WH- Obstretrics Flashcards
Routine pre-pregnancy and antenatal tests?
- FBE and iron studies
- Blood type and group
- HCV, HBV, HIV and syphilis serology
- Rubella Ab ± varicella Ab
Principles of PPH management
- Resuscitation: fluids, blood products
- Evacuate uterus: all placenta delivered?
- Uterine massage ± uterotonics (eg/ syntocinon IM)
- Inspect birth canal for points of bleeding
- Correct any coagulopathy present
- If the above fails, requires surgery for correction of problem, balloon tamponade, laparotomy or hysterectomy
Management of IDDM during normal vaginal birth
- Monitor BSLs every 4 hours (aim for 4-7mmol/L)
- Use a sliding scale insulin
- Continuous CTG monitoring of the fetus
- Anticipate for shoulder dystocia and PPH
Following delivery:
- Recommence pre-pregnancy insulin
- Monitor neonate for hypoglycaemia (2hrly)
- Aim for early and regular feeding
Management of pre-eclampsia
- Admission
- Stabilise BP (SBP
Management of mastitis
- Consider admission
- Keep feeding
- IV or oral flucloxacillin, analgesia and fluids
- If the above fails, consider abscess –> surgical drainage
Aims of management in eclampsia
- Protect patient and their airway
- Control convulsion: consider diazepam
- MgSO4 to prevent further seizures
- Review and optimise maternal and fetal state
- Expedite delivery
DDx of seizure in pregnancy
- Eclampsia
- Cerebral haemorrhage, intracranial space occupying lesion
- Amniotic fluid embolus
- TTP
- Drug or water toxicity
Management of breech presentation
- Determine aetiology: must exclude placenta praevia, fetal head extension or fetal abnormality
- External cephalic version (36-37w) should be offered to all women
- Birth type: planned CS or planned vaginal birth depending on indications for either, risks and patient preference
Management of shoulder dystocia
HELPERR:
- Help (call for it), stop pushing, re-position
- Evaluate for episiotomy to aid manoeuvres
- Legs: McRoberts manoeuvre
- Pressure: suprapubic
- Enter: rotational manoeuvres
- Remove posterior arm
- Roll onto hands and knees
Try each of the above for 30 seconds before moving on
Last resorts: deliberate cleidotomy, Zavanelli manoeuvre, hysterotomy, symphysiotomy
US parameters to determine fetal wellbeing in the third trimester
- MCA PSV to assess for anaemia
- Doppler UA to assess for hypoxia
- Assessment of activity: body movements, breathing movements, tone
- Assessment of size: head circumference, abdominal circumference, femur length
What is the presentation of placental abruption?
- Concealed bleeding
- Dark blood
- Painful ± contractions
- Abdominal tenderness
What is the management of placental abruption?
- Maternal resuscitation: ABCDE, IV lines, IDC
- Bloods: FBE, Kleihauer, coagulation studies, cross match
- Give anti-D if indicated
- Assess fetal state with CTG
- If dead or CTG is reassuring = NVB
- If severe abruption = emerg CS
- Monitor for DIC
- Epidural is C/I
What is the presentation of placenta praevia?
- Unprovoked, painless vaginal bleeding
- High presenting part
- Malpresentation
- Soft abdomen
What is the management of placenta praevia?
- Stabilise maternal condition
- Bloods: FBE, Kleihauer, coagulation studies, cross match
- Give anti-D if indicated
- Diagnose PP with US
- Immediate delivery if severe bleeding via CS
What are the causes of secondary PPH?
- Retained POC
- Infected uterus or POC
- GTD, choriocarcinoma (rare)
What is the management of secondary PPH?
- Ix: HVS, US and blood cultures
- Broad spectrum antibiotics
- Surgery
What US findings confirm a miscarriage?
- CRL ≥7mm with no fetal cardiac activity
- Empty GS of mean diameter 25mm with no yolk sac or fetal pole
- Absence of embryo ≥2 weeks after scan showing an empty GS
What are the causes of prolonged decelerations on CTG?
Sustained hypoxia due to:
- Cord compression
- Maternal hypotension (supine, epidural, anaphylaxis, blood loss, vasovagal, uterine rupture, arrhythmia)
- Maternal hypoxia (PE, APO)
- Sustained uterine contraction
- Placental abruption, vasa praevia
What is the cause of variable deceleration?
Cord compression (hypertension)
What is the cause of late decelerations?
Fetal hypoxia
What is the cause of early decelerations?
