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Week 235 - Pregnancy 2 Flashcards

1
Q

Week 235 - Pregnancy 2: What are the fetal indications for operative vaginal delivery?

A

Fetal compromise

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2
Q

Week 235 - Pregnancy 2: What are the maternal indications for operative vaginal delivery?

A

• Medical indications to avoid Valsalva e.g.

  • Cardiac disease
  • Hypertensive crisis
  • CVD
  • Myasthenia gravis
  • Spinal cord injury
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3
Q

Week 235 - Pregnancy 2: What are indications for operative vaginal delivery due to inadequate progress of labour?

A
  • Nulliparous women - Lack of progress for three hours with regional anaesthesia or two hours without regional anaesthesia.
  • Multiparous women - Lack of progress for two hours with regional anaesthesia or one hour without regional anaesthesia.
  • Maternal fatigue/exhaustion
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4
Q

Week 235 - Pregnancy 2: What are the 8 requirements for instrumental delivery?

A
  • Valid reason
  • Head must not be palpable abdominally
  • Head must be at or below the level of the ischial spines
  • Cervix must be fully dilated
  • Position of the fetal head must be known
  • Adequate analgesia
  • Bladder should be empty
  • Must have facilities to perform C-section in case of failure.
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5
Q

Week 235 - Pregnancy 2: What are the two methods for instrumental delivery?

A
  • Ventouse - Suction cup attached to point 2-3cm anterior to posterior fontanelle.
  • Forceps - Non-rotational and rotational (Kiellands)
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6
Q

Week 235 - Pregnancy 2: What are the eight positions of the fetal head?

A
  • Direct Occiput Anterior - Ideal position
  • Right/Left Occiput anterior
  • Right/Left Occiput Transverse
  • Direct Occiput Posterior - ‘Face to Pubes’
  • Right/Left Occiput Posterior
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7
Q

Week 235 - Pregnancy 2: What is the station of the babies head?

A

The level of the bony part of the fetal head in relation to the ischial spines. - is above and + is below.

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8
Q

Week 235 - Pregnancy 2: When should operative vaginal delivery be stopped?

A
  • There is no evidence of progressive descent with each pull.
  • Or delivery is not imminent following three pulls of a correctly applied instrument by an experience operator.
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9
Q

Week 235 - Pregnancy 2: What are the complications of caesarean section?

A
  • Bleeding
  • Infection
  • Venous thromboembolism
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10
Q

Week 235 - Pregnancy 2: What sort of incision is normally performed in the skin during a c-section?

A

Pfannensteil (Curved horizontal incision)

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11
Q

Week 235 - Pregnancy 2: What are the indications for emergency c-section?

A
  • Prolonged first stage of labour

* Fetal distress

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12
Q

Week 235 - Pregnancy 2: What are the absolute indications for caesarean section?

A
  • Placenta praevia
  • Severe antenatal fetal compromise
  • Uncorrectable abnormal lie
  • Previous classical c-section
  • Pelvic deformity
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13
Q

Week 235 - Pregnancy 2: What are the relative indications of caesarean section?

A
  • Breech presentation
  • DM
  • Previous c-section
  • Older nulliparous women
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14
Q

Week 235 - Pregnancy 2: What are the predisposing factors to having a multiple pregnancy?

A
  • Increasing maternal age
  • Family History
  • Race
  • Assisted conception
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15
Q

Week 235 - Pregnancy 2: What is the difference between monozygotic and dizygotic twins?

A
  • Monozygotic - A single zygote splits into two equal zygote they share the same genetic material. - Identical twins.
  • Dizygotic - Two different zygotes are formed by fertilization of two eggs by two different sperms - Different genetic material.
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16
Q

Week 235 - Pregnancy 2: What does chorionicity refer to?

A

Refers to placentation.

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17
Q

Week 235 - Pregnancy 2: What does amniocity refer to?

A

This refers to the relation of the amniotic membranes between the twins.

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18
Q

Week 235 - Pregnancy 2: What is dichorionic-diamniotic twinning?

A

This is where each twin has its own placenta and amniotic sac.

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19
Q

Week 235 - Pregnancy 2: When each baby has its own placenta, there will be two chorions and two amnions. What is this known as?

A

Dichorionic-diamniotic twinning.

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20
Q

Week 235 - Pregnancy 2: What is mono-chorionic diamniotic twinning?

A

This is where each twin has its own sac but they share a common placenta.

