Week 4 - Core clinical Problems Flashcards
What is Fergusons reflex
Pressure applied to internal cervix - causes the release of oxytocin - causes uterine contractions
What chemical initiates the softening of the cervix before birth?
Hyaluronic acid
What is Bishop’s score
A score to see if it is safe to induce labour
What is the normal progress of a dilating cervix
1cm per hour
In a multiparous women, what time is considered prolonged during delivery of a baby?
2 hrs (WITH regional anaesthetic) 1 hr (WITHOUT regional anaesthetic)
What chemical causes true labour contractions
Oxytocin
When the babies head is said to be ‘engaged’ - what does this mean?
3/5ths of fetal head has entered mother’s pelvis.
2/5ths can still be felt abdominally
When should the cord be clamped immediately?
If baby needs resuscitation (if baby loses its pulse)
How long after baby delivery should the placenta be expelled?
5-10mins
What should you do if there is any blood loss prior to baby delivery?
Refer to consultancy unit. This is serious.
Lactation is stimulated by 2 things - what are they?
Expulsion of placenta
Decrease in oestrogen & progesterone
Common medical problems in each trimester
1st - miscarriage (esp in diabetic mothers)
2nd congenital malformations (esp in diabetic mothers)
3rd - growth restrictions & pre-eclampsia
Pregnant women comes in complaining of chest pain, what investigations do you preform?
ECG
+/- CT
Warfarin is safe in pregnancy: T/F?
F. V unsafe. Switch to LMWH
LMWH is safe in pregnancy: T/F
T
What cardiovascular changes does a women go through during 1st trimester of pregnancy?
Increase in cardiac output, stroke volume, plasma volume
What common cardiovascular conditions are commonly seen in pregnancy?
Palpitations
Sinus tachycardia
SVT
When is breathlessness most commonly seen in pregnancy?
3rd trimester
How to help manage breathlessness in pregnancy?
It can IMPORVE with exertion
Pregnant women comes in with breathlessness - what are your thoughts?
Usually physiological so don’t do unnecessary tests but do have to be aware that it could be an underlying PE
What happens to PaO2 and PaCo2 during pregnancy?
PaO2 increases
PaCO2 decreases
How to manage asthma during pregnancy & during birth?
Inhalers are safe to take
IV hydrocortisone to be given to mother during labour as a substitute for any oral steroids she may be taking for her asthma
Pathogenesis behind VTE in pregnancy
Decreased blood flow in legs (esp towards the end of pregnancy)
What can increase risk of VTE in terms of baby delivery?
If baby is delivered by forceps or C-section
Why is LMWH safe compared to warfarin?
Heparins:
a) Do NOT cross the placenta
b) Are NOT secreted in breast milk
Why are DVTs and VTEs commonly missed in pregnancy?
They symptoms they cause are similar to those of a ‘normal’ pregnancy
What Ix do you preform (and what test do you NOT preform) on a pregnant woman with a suspected DVT?
DO a compression duplex ultrasound
DON’T do D-dimers test - they will be raised in pregnancy regardless of whether or not they have a DVT
Symptoms of DVT?
Swelling, oedema, Leg pain, Increased leg temp, lower abdo pain, elevated WCC
Pregnant women comes in with whole leg swollen + back pain. What investigation do you want to preform?
MRI venography (you suspect an iliac vein thrombosis)
Symptoms of PE in pregnancy?
Dyspnoea, Chest pain, Faintness, Collapse, Haemoptysis, Raised JVP
What Ix do you preform on a pregnant women with a suspected PE?
ECG
CXR
Difference in pros and cons with a CTPA vs V/Q scan?
CTPA - more sensitive & specific but can cause breast cancer
V/Q - Less sensitive & specific but lower radiation dose in comparison to CTPA
If a baby is born with a flat face, short arms, legs and fingers & scoliosis. What do you suspect?
Mother had taken warfarin during pregnancy
Warfarin can be taken during breastfeeding period: T/F?
T. It can be taken (do 5 days postnatally just to be safe from PPH)
Pregnant mother with Connective Tissue Disease, what drugs do you need to stay away from?
NSAIDS, Cyclophosphamide, MTX, Gold, Penicillamine
Azathioprine is safe in pregnancy: T/F?
T
What condition is Antiphospholipid Syndrome commonly associated with?
SLE (systemic Lupus Erythematous)
Clinical features of Antiphospholipid Syndrome
Arterial/Venous thrombosis
Recurrent pregnancy loss
Severe pre-eclampsia
How to diagnose APS?
Diagnosis can be clinical (if pregnant women has thrombosis or miscarriages)
Diagnosis can be via laboratory - IgM/IgG
Obstetric complications in mothers
Miscarriage, Pre term birth, Hypertension, post partum haemorrhage
Foetal risks with epileptic mothers
Maternal abdominal trauma
Pre term premature rupture of membrane
Congenital malformations
Anti-epileptic drugs increase teratogenicity risk?- T/F
T
What anti-epileptic drug MUST be avoided?
