Obstetrics Notes - Basic stuff nothing fancy PDF

Preview

Summary

Obstetrics NotesEctopic pregnancy 0% of pregnancies are ectopic Pathophysiology a. Most in ampulla b. Most dangerous if in isthmus Risk factors a. Pelvic inflammatory disease b. Endometriosis c. Surgical damage to the fallopian tubes d. Previous ectopic e. IVF f. Progesterone only pill Typical exam ...

Description

Obstetrics Notes Ectopic pregnancy 1. 0.5% of pregnancies are ectopic 2. Pathophysiology a. Most in ampulla b. Most dangerous if in isthmus 3. Risk factors a. Pelvic inflammatory disease b. Endometriosis c. Surgical damage to the fallopian tubes d. Previous ectopic e. IVF f. Progesterone only pill 4. Typical exam scenario a. Women with amenorrhea for 6-8 weeks b. Lower abdominal pain – can be constant, unilateral c. Vaginal bleeding d. +/- shoulder tip pain 5. On examination a. Abdominal tenderness b. Cervical excitation/cervical motion tenderness 6. Investigations a. Pregnancy test in ALL women of childbearing age with abdominal pain b. Transvaginal ultrasound scan – definitive c. Beta HCG 7. Management a. Expectant management – close monitoring over 48 hours – this means checking the hCG levels and monitoring for symptoms. If either of these occur then intervention is indicated. i. Criteria 1. 32 weeks with multiple pregnancy 5. Nausea and vomiting – antihistamines are first line

Antepartum haemorrhage 1. Definition – bleeding from the genital tract after 24 weeks 2. Do NOT perform a vaginal examination 3. Causes a. Placenta praevia b. Placental abruption Placenta praevia – painless PV bleeding 1. When the placenta is lying wholly or partly in the lower uterine segment 2. Risk factors a. Multiparity b. Multiple pregnancies c. Previous c-section 3. Features a. Shock b. A lot of blood loss c. Small bleeds leading up to large bleed 4. Investigations a. Look for placenta praevia on the 20-week scan b. Use transvaginal ultrasound for accuracy c. Rescan at 34 weeks d. Rescan at 36-37 weeks

5. Management a. If grade 1 – vaginal delivery can be attempted b. If grade 3/4 then elective c-section 6. Bleeding placenta praevia a. Admit b. ABCDE c. If unable to stabilise or they are in labour or term  emergency c-section Placental abruption 1. Separation of a normally sited placenta from the uterine wall causing haemorrhage into the space 2. Associated factors: a. Hypertension b. Cocaine use c. Multiparity d. Trauma e. Increased maternal age 3. Clinical features a. Shock out of keeping with the visible loss b. Constant pain c. Tender tense uterus 4. Management a. Foetus alive and < 36 weeks i. Foetal distress  immediate c-section ii. No foetal distress  observe closely, consider delivery b. Foetus alive and > 36 weeks i. Foetal distress  immediate c-section ii. No foetal distress  deliver vaginally c. Foetus dead  induce vaginal delivery 5. Complications a. Maternal i. Shock ii. DIC iii. Renal failure iv. Primary post-partum haemorrhage b. Foetal i. IUGR ii. Hypoxia iii. Death Placenta accreta 1. When the placenta does not attach to the decidua basalis and instead attaches to the myometrium 2. 3 types: a. Accreta – to myometrium b. Increta – invade into myometrium c. Percreta – invades through the perimetrium 3. Risk factors a. Previous c-section b. Placenta praevia

Amniotic fluid embolism 1. When amniotic fluid enters the mother’s bloodstream 2. Risk factors/associations a. Increased maternal age b. Induction of labour 3. Features a. Occur during labour/c-section or immediately post-part b. Chills, sweating, coughing c. Hypotension d. Tachycardia e. Cyanosis Causes of bleeding in pregnancy 1. Causes based on gestation a. 1st trimester i. Miscarriage ii. Ectopic iii. Hydatidiform mole b. 2nd trimester i. Miscarriage ii. Placental abruption iii. Hydatidiform mole c. 3rd trimester i. Bloody show ii. Placenta praevia iii. Vasa praevia iv. Placental abruption

Breast feeding 1. Problems a. Milk bleb – blocked duct causing pain b. Nipple candidiasis  miconazole cream for nipple and nystatin for baby c. Mastitis  flucloxacillin if systemically unwell etc. d. Engorgement e. Raynaud’s disease of the nipple

