Week 235 - Pregnancy 2 Flashcards
Week 235 - Pregnancy 2: What are the fetal indications for operative vaginal delivery?
Fetal compromise
Week 235 - Pregnancy 2: What are the maternal indications for operative vaginal delivery?
• Medical indications to avoid Valsalva e.g.
- Cardiac disease
- Hypertensive crisis
- CVD
- Myasthenia gravis
- Spinal cord injury
Week 235 - Pregnancy 2: What are indications for operative vaginal delivery due to inadequate progress of labour?
- 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
Week 235 - Pregnancy 2: What are the 8 requirements for instrumental delivery?
- 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.
Week 235 - Pregnancy 2: What are the two methods for instrumental delivery?
- Ventouse - Suction cup attached to point 2-3cm anterior to posterior fontanelle.
- Forceps - Non-rotational and rotational (Kiellands)
Week 235 - Pregnancy 2: What are the eight positions of the fetal head?
- Direct Occiput Anterior - Ideal position
- Right/Left Occiput anterior
- Right/Left Occiput Transverse
- Direct Occiput Posterior - ‘Face to Pubes’
- Right/Left Occiput Posterior
Week 235 - Pregnancy 2: What is the station of the babies head?
The level of the bony part of the fetal head in relation to the ischial spines. - is above and + is below.
Week 235 - Pregnancy 2: When should operative vaginal delivery be stopped?
- 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.
Week 235 - Pregnancy 2: What are the complications of caesarean section?
- Bleeding
- Infection
- Venous thromboembolism
Week 235 - Pregnancy 2: What sort of incision is normally performed in the skin during a c-section?
Pfannensteil (Curved horizontal incision)
Week 235 - Pregnancy 2: What are the indications for emergency c-section?
- Prolonged first stage of labour
* Fetal distress
Week 235 - Pregnancy 2: What are the absolute indications for caesarean section?
- Placenta praevia
- Severe antenatal fetal compromise
- Uncorrectable abnormal lie
- Previous classical c-section
- Pelvic deformity
Week 235 - Pregnancy 2: What are the relative indications of caesarean section?
- Breech presentation
- DM
- Previous c-section
- Older nulliparous women
Week 235 - Pregnancy 2: What are the predisposing factors to having a multiple pregnancy?
- Increasing maternal age
- Family History
- Race
- Assisted conception
Week 235 - Pregnancy 2: What is the difference between monozygotic and dizygotic twins?
- 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.
Week 235 - Pregnancy 2: What does chorionicity refer to?
Refers to placentation.
Week 235 - Pregnancy 2: What does amniocity refer to?
This refers to the relation of the amniotic membranes between the twins.
Week 235 - Pregnancy 2: What is dichorionic-diamniotic twinning?
This is where each twin has its own placenta and amniotic sac.
Week 235 - Pregnancy 2: When each baby has its own placenta, there will be two chorions and two amnions. What is this known as?
Dichorionic-diamniotic twinning.
Week 235 - Pregnancy 2: What is mono-chorionic diamniotic twinning?
This is where each twin has its own sac but they share a common placenta.
Week 235 - Pregnancy 2: What is it called when each baby has its own amniotic sac but share a placenta?
Mono-chorionic diamniotic twinning.
Week 235 - Pregnancy 2: What is it called when twin babies share both the amniotic sac and placenta?
Monochorionic-monoamniotic twinning.
Week 235 - Pregnancy 2: What is monochorionic-monoamniotic twinning?
This is when both twins share the same amniotic sac and placenta.
Week 235 - Pregnancy 2: In terms of chorionicity and amniocity what are dizygotic twins always?
Dichorionic-diamniotic
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?
Monochorionic
- Miscarriage
- Congenital abnormalities
- Preterm
- IUGR
- Perinatal loss
- TTT
Week 235 - Pregnancy 2: At which time should DCDA and MCDA twins be delivered?
- Uncomplicated DCDA 37-38wks
* Uncomplicated MCDA 36-37wks
Week 235 - Pregnancy 2: How does cardiac output change during pregnancy?
• Increases
- Increases by 30-50%
- Blood volume increases to 150% of non-pregnant level.
