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MD3 > WH- Obstretrics > Flashcards

WH- Obstretrics Flashcards

1
Q

Routine pre-pregnancy and antenatal tests?

A
  • FBE and iron studies
  • Blood type and group
  • HCV, HBV, HIV and syphilis serology
  • Rubella Ab ± varicella Ab
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2
Q

Principles of PPH management

A
  • 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
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3
Q

Management of IDDM during normal vaginal birth

A
  • 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
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4
Q

Management of pre-eclampsia

A
  • Admission

- Stabilise BP (SBP

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5
Q

Management of mastitis

A
  • Consider admission
  • Keep feeding
  • IV or oral flucloxacillin, analgesia and fluids
  • If the above fails, consider abscess –> surgical drainage
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6
Q

Aims of management in eclampsia

A
  • Protect patient and their airway
  • Control convulsion: consider diazepam
  • MgSO4 to prevent further seizures
  • Review and optimise maternal and fetal state
  • Expedite delivery
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7
Q

DDx of seizure in pregnancy

A
  • Eclampsia
  • Cerebral haemorrhage, intracranial space occupying lesion
  • Amniotic fluid embolus
  • TTP
  • Drug or water toxicity
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8
Q

Management of breech presentation

A
  • 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
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9
Q

Management of shoulder dystocia

A

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

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10
Q

US parameters to determine fetal wellbeing in the third trimester

A
  • 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
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11
Q

What is the presentation of placental abruption?

A
  • Concealed bleeding
  • Dark blood
  • Painful ± contractions
  • Abdominal tenderness
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12
Q

What is the management of placental abruption?

A
  • 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
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13
Q

What is the presentation of placenta praevia?

A
  • Unprovoked, painless vaginal bleeding
  • High presenting part
  • Malpresentation
  • Soft abdomen
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14
Q

What is the management of placenta praevia?

A
  • 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
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15
Q

What are the causes of secondary PPH?

A
  • Retained POC
  • Infected uterus or POC
  • GTD, choriocarcinoma (rare)
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16
Q

What is the management of secondary PPH?

A
  • Ix: HVS, US and blood cultures
  • Broad spectrum antibiotics
  • Surgery
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17
Q

What US findings confirm a miscarriage?

A
  • 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
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18
Q

What are the causes of prolonged decelerations on CTG?

A

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
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19
Q

What is the cause of variable deceleration?

A

Cord compression (hypertension)

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20
Q

What is the cause of late decelerations?

A

Fetal hypoxia

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21
Q

What is the cause of early decelerations?

A

Head compression in labour

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22
Q

What are the features of a reactive/normal CTG?

A
  • Baseline: 110-160bpm
  • Variability: 5-25bpm
  • Accelerations: 2x 15bpm in 20 mins
  • No ominous decelerations
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23
Q

Common causes of puerperal sepsis

A
  • Endometritis
  • CS wound infection
  • Mastitis
  • UTI
  • Consider DVT/PE
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24
Q

What are the causes of IUGR?

A
  • 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
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25
Q

What is the management of gestational DM in the puerperium?

A
  • Cease insulin following delivery
  • Monitor BSL 2x daily
  • Repeat OGTT in 6 weeks
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26
Q

What antibody titre is considered mild in Rhesus disease?

A

≤32

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27
Q

What antibody titre is considered moderate in Rhesus disease?

A

64-256

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28
Q

What antibody titre is considered severe in Rhesus disease?

A

≥512

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29
Q

What is the management of low risk Rhesus disease?

A
  • Ab titre at each visit

- Deliver at 38w

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30
Q

What is the management of moderate risk Rhesus disease?

A
  • Ab titre at each visit
  • US screening from 20w: MCA PSV and hydrops
  • CTGs from 32w
  • Deliver at 38w or earlier
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31
Q

What is the management of high risk Rhesus disease?

A
  • US screening from 17w
  • Fetal blood sampling from umbilical cord if MCA PSV increased
  • Intrauterine transfusions if fetal anaemia
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32
Q

What factors are considered in first trimester screening for Down syndrome?

A
  • Maternal age
  • Serum b-HCG and PAPP-A (10-12w)
  • NT and nasal bone measurement (11-13w)
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33
Q

What factors are considered in second trimester screening for Down syndrome?

A

Serum b-HCG, a-FP, unconjugated oestriol and inhibin A

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34
Q

What receptor is responsible for early decelerations?

A

Pain receptor

35
Q

What receptor is responsible for late decelerations?

A

Chemoreceptor

36
Q

What receptor is responsible for variable decelerations?

A

Baroreceptor

37
Q

What receptor is responsible for prolonged decelerations?

A

Chemoreceptor

38
Q

What are the complications of epidural anaesthesia?

A
  • Immediate: hypotension, dural puncture, high block or total spinal block, IV injection
  • delayed: PDPH, back ache, neurological, abscess, haematoma
  • Long term: paralysis, cord trauma
39
Q

What are the maternal complications of hypothyroidism?

A
  • Increased risk of pre-eclampsia, cardiac dysfunction and PPH
  • More likely to have lactation difficulty and puerperial mental illness
40
Q

What are the fetal complications of hypothyroidism?

A
  • Increased risk of miscarriage

- Risk of congenital hypothyroidism

41
Q

What is the management of hypothyroidism in pregnancy?

