Women's Health: Obstetrics Flashcards
What are the blood sugar targets in antenatal diabetics?
1 hour after meal: 7.8
2 hours after meal: 6.4
Fasting: 5.3
When is gestational diabetes screened?
Booking
24-28 weeks to confirm abnormal booking
What are the counselling points for miscarriage
ITS NOT THEIR FAULT
Help for common experience of low mood
Urine pregnancy test 3 weeks post event
Can have sex once menstruation resumes 4-8 weeks later
How do you investigate suspected pre-term prelabour rupture of membranes?
If confirmed how do you mansge?
Ix: Sterile speculum shows pooling in post. vaginal vault
+/- US if no fluid seen
Rx:
Admit to watch for chorioamnionitis
Oral erythromycin 10 days
Antenatal corticosteroids to reduce foetal distress
Consider delivery from 34 weeks
How do you manage a breech presentation
>=36 weeks: ECV if no contraindications
If above fails: C-section
What are the risk factors for placental abruption?
Increased age, blood pressure
Essentially any uterine complication
Narcotic use
Regarding hyperemesis gravidarum …
- What is it
- What warrants admission
- What is the antiemetic treatment
- Triad of 5% pre-pregnant weight loss, dehydration + electrolyte imbalance
- Continued N+V causing feeding difficulty or ketonuria +/- 5% weight loss / confirmed or suspected co-morbidity
- antihistamines –> ondasetron (1st tri cleft palate) OR metoclopramide (<5 days use to to EPSEs)
What is the dose and timescale for vitamin D supplementation in pregnancy
10mg / 4000IU for entire pregnancy
What would fulfil a diagnosis of recurrent miscarriage?
What 3 assessments should you undertake?
>=3 before 10 weeks gestation
>=1 normal loss after 10 weeks
APL antibodies –> aspirin + heparin
Genetic screening –> counselling
Pelvic US for uterine pathologies
what is given for a missed and incomplete miscarriage
Missed: 800ug misoprostol
Incomplete: 600ug misoprostol
Surgical if medical fails
How do you differentiate placenta praevia, vasa praevia and abruption in terms of
Bleeding
Pain
Uterine tenderness
Lie
Foetal heartbeat
Placenta praevia // Vasa praevia // placental abruption
Shock proportional // proportional // excessive shock
no pain // no pain // constant pain
non-tender // non-tender //tender
Abnormal // normal // normal
normal beat // bradycardia // distressed/absent
What are the risk factors for placenta praevia
Multiparity, previous C-sections
What are four causes of PPH
Tone (atony)
Thrombus
Trauma
Tissue (retained, up to 2 weeks)
On assessing pre-eclampsia, who needs
Emergency secondary care assessment
Emergency admission
Assessment: Anyone with symptoms
Admission: BP >=160/110mmHg
How do you manage a threatened miscarriage?
Give 400mg BD progesterone until 16 weeks
Return if bleeding has not stopped in 14 days
What is the treatment of placental praevia by grade
G1-2: Attempt SVD
G3-4: C-section
If bleeding: Stabilise and C-section
What is the gold standard investigation for ectopic pregnancy?
TVUS
What warrants gestational diabetes diagnosis in
Fasting glucose
2-hour OGTT
Fasting: >=5.6mmol/L
2hr: >=7.8mmol/L
‘5678’
Regarding folic acid supplementation…
What time scale + typical dose
Who gets 5mg
Take 400ug preconception-12 weeks
Take 5mg for same time if…
- FHx neural tube defects
- BMI >=30
- Epilepsy, T2DM, coeliac or thalassaemia trait
What is the first line treatment of miscarriage?
Who is eligible for further management?
Expectant management
Increased risk of haemorrhage/haemorrhage side effects psychological trauma/infection
How does fasting glucose direct management of gestational diabetes?
<7mmol
- Trial lifestyle
- Metformin if fails
- Insulin if metformin not tolerated
>=7mmol/L OR >=6 + macrosomnia/oligohydramnios
- Insulin
What are the risk factors for vasa praevia
IVF, low lying placenta
How do you manage vasa praevia?
Corticosteroids from 32 weeks
Elective C-section 34-36 weeks
What haemoglobin levels require iron supplementation in pregnancy?
0-12wks: <110
12-term: <105
Post-partum: <100
Take for 3 months
How can you differentiate ectopic pregnancy and miscarriage in terms of
Pain
Vaginal exam
US finding
Ectopic // miscarriage
Common // if inevitable/incomplete/complete
Cervical tenderness // Os may be open
‘sliding/bagel/tubal sign’ // Repeat gest sac >25mm/CRL >7 without heartbeat
What is the trend in blood pressure during pregnancy
Falls until ~24 weeks
Then increases to pre-pregnancy levels
How is gestational HTN distinguished from pre-existing hypertension?
new >140/90mmHg AFTER 20 weeks
OR
>30/15mmHg increase from booking
How do you manage pre-existing diabetes in pregnancy in terms of
Lifestyle
Drugs
Appointments
Lose weight if BMI >27
Stop drugs apart from metformin + commence insulin
20 week heart anomaly scan
How do you differentiate between expectant, medical and surgical management of ectopic pregnancy using
Pain
B-HCG
Foetal size and hearbeat
Expectant // Medical // Surgical
No // not significant // significant
<1000IU/L // >1500IU // >5000IU
<35mm + no beat // < 35mm + no beat // >35mm + beat
During artificial membrane rupture, you can palpate the cord and foetal heartbeat becomes distressed; what is the management?
