ACEM Fellowship > O&G > Flashcards

O&G Flashcards

(40 cards)

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1
Q

Pre-eclampsia definition

A

> 20/40 or <6/52 post-partum
AND
BP >=140/90 x2 OR 160/110 x1
AND
Proteinuria >300mg/day (>=2+ on UA) OR P:C >=0.3
+/-
Evidence of organ dysfunction
- Thrombocytopaenia
- Renal insufficiency (double Cr)
- Liver dysfunction (transaminases 2x ULN)
- Pulmonary oedema
- Cerebral or visual symptoms

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2
Q

HELLP syndrome definition

A

Haemolysis
Elevated liver enzymes
Low Platelet count
+/- hypertension

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3
Q

Pre-eclampsia management

A
  1. Left lateral position
  2. Deliver, if possible
  3. Fetus:
    - Continuous CTG monitoring
    - Consider betamethasone 11.4mg IM if premature
  4. BP managment
    - Aim initial 20/10mmHg reduction
    - IV labetalol 10-20mg q10 mins (or hydralazine) max 80mg
    - PO labetalol 100-200mg TDS
  5. MgSO4
    - If neuro features
    - 4g IV over 10-20 mins
    - Mg infusion 1g/hr, aim Mg 2.0-3.0, for 24hrs
    - Cease if loss of deep tendon reflexes or RR <12 (give CaGlu)
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4
Q

Eclampsia maternal mortality rate and most common cause of death

A

2%
ICH commonest cause
Give lots of Mg, aim Mg 2.0-4.0

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5
Q

HELLP syndrome management

A

BP control
- Labetalol, hydralazine
Dexamethasone
Platelet transfusion, as required
Deliver, if possible

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6
Q

Rh autoimmunisation sensitising events

A

First trimester
- Miscarriage 2%
- TOP 4%
- Chorionic villus sampling
- Ectopic

Second or third trimester
- Obstetric haemorrhage
* Placenta praevia
* abruptio placentae
* normal delivery
- Amniocentesis
- External cephalic version
- Abdominal trauma

Normal pregnancy
- Can occur without obvious precipitant
- Risk too low to warrant Anti-D

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7
Q

Anti-D immunoglobulin indications

A

Rh negative women
1. Following sensitising events
2. Not already formed their own Anti-D at 28 and 34 weeks
3. Delivery of a Rh+ baby
4. Following administration of Rh+ blood components to pre-menopausal women

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8
Q

Anti-D dose

A

IM injection (not SC)
Give within 72hrs

<12/40 + sensitising event: 250IU
- Threatened miscarriage without heavy bleeding or abdo pain DOESN’T qualify

> 12/40 OR multiple pregnancy: 625IU

Rh neg women without anti-D antibodies
- 625IU at 28/40, 34/40 and post-partum

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9
Q

Methods of measurement of feto-maternal haemorrhage, indications and purpose

A

Kleihauer or flow cytometry
- 7mL maternal venous blood in EDTA + newborn sample if possible

Indicated after any sensitising event in later pregnancy

Determines dose of anti-D to be given

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10
Q

Acute dysfunctional uterine bleeding management

A

Primolut (norethisterone) - 5mg TDS for 10/7
TXA - 1g PO TDS (until bleeding stops)
Ibuprofen 400mg TDS

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11
Q

Antepartum haemorrhage definition and causes

A

PVB >20/40 prior to onset of labour

Placenta praevia 30%
- blood, no pain, baby ok
Placental abruption 20%
- blood, pain++, baby at risk
Vasa praevia
- blood, mum fine, baby at risk

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12
Q

Antepartum haemorrhage management

A

ABCDE + TXA + steroids + anti-D + ?delivery

  1. Urgent obstetric involvement - urgent delivery required if unstable
  2. Monitor fetus and mother - CTG
  3. Resus - IVF +/- blood products (aim Hb >100, FFP + cryo for DIC)
  4. Reverse coagulopathy incl. TXA
  5. Consider steroids (betamethasone 11.4mg IM)
  6. Anti-D if indicated
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13
Q

Risk factors for placental abruption

A

Patient
- HTN (commonest, 45% of cases)
- Trauma; MVA, falls
- Smoking and EtOH
- Cocaine

Obstetric
- Short umbilical cord
- Sudden uterine decompression e.g. PROM
- Retroplacental fibroid
- Retroplacental bleeding from needing puncture (i.e. amniocentesis)

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14
Q

PPH definitions

A

> 1000L blood loss with signs and/or symptoms of hypovolaemia
Primary: <24hr
Secondary: 24hr-12 weeks
Massive: >50% replacement of circulating volume in <3h OR 150mL/min