A

Increase dose of thyroxine

42
Q

What are the maternal complications of hyperthyroidism?

A

Increased risk of pre-eclampsia and CCF

43
Q

What are the fetal complications of hyperthyroidism?

A

Fetal morbidity is untreated

44
Q

What is the management of hyperthyroidism in pregnancy?

A
  • Anti-thyroid drugs are safe

- Maintain at upper levels

45
Q

What are the causes of obstructed labour?

A

Maternal:

  • Small pelvis, large presenting part
  • Inefficient contractions
  • Exhaustion

Fetal:

  • Malpresentation
  • Macrosomia
  • Anomaly
46
Q

What are the causes of a non-reactive CTG?

A

5S’s:

  • Sick (hypoxia)
  • Sleep
  • Sedated (opioids, MgSO4, barbituates)
  • Small (premature)
  • Supine (maternal supine hypotension)
47
Q

Describe fetal circulation

A
  • 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
48
Q

Risk factors for shoulder dystocia

A

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
49
Q

Complications associated with maternal obesity?

A
  • 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
50
Q

Which of the following medications should you avoid in pregnancy: insulin, metformin, sulphonylureas, glitazones, ACE/AT2B, statins

A
  • Insulin: safe
  • Metformin: consider
  • Sulphonylureas, glitazones, ACE/AT2B, statins: avoid
51
Q

At what GA is OGTT done for GDM?

A

28w

52
Q

What are the values required to diagnose GDM on OGTT?

A
  • Fasting >5.1mmol/L
  • 1hr >10.0mmol/L
  • 2hr >8.5mmol/L
53
Q

What is the Mx of GDM in the antenatal period?

A
  • Optimise diet and encourage exercise

- Consider switch to insulin

54
Q

What are the complications of GDM in the mother and fetus?

A
  • Mother: risk of T2DM in future, pre-eclampsia, PPH, obstructed labour
  • Fetus: IUGR or macrosomia (hypoglycaemia), perinatal mortality, perinatal trauma, shoulder dystocia
55
Q

Principles of first antenatal visit

A

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

56
Q

From what GA are fetal movements felt?

A

20w

57
Q

What routine Ix are performed at 28w?

A

FBE, OGTT ± Rh Ab, anti-D

58
Q

What routine Ix are performed at 36w?

A

FBE if Hb low at 28w, GBS swab ± anti-D

59
Q

What are the causes of reduced variability on CTG?

A

Sick, sleeping, sedated, submature (3-5bpm)

60
Q

What is the cause of absent variability on CTG?

A

Severe hypoxia

61
Q

What is the cause on sinusoidal variability on CTG?

A

Anaemia

62
Q

Principles of active management of the third stage

A
  • Prophylactic administration of an oxytocic (syntocinon)
  • Cord traction
  • Early clamping
63
Q

What are the C/I to epidural anaesthesia?

A

Patient refusal, hypovolaemia, coagulopathy/anticoagulant treatment, sepsis, active neurological condition

64
Q

Why is the OCP C/I in breastfeeding?

A

Reduces quantity and quality of milk, steroids cross into milk

65
Q

If not breastfeeding, when should you commence the OCP following delivery of a baby?

A

21 days

66
Q

Mx of heart disease in pregnancy

A

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
67
Q

How does management of epilepsy change in pregnancy?

A
  • Lowered seizure threshold
  • Medications may be associated with anomalies, eg/ valproate
  • Safe medications: levetiracetam, lamotrigine, carbamazepine
  • Hypoxia increases fetal risk
68
Q

How long after a live vaccine should women avoid pregnancy?

A

1 month

69
Q

Mx of VZV infection in pregnancy

A
  • Pre-pregnancy vaccination is ideal

- Ig can be given to mother if

70
Q

Definition of hyperemesis gravidarum

A

Persistent vomiting accompanied by weight loss >5%, dehydration and ketonuria

71
Q

How is hyperemesis gravidarum diagnosed?

A

Dx of exclusion: requires thorough history ± TFTs, UEC, urine ketones, FBE, LFTs and US

72
Q

What is hyperemesis gravidarum associated with?

A

Multiple pregnancy and GTD

73
Q

What is the definition of threatened miscarriage?

A

Any bleeding

74
Q

Initial Ix for recurrent miscarriage

A

Pelvic US, thrombophilia screen, parental karyotype

75
Q

What risks are NOT increased in multiple pregnancy?

A

Macrosomia, post-dates

76
Q

What is used to prevent pre-eclampsia?

A

Low dose aspirin

77
Q

What are the features of HELLP syndrome?

A

Haemolysis, elevated LFTs, low platelets

78
Q

What GA is delivery favoured in IUGR?

A

38w

79
Q

What Ix are required for pre-term labour?

A
  • 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
80
Q

Which drug is preferred in short-term inhibition of labour?

A

Nifedipine

81
Q

Cause of PPH if uterus is empty, intact and contracted?

A

Coagulopathy

82
Q

Causes of primary PPH

A
  • Atony (70%)
  • Genital tract lacerations
  • Coagulopathy
  • Uterine inversion
83
Q

Causes of secondary PPH

A
  • Retained POC
  • Infection
  • GTD or choriocarcinoma

MD3 (21 decks)

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