Sodium Valporate
If the mother has a tonic-clonic seizure, what is the baby at risk of?
Hypoxia
A pregnant woman presents with a seizure for the first time. Is this epilepsy?
No, you assume this is pre-eclampsia
Mx of epileptic seizure during birth? (emergency!!)
Left lateral tilt
IV lorazepam/diazepam
IV Phenytoin
What is the sequence of BP changes during pregnancy?
BP falls in early pregnancy There is a steady rise until term BP falls after delivery Rises & peaks at day 3 postnatally By day 10 post natal - BP should be normal
Limits for BP hypertension (how to diagnose) ?
140/90 twice
160/110 once
How can you discriminate between pregnancy induced hypertension & pre-eclampsia?
Pregnancy induced:
- Occurs in 2nd half of pregnancy
- Resolves around 6 weeks of delivery
- No proteinuria or other features of pre-eclampsia
Pre-eclampsia triad
Hypertension
Proteinuria
Oedema
symptoms of pre-eclampsia
headaches visual disturbance epigastric pain N&V Rapidly progressing oedema
Ix for PET
U&Es Serum urate LFTs FBC Coagulation screen CTG scan
Mx of PET
75mg aspirin
Look for secondary cause of hypertension & treat (e.g. any endocrine disorder)
Treat the hypertension itself
Keep a careful surveillance on mother & baby
The only cure of PET is giving birth
Are you more at risk of PET if its your first pregnancy or a multiparous birth?
First pregnancy
What kind of imaging can be used for PET and what characteristics will it show?
MUAD
Notching indicates PET
Treatment of hypertension in pregnancy?
1st - Labetolol
2nd - Hydralazine
What hypertension medication should be avoided during pregnancy?
Diuretics
ACEI
What foetal surveillance is needed in a hypertensive mother or a mother with PET?
CTG
If you have a PET mother who needs to give birth, what should you give the baby (medication) to help? And why??
IV hydrocortisone - given to premature babies to promote foetal lung maturity
Then x2 dexamethasone
Mx for severe eclampsia?
Control BP - IV labetolol & hydralazine
Stop seizures - Magnesium sulphate
Fluid balance - be careful not to fluid overload do 80ml/hour
Delivery of baby - aim of vaginal, give epidural anaesthesia (helps BP too)
Symptoms of puerperal psychosis?
Sleep disturbance, Confusion, Irrational ideas, mania, suicidal thoughts
When is the usual onset of puerperal psychosis?
2 weeks post delivery
Symptoms of post-natal depression
Tearful, irritable, anxiety, lack of enjoyment, poor sleep, weight loss
When is the onset of post natal depression?
2-6 weeks post natal. Can last weeks-months
Can anti-psychotics be used in pregnancy?
Generally yes
What psych drugs should be avoided during pregnancy?
Sodium valproate
Benzodiazepines
Carbamazepine - neural tube defect
Lamotrigene - oral cleft
What vitamin can become deficient when a pregnant mother drinks alcohol? What is the condition associated with this called?
Vit B1
Wernicke’s encephalopathy
Effects of substance misuse in a pregnant woman?
IUGR, Pre term, miscarriage, sepsis, domestic abuse, STIs
What is placental abruption?
When the placenta separates from the uterine wall (partially or totally before birth of baby)
What could placental abruption cause in the baby?
Hypoxia - death
Mx of placental abruption?
Resuscitate mother - FBC, clotting, LFTs, U&Es, cross match, fluids, catheterise
Do a CTG on baby. If no heart beat, do a USS
Deliver baby
What are the 4 different types of urinary incontinence?
Stress incontinence - leakage on exertion
Urinary or ‘Urge’ incontinence- leakage with or immediately preceding the feeling of urge
Mixed incontinence - Leakage associated with both stress & urge
Overactive bladder - Same as urge but can be WITHOUT incontinence
If you had blood in your urine - what 2 diagnosis are you worried about?
Bladder cancer
Renal stones
Ix for incontinence
Urinalysis
Urodynamics
Cystoscopy
Imaging
Mx for incontinence
Lifestyle advice (least invasive) Bladder drill Pelvic floor physiotherapy Drugs (antimuscarinic) Botulinum toxin - woman must be able to self catheterise Reconstructive surgery (most invasive)
What antimuscarinic drug can you use for incontinence?
Why is it now used compared to the old drugs?
MIRABEGRON
Less likely to cause confusion
Mechanism of action of Mirabegron?
Selective B3 adrenoreceptor agonist
Works in parasympathetic control to inhibit involuntary contractions
Works in sympathetic control to relax the bladder
If pt is getting nocturia, what is a good drug to add into their treatment?
Desmopressin
Symptoms of prolapses
Sensation of pressure & dragging
Incontinence issues
Incomplete emptying (bladder & bowel)
Sexual dysfunction
Mx of prolapses
Conservative
Pessaries
Surgery - Pelvic floor repair
