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Obstetrics Flashcards

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1
Q

What is the role of the amniotic sac

A

Stores amniotic fluid: Prevents shock and infections to the baby

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2
Q

Why does someone’s ‘water’ break

A

Indicator of uterine contractions

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3
Q

What is the premature rupture of membranes

A

This is membrane rupture in the absence of uterine contractions

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4
Q

When is premature rupture of membranes diagnosed

A

If it happens after 37 weeks

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5
Q

What is preterm premature rupture of membranes(pPROM)

A

This is when membrane ruptures before 37 weeks.

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6
Q

What is prolonged rupture of membranes

A

When membrane rupture happens greater than 18 hours before delivery.

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7
Q

Risk factors for PROM or pPROM

A
  1. Previous PROM
  2. Genital or UTIs
  3. Smoking
  4. Polyhydramnios (too much amniotic fluid)
  5. Abdo trauma
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8
Q

Diagnosis of PROM

A
  1. Speculum Exam

AVOID DIGITAL EXAMINATION (increases risk of infection and precipitate labour in women with pPROM)

  1. Nitrazine and Fern test
  2. Check fetal status
  3. Screen for STIs (can be caused by rupture)
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9
Q

What does a speculum exam show in PROM

A
  1. Shows fluid pooling in posterior vaginal fornix
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10
Q

Is there a cause for concern if blood or meconium is found in the posterior vaginal fornix

A

No

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11
Q

What is the Nitrazine and Fern test

A

To check for amniotic fluid (make sure it is).

Nitrazine: fluid placed on pH sensitive paper (pos = dark blue)

Fern test: Fluid placed on slide and examined under microscope - positive if ferning pattern is seen (like a plant)

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12
Q

What do we do if no fluid is seen in posterior vaginal fornix when checking for PROM

A
  1. Individual asked to cough and press on uterine fundus.

May enhance amniotic fluid flow through cervical opening

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13
Q

If nothing is seen on the speculum exam for PROM after amniotic fluid press, what should be done and what is seen

A
  1. USS: should see low amniotic fluid volume (oligohydramnos)
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14
Q

What is oligohydramnios

A

When Amniotic fluid index <5cm

This confirms premature reupture of membrane

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15
Q

What do we do if AFI turns out low-normal when checking for PROM

A

6-7cm:
PAMG-1 test

IGFBP-1 test

Combined test

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16
Q

What is PAMG-1

A

Placental alpha-microglobulin-1

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17
Q

What does IGFBP-1 look for

A

Placental protein 12

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18
Q

What does the combined test look for

A
  1. Placental protein 12

2. Alpha fetoprotein

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19
Q

How is fetal status determined

A
  1. USS: to check for fetal position and gestational age

2. Non-stress test: fetal wellbeing

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20
Q

What is a non-stress test

A
  1. 20 minute recording of fetal heart rate using Cardiotocograph
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21
Q

What is a cardiotocograph

A

Electronic fetal monitor

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22
Q

What is a normal heart rate on cardiotocography

A
  1. 110-160BPM

2. at least 2 accelerations (changes in 15BPM up or down

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23
Q

What kind of accelerations do we see in preganncies above 32 weeks

A

changes in 15BPM lasting for 12 secs

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24
Q

What kind of accelerations do we see in pregnancies below 32 weeks

A

changes in 10BPM lasting at least 10 secs.