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21
Q

Week 235 - Pregnancy 2: What is it called when each baby has its own amniotic sac but share a placenta?

A

Mono-chorionic diamniotic twinning.

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22
Q

Week 235 - Pregnancy 2: What is it called when twin babies share both the amniotic sac and placenta?

A

Monochorionic-monoamniotic twinning.

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23
Q

Week 235 - Pregnancy 2: What is monochorionic-monoamniotic twinning?

A

This is when both twins share the same amniotic sac and placenta.

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24
Q

Week 235 - Pregnancy 2: In terms of chorionicity and amniocity what are dizygotic twins always?

A

Dichorionic-diamniotic

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25
Q

Week 235 - Pregnancy 2: Chorionicity is the the most important part of the management of twin pregnancy. Which form carries the highest risk? What are the risks?

A

Monochorionic

  • Miscarriage
  • Congenital abnormalities
  • Preterm
  • IUGR
  • Perinatal loss
  • TTT
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26
Q

Week 235 - Pregnancy 2: At which time should DCDA and MCDA twins be delivered?

A
  • Uncomplicated DCDA 37-38wks

* Uncomplicated MCDA 36-37wks

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27
Q

Week 235 - Pregnancy 2: How does cardiac output change during pregnancy?

A

• Increases

  • Increases by 30-50%
  • Blood volume increases to 150% of non-pregnant level.
  • Stroke volume increases 30%
  • Heart rate increases by about 15%
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28
Q

Week 235 - Pregnancy 2: What changes during pregnancy in relation to preload and afterload? Why is this?

A
  • Preload - increases due to increase in blood volume.

* Afterload - Reduced due to reduction systemic vascular resistance.

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29
Q

Week 235 - Pregnancy 2: What occurs to BP during pregnancy?

A
  • Reduction in systemic arterial BP during first 24 weeks, due to smooth muscle relaxation due to progesterone.
  • The BP then gradually rises after this to non-pregnant levels by term.
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30
Q

Week 235 - Pregnancy 2: What is the mechanism behind the peripheral oedema associated with pregnancy? What is the benefit of it?

A

• Increased Renin-angiotensin-aldosterone activity leading to retention of water and sodium.
- This causes peripheral oedema but also increases intravascular volume.

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31
Q

Week 235 - Pregnancy 2: What are some of the ECG changes that may occur with pregnancy?

A
  • Borderline sinus tachycardia.
  • Axis deviation to left.
  • ST changes and inversion of T wave in lead III/AVF may occur.
32
Q

Week 235 - Pregnancy 2: What changes occur to the coagulation system during pregnancy? What is the benefit and problem with this change?

A

• Increase of factors I, VII, VIII, IX, X, XII

  • This protects from haemorrhage at delivery BUT
  • Increases risk of thromboembolism
33
Q

Week 235 - Pregnancy 2: Haemorrhage is well tolerated in pregnant ladies. How much can be tolerated and what is the management of any haemorrhage?

A
  • Tolerate 1.5L but then will rapidly decompensate.

* Loss needs to be estimated and monitored with early replacement of volume/02 carrying capacity and clotting factors.

34
Q

Week 235 - Pregnancy 2: What changes in terms of lung capacity during pregnancy?

A

• Increased 02 requirements of fetus is met by,

  • Increase in tidal volume of 30-40%
  • Decreased residual volume by 20%
  • RR and vital capacity remain unchanged.
35
Q

Week 235 - Pregnancy 2: Why do pregnant women have a compensated respiratory alkalosis?

A

This facilitates fetomaternal 02 transfer at the placenta.

36
Q

Week 235 - Pregnancy 2: What are the two reasons for pregnant women to feel short of breath?

A
  • Subjective feeling due to progesterone.

* Rising fundus.

37
Q

Week 235 - Pregnancy 2: How does Renal physiology change in pregnancy? (5 ways)

A
  • Renal blood flow increases by 75%
  • GFR increases 150% of non-pregnant rate.
  • Altered tubular function - increased glycosuria, proteinuria, calciuria and bicarbonaturia.
  • Plasma urea and creatinine fall due to increased creatinine clearance.
  • Plasma renin, ATII and aldosterone rise.
38
Q

Week 235 - Pregnancy 2: Why do pregnant women suffer from increased reflux?

A

Progesterone causes smooth muscle relaxation so the lower oesophageal sphincter has less tone.

