia, hypovolaemia, hypo/hypermetabolic , hypothermia
4T’s = thrombo-embolism, tamponade, toxins, tension pneumothorax
And in pregnancy, 2 C’s
Eclampsia
Intracerebral bleed