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25
What readings show fetal distress on an NST
1. Decreased heart rate 2. Fewer/shorter accelerations This is calleed non-reactive result
26
Infectious causes for STIs as a cause of membrane rupture
1. UTI (urinalysis) | 2. Chalmydia/gonorrhoea (cervical swabs)
27
What are infectious consequences of PROM, pPROM and prolongued PROM
1. Inauterine infections as environment is no longer sterile This can cause an ascending infection of endometritis/chorioamnnionitis
28
What bacteria make up normal vaginal flora
1. Gram negative lactobacilli (anaerobic) | 2. Group B strep (vaginal and rectal swabs for culture)
29
What is endometritis
1. Where to endometrium is infected
30
Symptoms of ascending infections from vaginal flora in PROM
1. Fever 2. Tachycardia 3. tender uterus 4. Septic
31
How is PROM managed
1. After 37 weeks: Labour is induced with oxytocin or c section
32
If the cervix is unfavourable, what should be given
25mcg misoprostal intravaginally every 3-6 hours Perorally every 2 hours. 5 times total
33
If someone with PROM is GBS positive, what should be given
Ampicillin during delivery
34
How should pPROM be managed
Intrauterine infection is major concern Azithromycin single dose IV ampicillin (2g) every 6 hours for 48 hours. Oral Amoxicillin for 5 more days
35
When should delivery be induced in PROM
1. >34 weeks as fetal lungs have matured Waiting would cause infection GBS posiitive: Ampicillin
36
24-34 weeks gestation (PROM and pPROM), what should be management plan
1. Antenatal corticosteroids 2. tocolytic meds for 48 hours (Nifedipin, NSAID and terbutaline 3. Mg Sulfate to protect CNS and cerebral palsy Delivery should be within 1 week.
37
management of pProm before 24 weeks
Fetus is non-viable = abortion
38
When does vaginal bleeding most commonly occur
1st Trimester
39
Management of vaginal bleeding
1. Assess haemodynamic stability (hypovolaemia/ Vital Sign Status). 2. Compensate blood loss (ABC) B- breathing (non-rebreathable mask) C - circulation (measuring hypovolaemia/ IV catheter for fluid resus) 3. Exams: Pelvic, TVUSS, Lab tests
40
Findings of hypovolaemia: Stage 1, Stage 2, Stage 3, Stage 4
Stage 1: Hypo: 500-1000 mL Vital Sign Status: BP Normal Tachycardia Palpitations Dizziness Stage 2: Hypo: 1000-1500 mL Vital Sign Status: - SBP: 80-100 mmHg - Tachycardia - Weakness - Sweating Stage 3: Hypo: 1500-2000 mL Vital Sign Status: - SBP: 70-80 mmHg - Restelessness - Palor - Decreased Urine Stage 4: Hypo: >2000 mL Vital Sign Status: - SBP: 70-80 mmHg - Cardio/Resp Collapse - Loss of Consciousness - Anuria
41
Management of those in stage 3 hypovolaemia or higher
Blood transfusion
42
Causes of antepartum haemorrhages in first trimester
1. Implantation bleeding 2. Ectopic 3. Miscarriage 4. Genital tract pathology Always assume ectopic Vaginal Pathology: Vaginitis: Discharge + wet mount needed Vaginal Tumours: Warts: Remove and histopathology Cervical Pathology: Cervical Ectropion/polyps Fibroids
43
Causes of antepartum haemorrhage in second trimester
1. Miscarriage | 2. Genital tract pathology
44
Why does implantation bleeding occur
1. Developing embryo burrows into uterine lining 10-14 days after fertilisation (light bleeding lasting 2 days max) Mistaken for menstrual period Diagnosed by exclusion
45
What is an ectopic pregnancy
Where embryo implants elsewhere instead of the uterine cavity (the ampulla of fallopian tube usually )
46
RF for ectopic pregnancy
1. Previous ectopic 2. Previous tubal surgery 3. IUD 4. Bilateral tubal ligation
47
Symptoms of ectopic pregnancy
1. Pain | 2. Vaginal bleeding
48
Diagnosis of ectopic pregnancy
1. Serum HCG >2000 mIU/ mL Pregnancy can be seen on TVUSS <2000 mIU/mL Measurements every 48-72 hours TVUSS Methotrexate or surgery to terminate
49
Symptoms of cervical ectopic pregnancy
1. Painless and profuse bleeding - leads to haemodynamic instability Must be terminated
50
Termination of pregnancy in haemodynamically stable vs unstable pregnancies
1. Stable: Methotrexate 2. Unstable Dilation Curettage
51
What is a curettage
1. Scoop that removes tissue by scrapping the lining of the uterus.
52
Two types of miscarriage
1. Threatened (may be eliminated) | 2. Inevitable (definitely - elimination 2-4 weeks after diagnosis )
53
Findings of a threatened miscarriage
1. Closed cervix 2. Detectable fetal cardiac activity Either resolves or progresses to inevitable
54
Advice to someone with threatened miscarriage
1. Avoid exercise 2. Avoid heavy lifting 3. Avoid sexual intercourse
55
Management of threatened miscarriage
1. Expectant management | 2. Intravaginal progestins
56
Role of intravaginal progestins
1. Helps uterine viability, stops lining from giving in during pregnancy
57
Examination findings of an inevitable miscarriage
1. Cramps or contractions 2. Cervix dilated 3. Increased vaginal bleeding Sometimes gestational tissue is seen in opening
58
Management of inevitable miscarriage
1. Haemodynamically stable: - Expectant management - Reevaluation at 4 weeks
59
Complete vs incomplete miscarriage
1. After an inevitable miscarriage: placental tissue may be left behind (incomplete) or complete evacuation (complete)
60
Management of incomplete miscarriage
1. Medical or surgical evacuation In first trimester: Mifepristone (200 mg orally) - THEN Misoprostol (800 microgram intravaginally) after 24 hrs. Or repeat dose of misoprostol 2nd trimester: Dilation and curettage/aspiration
61
How does mifepristone work
1. Progesterone antagonist
62
How does misoprostol work
1. Prostaglandin E1 Analogue
63
Role of prostaglandin E1
Vasodilator
64
What is cervical ectropion
1. Glandular epithelium of endocervix is present in vagina because of endocervical eversion
65
Examination finding for cervical ectropion
1. Bright red vagina, columnar epithelium prone to light bleeding when touched (after intercourse or speculum examination)
66
management of cervical ectropion
1. PAP smear to screen for cervical neoplasia Ectropion is usually harmless and needs no treatment
67
Diagnosis of uterine polyps and fibroids
1. TVUSS
68
Polyps vs fibroids
1. Polyps emerge from endometrium | 2. Fibroids emerge from uterine smooth muscle
69
Consequences of fibroids
1. Fetal growth restriction 2. Miscarriage 3. Preterm birth
70
In what trimester is cervical insufficiency seen in
Second trimester
71
What is cervical insufficiency
When cervical dilation and effacement (thinning) too early in pregnancy 1. Vaginal fullness 2. Pelvic pressure 3. Lower back pain
72
Clinical signs of cervical insufficiency
1. Dilation 2. Effacement 3. Fetal membrane visible
73
Diagnosis of CI in obstetric history
1. Two + consecutive pregnancy loses in second trimester or preterm brith (less than 28 weeks)
74
When is TV USS in CI appropriate
1. When cervix is less than 25 mm
75
Treatment of cervical insufficiency
1. Cervical Cerclage
76
What is cervical cerclage
Strong sutures sewn into or around the cervix
77
When is cervical cerclage done
1. History based: 12-14 weeks | 2. Exam-based : <24 weeks
78
Painless causes of bleeding in third trimester
1. Placenta Praaevia (placenta is covering cervical opening) | 2. Vasa Parvaeia (Blood supply of fetus covers cervical opening)
79
Painful causes of bleeding in third trimester
1. Placental abruption (Placenta prematurely detaches from uterine wall) 2. Uterine Rupture
80
Important changes to examination approach in third trimester
1. Avoid digital examination. Can cause immediate haemorrhage in placenta praevia.
81
Diagnosis of placenta and vasa praaevia
1. TVUSS to grade
82
Grading of placenta praaevia
1. Grade 1: Low lying placenta (in lower segment but lower edge is still 0.5-5cm away from cervical opening) Grade 2: Marginal Placenta Grade 3: Partial Praaevia Grade 4: Complete Praaevia
83
Management of placenta praaevia
Based on three factors: - Haemodynamic stability - Fetal Heart Rate - gestational Age 1. However, C-Section ALWAYS occurs If all three are fine: - Expectant management - Antenatal corticosteroids - C section Emergency C section if any of these are compromised
84
How is vasa pavia categorised
Type 1: Velamentous umbilical cord (cord inserts into chorioamniotic membranes rather than centre of placenta) Type 2: Bilobed placenta (two equal sized lobes split by chorionic tissue) If uneven: Succenturiate lobe
85
How is vasa praaevia diagnosed
1. Colour doppler to look at fetal vessels crossing cervical opening
86
Management of vasa praaevia
Between 28-32 weeks: Weekly NST and antenatal corticosteroids Between 30-34 weeks: Hospital admission for NST 2-3 times a day Emergency c-section if labour starts, PROM, haemodynamic instability, NST abnormalities, blood coming out of vagina is pure fetal blood
87
How is pure fetal blood tested
1. Apt Test or Kleihauer-Betke test
88
RF for placental abruption
1. Prior 2. trauma 3. Smoking 4. HTN 5. Cocaine 6. PROM
89
Why can blood loss be underestimated in placental abruption
1. Pools behind the placenta In this case bleeding may be light or non-existent depending on clinical symptoms.
90
Categories of placental abruption and associated symptoms
1. Light: 2. Mild - Light bleeding - tenderness - No haemodynamic change - No distress 3. Moderate - Greater tenderness - Contractions - Signs of haemodynamic instability and fetal distress 4. Severe: - Severe bleeding - tetanic uterus (board like on palpitation) - Maternal shock or fetal death PAIN IS SUDDEN, AND CONSTANT Fetal heart is absent Severe needs immediate delivery
91
Consequences of severe placental abruption
1. Progress to DIC
92
What is DIC
1. Excessive clotting factor use up
93
Blood test findings in DIC
1. Decreased fibrinogen 2. Increased INR 3. Prolongues PT and PTT 4. Reduced platelets
94
Rf for uterine rupture
1. Previosu c section as caused by abdominal trauma.
95
Consequences of uterine rupture
1. Blood spills into peritoneum
96
Symptoms of Uterine rupture
1. Sudden abdo pain 2. Haemodynamic instability 3. Fetal HR abnormalities
97
Treatment of uterine rupture
1. Suture/ sometimes Hysterectomy
98
What causes bleeding disorders in: primary/secondary haemostasis
1. Formation of platelet plug | 2. Strong fibrin clot through activation of intrinsic and extrinsic pathway
99
How is haemophilia A and B passed on
1. X-linked affects males and females carriers
100
Two types of haemophilia
A: reduction in factor 8 B: reduction in factor 9 C: autosomal recessive (male and females) factor 11
101
What is von willebrand disease
1. Mutations of vWF making hard for platelets to adhere to collagen Causes impaired platelet function
102
What is cervical incompetence
1. Inability of the cervix to retain pregnancy during second trumester Usually as a result of premature cervical os opening = fetal expulsion
103
Complications of cervical incompetence
1. Chorioamnionitis 2. PROM 3. Cervical lacerations
104
When does GDM occur in pregnancy
BEGINS second trimester, peaks in third | insulin resistance is normal in the second trimester
105
Screening for GDM
DO NOT use OGTT in women already at risk (only offer testing for those with previous GDM): 1. 75g 2-hour OGTT Urine Ketone bodies
106
When is oral glucose tolerance test contraindicated
Diagnosis of GDM but glucose levels return to normal after birth
107
Management plans for pregnant women with T1DM
1. Ketone blood testing strips | 2. HbA1c levels monthly
108
Prevention of GDM
1. Vitamin D supplementation | 2. Diet and physical activity
109
Advice to give to diabetic women planning a pregnancy
1. Lose weight (if above 27kg/m^2) | 2. Take 5mg folic acid a day until 12th wekk of gestation
110
RF for GDM
1. BMI over 30 2. Previous macrosomic baby 3. Previous GDM 4. Family History 5. Ethnciity
111
OGTT results that indicate GDM
1. Fasting plasma glucose level over 5.6 mmol/litre | 2. 2-hour plasma glucose level over 7.8 mmol/litre
112
Consequences of GDM
1. Macrosomia 2. Neonatal hypoglycaemia 3. Increased c section risk 4. Resp distress 5. Polycythaemia 6. Obesity
113
Signs of GDM in infant
1. Low APGAR score 2. Large for gestational age (>4kg) 3. Plethora 4. Hypoglycaemia
114
Neonatal diagnostics for GDM
1. Fetal ultrasound for fetal seize and weight estimation | 2. Pulse oximetry to see decreased saturation
115
Postnatal management of GDM
1. Serial capillary glucose test and continue glucose management til normal 2. Neonatal: supplemental oxygen, oral/IV glucose
116
Advice to give a woman with GDM
1. Healthy diet and low gylcaemic index food 2. Excercise regularly (walk for 30 mins after a meal) 3. Offer retinal testing
117
When does Gestational HTN occur
20 weeks of gestation
118
When does gestational HTN resolve
Postpartum week 12
119
RF for gestational HTN
1. Primigravidas | 2. Genetic factors
120
Complications of gestational HTN
1. Preeclampsia
121
1. Diagnosis of Gestational HTN
1. Urine dipstick (normal protein) 2. Normal platelet 3. Creatinine, hepatic transaminases
122
When does hyperemesis Gravidum occur
1. Week 4-8 of gestation
123
How long does hyperemesis Gravidarum last
16 weeks
124
Symptoms of hyperemesis Gravidarum
1. Prolongues nausea/vomiting 2. Dehydration 3. Weight Loss 4. Low PB
125
RF for Hyperemesis Gravidarum