39
Q

Week 235 - Pregnancy 2: Why does a pregnant lady have reduced GI motility what is the side effect of this?

A
  • Oestrogen and progesterone reduce motility.

* This allows for better absorption but can lead to constipation.

40
Q

Week 235 - Pregnancy 2: Why do pregnant ladies develop an altered gait and exaggerated lordosis?

A

Connective tissue is softened - sacroiliac, symphysis pubis, intercostal and interspinous ligaments.

41
Q

Week 235 - Pregnancy 2: What impact does pregnancy have on the thyroid hormones?

A
  • Oestrogen causes the liver to increase the levels of thyroxine-binding globulin (TBG).
  • This leads to reduced freeT4 and elevated TSH.
  • Ultimately leading to increased T3 and T4.
  • hCG will bind to TSH receptor causing transient hyperthyroidism.
42
Q

Week 235 - Pregnancy 2: What is the are the causes of bleeding in early pregnancy?

A
  • Miscarriage

* Ectopic pregnancy

43
Q

Week 235 - Pregnancy 2: What is a threatened miscarriage?

A

This is where there is bleeding, the foetus is alive and the OS is closed.

44
Q

Week 235 - Pregnancy 2: What is an inevitable miscarriage?

A

This is where there is heavy bleeding, the foetus may be be alive and the OS is open.

45
Q

Week 235 - Pregnancy 2: What is an incomplete miscarriage?

A

This is where there is bleeding, some foetal parts are passed and the OS is open.

46
Q

Week 235 - Pregnancy 2: What is a complete miscarriage?

A

This is when all pregnancy tissue has passed, bleeding has settled and the OS is closed.

47
Q

Week 235 - Pregnancy 2: What is a missed miscarriage?

A

This is where the foetus has not developed or has died in utero. The OS is closed, often asymptomatic.

48
Q

Week 235 - Pregnancy 2: What is a septic miscarriage?

A

Infected uterine contents, offensive loss and a tender uterus.

49
Q

Week 235 - Pregnancy 2: What is the medical management of miscarriage?

A

Mifepristone and misoprostol (Prostaglandin)

- Success rate varies.

50
Q

Week 235 - Pregnancy 2: What are the indications for the surgical management of miscarriage?

A

• Unstable vital signs

  • Excessive/persistant
  • Bleeding

• Infected retained tissue.

51
Q

Week 235 - Pregnancy 2: What should be given to all rhesus -ve mothers after surgical/medical intervention of miscarriage?

A

Anti-D prophylaxis

52
Q

Week 235 - Pregnancy 2: What is the most common location of ectopic pregnancies?

A

Ampulla of tube.

53
Q

Week 235 - Pregnancy 2: How can an ectopic pregnancy be diagnosed?

A
  • Cautious examination
  • Ultrasound
  • hCG does not rise as expected.
54
Q

Week 235 - Pregnancy 2: What is the medical and surgical management of an ectopic pregnancy?

A
  • Medical - Methotrexate

* Surgical - Laparoscopy/Laparotomy

55
Q

Week 235 - Pregnancy 2: What are the signs and symptoms of a molar pregnancy?

A
  • Very high HCG
  • Biochemical hyperthyroid
  • Hyperemesis
56
Q

Week 235 - Pregnancy 2: What are the signs of haemorrhage in late pregnancy?

A
  • Pale
  • Confused
  • Reduced urine output
  • Foetal hear abnormalities
  • Increased HR
  • Bleeding - obvious/hidden
57
Q

Week 235 - Pregnancy 2: What are the clinical features of placenta praevia?

A
  • Asymptomatic
  • Painless - Bright red bleed
  • Malpresentation/high presenting part
  • USS
58
Q

Week 235 - Pregnancy 2: What are the clinical features of a placental abruption?

A
  • Vaginal bleeding (Unless concealed).
  • Abdominal pain.
  • Irritable ‘woody hard’ uterus.
  • Uterine tenderness
  • Disproportionate shock
  • Foetal distress
59
Q

Week 235 - Pregnancy 2: What are the risk factors for developing placenta praevia?

A
  • Previous praevia
  • Previous lower segmental Caesarean section.
  • Smoking
  • Older mother
  • Defective endometrium
  • Previous TOP
  • Assisted Conception
60
Q

Week 235 - Pregnancy 2: What are the risk factors for developing a placental abruption?