Breech presentation 1. Types of breech presentation a. Frank – hips flexed and knees extended – most common b. Footling c. Complete – hips and knees flexed 2. Risk factors a. Structural uterine abnormalities e.g. fibroids b. Placenta praevia c. Previous c-section d. Polyhydramnios or oligohydramnios

e. Foetal abnormality 3. Management a. 36 weeks  ECV at 36 weeks in nulliparous women and 37 weeks in multiparous 4. Complications a. Cord prolapse is more common 5. Contraindications to ECV a. Antepartum haemorrhage within the last 7 days b. Abnormal CTG c. Ruptured membranes d. Major uterine abnormality Cardiotocography Dr C BraVADO 1. Define risk – is the pregnancy high risk for foetal distress? 2. Contractions – Normal – 3-5 in 10 mins lasting 60 seconds. Hyperstimulation - >5 in 10 mins or last longer than 2 minutes each. Labour not progressing - 90 diastolic after 20 weeks gestation c. Oedema 2. Definition a. New onset hypertension after 20 weeks AND ONE OR MORE OF: i. Proteinuria

ii. Other organ involvement e.g. renal with increased creatinine, liver, neurological, haematological, uteroplacental dysfunction 3. Risk factors a. High risk i. Previous pre-eclampsia or hypertensive disease in previous pregnancy ii. CKD iii. Autoimmune disease iv. Diabetes v. Hypertension b. Moderate risk factors i. First pregnancy ii. >40 iii. 10-year gap between pregnancies iv. BMI >35 v. Family history vi. Multiple pregnancies 4. Prevention  daily 75mg aspirin from 12 weeks gestation until birth IF a. 1+ high risk factor b. 2+ moderate risk factors 5. Management a. Measure BP – admit if >160/110 b. Oral labetalol OR nifedipine if asthmatic c. Delivery of baby is definitive Eclampsia 1. Pre-eclampsia + seizure 2. Management a. Magnesium sulphate – can be used if seizures occur or in severe pre-eclampsia to prevent seizures i. Give once you decide you are delivering the baby ii. Bolus of 4g over 10 mins then infusion of 1g/hour b. Observations very important i. Urine output ii. Reflexes iii. Respiratory rate iv. O2 saturations c. Complication  respiratory depression i. Give calcium gluconate d. Continue infusion for 24 hours post delivery or from seizure Folic acid 1. All women should take 400mcg from before conception until the 12th week of pregnancy 2. Women with risk factors for NTD should take 5mg until the 12th week of pregnancy a. Previous NTD in child b. Mother or father has NTD c. Family history of NTD d. Antiepileptic medication e. Diabetes f. Coeliac disease g. Thalassaemia trait

h. BMI >30

Gestational diabetes 1. Risk factors a. Obesity BMI >30 b. Previous pregnancy with GDM c. First degree relative with DM d. Previous macrosomic baby >4.5kg e. Family origin with high prevalence of diabetes 2. Screening a. No history of GDM but has risk factors  OGTT at 24-28 weeks b. Previous GDM  OGTT asap after booking scan  if normal then repeat at 24-28 weeks 3. Diagnostic thresholds – either or a. Fasting glucose >/= 5.6 b. 2-hour glucose >/= 7.8 4. Management a. Joint diabetes and antenatal clinic within 1 week b. Diet and lifestyle advice i. Fasting glucose < 7  trial of diet and lifestyle advice for 1 week  no improvement  metformin  BM sill high  + insulin (short acting) ii. Fasting glucose >/= 7  insulin iii. Fasting glucose 6-6.9 + macrosomia/polyhydramnios  insulin *if metformin is not tolerated or refuse insulin  glibenclamide

Pre-existing diabetes in pregnancy 1. Weight loss is BMI >27 2. Only continue metformin and no other diabetes drugs 3. Folic acid 5mg Diabetes blood sugar targets during pregnancy 1. Fasting  5.3 2. 1 hour after meal  7.8 3. 2 hours after meals  6.4

Gestational trophoblastic disorders 1. Complete hydatidiform mole – all paternal DNA a. When an empty egg is fertilised by a single sperm which duplicates its own DNA b. Features i. Hyperemesis ii. Very high HCG levels iii. Uterus bigger than dates iv. Bleeding c. Management i. Urgent referral to specialist

ii. Do not conceive for 12 months d. Complications  choriocarcinoma 2. Partial hydatidiform mole has both maternal and paternal DNA

Group B strep 1. Risk factors a. Prematurity b. Prolonged rupture of membranes c. Maternal pyrexia d. Previous sibling GBS infection 2. Management a. Women with a previous GBS infection in pregnancy  IP antibiotics or test in late pregnancy and if positive then IP abx 3. Swabs should be offered at 35-37 weeks or 3-5 weeks before delivery 4. Antibiotics  benzylpenicillin

Intrapartum antibiotics 1. Women with previous GBS infection in pregnancy 2. Maternal pyrexia >38 C 3. Preterm labour

HELLP Syndrome 1. HElLp a. Haemolysis – anaemia b. Elevated liver enzymes – raised ALT, AST c. Low platelets – thrombocytopenia 2. Features a. RUQ pain b. Lethargy c. Nausea and vomiting 3. Associated with pre-eclampsia but not always 4. Management  deliver baby

Hepatitis B 1. Screening offered to all women 2. Mothers who are chronically infected  babies get full hep B vaccine + hep B immunoglobulin