1. Previous 2. Raised hCG 3. Biologically-female fetus 4. Hyperthyroidism
126
Complications of hyperemesis Gravidarum
1. Electrolyte imbalance 3. Mallory-weiss tear 3. Metabolic alkalosis
127
Treatment of HG
1. Antiemetics 2. Vit B6 tor educe nausea 3. Bland food (avoid spicy food)
128
What is Inauterine Growth Restriction
1. Full fetal growth not accomplished during gestation
129
Types of IGR
1. Symmetric | 2. Asymmetric
130
What causes symmetric IGR
1. Early in gestation Caused by infection or chromosomal abnormality
131
What is symmetric IGR
1. All organs and body parts have restricted sizes
132
What is asymmetric IGR
1. Head circumferences usually affected on its own
133
When does asymmetric IGR manifest
Late second/third trimester
134
What causes asymmteirc IGR
1. Reduced delivery of nutrients to fetus
135
Causes of IGR
Fetal: Genetic (aneuploidy) Infection (CMV, rubella) Multiple gestation Placental: Preeclampsia Single umbilical artery Maternal: Chronic disease Substance use Environmental: SMOKING
136
Complications of IGR
1. Inauterine asphyxia 2. Impaired thermoregulation 3. Hypoglycaemia 4. Polycythaemia 5. Hypocalcaemia
137
Signs and symptoms of IGR
1. Thin, loose skin | 2. Growth restriction (head could be normal but large relative to rest of body in asymmetrical
138
Diagnosis of IGR
1. Ultrasound Biometry to measure head, abdo and AFI 2. Doppler velocimetry to measure vascular resistance and cardiac function 3. Ponderal index (body weight: length ratio) and Ballard score (gestational age assessment)
139
Treatment of IGR
1. Glucose
140
What is mastitis
1. Localised infection from one/more mammary ducts
141
Causes of mastitis
1. Microorganisam introduction from breatfeeding baby's mouth 2. Milk stasis
142
RF of mastitis
1. Cracked/damaged nipples 2. Poor Hygeiene 3. Impaired Immunity 4. Diabetes
143
Signs and Symptoms of Mastitis
1. Localised firmness 2. Palpable lump 3. Breast pain 4. Tender axillary nodes
144
Diagnostics of Mastitis
1. USS to exclude abscess | 2. Breast milk culture
145
Treatment of mastitis
1. Analgesics NOT antibiotics | 2. Continue breast feeding
146
What is cervical incompetence
1. Inability of the cervix to retain pregnancy during second trumester Usually as a result of premature cervical os opening = fetal expulsion
147
Complications of cervical incompetence
1. Chorioamnionitis 2. PROM 3. Cervical lacerations
148
When does GDM occur in pregnancy
BEGINS second trimester, peaks in third | insulin resistance is normal in the second trimester
149
Screening for GDM
DO NOT use OGTT in women already at risk (only offer testing for those with previous GDM): 1. 75g 2-hour OGTT Urine Ketone bodies
150
When is oral glucose tolerance test contraindicated
Diagnosis of GDM but glucose levels return to normal after birth
151
Management plans for pregnant women with T1DM
1. Ketone blood testing strips | 2. HbA1c levels monthly
152
Prevention of GDM
1. Vitamin D supplementation | 2. Diet and physical activity
153
Advice to give to diabetic women planning a pregnancy
1. Lose weight (if above 27kg/m^2) | 2. Take 5mg folic acid a day until 12th wekk of gestation
154
RF for GDM
1. BMI over 30 2. Previous macrosomic baby 3. Previous GDM 4. Family History 5. Ethnciity
155
OGTT results that indicate GDM
1. Fasting plasma glucose level over 5.6 mmol/litre | 2. 2-hour plasma glucose level over 7.8 mmol/litre
156
Consequences of GDM
1. Macrosomia 2. Neonatal hypoglycaemia 3. Increased c section risk 4. Resp distress 5. Polycythaemia 6. Obesity
157
Signs of GDM in infant
1. Low APGAR score 2. Large for gestational age (>4kg) 3. Plethora 4. Hypoglycaemia
158
Neonatal diagnostics for GDM
1. Fetal ultrasound for fetal seize and weight estimation | 2. Pulse oximetry to see decreased saturation
159
Postnatal management of GDM
1. Serial capillary glucose test and continue glucose management til normal 2. Neonatal: supplemental oxygen, oral/IV glucose
160
Advice to give a woman with GDM
1. Healthy diet and low gylcaemic index food 2. Excercise regularly (walk for 30 mins after a meal) 3. Offer retinal testing
161
When does Gestational HTN occur
20 weeks of gestation
162
When does gestational HTN resolve
Postpartum week 12
163
RF for gestational HTN
1. Primigravidas | 2. Genetic factors
164
Complications of gestational HTN
1. Preeclampsia
165
1. Diagnosis of Gestational HTN
1. Urine dipstick (normal protein) 2. Normal platelet 3. Creatinine, hepatic transaminases
166
When does hyperemesis Gravidum occur
1. Week 4-8 of gestation
167
How long does hyperemesis Gravidarum last
16 weeks
168
Symptoms of hyperemesis Gravidarum
1. Prolongues nausea/vomiting 2. Dehydration 3. Weight Loss 4. Low PB
169
RF for Hyperemesis Gravidarum
1. Previous 2. Raised hCG 3. Biologically-female fetus 4. Hyperthyroidism
170
Complications of hyperemesis Gravidarum
1. Electrolyte imbalance 3. Mallory-weiss tear 3. Metabolic alkalosis
171
Treatment of HG
1. Antiemetics 2. Vit B6 tor educe nausea 3. Bland food (avoid spicy food)
172
What is Inauterine Growth Restriction
1. Full fetal growth not accomplished during gestation
173
Types of IGR
1. Symmetric | 2. Asymmetric
174
What causes symmetric IGR
1. Early in gestation Caused by infection or chromosomal abnormality
175
What is symmetric IGR
1. All organs and body parts have restricted sizes
176
What is asymmetric IGR
1. Head circumferences usually affected on its own
177
When does asymmetric IGR manifest
Late second/third trimester
178
What causes asymmteirc IGR
1. Reduced delivery of nutrients to fetus
179
Causes of IGR
Fetal: Genetic (aneuploidy) Infection (CMV, rubella) Multiple gestation Placental: Preeclampsia Single umbilical artery Maternal: Chronic disease Substance use Environmental: SMOKING
180
Complications of IGR
1. Inauterine asphyxia 2. Impaired thermoregulation 3. Hypoglycaemia 4. Polycythaemia 5. Hypocalcaemia
181
Signs and symptoms of IGR
1. Thin, loose skin | 2. Growth restriction (head could be normal but large relative to rest of body in asymmetrical
182
Diagnosis of IGR
1. Ultrasound Biometry to measure head, abdo and AFI 2. Doppler velocimetry to measure vascular resistance and cardiac function 3. Ponderal index (body weight: length ratio) and Ballard score (gestational age assessment)
183
Treatment of IGR
1. Glucose
184
What is mastitis
1. Localised infection from one/more mammary ducts
185
Causes of mastitis
1. Microorganisam introduction from breatfeeding baby's mouth 2. Milk stasis
186
RF of mastitis
1. Cracked/damaged nipples 2. Poor Hygeiene 3. Impaired Immunity 4. Diabetes
187
Signs and Symptoms of Mastitis
1. Localised firmness 2. Palpable lump 3. Breast pain 4. Tender axillary nodes
188
Diagnostics of Mastitis
1. USS to exclude abscess | 2. Breast milk culture
189
Treatment of mastitis
1. Analgesics NOT antibiotics | 2. Continue breast feeding
190
When does preeclampsia typically develop
After 20 weeks gestation and 6 weeks after delivery
191
What is preeclampsia
New onset hypertension and proteinuria
192
Why is preeclampsia important to detect
1. Marker of Kidney Damage
193
What is Eclampsia
Combination of preeclampsia and seizures.
194
RF for preeclampsia
1. First pregnancy 2. Multiple gestations 3. Mothers > 35 years 4. HTN 5. Diabetes 6. Obesity 7. Family History
195
What causes preeclampsia
Development of an abnormal placenta. Spiral arteries expand to 10 times normal size, to deliver large quantities of blood to feats, these become fibrous in preeclampsia
196
Consequences of preeclampsia to baby
1. Intrauterine growth restriction and death
197
Consequences of preeclampsia to mother
1. Intrauterine growth restriction causes the release of pro-inflammatory proteins into mother's circulation 2. These proteins cause endothelial cells to become dysfunctional: 1. Vasoconstriction 2. Salt retention by kidneys HTN! Can cause haemorrhage stroke or placental abruption Also causes local vasospasming, restricting blood flow to other organs (e.g. kidneys, leading to glomurlar damage = oliguria). Retina (scotoma) Liver (LFT abnormal) = RUQ pain
198
Diagnosis of preeclampsia
140/90 or more severe: 160/110 (just be aware)
199
What is placental abruption
Premature detachment of placenta from uterine wall.
200
Symptoms of preeclampsia
1. Stroke symptoms 2. Oliguria 3. HTN 4. Blurred vision/flashing lights/scotoma 5. RUQ pain (liver) 6. HELLP syndrome 7. Increases vascular permeability from endothelial damage = Generalised oedema, pulmonary oedema, cerebral oedema (headaches, confusion and SEIZURES) Haemoolysis Elevated Liver enzymes Low Platelets HELLP is common
201
What does HELLP syndrome stand for
Haemoolysis Elevated Liver enzymes Low Platelets
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What causes seizures in eclampsia
1. Endothelial damage, increases vascular permeability, causing fluid to enter local sites, including the brain 2. Causes cerebral oedema Headaches, nausea and seizures
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Treatment of preeclampsia
1. After delivery, treat symptoms: Supplemental oxygen for organ damage Medications for seizures etc
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What is placenta accrete
When all or part of the placenta attaches to the myometrium
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What are the grades to the placenta accrete spectrum
Graded depending on what layer of the myometrium, the placenta has invaded: 1. Accreta: Chorionic villi attach to the myomteirum 2. Increta: Villi invade into the myometrium 3. Perceta: Invade through to the perimetric (serosal layer)
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RF for placenta accreta spectrum
1. Placenta previa in the presence of a uterine scar. | 2. Anything causing scar tissue formation: termination, postpartum haemorrhage, miscarriage etc, c section.
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Most common placenta accrete spectrum type
Accrete
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Diagnosis of placenta accreta spectrum
USS doppler 1. Vascular lacunae (Swiss cheese appearance) 2. Blood vessels crossing the myometrium or serosla layer.
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Complications of PAS
1. Damage to local organs 2. Thromboembolism and infection. 3. Increased preterm bleeding
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Treatment of PAS
1. Hysterectomy to control bleeding | 2. Cesearaen hysterectomy (foetus delivery by uterus and placental removal)
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What is gestational trophoblastic disease
Bengin: The development of hydatidiform moles Malignant: Invasive moles from hydatidiform or choriocarcinomas Moles result from errors in normal fertilisation, lead to abnormal proliferation of trophoblast cells
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How do moles in GTD form
Two ways: Complete/Classic: Chromosomally empty egg fuses with normal sperm. The normal sperm duplicates to form 46 chromosomes, to make up for lacking egg. No maternal chromosomes so cells continue to divide into a mass. Incomplete/Partial: When a normal egg is fertilised by two sperms. Forms an organism with 69 chromosomes (23+ 23+ 23). Becomes non-viable fatal parts
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What does a complete mole secrete/ symptoms?
1. Extremely high hCG So, 1. Signs of missed pregnancy (missed periods) 2. Vaginal bleeding/ parts of the mole may be eliminated (cherry like clusters) 3. Early preeclampsia 4. Hyperemesis Gravidarum (dehydration) 5. Hyperthyroidism 6. Theca lutein cysts/ pelvic pain or pressure 7. Since mole grows faster than normal pregnancy so ultrasound/examination shows uterus too big for gestational age.
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Signs on examination for complete mole
1. Hydropic villi (oedematous) 2. Circumferential proliferation of syncytiotrophoblasts (multiple nuclei, dark cytoplasm) and cut-trophoblast (pale cytoplasm, central nuclei)
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Screening for complete mole
1. Stain for p57 protein. only expressed on maternal cells so should be negative.
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Diagnosis for complete mole
1. p57 staining | 2. TVUSS, NO FETAL PARTS, just SNOWSTORM PATTERN (cluster of grapes from abnormal blood clots and placental villi).
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What does a complete mole secrete/ symptoms?
hCG but not as much as complete. 1. Missed periods/vaginal bleeding 2. Uterus is NOT larger than expected for gestational age 2. No symptoms of hCG hyper stimulation
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Complete vs incomplete on examination
1. Thyroid symptoms vs none 2. Lots of hydronic villi vs little 3. p57 is neg vs pos 4. TVUSS no fetal parts vs fetal parts
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treatment for moles
1. Suction Curetage 2. Methotrexate Monitor hCG levels til back to normal
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Why is methotrexate used for moles
1. Toxic to rapidly dividing cells of embryo