A
  • Previous abruption
  • Smoking/drug abuse
  • 1st trimester bleeding
  • Pre-eclampsia
  • Multiparity
  • Blunt force trauma
  • Assisted Conception
  • Low BMI
61
Q

Week 235 - Pregnancy 2: Aside from placenta praevia and placental abruption what are the other main causes of late pregnancy bleeding?

A
  • Placenta Accreta - Firmly adherent placenta.
  • Placenta Increta - Placenta invades the myometrium.
  • Placenta Percreta - Invades through to serosa and beyond.
  • Vasa Praevia - Placental vessels overlie the cervix due to a succenturiate lobe of the placenta.
62
Q

Week 235 - Pregnancy 2: What is the timescale for primary and secondary post-partum haemorrhage?

A

• Primary - 24hrs-6 weeks post delivery.

63
Q

Week 235 - Pregnancy 2: What are the risk factors for developing post-partum haemorrhage?

A
  • Pregnancy - Previous hx, Ante-partum haemorrhage, placenta praevia, twins, nulliparity, pre-eclampsia, Maternal obesity, maternal age >40.
  • Delivery - Emergency C-section, repeat elective c-section, operative vaginal birth, induction of labour, long labour, large foetal birth weight.
64
Q

Week 235 - Pregnancy 2: What are the four broad causes of PPH? Give examples of each.

A
  • Thrombin - Pre-eclampsia, placental abruption, pyrexia in labour, bleeding disorders.
  • Tissue - Retained placenta, placenta accreta, retained products of conception.
  • Tone - Placenta praevia, overdistension of uterus (macrosomia, multiple pregnancy), uterine relaxants, previous PPH.
  • Trauma - instrumental delivery, episiotomy, macrosomia.
65
Q

Week 235 - Pregnancy 2: What is the management of PPH due to tone?

A
  • Empty bladder.
  • ‘Rub up’ a contraction.
  • Bimanual compression.
  • Give oxytocics.
66
Q

Week 235 - Pregnancy 2: What is the management of PPH due to trauma?

A

• Repair perineal and cervical tears.

67
Q

Week 235 - Pregnancy 2: What is the management of PPH due to tissue?

A
  • Empty uterus if not delivered.

* Remove placenta/products.

68
Q

Week 235 - Pregnancy 2: What is the management of PPH due to thrombin?

A
  • Check coag.

* Replace clotting factors / blood products.

69
Q

Week 235 - Pregnancy 2: What are the three key elements of pre-eclampsia?

A
  • Increased BP
  • Proteinuria
  • Oedema
70
Q

Week 235 - Pregnancy 2: What are the minor symptoms of pre-eclampsia?

A
  • Headaches
  • Visual disturbances
  • Nausea or vomiting
  • Epigastric pain
  • Sudden weight gain - fluid
  • Brisk refelexes
71
Q

Week 235 - Pregnancy 2: What are the risk factors for developing pre-eclampsia?

A
  • Primiparous
  • Multiparous but with a new partner
  • Previous pre-eclampsia
  • Multiple pregnanacy
  • 35 years
  • Obesity
  • Diabetes
  • Renal Failure
72
Q

Week 235 - Pregnancy 2: What are the classifications of pre-eclampsia?

A
  • Mild - Proteinuria and mild/moderate HT 140-159
  • Moderate - Proteinuria with severe HT >160

• Severe - Proteinuria with mild-severe HT with one of;
- Seizures, visual disturbance, clonus, headache or epigastric pain, papilloedema, liver tenderness, HELLP, platelets 70

73
Q

Week 235 - Pregnancy 2: What is HELLP syndrome?

A

Complication of pre-eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
74
Q

Week 235 - Pregnancy 2: What is the conservative treatment of a lady with pre-eclampsia?

A
  • Admit if severe HT or new proteinuria >2+
  • Antihypertensive-
  • Labetalol
  • Nifedipine
  • Hydralazine
  • Magnesium sulphate - treatment and prevention of eclampsia
  • Corticosteroids - aide foetal lung development for early delivery.
75
Q

Week 235 - Pregnancy 2: In severe pre-eclampsia what is the management?

A

Immediate c-section (if greater than 34 weeks)

76
Q

Week 235 - Pregnancy 2: What is pre-eclampsia?

A

Diffuse vascular endothelial dysfunction with circulatory disturbances involving renal, hepatic, cardiovascular, central nervous and coagulation systems.

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