Hypertension in pregnancy 1. High risk of pre-eclampsia a. Type 1 or 2 DM b. Hypertension in previous pregnancy

c. CKD d. Autoimmune disorders 2. Definition a. >140 systolic or >90 diastolic b. Increased of >30 systolic or >15 diastolic from booking 3. Types of hypertension a. Pre-existing – hypertension before 20 weeks b. Gestation hypertension – after 20 weeks c. Pre-eclampsia – hypertension after 20 weeks + proteinuria (0.3g./24hours)

Induction of Labour 1. Indications a. Over the due date by 1-2 weeks b. Prelabour premature rupture of membranes c. Diabetes d. Pre-eclampsia e. Rhesus incompatibility 2. Bishop score – likelihood of labour occurring spontaneously a. /= 8  likely

3. Options for induction a. 1st - Membrane sweep b. Vaginal PGE2 if Bishop 6 or less i. Offer cervical balloon if PGE2 not suitable c. Bishop score >6 offer amniotomy + IV oxytocin 4. Complications  Uterine hyperstimulation a. Foetal hypoxia b. Uterine rupture c. Management i. Remove offending drug i.e. vaginal PGE2 or infusion ii. Tocolysis with terbutaline Labour

1. Stages a. First – from onset of regular contractions to full cervical dilation i. Latent phase – 0-3cm dilation ~6 hours ii. Active – 3-10cm, dilation 1cm/hr b. Second – from cervical dilatation to delivery of baby ~1 hour in multip and 2 hours in prim i. Passive stage – no pushing ii. Active stage – desire to push iii. If prolonged consider Ventouse or forceps or c-section c. Third – from delivery of baby to delivery of placenta and membranes i. Before removing the placenta, you must wait for: 1. Gush of blood 2. Rock hard uterus 3. Elongation of the umbilical cord Oligohydramnios 1. Causes a. b. c. d.

Pre-eclampsia Renal agenesis of baby IUGR Premature rupture of membranes

Perineal tear 1. First degree  superficial only no involvement of muscle 2. Second degree  perineal muscle involvement but no sphincter involvement 3. Third degree  anal sphincter involvement a. 3a  50% external anal sphincter thickness c. 3c  IAS torn 4. Fourth degree  injury to EAS, IAS, and rectal mucosa

Post-partum mental health problems Baby blues – common 3-7 days post-partum Postnatal depression – within 1 month of birth to 3 months Puerperal psychosis – first 2-3 weeks Post-partum thyroiditis 3 phases: 1. Thyrotoxicosis  propranolol for symptoms 2. Hypothyroidism  levothyroxine 3. Euthyroid Thyroid peroxidase enzymes are commonly found

Postpartum haemorrhage >500ml 1. Primary – within 24 hours of birth a. Atonic uterus is most common cause b. Risk factors i. Prolonged labour ii. Previous PPH iii. Placenta praevia iv. Placenta accrete c. Management i. ABCDE ii. Mechanical 1. Bimanual compression of uterus 2. Catheterisation of bladder iii. IV syntocinon 10 units OR IV ergometrine 500 mcg iv. IM carboprost v. If medical treatment fails then  intrauterine balloon tamponade is first line for uterine atony vi. Other surgical options for management 1. B-lynch suture 2. Ligation of uterine arteries of internal iliac 3. Hysterectomy 2. Secondary PPH a. 24 hours – 12 weeks b. Due to retained placental tissue or endometritis Intrahepatic cholestasis of pregnancy 1. Typically happens in the 3rd trimester 2. Features a. Itching – palms and soles. No rash. b. Jaundice 3. Management a. Ursodexycholic acid b. Weekly liver function tests c. Induce at 37 weeks 4. Complications  still birth

Acute fatty liver 1. Rare complication in pregnancy 2. 3rd trimester or period following delivery 3. Features: a. Abdominal pain b. Nausea and vomiting c. Jaundice d. Hypoglycaemia 4. ALT raised

Puerperal pyrexia 1. Temperature of >38C in the first 14 days following delivery 2. Causes a. Endometritis ** most common cause b. UTI c. Wound infection d. Mastitis e. VTE 3. Management if endometritis  IV abx clindamycin and gentamicin Reduced foetal movement 1. If >28 weeks a. Handheld doppler to confirm heartbeat i. Yes heartbeat  GTG for 20 minutes ii. No heartbeat  immediate ultrasound 2. If between 24-28 weeks  handheld doppler 3. If 35 years old b. BMI >30 c. Parity >3 d. Smoker e. Gross varicose veins f. Current pre-eclampsia g. Immobility h. Family history of unprovoked VTE i. Thrombophilia j. Multiple pregnancy k. IVF pregnancy 2. Management a. 4 or more risk factors  immediate treatment with LMWH until 6 weeks postpartum b. 3 risk factors  LMWH from 28 weeks until 6 weeks postpartum c. DVT before delivery  continue anticoagulation for 3 months...