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What does hCG not returning back to normal levels indicate
1. Invasive mole | 2. Choriocarcinoma
222
What causes invasive moles
1. Villi invade into myomteirum.
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When in pregnancy can choriocarcinomas develop
1. During or after a non-molar pregnancy Usually small but if large can cause lower abdominal pain
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Where can choriocarcinomas metastasise
1. To lungs ``` DISTINCTIVE: CANNONBALL METASTASES (well circumsised metastasises) ``` Haemptysis SOB And can go to brain
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Choriocarcinoma vs molar pregnancy caused malignant moles
1. Cytotophoblasts and synctioblasts BUT NO VILLI vs VILLI.
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What is morbidly adherent placenta
1. Abnormal attachment of placenta to uterine wall
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What part of the uterine wall does the placenta bind to
1. Decidua basalis.
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What usually causes binding of placenta to myometrium
If decidua is too thin.
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What are the four causes of post parts haemorrhage
4Ts: Uterine Antony (loss of TONE) Trauma (lacerations, incisions, uterine rupture) Thrombin (coagulopathies) Tissues (PAS)
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Consequences of postpartum haemorrhage
Hypovolaemic shock and Sheehan's syndrome
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Treatment of PAS
1. Uterine massage 2. Oxytocin for tone 3. Bilateral ligation of internal iliac artery 4. Hysterectomy
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What is Sheehan's syndrome
1. postpartum hypopituitarism caused by pituitary gland necrosis. Caused by severe Hypotension from postpartum haemorrhage
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What causes polyhydramnios
1. Fetus cannot swallow amniotic fluid, causing I to build. Attributed to oesophageal or duodenal atresia Anencephaly (parts of brain responsible are absent) Increased urine production
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What causes oligohydramnios
1. Bilateral renal agenesis: failure of kidneys develop 2. Posterior urethral valves blocking excretion (thus usually affecting boys) 3. Placental insufficiency 4. Amniotic rupture
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Consequence of oligohydramnios
POTTER SEQUENCE: Pressing of the baby against the membrane of the amniotic sac = developmental abnormalities.
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Signs of potter sequence
1. FLATTENED face 2. Widely separated eyes 3. Low-set ears 4. Clubbed feet. Pulmonary hypoplasia ``` P- Pulmonary hypoplasia O- Oligohydramnios T - twisted skin T - twisted face E - extreme deformities R - renal agenesis. ```
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Role of amniotic fluid
1. Development of metal lungs (stretched the airways) | 2. Contributes to the production of proline (helps form connective tissue and collagen in the lungs)
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Diagnosis of potter sequence
USS
239
What is cervical show
Bloody discharge from the uterus. mixed in with mucuous. that blocks cervical Canal during normal labour
240
What causes cervical show
Caused by slow cervical dilation that characterises early labour.
241
When is a foetus full term
Between 37 and 42 weeks gestation
242
Two ways a woman might show signs of going into labour
1. Cervical Show 2. Amniotic sac rupture Cause true labour contractions
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What are Braxton hicks contractions
Sporadic contractions and relaxations of the uterus Can be caused by sex, full bladder or exercise.
244
Braxton hicks contractions vs full labour contractions
1. Irregular in duration and intensity 2. Non-rhythmic 3. Uncomfortable vs painful
245
How do true labour contractions change over the course of labour
1. Increase in frequency, duration and intensity. Then decrease
246
What are the point of contractions
1. To thin the cervix and dilate it
247
How long does a first time preganncy take vs multiple gestations
1. 12-18 hours | 2. 6-9 hours.
248
What phases make up the first stage of pregnancy
1. LATENT/ Early: dilation of cervix to 6 cm | 2. ACTIVE Phase
249
How long does the latent phase last
20 hours
250
What characterises the latent phase of pregnancy
1. Irregular contractions 2. Every 5-30 mins 3. Last 30 seconds. THEN these become regular Every 3-5 mins Last 1 min
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What is the active phase of labour
1. Cervix dilates to 6-10 cm 2. Intense contractions (60-90 seconds each). 3. Every 0.5-2 mins These contractions can overlap Water defo breaks by this point
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What is the second stage of labour
The pushing stage: Baby's head must navigate through the maternal pelvis. PPP: Power Passenger Passage: Bony pelvis. In fact baby's have unfused skulls to allow them to pass through the pelvis. Cardinal Movements of Labour - Foetal Enaggement - Foetal Flexion - Foetal internal rotation - Foetal Extension - Restitution - Expulsion
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What factors dictate how easy the passage of the baby is in the second stage of labour
1. Featl size (head) 2. Fetal attitude (how flexed the foetus is) 3. Fetal Lie (ideally should be longitudinal) 4. Fetal presentation (ideally vertex cephalic)
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What is a normally fully flexed foetus
1. Chin on chest 2. Rounded back 3. Flexed arms and legs
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What is the suboccipitobregmatic diameter
Smallest diameter of the foetus - presents at the pelvis inlet
256
Types of foetal presentation
1. Cephalic (ideally cephalic vertex - flexion of the head) 2. Breech (Bottom first) 3, shoulder
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What is the foetal station
1. The degree to the descent of the foetus in the second stage Measured by how relative the descent is to the ischial spine
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What is foetal engagement
Where the head moves from the pelvic inlet (station -5) to the ischial spine
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What is foetal flexion
Chin goes against chest as it receives resistance.
260
What is foetal internal rotation
Shoulders internally rotate at 45 degrees until the widest part of the shoulders is lined with the widest part of the pelvic inlet .
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When does foetal extension occur
1. When the baby reaches the symphysis pubis (-4), extension of the head and emerge out the vagina
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What is foetal restitution
Where head externally rotates so the shoulders can pass through the pelvic outlet and under the symphysis pubis
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What is expulsion
1. Anterior shoulder slips under symphysis pubis, followed by posterior shoulder and rest of the body.
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What is the third stage of labour
Delivery of the placenta: | Uterus contracts firmly and carefully removed.
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What is the fourth stage of labour
1. Major physiological chagnges: Adaption to blood loss and uterine involution
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What causes VTE in pregnancy
1. Hypercoagulability and decreased venous blood flow
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What factors conctibute to VTE
1. 7, 8, 10 and vWF Less protein S
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What are the two stages of haemostats
1. Primary: Formation of a platelet plug 2. Secondary: Coagulation - Clotting Factors - Proteolytically activated - Activation of Fibrin (Factor 1a)
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What activates the extrinsic pathway
1. Tissue Factor found outside the blood Instrinsic: Factors found in the blood
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What is the extrinsic pathway
1. Factor VIIa in blood binds to tissue factor and calcium ions = VIIaTF complex on smooth muscle walls 2. Cleaved factor X -> Xa 3. Xa: V -> Va 4. Xa + Va (prothrombinase complex) = II -> IIa (Thrombin) 5. IIa = V -> Va VIII -> VIIIa IX -> IXa
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What is the role of thrombin
1. Thrombin binds to platelets to activate them = adhesion 2. Thrombin cleaves fibrinogen to fibrin 3. Cleaves XIII -> XIIIa
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Why does fibrinogen need to be cleaved into fibrin
Can move out of plasma to form chains
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Role of XIIIa
Reinforces fibrin mesh (tentacles)
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Intrinsic Pathway
XII: Detects endothelial collagen exposed by trauma or activated platelets XII -> XIIa XIIa = XI -> XIa XIa = IX -> IXa IXa + VIIIa = X -> Xa
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Why is VWF needed
Keeps VIII soluble.
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What produces VWF
Released by endothelial cells in primary haemostats
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Role of Prothrombin Time
Checks if extrinsic pathway is working
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aPTT role
Checks if intrinsic pathway (TT = table tennis indoors)
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Role of Protein S and C
1. excess thrombin bind to thrombomodulin, Protein C and S join the complex Activates protein C to destroy factor V, needed for thrombin production
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What is Factor V Leiden
1. Forms in the femoral veins Cannot be cleaved by Factor C because their shape mutates: causes multiple clots
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Blood types
A (antibodies to B) B (antibodies to A) AB (universally none): Can receive any bloody O (A and B antibodies): Receive only O blood
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What's the problem giving RH+ to Rh= individuals
Haemolytic Transfusion Reaction Rh+: can receive either Rh-: No Rh+ unless emergency, can only use once and then they'll develop antibodies
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What's the usual cause for anaemia in pregnancy
Iron
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What is a complicated UTI
1. Structural or functional condition of GU tract | Underlying disease = severe infection
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RF for complicated UTI
1. Male 2. Pregnancy Female 3. Indwelling Urinary Catheter
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What pathogens cause uncomplicated cystitis
KEEPS Klebsiella pnuemoniae Escherichia Coli Proteus Mirabilis Staphylococcus saprophyticus
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RF for cystitis
1. Sex/Spermicides
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Interventions for UTI
1. Dipstick: +Leucocyte esterase (Pyuria) and nitrites (enterobacteriases) 2. Microscopy (>10 leucocytes/microletre) Rcs/microleter 3. Midstream sample (bacteriuria)
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How is cystitis treated
1. 100mg Nitrofurantoin daily for 5 days
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Symptoms of pyelonephritis
1. Fever, costovertebral angle tenderness, nausea, vomtiing, cystitis
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Interventions for pyelonephritis
1. CBC: Leucocytosis e/ Neutrophilia 2. BUN + Creatinine Levels : renal functinos 3. Dipstick and microscopy 4. Urine culture
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Treatment of pyelonephritis
1. IV or oral Ceftriaxone until afebrile | 2. Then switched to oral cefepime for 10 days.
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How is urinary obstruction treated
IV Imipenem
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What bacteria commonly infects pregnant women and newborns
1. Gram-Positive Strep Agalactiae:
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Properties of gram positive strep agalactiae
1. Non motile 2. Doesn't form spores 3. Facultative Anaerobe 4. Catalase negative
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How does strep agalactiae infect women
1. Ascencds from vagina through cervix into the foetal membranes = chorioamnioninitis, miscarriage as they rupture prematurely . infect the baby = intrauterine death Cystitis Pass to newborn = pneumonia by destroying lung cells = neonatal sepsis PENECILLIN G/ AMPICILLIN
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RF for cephalopelvic disproportion
1. Large fetus: Gestational diabetes, poster pregnancy and multiparty
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Treatment of cephalopelvic disproportion
