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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
What is the management of gestational DM in the puerperium?
- Cease insulin following delivery - Monitor BSL 2x daily - Repeat OGTT in 6 weeks
26
What antibody titre is considered mild in Rhesus disease?
≤32
27
What antibody titre is considered moderate in Rhesus disease?
64-256
28
What antibody titre is considered severe in Rhesus disease?
≥512
29
What is the management of low risk Rhesus disease?
- Ab titre at each visit | - Deliver at 38w
30
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
31
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
32
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)
33
What factors are considered in second trimester screening for Down syndrome?
Serum b-HCG, a-FP, unconjugated oestriol and inhibin A
34
What receptor is responsible for early decelerations?
Pain receptor
35
What receptor is responsible for late decelerations?
Chemoreceptor
36
What receptor is responsible for variable decelerations?
Baroreceptor
37
What receptor is responsible for prolonged decelerations?
Chemoreceptor
38
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
39
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
40
What are the fetal complications of hypothyroidism?
- Increased risk of miscarriage | - Risk of congenital hypothyroidism
41
What is the management of hypothyroidism in pregnancy?
Increase dose of thyroxine
42
What are the maternal complications of hyperthyroidism?
Increased risk of pre-eclampsia and CCF
43
What are the fetal complications of hyperthyroidism?
Fetal morbidity is untreated
44
What is the management of hyperthyroidism in pregnancy?
- Anti-thyroid drugs are safe | - Maintain at upper levels
45
What are the causes of obstructed labour?
Maternal: - Small pelvis, large presenting part - Inefficient contractions - Exhaustion Fetal: - Malpresentation - Macrosomia - Anomaly
46
What are the causes of a non-reactive CTG?
5S's: - Sick (hypoxia) - Sleep - Sedated (opioids, MgSO4, barbituates) - Small (premature) - Supine (maternal supine hypotension)
47
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
48
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
49
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
50
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
51
At what GA is OGTT done for GDM?
28w
52
What are the values required to diagnose GDM on OGTT?
- Fasting >5.1mmol/L - 1hr >10.0mmol/L - 2hr >8.5mmol/L
53
What is the Mx of GDM in the antenatal period?
- Optimise diet and encourage exercise | - Consider switch to insulin
54
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
55
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
56
From what GA are fetal movements felt?
20w
57
What routine Ix are performed at 28w?
FBE, OGTT ± Rh Ab, anti-D
58
What routine Ix are performed at 36w?
FBE if Hb low at 28w, GBS swab ± anti-D
59
What are the causes of reduced variability on CTG?
Sick, sleeping, sedated, submature (3-5bpm)
60
What is the cause of absent variability on CTG?
Severe hypoxia
61
What is the cause on sinusoidal variability on CTG?
Anaemia
62
Principles of active management of the third stage
- Prophylactic administration of an oxytocic (syntocinon) - Cord traction - Early clamping
63
What are the C/I to epidural anaesthesia?
Patient refusal, hypovolaemia, coagulopathy/anticoagulant treatment, sepsis, active neurological condition
64
Why is the OCP C/I in breastfeeding?
Reduces quantity and quality of milk, steroids cross into milk
65
If not breastfeeding, when should you commence the OCP following delivery of a baby?
21 days
66
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
67
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
68
How long after a live vaccine should women avoid pregnancy?
1 month
69
Mx of VZV infection in pregnancy
- Pre-pregnancy vaccination is ideal | - Ig can be given to mother if
70
Definition of hyperemesis gravidarum
Persistent vomiting accompanied by weight loss >5%, dehydration and ketonuria
71
How is hyperemesis gravidarum diagnosed?
Dx of exclusion: requires thorough history ± TFTs, UEC, urine ketones, FBE, LFTs and US
72
What is hyperemesis gravidarum associated with?
Multiple pregnancy and GTD
73
What is the definition of threatened miscarriage?
Any bleeding
74
Initial Ix for recurrent miscarriage
Pelvic US, thrombophilia screen, parental karyotype
75
What risks are NOT increased in multiple pregnancy?
Macrosomia, post-dates
76
What is used to prevent pre-eclampsia?
Low dose aspirin
77
What are the features of HELLP syndrome?
Haemolysis, elevated LFTs, low platelets
78
What GA is delivery favoured in IUGR?
38w
79
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
80
Which drug is preferred in short-term inhibition of labour?
Nifedipine
81
Cause of PPH if uterus is empty, intact and contracted?
Coagulopathy
82
Causes of primary PPH
- Atony (70%) - Genital tract lacerations - Coagulopathy - Uterine inversion
83
Causes of secondary PPH
- Retained POC - Infection - GTD or choriocarcinoma

MD3 (21 decks)

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