Head compression in labour
What are the features of a reactive/normal CTG?
- Baseline: 110-160bpm
- Variability: 5-25bpm
- Accelerations: 2x 15bpm in 20 mins
- No ominous decelerations
Common causes of puerperal sepsis
- Endometritis
- CS wound infection
- Mastitis
- UTI
- Consider DVT/PE
What are the causes of IUGR?
- Fetal: congenital (chromosomal, single gene, structural, familial) or infection (CMV, TORCH)
- Maternal: vascular disease (DM, HTN), thrombophilia, malnutrition, toxins, anaemia, respiratory disease/high altitude, CVD
- Placental: abnormalities (insufficiency), abruption or multiple pregnancy
What is the management of gestational DM in the puerperium?
- Cease insulin following delivery
- Monitor BSL 2x daily
- Repeat OGTT in 6 weeks
What antibody titre is considered mild in Rhesus disease?
≤32
What antibody titre is considered moderate in Rhesus disease?
64-256
What antibody titre is considered severe in Rhesus disease?
≥512
What is the management of low risk Rhesus disease?
- Ab titre at each visit
- Deliver at 38w
What is the management of moderate risk Rhesus disease?
- Ab titre at each visit
- US screening from 20w: MCA PSV and hydrops
- CTGs from 32w
- Deliver at 38w or earlier
What is the management of high risk Rhesus disease?
- US screening from 17w
- Fetal blood sampling from umbilical cord if MCA PSV increased
- Intrauterine transfusions if fetal anaemia
What factors are considered in first trimester screening for Down syndrome?
- Maternal age
- Serum b-HCG and PAPP-A (10-12w)
- NT and nasal bone measurement (11-13w)
What factors are considered in second trimester screening for Down syndrome?
Serum b-HCG, a-FP, unconjugated oestriol and inhibin A
What receptor is responsible for early decelerations?
Pain receptor
What receptor is responsible for late decelerations?
Chemoreceptor
What receptor is responsible for variable decelerations?
Baroreceptor
What receptor is responsible for prolonged decelerations?
Chemoreceptor
What are the complications of epidural anaesthesia?
- Immediate: hypotension, dural puncture, high block or total spinal block, IV injection
- delayed: PDPH, back ache, neurological, abscess, haematoma
- Long term: paralysis, cord trauma
What are the maternal complications of hypothyroidism?
- Increased risk of pre-eclampsia, cardiac dysfunction and PPH
- More likely to have lactation difficulty and puerperial mental illness
What are the fetal complications of hypothyroidism?
- Increased risk of miscarriage
- Risk of congenital hypothyroidism
What is the management of hypothyroidism in pregnancy?
Increase dose of thyroxine
What are the maternal complications of hyperthyroidism?
Increased risk of pre-eclampsia and CCF
What are the fetal complications of hyperthyroidism?
Fetal morbidity is untreated
What is the management of hyperthyroidism in pregnancy?
- Anti-thyroid drugs are safe
- Maintain at upper levels
What are the causes of obstructed labour?
Maternal:
- Small pelvis, large presenting part
- Inefficient contractions
- Exhaustion
Fetal:
- Malpresentation
- Macrosomia
- Anomaly
What are the causes of a non-reactive CTG?
5S’s:
- Sick (hypoxia)
- Sleep
- Sedated (opioids, MgSO4, barbituates)
- Small (premature)
- Supine (maternal supine hypotension)
Describe fetal circulation
- UA from the maternal aorta perfuses the placenta
- UV from the placenta, blood then either goes via the liver or the DV (bypassing the liver) into the IVC
- Blood enters the RA
- Some blood crosses the FO to directly enter the LA –> LV –> aorta
- Other blood enters the RV –> pulmonary artery –> bypasses the lung via DA –> aorta
- Blood then flows to the rest of the fetus
Risk factors for shoulder dystocia
Antepartum:
- Prior shoulder dystocia
- Fetal macrosomia
- Maternal DM and/or obesity
- Post-term pregnancy
- Male fetal gender
Intrapartum:
- Prolonged labour
- Induction or augmentation of labour
- Instrumental delivery
Complications associated with maternal obesity?
- Increased DM, pre-eclampsia, HTN, mortality
- Increased macrosomia and IUGR
- Risk of chromosomal abnormalities, NT defects
- Increased fetal and neonatal mortality and NICU
- Increased post-dates risk
- Prolonged labour and CS more likely
- Difficult epidural
- VTE and infection post-partum more likely
- Decreased breast milk production
Which of the following medications should you avoid in pregnancy: insulin, metformin, sulphonylureas, glitazones, ACE/AT2B, statins
- Insulin: safe
- Metformin: consider
- Sulphonylureas, glitazones, ACE/AT2B, statins: avoid
At what GA is OGTT done for GDM?