1. Induced labour | 2. During active labour, this results in a c-section
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When does preterm labour occur
1. Between 20 and 37 weeks Before 20 weeks = abortion
300
RF for preterm labour
1. Prior preterm, multiple or short cervical length Urinary infections Preeclampsia HELLP Syndrome Placenta Praevia
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Prophylaxis of preterm labour
Intravaginal Progesterone
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How is preterm labour managed
1. Screening of preterm labour: Cervical Changes: If cervix is longer than 30mm = low risk Check 4-6 hours -> discharged and reevaluated 2 weeks later If less than 20 mm = high risk Foetal Well-Being: Sample of cervicovaginal discharge sample for fibronectin: if present, risk is high. Obstetrical Complications
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If preterm labour seems imminent (cervical size <20 mm, fibronectin positive), what measures are taken
1. Antenatal corticosteroids to mature fetal lungs 2. Tocolytic medications (Nifedipine, NSAIDs) - to suppress contracts, gives time for steroids to give effect 3. Antibiotics (Ampicillin and Gentamicin) for group B strep 4. Magnesium Sulfate to reduce cerebral palsy
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What is post-term pregnancy
No birth after 42 weeks
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RF post term pregnancy
Prior post term
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Management of post term pregnancy
Fetal monitoring (high likelihood for macrosomia or inauterine foetal death)
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How does foetal monitoring in post term pregnancy occur
1. Foetal size 2. Amniotic fluid 3. NST 4. BPP
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What is an NST
1. Cardiotocograph (20 mins): Normal: Varies between 110-160 BPM + 2 accelerations (changes between 15bpm for 15 seconds above 32 weeks or 10bpm for 10 seconds below 32 weeks).
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What is a BPP
``` 5 Criteria: NST results (is it non reactive) Breathing movements Torso and limb movements Muscle tone Amount of amniotic fluid ``` Score of 10 (higher = better) Should be 6/10 or higher.
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When is induced labour indicated from the get-go
1. Post Term delivery 2. Oligohydramnios 3. Distress on NST or BPP Basically, when there's no labour and the foetus is well
311
Four methods of induced labour
1. Amniotomy (when foetal head is pressed against the cervix, foetal membrane is cut through the cervix ) or Membrane Sweep 2. Cervical Ripening agent 3. IV Oxytocin (60 mU/mL at 1mL/hr) IN this preference
312
Name two cervical ripening agents
Prostaglandin (PGE2 and PGF2a) | Balloon Catheter
313
How does a balloon catheter induce labour
1. Inflates in the womb and puts pressure on the cervix to encourage dilation
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How do prostaglandins work in induced labour
1. Acts on cervical collagen to encourage cervix softening
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What is the role of Oxytocin
Causes contractions
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Side effects of oxytocin use
1. Non-reactive NST
317
What is a membrane sweep
1. Lubrictaed fingers put into vagina into opening of the cervix, in a circular movement separate the membranes of the amniotic sac
318
RF for prolongs latent phase
1. Early Analgesia (epidural) | 2. Abnormal foetal position
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Management of prolongs latent phase
1. Rest (stops false labour) 2. Morphine (5-10mg IM + IV) May tire out the mother from the beginning Also distinguishes between false and true labours 3. Oxytocin 4. Amniotomy NO C-SECTION
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How long does the active phase of labour last
4-6 hours (dilates 1.2 cm/hr)
321
When is labour induced in the active phase of stage 1 labour
1. If cervix dilates less than 1cm/2hr , Oxytocin is given + amniotomy is membrane hasn't ruptured
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How are uterine contractions measures
Pressure catheter (MVU)
323
Formula of MVU
(Peak Pressure per Contraction - Resting Tone of the Uterus) x number of contractions in 10 mins 200 is adequate for labour progression
324
When is a C-Section indicated
1. If after 4 hours of adequate contractions, or 6 hours of no adequate contractions = C-Section
325
Methods of C-Section
1. Transverse: Done 2-3 cm above the symphysis pubis Better for planned c-sections (cosmetic) + less hernia risk 2. Vertical: Done on midline and extends to belly button Emergency only
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How long does stage 2 labour last
Less than 3hours
327
When is labour induced if stage 2 prolongs
1. Contractions less than 3 minutes apart 2. Lower than 200 MVU OXYTOCIN If foetal head not engaged = c-section If foetal head engaged = operative vaginal delivery
328
Two methods of operative vaginal delivery
1. Vacuum | 2. Forceps
329
When is a vacuum delivery indicated
1. When an easy extraction is indicted A plastic cup is put on baby head and sucked out CAN CAUSE MINOR SWELLING
330
What is a forceps delivery
1. When there is a sign of foetal distress and more urgent delivery needed 2. Locked into position on baby's head. CAN CAUSE BRUISING
331
When do we go from operative vaginal delivery to emergency c-section
After 15-20 mins or 3 PULLS
332
How long does stage 3 pregnancy take
1. Less than 30 Mins More is retained placenta
333
Management of retained placenta
1. Increase Oxytocin 2. Controlled cord traction 2. Manual extraction 4. Hysterectomy
334
What is a controlled cord traction
1. One hand is placed on the abdomen to secure uterine funds, the other GENTLY tugs at the umbilical cord.
335
What is uterine inversion
1. When the uterus comes out of the vagina if you pull too hard in cord traction.
336
What is Manual Extraction
1. One hand secures the funds of the uterus 2. The other hand goes all the way into the uterus with side to side motion of the uterus to break placenta STOP is abnormally adherent (placenta accreta, can cause postpartum haemorrhage and requires hysterectomy)
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What is Bishop Scoring
1. Assesses ripeness of the cervix: - Dilation: Closed, 1-2, 3-4, 5+ - Efficacement 0-30%, 40-50, 60-70, 80%+ - Station (where the baby's head is I relation to pelvis) - 3, -2, -1/0, +1,+2 - Consistency Firm, Medium, Soft - Position Posterior, Middle, Anterior. Score, 1-3
338
Bishop score that indicates labour ready
8 or more, labour will more likely commence Less than 6 is an unripe cervix, induction is not likely to be successful.
339
What is Apgar scoring
A- Appearance (skin colour) 0 - Blue/Pale all over 1 - Blue at extremities 2- No cyanosis P - Pulse 0- Absent 1 - <100 BPM 2- >100 BPM G - Grimace (Reflex irritability grimace) 0 - No response 2- Grimace on suction or agressive stimulation 3 - Cry on stimulation A - Activity (muscle tone) 0 - None 1 - Some flexion 2- Flexed arms and legs resisting extension R - Respiration (resp effort 0- Absent 1- Weak, irregular gasping 2- Strong, robust cry
340
When is the Apgar Score done
1. At one and five minutes after birth
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What is an abnormal score for APGAR
Below 7
342
Complications of a low Apgar Score
Remains low three times in a row, indicates long term near damage like seizures or ischaemic encephalopathy
343
What's a partogram
1. Measurements of cervical dilation, fetal heart rate, labour duration and vital signs during a time-stamped labour
344
4 components of a partogram
``` 1. Time Fetal heart rate State of membranes Dilation Head descent Uterine contractions BP Pulse rate Oxytocin Urine analysis Temp Drugs an dfluids ```
345
How is a cardiotocography conducted
1. Two transducers placed on mother's abdomen: One above the fetal heart to monitor heart rate, the other at the funds of the uterus to measure contraction frequency. Dopper US provides information . 2. Internal: Transucers placed on baby's scalp, can only be used if cervix is open.
346
Type sof cardiotocography
External, Internal
347
4 Elements of a cardiotocograph
DR C BRA VADO 1, Contractions 2. Define Risk 3. Baseline fetal heart rate 4. Accelerations 5. Periodic or episodic decelerations
348
How is foetal blood sampling done
1. A shallow cut is made transvaginally, a blood lancet is inserted and a thin pipe is inserted into the capillary site of the scalp.
349
Name three types of oestrogen
1. Oestradiol 2. Oestrone 3. Oestriol
350
What form of oestrogen is produced by the ovaries
Oestridiol (most active)
351
Role of Oestradiol (2)
1. Monthly Ovulation and Menstruation | 2. Secondary Sex Characteristics
352
Name four organs which produce oestrogen
1. Fat cells 2. Adrenal Cortex 3. Ovaries 4. Placenta
353
Describe the role of GnRH
1. Produced by the anterior pituitary gland | 2. Produces LH and FSH
354
What is the role of LH and FSH
1. Development of the ovarian follicles
355
What is an ovarian follicle
1. A sack containing a primary oocyte, surrounded by follicular cells
356
What do the follicular cells differentiate into after stimulation
1. theca Cells | 2. Granulosa cells
357
What cell produces progesterone (follicles)
Theca cells
358
What foccilular cell produces oestrogen
Granulosa cells
359
How long does the menstrual cycle last
1. 28 Days
360
What happens on day 14 of the menstrual cycle
1. Surge of FSH and LH (OVULATION)
361
Two phases of the menstural cycle
1. Follicular phase (mostly oestrogen is produced) 1-14 | 2. Luteal Phase (mostly progesterone is produced) 14-28
362
What happens in the follicular phase
1. Oestrogen causes the endometrium to thicken and produce progesterone receptors. 2. Oestrogen acts on pituitary glands to stop FSH production 3. As oestrogen levels rise, pituitary becomes more sensitive, causing MORE LH AND FSH to be produced. Causes ovulation
363
What happens in the luteal phase
1. Progesterone binds to receptors in the endometrium, causes endometrial glands to secrete and prepare for pregnancy 2. Inhibits LH, causing menstruation as progesterone levels decrease.
364
Describe the cascade that causes th production of Oestrdiaol
1. Cholesterol -> Pregnenolone -> 17-Hydroxypregnenolone -> Dehydroepiandrosterone (DHEA) -> Androstenedione Broken down by granulose cells -> Testosterone -> 17b-estradiol
365
What enzyme is used to break testosterone down to 17b-oestradiol
Aromatase.
366
4 Roles of Oestrogen and Progesterone
1. Maturation of Fallopian tubes, uterus, cervix and vagina 2. Development of secondary sex characteristics Fat distribution, hips widening, breast growth 3. Keeps blood vessels flexible Bone density protection Lowers LDL cholesterol Progesterone: Bone strength and skin elasticity
367
What happens to progesterone and oestrogen during pregnancy
Placenta takes over their secretions. BUT THERE'S a TWIST: Estriol is produced instead of 17 beta-estradiol Both Prepare breast for lactation too
368
What happens between 1-10 days of cycle
Production of LH, binds to theca cells -> androstenedione which is converted into 17 beta estradiol by aromatase.
369
What cell produces aromatase
Granulose cells
370
What happens day 10-14
Increased oestrogen levels act as a negative feedback mechanism, reducing GnRH production. Causes some of the follicles to die off and stop growing. However the follicle with the most FSH receptors will continue to grow and become the most dominant follicle. continues to secrete oestrogen which increases pituitary sensitivity = more gNRH NOW POSITIVE FEEDBACK Happens a day or two before ovulation Excess LH and FSH causes rupture of the ovarian follicle and release of oocyte. OBVULATION
371
How long does the menstrual phase lasts
5 days
372
What phase follows the menstrual phase
Proliferative phase
373
Three stages of the proliferative phase
1. Endometrium thickening 2. Growth of the Endometrium Glands 3. Emergence of Spiral Arteries 4. Changes cervical mucous Optimise chance of fertilisation
374
When is fertility highest
Day 11-15 of the cycle
375
What happens following ovulation to the follicles
1. Remannt of follicle becomes the corpus luteum 2. Luteinised theca cells continue producing androstenedione, and Grnaulosa cells continue to convert it to 17 beta-estradiol
376
Cells found in the corps lute
LUTEINISED 1. Theca cells 2. Granulose cells
377
Role of luteinised Granulose cells in the luteal phase
1. Produce P450scc enzyme to convert cholesterol -> pregnenolone 2. Produce Inhibin to enhance negative feedback effect of progesterone on the pituitary
378
What is the secretory phase
1. Spiral arteries grow longer and uterine glands secrete mucous (however, after day 15 it can be too thick and reduce fertility window).
379
What happens to the corpus lute after day 15
Turns into the corpus albicans: does not produce any hormones, so progesterone and oestrogen levels decrease When progesterone reaches lowest levels, spiral arteries collapse and sloughs off.