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15
Q

Risk factors for PPH

A

Tone, trauma, tissue, thrombin

“An empty, contracted, intact uterus will not bleed in the absence of coagulopathy”

Tone:
- Over-distension of uterus from:
* Polyhydramnios
* Multiple pregnancy
* Macrosomia
Tissue:
- Abnormal placenta e.g. placeta accreta
Truama:
- Prolonged labour
- Instrumental delivery
Thrombin:
- Coagulopathy
History:
- APH
- Previous PPH

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16
Q

Primary PPH management

A

Tone, trauma, tissue, thrombin

  1. Tone (massage, IDC, drugs)
    - Uterine stimulation with fundus massage (requires analgesia)
    - IDC to empty bladder
    - Oxytoxin 10U IM/IV stat -> 40U in 1L NaCL over 4hrs
    - Ergometrine 250mcg IM then 250mcg slow IV push
    - Carboprost 250mcg IM
  2. Trauma
    - Check birth canal for local bleeding
    - Apply direct pressure and suture visible lacerations, as required
  3. Tissue
    - Check placenta for completeness
    - Remove placental remains, if possible (in OT, as able)
  4. Thrombin
    - MTP
    - TXA 1g IV over 10 mins (reduced mortality, MOTHER trial, NNT = 20)
    - Rotem-guided, ideally
    Targets:
    - Hb >80
    - Fibrinogen >2
    - Plt >50
  5. Other:
    - Tamponade
    * External abdominal aortic compression
    * Bimanual pressure
    * Uterine packing
    * Balloon tamponade e.g. Bakri balloon
    - IR embolisation
    - OT for most of above
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17
Q

Secondary PPH management and likely causes

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A

Causes: retained products or infection

  1. ABC
  2. Fluid resus
  3. Analgesia
  4. Ergometrine 500mcg IV or IM
  5. Antibiotics, triple
    - Amp + gent + metro
  6. O&G for curettage
18
Q

Emergency contraception: options and SEs

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A
  1. Levonorgestrel
    - 0.75mg stat and 12h (or 1.5mg once only)
    - Most effective within 24 hours, up to 72 hours (failure rate 1.1% at 72hr), may be useful to 5 days
    - Continue usual oral contraceptives if using
    - Prevents 85% expected pregnancies
    - SEs: N+V, dizziness, fatigue; withdrawal bleed after few days, period delayed

Mifepristone
- 50mg PO stat
- More effective than levonorgestrel
- Expensive
- SEs similar

IUCD (Cu coil or Mirena)
- 99.9% effective within 5 days

19
Q

Preterm labour signs, symptoms and confirmatory test

Study These Flashcards
A

Labour <37/40
Uterine contractions >4/hr
PLUS
Cervical change (effacement and dilation)
May also have:
- Cramping abdominal/back pain
- Pelvic pressure
- Vaginal bleeding (“bloody show”)

Fetal fibronectin in vaginal secretions to rule-out

20
Q

Preterm labour management

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A
  1. In utero transfer when possible
    - High level risk of birth en-route if <28/40
  2. Steroids if <35/40
    - Betamethasone 11.4mg IM stat and at 24h
  3. Tocolysis
    - Nifedipine 20mg PO, repeated q30min up to 60mg to cease contraction
    - Salbutamol 100mcg slow IV then infusion
  4. Antibiotics
    - Benpen 1.2mg IV stat (GBS)
    - Amp + gent + met if PROM
  5. MgSO4
    - Fetal neuroprotection if <32/40
    - 4g IV slow bolus then 1g/hr infusion
21
Q

Preterm labour: contraindications to transfer

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A
  1. Active labour with >5mg cervical dilatation
  2. Fetal distress
  3. Maternal haemodynamic instability
  4. No safe transfer option or escort
  5. Cord prolapse
22
Q

Preterm labour: benefits of steroid cover

Study These Flashcards
A

Lung maturation
Reduced intraventricular bleed
Reduced NEC

11.4mg betamethasone IM stat and at 24hr if <35/40

23
Q

Preterm labour: contraindications for tocolysis

Study These Flashcards
A
  1. Cervix >4cm dilated
  2. Fetal distress
  3. Chorioamnionitis
  4. Pre-eclampsia (severe)
24
Q