- Stroke volume increases 30%
- Heart rate increases by about 15%
Week 235 - Pregnancy 2: What changes during pregnancy in relation to preload and afterload? Why is this?
- Preload - increases due to increase in blood volume.
* Afterload - Reduced due to reduction systemic vascular resistance.
Week 235 - Pregnancy 2: What occurs to BP during pregnancy?
- 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.
Week 235 - Pregnancy 2: What is the mechanism behind the peripheral oedema associated with pregnancy? What is the benefit of it?
• Increased Renin-angiotensin-aldosterone activity leading to retention of water and sodium.
- This causes peripheral oedema but also increases intravascular volume.
Week 235 - Pregnancy 2: What are some of the ECG changes that may occur with pregnancy?
- Borderline sinus tachycardia.
- Axis deviation to left.
- ST changes and inversion of T wave in lead III/AVF may occur.
Week 235 - Pregnancy 2: What changes occur to the coagulation system during pregnancy? What is the benefit and problem with this change?
• Increase of factors I, VII, VIII, IX, X, XII
- This protects from haemorrhage at delivery BUT
- Increases risk of thromboembolism
Week 235 - Pregnancy 2: Haemorrhage is well tolerated in pregnant ladies. How much can be tolerated and what is the management of any haemorrhage?
- 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.
Week 235 - Pregnancy 2: What changes in terms of lung capacity during pregnancy?
• 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.
Week 235 - Pregnancy 2: Why do pregnant women have a compensated respiratory alkalosis?
This facilitates fetomaternal 02 transfer at the placenta.
Week 235 - Pregnancy 2: What are the two reasons for pregnant women to feel short of breath?
- Subjective feeling due to progesterone.
* Rising fundus.
Week 235 - Pregnancy 2: How does Renal physiology change in pregnancy? (5 ways)
- 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.
Week 235 - Pregnancy 2: Why do pregnant women suffer from increased reflux?
Progesterone causes smooth muscle relaxation so the lower oesophageal sphincter has less tone.
Week 235 - Pregnancy 2: Why does a pregnant lady have reduced GI motility what is the side effect of this?
- Oestrogen and progesterone reduce motility.
* This allows for better absorption but can lead to constipation.
Week 235 - Pregnancy 2: Why do pregnant ladies develop an altered gait and exaggerated lordosis?
Connective tissue is softened - sacroiliac, symphysis pubis, intercostal and interspinous ligaments.
Week 235 - Pregnancy 2: What impact does pregnancy have on the thyroid hormones?
- 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.
Week 235 - Pregnancy 2: What is the are the causes of bleeding in early pregnancy?
- Miscarriage
* Ectopic pregnancy
Week 235 - Pregnancy 2: What is a threatened miscarriage?
This is where there is bleeding, the foetus is alive and the OS is closed.
Week 235 - Pregnancy 2: What is an inevitable miscarriage?
This is where there is heavy bleeding, the foetus may be be alive and the OS is open.
Week 235 - Pregnancy 2: What is an incomplete miscarriage?
This is where there is bleeding, some foetal parts are passed and the OS is open.
Week 235 - Pregnancy 2: What is a complete miscarriage?
This is when all pregnancy tissue has passed, bleeding has settled and the OS is closed.
Week 235 - Pregnancy 2: What is a missed miscarriage?
This is where the foetus has not developed or has died in utero. The OS is closed, often asymptomatic.
Week 235 - Pregnancy 2: What is a septic miscarriage?
Infected uterine contents, offensive loss and a tender uterus.
Week 235 - Pregnancy 2: What is the medical management of miscarriage?
Mifepristone and misoprostol (Prostaglandin)
- Success rate varies.
Week 235 - Pregnancy 2: What are the indications for the surgical management of miscarriage?
• Unstable vital signs
- Excessive/persistant
- Bleeding
• Infected retained tissue.
Week 235 - Pregnancy 2: What should be given to all rhesus -ve mothers after surgical/medical intervention of miscarriage?
Anti-D prophylaxis
Week 235 - Pregnancy 2: What is the most common location of ectopic pregnancies?