380
Role of the spiral arteries
1. Supplies nutrients to the placenta and fundus
381
Phases of the uterus in the cycle
1-14: Menstural and Proliferative phase 15-28: Secretory Phase.
382
What are the three ligaments that suspend the ovaries
1. Ovarian 2. Suspensory 3. Broad
383
What is the role of the suspensory ligament
1. Ovarian artery vein and nerve endings are found there
384
Layers of the ovaries
1. Cortex (contains follicles) | 2. Medulla (nerves and blood vessels)
385
What are the primordial follicles
The number of follicles one is born with
386
What is contained within the follicle
1. Primary oocyte with 46 chromosomes.
387
Describe the stages of gamete development
1. Primary Oocyte gets through Prophase of Meiosis I Primordial cell s-> primary follicle (grnaulosa and theca) 2a. A few LUCKY primary follicles. The primary oocyte remains in prophase step, but has more grnaulosa and theca cells 2b. Formation of Grafian Follicle: A central cavity call ed the antrum forms, granulose cells secrete nourishing fluids for the primary oocyte (75-80 days)
388
Where does fertilisation typically take place
Ampula
389
What is the entrance to the fallopian tube called
Fimbriae
390
Three causes of hymens to break
1. Sex 2. Excercise 3. Tampons
391
Describe the process off pregnancy
1. Day 1 - Fertilisation Day 4 - Blastocyst Forms and floats around the uterus Day 5 - Implantation, oestrogen: progesterone ratio drops, to allow for implantation Day 6 - Blastocyst has two layers, foetal tissue and trophoblasts. Trophoblasts bury into endometrium to cause implantation and start developing the placenta Day 8 - Trophoblasts Produces HcG: - Allows corpus luteum to continue oestrogen and progesterone production to suppress other follicles from maturing - Pregnancy Day 10 - Mensturation if nothing happens
392
When does HCG production peak
Week 9, then falls off causing the corpus letup to shrivel up and placenta takes over progesterone and oestrogen production
393
What do the placenta's syncytiotrophoblasts produce
Produce progesterone and estriol
394
What is the role of human placental lactogen
Counters the effect of maternal insulin
395
Landmarks for gestation growth
1. Grows up to the umbilicus by week 20 | 2. Grows towards the xiphoid process by 36 weeks
396
How is fundal height measured
Symphysis pubis to top of the uterus
397
Physiological impacts of pregnancyy to CV
Blood volume increases by 30-50% (7.5 L of blood by third trimester) Increase in plasma volume but RBC is unchanged: causes haematocrit to go down Heart Rate increases by 20BPM Mild Hypertrophy of the heart Blood pressure decreases as progesterone dilates it Uterus pushes up on the diaphragm, nudging the heart upwards and to the left Presses on the pelvic veins causing varicose veins and swelling in lower legs and ankles. Uterus presses on inferior vena cava -> less blood to right atrium = hypotension Increased CO: higher GFR and urinary output = urinary frequency Increase in size in response, by expanding calyces and renal pelvis = hydronephrosis Increased size of ureters = hydrometer Progesterone causes hyper motility of the ureters = increased UTi infection Pressing on diaphragm causes SOB. Decreased peristalsis = constipation and bloating Relaxation of oesophageal sphincter = heartburn and gastric reflux and morning sickness Changes in taste Irritability, Anger, depression, anxiety Mental fogginess and reduced concentration Sleep Deprivation
398
Heart sounds heard in a pregnant woman
1. Split S1 sound (from mitral and tricuspid valves shutting) 2. S2 and a physiological S3 sound
399
Advice to hypotensive pregnant woman
Put pillow under hips or lay sideways
400
How does progesterone and oestrogen act on preventing SOB in pregnancy
1. Relaxes ligaments in the thorax, increasing transverse diameter of the ribcage and anterior posterior diameter of the ribcage This increases the tidal volume and minute volume Causes respiratory alkalosis but improves gas exchange with the placenta Oestrogen causes increased vascularisation and capillary engorgement in the thorax = sinus congestion and nasal stuffiness. Thyroid glands increase in activity Promotes blood clotting and platelet aggregation: decreases activity of antithrombin III, leading you in a hypercoaguable state. VTE
401
Role of progesterone and relaxin in the pelvis
Loosen the sacroiliac joints and symphysis pubis = waddling gait and joint pain in ribs and coccyx
402
Role of progesterone and oestrogen in breast
1. Breast development, causes tingling fullness and tenderness. 2. Production for prolactin 3. Stimulates production of melanocytes, darkening the areola
403
How does progesterone inhibit prolactin
Not in its production, but inhibits its release until the baby is born
404
Four causes for weight gain in women
1. Increase in blood volume 2. Fetus volume 3. Fat stores 4. Uterus and placental weight
405
Consequences of weight gain during pregnancy
1. Lordosis 2. Diastasis Recti (where the uterus puts direct pressure on the rectus abdominus, separating them and causing pain at night).
406
If the umbilical cord is palpitated at the vaginal Introitus, what does this indicate
Cord Prolapse (where age umbilical cord is comprised between the foetus and the cervix
407
What is the management in a patient with a cord prolapse
Push back the presenting part of the foetus to avoid compression If cord is passed the Introits, then Ask mother to go on all fours
408
RF for a cord prolapse
Artificial rupture of membranes
409
When is a nuchal scan performed
11-13 weeks
410
What can cause increased nuchal translucency
1. Down's Syndrome 2. Congenital Heart Defects 3. Abdominal wall defects Basically, when dilated lymphatic channels
411
What is nuchal translucency
Normal fluid-filled subcutaneous space at the back of the fetal neck
412
What three conditions can cause an echogenic fetal bowel (fetal bowel appears brighter than usual)
1. Cystic Fibrosis 2. Down's Syndrome 3. CMV
413
What defines proteinuria
>0.3g over 24 hours
414
What corticosteroid is used to mature the baby's lungs in pPROM
1. Dexamethasone
415
What should babies with Hep B positive mothers be given
1. Hep B vaccine + 0.5mg of HB-IG within 12 hours of birth and another vaccine at 1-2 months and another at 6
416
What anticoagulants are contraindicated for use in pregnancy and why
1. DOACs (rivaroxaban) - Because they cause placental haemorrhage 2. Warfarin - because it can lead to warfarin embryopathy
417
Signs of warfarin embryopathy
1. Mid face flattening | 2. Dwarfism
418
What anticoagulant should all women be switched to during pregnancy if absolutely needed
Low molecular weight heparin
419
RF for VTE
1. Age> 35 2. BMI > 30 3. Parity > 3 SMoker Gross Varciose veins Pre eclampsia FH Immobility IVF Multiple Pregnancy
420
How should pregnant women with hyperthyroidism be treated
Propranolol only, NO ANTIHYPERTHROID MEDICATIONS as it will resolve on its own, becoming hypothyroid which does need levothyroxine treatment
421
What are the three stages if postpartum thyroiditis
1. Thyrotoxicosis 2. Hypothyroidism 3. Normal thyroid Function
422
What antibodies are found in post-partum thyroiditis
Thyroid Peroxidase antibodies
423
4 Causes of hypothyroidism
1. Amiodarone (can also cause hyper) 2. Lithium 3. Iodine deficiency 4. Hashimoto's
424
Why is the uterus in placental abruption hard and birdlike
Because retroplacental blood tracks into the myometrium
425
A woman complains of itching during her pregnancy and a still birth 31 weeks into gestation, what is the diagnosis and effective treatment
1. Intrahepatic cholestasis 2. Ursodeoxycholic acid Labour induction Vit K
426
Consequences of intahepatic colhestasis
Stillbirths and premature births
427
Signs and symptoms of intrahepatic cholestaiss
1. Intense pruritus and raised arum bile acid | 2. Bilirubin and LFTs may be normal
428
How many antenatal care visits are needed in an uncomplicated pregnancy
1. 10 in first, 7 in subsequent
429
Name three checks done in 8-12 week visit
1. Hep B 2. Syphillis 3. HIV 4. BP and urine culture 5. Anaemia
430
In what visits are early scans conducted to confirm dates and exclude multiple pregnancies
10- 13+6 weeks
431
In what visits is Down syndrome screening and nuchal scan done
11 (13+6 weeks)
432
What is done in the 16th week of gestation visit-wise
1. BP and urine dipstick
433
When during gestation, is an anomaly scan conducted
18 (20+6 weeks)
434
On the 25th week visit, what is done
1. BP 2. Urine dipstick 3. Symphysis-fundal height
435
In what visit, is the first anti-D prophylaxis to rhesus negative women given
28 weeks
436
When is the second dose of anti-d prophylaxis to rhesus negative women given
34 weeks
437
When is external cephalic version given
36th week gestation
438
What is the most common cause of primary postpartum haemorrhage
Uterine Antony
439
What defines postpartum haemorrhage
Loss of >500 pls of blood
440
How is postpartum haemorrhage managed
1. IV syntocinon (oxytocin) | 2. IM Carboprost
441
First line surgical intervention for post parts bleeds
1. Inauterine balloon tamponade 2. Ligation of the internal iliac arteries 3. Hysterectomy
442
What causes secondary post aprtum haemorrhage
1. Retained placental tissue or endometritis (24-12 weeks after delivery)
443
When do baby blues dissipate by
Day 3 of giving birth
444
What scale should be used to assess post parts depression
Edinburgh Depression Scale (>10 = possible depression)
445
Postnatal blues vs depression vs puerperal psychoses
1. subsides within 10 days vs months vs first two weeks
446
Symptoms of puerperal psychoses
Manic depression or schizophrenia
447
If no foetal movement has been felt by 24 weeks, what should be done
Urgent referral to maternal foetal medicine unit
448
What should be done if baby movements reduced between 24 and 28 weeks an below
Doppler USS
449
What is the first onset of recognised foetal movement known as
Quickening, occurs between 18-20 weeks of gestation until 32 before plating
450
RF for reduced foetal movements
1. Posture 2. Distraction 3. Medication 4. Position
451
What virus causes chicken pox
Varicella-zoster virus
452
What is shingles
Reactivation of dormant virus in dorsal root ganglion
453
What if foetal varicella syndrome
1. Exposure to the virus causes pneumonitis in the mother, skin scorning, eye defects and limb hypoplasia, microcephaly and LD in babies
454
How is chicken pox exposure managed
1. Check of VZIG then either given them IG or acyclovir if no antibodies are present 2. If infected, given oral acyclovir within 24 hours of rash onset
455
At what glucose level should insulin be given in GDM
1. 7 mol/l or higher Lower than this, we should stick to lifestyle changes, if lower than 7 mol/l and no changes in glucose levels within 1-2 weeks, then metformin is given
456
Targets for GDM
1. Fasting: 5.3 2 hour: 6.4
457
What do late decelerations on a CTG imply
1. Foetal hypoxia and acidosis We should do a foetal blood sample asap to check pH
458
What is the preferred method of labour induction above all else
Vaginal prostaglandin E2
459
Main complication of labour induction
Uterine hyperstimulation
460
What ia a risk factor for shoulder dystocia
DM, due to foetal macrosomia,
461
What is the McRobert's Manouevre
1, Flexion and abduction of maternal hips, bringing thighs towards abdomen, relieves shoulder dystocia in DM
462
What causes shoulder dystocia
1. impaction of anterior foetal shoulder on maternal pubic symphysis
463
How should LMWH be monitored
Anti-Xa activity (look at how heparin/aspirin etc work)
464
What us puerperal pyrexia
Temperature over 38 degrees in first 14 days
465
What can cause puerperal pyrexia
1. Endometritis 2. UTI 3. Wound Infection 4. Mastitis 5. VTE
466
What is the wood's screw manoeurvre
1. Putting the hand in the vagina and rotating the foetus 180 degrees to dislodge anterior shoulder from symphysis pubis - tried after the mcroberts
467
A woman just had an artificial rupture of membranes for progressing labour, but collapses from low BP and raised HR. what is the likely diagnosis
Amniotic fluid embolism (when foetal cells enter mothers bloodstream and causes a reaction
468
What can be given to reduce the risk of eclampsia
MG SO4
469
What is sensitisation
Where RHD-positive foetal red blood cells enter RhD-negative maternal circulation This means subsequent pregnancies, sensitisation means greater immune response = death
470
Treatment of rhesus positive blood being introduced to foetus
UV phototherapy
471
What tests should be done to a baby to check for rhesus blood
1. COOMBS test: antibodies on RBCs Kleihauer test: maternal blood, foetal cells are resistant
472
How long is LMWH given to women during pregnancy
6 weeks postnatal
473
Why is warfarin not given during pregnancy
Teratogenic
474
In surgical management of an ectopic pregnancy, what immunoglobulin should be given
Anti-D
475
People at risk of eclampsia should be started on what prophylaxis
Aspirini daily from 12 weeks gestation onwards.
476
Screening for Down syndrome in pregnancy
1. Nuchal Translusceny at week 11 | 2. Beta-hCG and PAPP-A (pregnancy associated plasma protein a)