Initial
- Push presenting foetus back into uterus to reduce compression
- Avoid handling + keep cord warm if past introitus
- Go on all fours OR left lateral position
+ tocolytics
+ Retrofilling bladder 500-700ml
Definitive: Delivery via C-section
How do you manage ectopic…
expectantly
Medically
Surgically
Watch B-HCG levels 48hrs
Methotrexate
Laparoscopic removal with Anti-D if Rh-ve
What are the contraindications to ECV?
Abnormal CTG, uterine state
Multiple pregnancy
Ruptured membranes
APH in past 7 days
How is gestational HTN distinguished from pre-eclampsia or eclampsia?
GHTN: new >140/90mmHg at >=20wks
Pre-eclampsia: above + proteinuria, headache, N+V
Eclampsia: Seizures
What is the treatment for placental abruption?
<36 weeks
no distress: Observe + steroids. AVOID TOCOLYTICS
Distress: Immediate C-section
>36 weeks:
No distress: Delivery
Distress: C-section
What are the grades of placenta praevia
G1: lower edge low lying
G2: lower edge touches os
G3: Lower edge partially covers os
G4: Lower edge majority covers os
For pre-eclampsia treatment what is
First-line
Definitive
1st: Labetalol (nifedipidine if contraindicated)
Def: Delivery of baby
How do you diagnose and treat post-partum haemorrhage
>=500ml blood loss
- ABCDE 2 x 14 gauge cannulae
- IV oxytocin (10 units) OR IV erometrine (500ug)
- IM carboprost
- IU balloon tamponade/B-lynch/iliac artery ligation
- Hysterectomy if life-saving
Oh/Effing Christ That’s Hell
Oxytocin/Ergometrine
Carboprost IM
Tamponade
Hysterectomy
What is preferable for testing pregnancy: serum or urine HCG?
Urine
What should you do if gentle traction does not deliver the foetus?
- Call for senior help + McRoberts manouvre
+ Episiotomy to help
RISK OF SHOULDER DYSTOCIA, THIS CAUSES TEARS IN MUM, BRACHIAL PLEXUS IN CHILD
Outline the stages of labour?
Stage 1: Onset of true labour to full dilation of the cervix
Stage II: Full dilation to delivery of foetus
Stage III: Delivery of foetus to delivery of membranes
What is the difference between latent and active phase in stage I of labour?
Latent: 0-3cm, normally takes 6 hours
Active phase: 3-10cm, normally 1cm/hour
How can you differentiate between passive and active stage II of labour
When is this abnormal?
Reminder: Stage II is full dilation to delivery
Passive: no pushing
Active: pushing
Abnormal if >1 hour
How is bishops score calculated based on…
Cervical position
Cervical consistency
Cervical effacement
Cervical dilatation
Fetal station
What do the following Bishop’s scores mean?
4
12
under 5 so spontaneous labour unlikely
>=8 so labour is favourable
If labour requires artificial induction, what are the options?
1st: Vaginal prostaglandins
Membrane sweep if 40 weeks (primi) 41 (multi)
What is the main complication from inducing labour?
Uterine hyperstimulation: Prolonged and frequent contractions
Can interrupt foetal blood supply
Give tocolysis with terbutaline
What are the risk factors for GBS infection?
4 Ps
Prematurity
Prolonged rupture of the membranes
Previous sibling infection
Pyrexia in mother due to chorioamnionitis
Who gets GBS interventions and what are they?
If mother or baby previously had it, pyrexia >38 degrees in labour
Either…
intrapartum benpen prophylaxis
OR
Test at 35-37 weeks and give if positive
Regarding foetal movements, what do if…
Reduced foetal movements after 24 weeks?
reduced: Doppler –> US
Absent: Referral to maternal fetal medicine
What do the following CTG findings mean?
HR <100/min
HR >160/min
variability <5/min
deceleration during contraction that returns to normal
deceleration that lags during and >30s after contraction
Decelerations independent of contractions
Baseline bradycardia: foetal tone, maternal beta blocker use
Baseline tachycardia: Pyrexia, infection, hypoxia, prematurity
Loss of variability: prematurity, hypoxia
Early decels: innocuous, contraction compressions
Late decels: FOETAL DISTRESS
Variable decels: inidicate cord compression
How do you investigate and treat suspected DVT/PE in pregnancy?
US doppler for DVT evidence
V/Q scanning for PE
Treat with SC heparin (IV if have to)
Regarding Hep B in pregnancy…
Who gets screened
What treatment is given
How does this affect breastfeeding
All pregnants
Full hep B vaccinations + hep B IG for babies
It does not
Regarding HIV in pregnancy…
Who gets screened
How does treatment work
How does breastfeeding change
All pregnants
Mum gets anti-retrovirals
Birth: vaginal < 50 copies/ml < C-section at 36 weeks
Baby: zidovudine < 50ml viral load < Triple ART; for 4-6 weeks
Dont breastfeed
How long can lochia last for post partum?
6 weeks
What does the following Down’s test consist of and what time is it given?
Combined testing
quadruple testing
11-13+6
Screening: Thickened nuchal, raised B-HCG, low PAPP-A
15-20 weeks
Triple: Raised B-HCG, low AFP, low oestriol
Quadruple: triple + low inhibin A
How is rhesus -ve pregnancy dealt with…
preventatively
If event occurs at 2/3rd trimester
If complication causes event
If baby affected
Test at booking, anti-D at 28 and 34 weeks
Large anti-D dose + kleihauer test
Give anti-D <72 hours
Test FBCs, Blood group + direct coombs test
Transfusions + UV resistance