28w
What are the values required to diagnose GDM on OGTT?
- Fasting >5.1mmol/L
- 1hr >10.0mmol/L
- 2hr >8.5mmol/L
What is the Mx of GDM in the antenatal period?
- Optimise diet and encourage exercise
- Consider switch to insulin
What are the complications of GDM in the mother and fetus?
- Mother: risk of T2DM in future, pre-eclampsia, PPH, obstructed labour
- Fetus: IUGR or macrosomia (hypoglycaemia), perinatal mortality, perinatal trauma, shoulder dystocia
Principles of first antenatal visit
1- Confirm pregnancy (Hx, Ex, b-HCG)
2- Determine gestational age (USS or Naegele’s rule)
3- Screen for problems with Hx and RANIX
4- Condition Mx
5- General advice: diet, supplements, exercise, smoking, alcohol, sex, working, medication
6- Booking
From what GA are fetal movements felt?
20w
What routine Ix are performed at 28w?
FBE, OGTT ± Rh Ab, anti-D
What routine Ix are performed at 36w?
FBE if Hb low at 28w, GBS swab ± anti-D
What are the causes of reduced variability on CTG?
Sick, sleeping, sedated, submature (3-5bpm)
What is the cause of absent variability on CTG?
Severe hypoxia
What is the cause on sinusoidal variability on CTG?
Anaemia
Principles of active management of the third stage
- Prophylactic administration of an oxytocic (syntocinon)
- Cord traction
- Early clamping
What are the C/I to epidural anaesthesia?
Patient refusal, hypovolaemia, coagulopathy/anticoagulant treatment, sepsis, active neurological condition
Why is the OCP C/I in breastfeeding?
Reduces quantity and quality of milk, steroids cross into milk
If not breastfeeding, when should you commence the OCP following delivery of a baby?
21 days
Mx of heart disease in pregnancy
Pre-pregnancy:
- Determine lesion and assess NYHA status
- Advise on prognosis in pregnancy, effects on offspring
- Consider SBE prophylaxis
- Medication issues (WARFARIN)
During pregnancy:
- CO and HR increase may cause decompensation
- Risk of VTE
In labour:
- Poor toelrance to rapid volume changes
- Vaginal delivery is best with syntocinon for S3 and to prevent PPH
- Close monitoring
- Abx for SBE
How does management of epilepsy change in pregnancy?
- Lowered seizure threshold
- Medications may be associated with anomalies, eg/ valproate
- Safe medications: levetiracetam, lamotrigine, carbamazepine
- Hypoxia increases fetal risk
How long after a live vaccine should women avoid pregnancy?
1 month
Mx of VZV infection in pregnancy
- Pre-pregnancy vaccination is ideal
- Ig can be given to mother if
Definition of hyperemesis gravidarum
Persistent vomiting accompanied by weight loss >5%, dehydration and ketonuria
How is hyperemesis gravidarum diagnosed?
Dx of exclusion: requires thorough history ± TFTs, UEC, urine ketones, FBE, LFTs and US
What is hyperemesis gravidarum associated with?
Multiple pregnancy and GTD
What is the definition of threatened miscarriage?
Any bleeding
Initial Ix for recurrent miscarriage
Pelvic US, thrombophilia screen, parental karyotype
What risks are NOT increased in multiple pregnancy?
Macrosomia, post-dates
What is used to prevent pre-eclampsia?
Low dose aspirin
What are the features of HELLP syndrome?
Haemolysis, elevated LFTs, low platelets
What GA is delivery favoured in IUGR?
38w
What Ix are required for pre-term labour?
- Fetal fibronectin
- Cervical and low vaginal swab simultaneously
- Amnisure may be used to confirm ROM
- MSU
- Uterine examination
- PV only if ROM and PP excluded
- Consider need for expectant Mx
Which drug is preferred in short-term inhibition of labour?
Nifedipine
Cause of PPH if uterus is empty, intact and contracted?
Coagulopathy
Causes of primary PPH
- Atony (70%)
- Genital tract lacerations
- Coagulopathy
- Uterine inversion
Causes of secondary PPH
- Retained POC
- Infection
- GTD or choriocarcinoma