477
Results of Down syndrome screening in pregnancy
1. PAPP-A is low | 2. beta-hCG is raised
478
When is the combined test for gestation done
14-20 weeks gestation
479
If the combined test was missed, what test is offered for screening for down syndrome
AFP, estriol, beta-hCG and inhibit A AFP and oetsrioil low beta-HCG and inhibit raised
480
What seizure medication should be given to pregnant women who suffer from seizures
Lamotrigine
481
In asthmatic women with gestational HTN, what medication should be given
AVOID LABETOLOL, give oral nifedipine
482
What is an episiotomy
1. an incision between the vaginal opening and the anus done in the second stage of birth to facilitate birth
483
Foetal physiological changes in stage 2 birth
Foetal bradycardia
484
When is an episiotomy necessary
Following crowning
485
What is crowning
Seeing the top of the baby's head through the vaginal opening
486
What is lochia
Fresh bleeding from c-section or vaginal birth which then turns brown once stopping
487
How long does lochia last
6 weeks after childbirth
488
When does acute fatty liver of pregnancy occur
Third trimester
489
Fatures of acute fatty liver of pregnancy
1. Abdo pain 2. Nausea and Vomiting 3. Headache 4. Jaundice 5. Hypoglycaemia
490
Investigations for fatty liver
ALT levelled
491
The requirement criteria for instrumental delivery
1. FULLY DILATED CERVIX 2. RUPTURE MEMBRANE 3. OA position 4. Cephalic 5. Pain Relief 6. Sphincter
492
Indications for forceps delivery
1. Foetal distress 2. Maternal distress 3. Failure to progress 4. Control of head in breech delivery
493
What is gestational thrombocytopenia
1. Decreased production and increased destruction of platelets ONLY affecting pregnant women
494
What is Immune Thrombocytopenia (ITP)
1. Autoimmune condition associated with acute purports episodes in children and women
495
What is ventouse delivery
Vacuum
496
What procedure in delivery carries the greatest risk of haemorrhage in newborns
Prologued ventouse delivery
497
Chorioamnionitis vs uterine fibroids
Chorioamnionitis has uterine tenderness and foul-smelling discharge with foetal tachycardia showing infection. Fibroids only affects the mother and happens earlier on, in first or second trimester,
498
What does bradycardia on CTG indicate
Beta blocker use by mum
499
What does tachycardia on CTG indicate
Chorioamnionitis, hypoxia, maternal pyrexia
500
What does loss of baseline variability indicate
Hypoxia
501
What do early decelerations indicate
Head compression
502
What do late decelerations indicate
Foetal distress
503
What do variable decelerations indicate
Cord Compression
504
What is breast engorgement
Affects BOTH breasts, and is discomfort just before a feed. Infant may find it difficult to attach.
505
Treatment of breast engorgement
Hand expression
506
What is Raynaud's disease of the nipple
Intermittent pain, during and after feeding It's where the nippled blanches, coyness or srthemas.
507
treatment of rayndaud's disease of the nipple
Nifedipine or heat packs.
508
What drug should be avoided when breast feeding
``` Amiodarone Aspirin Psychiatric drugs Antibiotics Mtehotrexate Sulfonylureas Carbimazole ```
509
Contraindications to breast feeding (diseases)
1. Galactosaemia | 2. Viral infections (HIV)
510
Why should cooked liver be avoided in pregnancy
Vit A is a teratogen
511
What procedure can reduce the incidence of shoulder dystocia in women with GDM
Induction of labour
512
What measures can improve the effectiveness of the McRobert's manoeuvre
Suprapubic Pressure
513
What is given as GBS prophylaxis
Benzyl penecillin
514
Sources of folic acid
Green leafy vegetiables
515
What is the consequence of folic acid deficiency
Macroycytic, megaloblastic anaemia | 2. Neural tube defects
516
What is an indicator of megaloblastic anaemia
Hypersegemnted neutrophils
517
What is the choice of SSRIs in breastfeeding women
Sertraline
518
Why is fluoxetine not fabvourable in women
Has a high half life and present in breast milk.
519
How are atonic uterine primary haemorrhages treated
1. Syntometrine or oxytocin to contract the uterus | 2. Cord traction and massage the uterus.
520
How should pregnant women with abdomen trauma be managed
Rhesus testing, so they can be given atni-D to prevent rhesus isoimmunisation
521
Symptoms of exotic pregnancy
6-8 weeks amenorrhoea, with lower, unilateral abdomen pain. Vaginal bleeding later, sometimes with tender cervix.
522
Symptoms of placental abruption
CONSTANT lower abdomen pain, woman may be in more shock than visible blood loss seen.
523
If after 28/40 weeks, woman reports reduced foetal movements and no heart is detected by a handheld doppler, what should be done
USS.
524
What is active management of the third stage of labour
1. Uterotonic drugs (oxytocin) 2. Deferred clamping and cutting of the cord (1-5 mins after delivery) 3. Controlled cord traction
525
When is erogemetrine or syntometrine contraindicated
1. Gestational HTN, eclampsia or preeclampsia
526
How often should FHR be monitored
15 mins
527
How often should contractions be monitored
Every 30 mins
528
When do galactoceles develop
Typically after women stop breastfeeding, builds up
529
In what conditions is AFP low
DOwn's syndrome GDM
530
In what conditions is AFP high
Neural tube defects
531
What infectious diseases are routinely screened for in pregnancy
HIV Rubella Syphillis Hep B
532
Where is fibronectin produced
Gestational sac
533
When is foetal fibronectin raised
Early labour
534
When should folic acid be given in pregnancy
400mcg until the 12th week of pregnancy
535
When is folic acid stepped up to 500mcf
1. NTD 2. Antiepileptic drugs or has chronic disease 3. Obese
536
RF for breech presentation
Fibroids 2. Placenta praevia 3. Polyhydramnios or oligohydramnios 4. Prematurity
537
When is external cephalic version offered
36 weeks
538
Placental abruption vs placental preavia
Painless and bright red vs painful and dark brown.
539
Vasa praevia vs placental praaevia
Both have vaginal bleeding that's painless HOWEVER: Vasa has foetal bradycardia and memraben rupture.
540
Then grade for perineal tears
1. First: Superficial damage to skin 2. Second: Injury to perineal muscle but no anal sphincter 3. Injury involving anal sphincter
541
RF for perineal tears
1. Shoulder dystocia 2. Forceps Delivery 3. Large babies 4. Primigravidas
542
Consequence of cord prolapse
Cord compression
543
How is cord compression managed
Place hand into vagina to elevate the cord.
544
Treatment of all women with pPROM
10 days erythromycin
545
What should be given to women with a previous baby suffering from early or late onset GBS disease
IV maternal antibiotics during labour
546
What is the appropriate management of placenta praaevia during labour
Emergency C-Section
547
Management for babies at risk of strep B infection
1. Regular observations for 24 hours
548
Management of strep B infection in pregnant women
1. Intrapartum antibiotics | 2. 24-hours before or after birth
549
Treatment of Eclampsia in women
Magnesium for 24 hours after last seizure or delivery
550
RF for placental abruption
``` A - Abruption previously B - BP R - Ruptured Membranes (PROM) U - Uterine Injury P - Polyhydramnios T - Twins I - Infections in the uterus (chorioamnionitis) O - Older Age N - Narcotic. ```
551
Consequence of shoulder dystocia
Erb's Palsy
552
What is Erb's Palsy
1. Damage of the upper brachial plexus Signs: Adduction Internal Rotation of the arm Pronation of the Forearm.
553
What is an absolute contraindications for a vaginal delivery
Vertical caesarean scar
554
What cell produces hCG
Syncytiotrophoblasts
555
When can HcG be detected in maternal blood
Day 8 after conception
556
Most common agent causing mastittis
Staph aureus
557
If symptoms of mastitis do not improve after conservative management, what treatment is given
Oral Flucloxacillin or erythromycin if allergic
558
When, during gestation, is same day delivery an option
After 34 weeks
559
What will reduce the BP in induced labour of someone with eclampsia
Epidural anaesthesia
560
When does a miscarriage become a stillbirth
After 24 weeks of gestation
561
Contraindication of epidural anaesthesia
Coagulopathy
562
What parts of the cardinal movements of labour, form crowning
1. Extension 2. Restituition 3. Delivery of anterior and posterior shoulders.
563
In what position does the feats head enter the pelvic inlet
Either L or R OT (45 degree angle, not direct OP)
564
What is syncretism
Saggital suture lies halfway between pubic symphysis and sacral pronometry
565
Differences in foetal descent between nulliparas and multiparae women
1. Nulli: Occurs during 2nd stage | 2. Descent begins alongside engagement.
566
What is the name of the diameter given to the change in shape as the baby feels resistance during flexion
Occiptofrontal diameter (12cm) -> subocciptobregmatic diameter.
567
What position does the baby move into during internal rotation
OA position
568
Two forces that act on the baby during extension
1. Forces from the uterus acting posteriorly | 2. Force from pelvic floor and pubic symphysis
569
What structure does the baby face during external rotation
Ischial tuberosity
570
What causes macrosomia
An abundance of glucose
571
How does DM affect the glucose levels of a newborn
The newborn will be born hyperglycaemic and quickly turn to hypoglycaemia
572
What is station 0
Ischial spine
573
What do positive numbers in the stations indicate
The feoutus has entered the birth canal
574
What is foetal engagement
Head enters pelvis, causing effacement and dilation of the cervix as it presses its head against it
575
What is foetal lie
Relationship of the foetal spinal column to the mother's
576
What is complete breech presentation
Buttocks and flexed feet present first
577
What is frank presentation
1. Hips are flexed but legs are extended resting on chest
578
What presentation is a result of a transverse lie
Shoulder
579
What causes the foetus head to extend
Upward resistance from the pelvic floor
580
What keeps the placenta from separating prematurely during labour
Pressure from the foetus
581
What is the name given to the following placentas: 1. Feotal side Mother's side
1. Foetal: Schultze's (shiny) | 2. Mother: Duncan (raw)
582
What is Leopold's manoeuvre
1. Palpating the funds to identify the occupying foetal part
583
Three situations where finternal cardiotocography is used
1. Foetal descent 2. 2cm dilation 3. Active phase of labour
584
What FHR is associated with low APGAR scores
1. Late decelerations (hypoxia)
585
What causes FHR accelerations
Foetal movement
586
What drug is used to halt uterine contractions in preterm labour
Magnesium Sulfate or tocolytics
587
What opioids are given during labour
1. Fentanyl or Morphine
588
How is an epidural delivered
1. L4 level.
589
What is toxic shock syndrome
Fever, rash. Low BP caused by strep progenies or Staph aureus.
590
Where is oxytocin naturally produced
Posterior pituitary gland
591
What nerve is commonly injured during prolonged labour
Pudendal nerve (runs along the back of the ischial spine): can cause faecal, urinary and sexual dysfunction
592
What muscle is strengthened in keels and pelvic floor excercises
Levator ani
593
Indications for episiotomy
1. Foetal distress | 2. Macrosomia
594
Two types of episiotomy
1. Median: From posterior vaginal wall vertically into perineal body (as the healing tissue is similar to the perineal body) 2. Mediolateral: From posterior vaginal wall diagonally to the outer part of the anus. Lowers risk of anal muscle tears
595
What nerve roots are affected in an epidural block (does not pierce the dura or subarachnoid space)
s2-s4 nerve roots
596
When does an epidural need to be delivered before it becomes contraindicated
In ADVANCE OF DELIVERY (1st stage of labour)
597
What is the ponderal index
Assess if a newborn is malnourished, healthy or overweight.
598
CV changes during pregnancy
Increased HR Increased SV Increased CO BP drops from peripheral vasodilation and then increases back to normal.
599
Resp changes during pregnancy
Progesterone: Bronchial dilation Increased subcostal angle Increased pulmonary blood flow Increased tidal volume but decreased vital capacity.
600
Foetal blood vs normal blood
Has two gamma chains instead of two beta chains.
601
GI change sin pregnancy
Delayed Gastric Emptying (HEARBURN) - likely to get aspiration pneumonitis
602
What is contained in entonox
O2 and NO
603
What causes labour pains in stage 2 of pregnancy
Stretching of the vagina and perineum
604
Types of PCA opioids
Fentalu, Alfentanil, Remifentanil
605
What is the criteria for early referral to infertility clinics
1. Over 35 2. Menstrual disorder 3. Previous ado surgery 4. Previous PID/STD
606
Name two hormone profiles used when checking inferiority
D2 FSH and D21 Progesterone
607
What are indications for tubal latency testing (HSG)
STI, PID, Pain and previous surgery
608
Treatment of male infertility
Usually IVF Intracytoplasmic cperm injection Azoospermia: Surgical sperm recovery or donor insemination
609
What occupations drive male infertility
Overheating: Lorry drivers
610
Diet and supplements that can improve male infertility