Cord prolapse management

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A
  1. Put mum in knees-to-nipples position (McRobert’s)
  2. Push up on the presenting part to relieve pressure on the cord
  3. OT for emergency C-section
25
Methods of diagnosis of premature rupture of membranes
1. Clinical history - Sudden gush of fluid loss from vagina OR steady loss of small amount of fluid 2. Pooling test - Collection of amniotic fluid in vaginal fornix on speculum exam 3. Nitrazine test - Amniotic fluid turns nitrazine paper from orange to dark blue 4. Ferning test - Fluid from vagina placed on microscope slide, dries to form a crystallisation pattern called arborisation
26
Bacterial vaginosis treatment
Non-pregnant: - Metro 400mg PO BD for 7 days OR - Metro 2g stat (lower clearance rate but better adherence) Pregnant: - Clindamycin 300mg PO BD for 7 days
27
Bacterial vaginosis: diagnostic criteria
Amsel criteria (3 of 4 present) 1. Thin, white, homogenous discharge 2. Vaginal fluid pH >4.5 3. Clue cells on wet preparation of vaginal swab (epithelial cells with small curved coccobacilli and mixed flora) 4. Fish odour when adding alkali (potassium hydroxide 10%) to discharge Also: Gram stain showing gram-variable coccobacilli and mixed anaerobes
28
Candidal vulvovaginitis treatment
Clotrimazole 1% vaginal cream intra-vaginal nocte for 6 nights OR Clotrimazole 100mg pressary once daily at bedtime for 6 nights Can use higher strength cream or pessary for shorter time: - 2% for 3 night; 10% once - 500mg pessary once If severe (extensive vulval erythema, oedema, excoriation, fissuring): Fluconazole 150mg PO day 1 and 4 OR Clotrimazole 500mg pessary bedtime day 1 and 4
29
Resuscitative hysterotomy: indications and contraindications
Indications: Maternal cardiac arrest for >4mins AND Gestation >20/40 (fundus palpable above umbilicus if unknown) Contraindications: Maternal cardiac arrest >15 mins *Tight window: 4-15mins*
30
Benefits of resuscitative hysterotomy
1. Removes aortocaval compression -> increases venous return and cardiac output 2. Allows autotransfusion of placenta blood back to mother 3. Increased functional residual capacity of lungs 4. Allows for more effective CPR
31
CTG indications of foetal distress
1. Baseline rate <100 or >160 (normal 100-160BPM) 2. Variable or late decelerations (after contractions), prolonged recovery 3. Premature contractions
32
Changes to repiratory physiology in pregnancy
1. TV increases 30-40% 2. TLC decreased 5% (diaphragm elevation) 3. RR and MV increases 30-40% 4. Resp alkalosis with low pCO2 5. Expiratory reserve volume decreases
33
Gestation from which CTG monitoring is useful
22-24 weeks
34
Causes of PV bleeding with negative betaHCG
1. DUB – absence of any other cause, age perimenopausal 2. Cervical cancer – lesion seen on speculum 3. Trauma – Hx of trauma, laceration on examination 4. Endometrial cancer - USS showing endometrial mass, bulky uterus on bimanual (accept fibroids for same reasons) 5. Coagulopathy – Hx coagulopathy, abnormal coags 6. Hypothyroidism – abnormal TFTs 7. PID - cervical motion tenderness / purulent dc / recent instrumentation
35
Examination findings suggestive of pre-ecclampsia
Hypertension RUQ tenderness (tender hepatomegaly) Papilloedema Hyper-reflexia Peripheral oedema
36
Differential for pre-term labour in woman with abdominal pain in late pregnancy
● Placental abruption ● Acute appendicitis ● Ovarian pathology - Cyst rupture, Torsion ● Cystitis/Urinary tract infection/Pyelonephritis ● Renal Colic ● Braxton Hicks contractions ● HELLP syndrome ● Round ligament pain ● Acute Gastroenteritis
37
Changes in cardiovascular physiology in pregnancy
1. Plasma volume increased by 50% 2. HR increased by 15-20bpm 3. CO increased by 40%, gravid uterus pressure on IVC significant (decreased venous return) 4. Uterine blood flow 10% CO 5. SVR decreased 6. Arterial BP decreased by 15mmHg
38
Investigations and assessments for trauma in pregnancy
1. Uterine examination - fundal height, tenderness, contractions 2. CTG 3. Ultrasound/eFAST 4. Kleihauer - determine amount of Anti-D required for FMH
39
Criteria for safe discharge of trauma in pregnancy
1. Normal examination with no abdominal tenderness, bruising or contractions 2. No PV loss or discharge 3. Normal fetal movements 4. Safe discharge environment - SW, no DV, increased antenatal surveillance
40
TGA pregnancy category definitions
A - Taken by a large number of pregnant women with no evidence of harm to foetus B - Taken by a limited number of pregnant women with no increase in frequency of harmful foetal effects. Varying evidence from animal studies B1-3 from no harm to demonstrated harm C - Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing harmful foetal effects but may be reversible D - Drugs which are suspected to have caused or may be expected to cause, an increased incidence of irreversible foetal malformations or damage X - High risk of permenant damage to foetus and should not be used in pregnancy or possibility of pregnancy
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