Ampulla of tube.
Week 235 - Pregnancy 2: How can an ectopic pregnancy be diagnosed?
- Cautious examination
- Ultrasound
- hCG does not rise as expected.
Week 235 - Pregnancy 2: What is the medical and surgical management of an ectopic pregnancy?
- Medical - Methotrexate
* Surgical - Laparoscopy/Laparotomy
Week 235 - Pregnancy 2: What are the signs and symptoms of a molar pregnancy?
- Very high HCG
- Biochemical hyperthyroid
- Hyperemesis
Week 235 - Pregnancy 2: What are the signs of haemorrhage in late pregnancy?
- Pale
- Confused
- Reduced urine output
- Foetal hear abnormalities
- Increased HR
- Bleeding - obvious/hidden
Week 235 - Pregnancy 2: What are the clinical features of placenta praevia?
- Asymptomatic
- Painless - Bright red bleed
- Malpresentation/high presenting part
- USS
Week 235 - Pregnancy 2: What are the clinical features of a placental abruption?
- Vaginal bleeding (Unless concealed).
- Abdominal pain.
- Irritable ‘woody hard’ uterus.
- Uterine tenderness
- Disproportionate shock
- Foetal distress
Week 235 - Pregnancy 2: What are the risk factors for developing placenta praevia?
- Previous praevia
- Previous lower segmental Caesarean section.
- Smoking
- Older mother
- Defective endometrium
- Previous TOP
- Assisted Conception
Week 235 - Pregnancy 2: What are the risk factors for developing a placental abruption?
- Previous abruption
- Smoking/drug abuse
- 1st trimester bleeding
- Pre-eclampsia
- Multiparity
- Blunt force trauma
- Assisted Conception
- Low BMI
Week 235 - Pregnancy 2: Aside from placenta praevia and placental abruption what are the other main causes of late pregnancy bleeding?
- 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.
Week 235 - Pregnancy 2: What is the timescale for primary and secondary post-partum haemorrhage?
• Primary - 24hrs-6 weeks post delivery.
Week 235 - Pregnancy 2: What are the risk factors for developing post-partum haemorrhage?
- 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.
Week 235 - Pregnancy 2: What are the four broad causes of PPH? Give examples of each.
- 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.
Week 235 - Pregnancy 2: What is the management of PPH due to tone?
- Empty bladder.
- ‘Rub up’ a contraction.
- Bimanual compression.
- Give oxytocics.
Week 235 - Pregnancy 2: What is the management of PPH due to trauma?
• Repair perineal and cervical tears.
Week 235 - Pregnancy 2: What is the management of PPH due to tissue?
- Empty uterus if not delivered.
* Remove placenta/products.
Week 235 - Pregnancy 2: What is the management of PPH due to thrombin?
- Check coag.
* Replace clotting factors / blood products.
Week 235 - Pregnancy 2: What are the three key elements of pre-eclampsia?
- Increased BP
- Proteinuria
- Oedema
Week 235 - Pregnancy 2: What are the minor symptoms of pre-eclampsia?
- Headaches
- Visual disturbances
- Nausea or vomiting
- Epigastric pain
- Sudden weight gain - fluid
- Brisk refelexes
Week 235 - Pregnancy 2: What are the risk factors for developing pre-eclampsia?
- Primiparous
- Multiparous but with a new partner
- Previous pre-eclampsia
- Multiple pregnanacy
- 35 years
- Obesity
- Diabetes
- Renal Failure
Week 235 - Pregnancy 2: What are the classifications of pre-eclampsia?
- 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
Week 235 - Pregnancy 2: What is HELLP syndrome?
Complication of pre-eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
Week 235 - Pregnancy 2: What is the conservative treatment of a lady with pre-eclampsia?
- 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.
Week 235 - Pregnancy 2: In severe pre-eclampsia what is the management?
Immediate c-section (if greater than 34 weeks)
Week 235 - Pregnancy 2: What is pre-eclampsia?
Diffuse vascular endothelial dysfunction with circulatory disturbances involving renal, hepatic, cardiovascular, central nervous and coagulation systems.