Folic acid and Zinc Lose Weight
611
When is IVF indicated
After 2 years of infertility.
612
What does the combined test offered to pregnant womenn consist of
T21, T18 (Edwards) and T13 (pate) screening.
613
What is the optimum crown-rump length in the first trimester
45-84 mm
614
In a pregnant woman with pre-existing hypothyroidism, what should be done to her levothyroxine medication
It should be increased
615
What is a marker for end organ damage in pre-eclampsia
Thrombocytopenia (can be a sign off eclampsia without proteinuria) Can cause VTEs, HTN and ischaemic heart disease later in life.
616
What is the purpose of giving anti-D immune globulin
It is to prevent the mother from developing Rh+ antigens against Rh-D positive blood in an infant. It is not needed in people who are already negative as long as both parents are rhesus negative.
617
What pre-existing condition can result in APL
SLE
618
What are the indications for taking 5mg folic acid instead of 400mcg
1. If either partner has an NTD, a previous child with an NTD or FH with NTD 2. Antiepleptic Drugs 3. Coeliac's, Diabetes, Thalassaemia 4. Obese (over 30BMI)
619
What are the indications for Aspiring prophylaxis from the 12th week gestation until birth
``` HTN in a previous disease CKD Autoimmune diseases (SLE, APL) DM 1 or 2 Chronic HTN ``` ``` 2 of: BMI over 35 FH of pre-eclampsia Multiple Pregnancy Age 40 or older ```
620
When should women with pre-eclampsia bet admitted and observed
160/110 mmHg
621
When would administration of Anti-D not work
1. Ectopic 2. Evacuation of retained products of molar pregnancy or abortions 3. Vaginal Bleeding under 12 weeks if heavy or persistent 4. Vaginal Bleeding over 12 weeks 5. Chorionic Villus Sampling and Amniocentesis 6. PPH 7. External Cephalic Version 8. Intrauterine death or post-delivery
622
In what foetal occipital-position, are women more likely to experience an earlier urge to push: OA or OP
OP
623
Why is labour longer in OP
Because a greater rotation is required during the physiological stages of birth
624
Management of a face presentation
Emergency C-Section
625
What is the risk with a footling presentation at delivery
Can cause cord prolapse, obstructing foetal blood flow
626
What is a face presentation
When the head extends prematurely instead of flexing after engagement
627
What is Reverse End-Diastolic Flow in Pregnancy and how is this treated
This is where blood flows back into the foetus instead of exiting You must give them another course of steroids (this only lasts 1-4 weeks) MgSO4
628
Signs of Chronic Lung Disease of Prematurity on X-Ray
Hyperinflation but no alveoli
629
Treatment of Apnoea of Prematurity
NCPAP, tactile stimulation and CAFFEINE (phosphodiesterase inhibitor)
630
Treatment of Grade I Placenta Praevia
Vaginal Delivery can be offered. The others usually require a C-Section
631
What is the only oral therapy that is allowed in DM mothers when they're breast feeding
Metformin
632
Difference in presentation between Placenta Accrete and Placenta Praevia
Placenta Accreta only presents as PPH, and is asymptomatic until labour
633
First Line Treatment for PROM according to NICE Guidelines
10 Days ERYTHROMYCIN
634
What should be given as intrapartum antibiotics if a pregnant woman is allergic to penecillin
Vancomycin
635
Galactocele vs a Breast Abscess
Galactoceles are painless and non-tender, with no systemic signs of infection (e.g., tachycardia or fevers)
636
How does Methotrexate work
It Inhibits Dihydrofolate Reductase - can cause Macrocytic Megaloblastic Anaemia
637
What is the triple test for Down' Syndrome and when is it conducted
15-20 weeks: | AFP (Low), Unconjugated Oestradiol (Low) and Beta-HCG (High)
638
At what point after birth does a midwife handover to a health visitor after birth
10-14 days
639
Features of aspirin overdose
Respiratory alkalosis due to hyperventilation -> metabolic acidosis Tinnitus, vomiting and severe dehydration
640
What is the complication that can occur if a pregnant woman takes sodium valproate
Hypospadias and ASDs
641
Main pregnancy complication from GDM
Polyhydramnios
642
What makes up baby weight size monitoring
1. Femoral height 2. Abdominal circumference 3. Palpation of the head
643
What antibiotic is safe for use throughout pregnancy
Cephalosporins
644
What is the first line management of PID
Metronidazole ceftriaxone Doxycyclines
645
How is Mifepristone and Misoprostol given
ORAL mifepristone VAGINAL Misoprostol
646
What is the first line intervention for a failure to progress in the first stage
Membrane sweep (amniotomy) Then wait and re-assess, then give oxytocin
647
What is the first line tocolytic that is given in Obstetrics
Oral Nifedipine
648
According to NICE, what should be the first line management of a possible preterm birth/miscarriage
As long as th ecervix is less than 25mm, Vaginal Progesterone should be given No point giving Steroids at this time as foetal lungs haven't even developed yet. We need to keep the baby in for as long as possible
649
What is multiple pregnancies a risk factor for
``` Vasa Praevia (NOT PLACENTA) Placental Abruption ```
650
What is Ovarian Hyperthecosis
Presence of lots of lutenised theca cells in the ovarian storm -> jhyperandrogenism Most common cause of hirstusim in postmenopausal women
651
When is the combined test for Down syndrome done
11-13 weeks
652
After 13 weeks gestation, what test is offered instead of the combined test
Triple or Quadruple
653
Prior to C-Sections, what medication should be given to pregnant women
Omeprazole Rhesus- D if they're negative If positive, leave it
654
Sub types of type 3 perineal tears
3a. Less than 50% of the thickness of the external anal sphincter is torn 3b. More than 50% of the thickness of the external sphincter is torn 3c. External and internal sphincter is torn but mucosa is intact
655
What is a type 4 perineal tear
Both internal and external sphincters and anal mucosa is torn
656
Management of a first degree tear
Nothing, leave alne
657
Management of a second degree tear
Suturing by midwives
658
Management of a third degree tear
3rd degree tear + requires surgical repair
659
First step in managing a post-term pregnancy
Cervical membrane sweep and then induction of labour
660
Management of APL
Aspirin and LMWH
661
What is polymorphic eruption of pregnancy
Itchy papular rash the starts on the abdomen Compared to Cholestasis of Pregnancy which is itching of palms and soles without a rash
662
How long does it take for a uterus to go back to its original size
4 Weeks
663
What is a Dichorionic and diamniotic sac
Two Different sacs
664
What is a monochorionic and diamniotic sac
Same outer sac, two inner sacs
665
When is lactational breast feeding indicated
1. FULLY breast feeding 2. Amenorrhoea 3. Less than 6 months post partum
666
What is an early sign that can be seen in a urine dipstick during Hyperemesis Gravidarum
Ketones
667
When is tocolysis contraindicated
Over 34 weeks gestation
668
After what cervix size is tocolysis contraindicated
2cm
669
What pain relief should be avoided d in pregnancy
NSAIDs - they can cause premature closure of the ductus arteriosus
670
What examination finding is consistent with oligohydramnios
The baby foetal parts will be abnormally prominent
671
What is normal variability in a baby
Between 5 and 25 BPM
672
First line treatment for pain relief
Paracetamol If not tolerated, codeine phosphate
673
What is a major indication for thromboprophylaxis post partum?
A twin pregnancy
674
What is the role of the Kleihauer test
t gauge the dose of anti-D required
675
What should be done to patients on ramipril who no have gestational hypertension
Switch ACEi to Labetolol, discontinue ramipril
676
What defines PPH
Loss of 1000ml over 24 hours
677
How successful is an ECV
50%
678
How long is rump-crown length the main way of measuring a baby
13 weeks
679
After 13 weeks, what is the main way we measure a baby
Femoral length | Head circumference
680
When is a surgical management of a miscarriage indicated
Bleeding for over 2 weeks
681
How many contractions are normal within 10 minutes during labour to show healthy progression
3-5 in 10 mins - first stage
682
First line treatment for hyperemesis Gravidaru
Promethazine
683
What is a category 1 cesarean section
When there is acute foetal compromise
684
What is the main consequence of polyhydramnios that mother's can get during delivery
Umbilical cord prolapse
685
Inevitable miscarriage vs complete miscarriage
Inevitable: Cervical os is open and there is active bleeding Complete: Cervical os is closed, previous bleeding and cramping which has now stopped. Can only be confirmed on USS
686
When should women with gestational diabetes give birth by
40 + 6 weeks of gestation
687
When is an epidural anaesthesia given
During the active phase of labour, this is contraindicated in the latent phase
688
What pain relief can be given in the latent phase of pregnancy
Diamorphine IM
689
How long does epidural anaesthesia last for
2 Hours
690
When is arterial rupture of membranes done
Ripened cervix | Head is well-engaged
691
First line management of placental abruption in <36 weeks who are asymptomatic/ not systemically unwell
Admit and administer steroids
692
Most common cause of polyhydramnios
Idiopathic
693
Indications for C-Section
1. Woman is in established labour 2. Foetal Compromise 3. Ruptured Membranes or vaginal bleeding 4. Severe Hypertension
694
If the baby in a Herpes +ve mother appears unwell, what is the first line management plan
Lumbar puncture HSV PCR
695
If a miscarriage is suspected and the crown-rump length on TVUSS is <7mm, what should be done
Another TVUSS in 7 days as the foetus may still be developing - it's too early to tell
696
Pseudosac vs a true sac
In PUL: A cyst would be seen in the endometrium that is centrally located. In a confirmed Intrauterine Pregnancy, this cyst would be slightly off centre. So a centrally located cyst in the endometrium would still be a PUL.
697
What is a major complication of polyhydramnios
Pre-Term Labour
698
How should unstable Bipolarism be treated during pregnancy
Switch gradually to an atypical antipsychotic (mood stabiliser)
699
How does age affect pre-eclampsia
Over 40 increases risk
700
AT what pregnancy interval, do we get an increased risk of pre-eclampsia
If a previous pregnancy was greater than 10 years before the new one
701
What is a complication of Chorionic Villus Sampling
Total limb abnormalities if performed before 11 weeks gestation
702
If a woman has a diagnosed Gestational Diabetes in a previous pregnancy, when should the OGTT be offered
As soon as possible following a booking visit Should not be routinely offered Usually, do fasting glucose at 13 weeks gestation
703
How does parity affect the chances of a PPH
Multiparity increases its risk
704
Name a brain complication found in congenital rubella syndrome
Hydrocephalus
705
What is more accurate, Chorionic Villus Sampling or Amniocentesis
Amniocentesis
706
When is benzylpenecillin given to pregnant women
During delivery and after
707
What is the target fasting glucose level for pregnant women
5.3 mmol/mol
708
First line management of suspected endometritis
Admission to hospital for IV antibiotics
709
Does pre-eclampsia cause oligohydramnios or polyhydramnios
Oligohydramnios
710
What is the first line management of a woman with moderate/high gestational hypertension or pre-eclampsia after 37 weeks
Plan immediate delivery
711
From what gestation age should mothers with placenta praaevia and vasa praaevia be admitted
34 weeks
712
At what age doe physiological jaundice present
2-3 days of being born
713
When is prophylactic vaginal progesterone indicated in a pregnancy
A history of spontaneous pre-term births AND a cervix length less than 25mm between 16 and 24 weeks
714
When can intravaginal progesterone use be stopped
After 34 weeks
715
When is cervical cerclage indicated for pregnant women
Cervical length < 25mm AND: Previous pPROM History of cervical trauma
716
When can rescue cervical cerclage be used (rescue, being during the course of the pregnancy itself)
Between 16 and 27 weeks with a dilated cervix.
717
When is the earliest we can do a foetal fibronectin testing done for a preterm pregnancy
30 weeks
718
When should someone with Peuperal pyrexia be taken to the hospital instead of conservative management
1. >38 degrees 2. Tachycardia 3. Breathlessness 4. Abdominal Pain 5. Diarrhoea If the woman is in distress
719
What is an absolute contraindication to ECV
Bleeding in the past 7 days
720
Why is promethazine the first line for hyperemesis gravidarum
BNF suggest promethazine (anti-histamines) as the first line Metoclopramide is second line
721
How do we calculate a due date
Last Menstrual period + 9 months + 7 days
722
Umbilical cord prolapse vs uterine rupture
Both cause foetal tachycardia etc But Umbilical cord prolapse is painless vs uterine rupture which is painful
723
When should steroids be given during placental abruption
As long as the foetus and mother have stable obs and there is no sign of foetal distress.
year 3
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