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218 Cards in this Set
- Front
- Back
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When does hyperemesis typically occur in early pregnancy?
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6-12 weeks
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What can be used to treat hyperemesis in pregnancy?
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An anti-emetic, like maxalon which is safe in pregnancy
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When does a mother generally start to feel foetal movements?
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18-20 weeks, depending on placental location
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What is a pregnancy test measuring?
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beta-HCG
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How early can home pregnancy tests detect a pregnancy?
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Two weeks
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When taking an obstetrics history what does G3 P2 mean?
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Gravidity= 3: number of pregnancies
Parity: 2: live births (at any stage of gestation) or still births after 24 weeks. |
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What antenatal serology is taken?
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Antentatal serology
- Rhesus - HIV - HepB, C - Syphillus - Variecella - FBC |
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How long does bHCG stay +ve after abortion or miscarriage?
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Remains positive for ≈5d. after miscarriage/abortion or foetal death.
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When is a dating US done?
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8-10 weeks
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In a nm pregnancy what happens to B-hCG, and for how long?
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B-hCG doubles every 48 hours for the first 8 weeks
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What key pre-existing medical conditions need to be addressed in pregnancy? (4)
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1. diabetes
2. hypertension 3. epilepsy 4. thyroid disease |
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What day of the menstrual cycle does ovulation occur on?
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Day 14
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How long does an egg live for in utero?
Semen? |
Egg: 12-24 hours
Semen: 3 days |
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What days should a couple have sex on when trying to conceive?
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10, 12, 14, 16
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How long does corpur luteum persist for in pregnancy?
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10 weeks
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After conception, when does implanation occur?
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Day 6
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How does the maternal system react to conception?
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1. progesterone to keep corpus luteum alive
2. modify trophoblast expression of HLA antigens to facilitate maternal tissue acceptance of the fetal graft. 3. occasional there is an implantation bleed |
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How long does the embryonic period last?
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8 weeks post conception
10 weeks post last menstrual period |
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What does the primitive streak occur in embryonic development?
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2 weeks
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When does the heart develop?
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3 weeks
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How long is the human gestational period? (days, weeks)
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280 days
40 weeks |
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Are maternal and foetal circulation in continuation?
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Nope, they are completely separated.
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How does the placental develop?
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Trophoblasts invade the endometrium as fingerlike projections (vili)
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What are the functions of the placenta? (5)
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1. gas exchange
2. provision of nutrients 3. waste disposal 4. hormone synthesis: HCG, progesterone, oestrogen, etc. 5. drug transfer |
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What percentage of the worlds population are rhesus -ve?
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15%
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How do you treat rhesus -ve women, and when?
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Administer Anti-D at 28 weeks, and 34 weeks.
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When is the uterus palpable above the symphis? at the umbilicus?
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symphis: 12 weeks
umbilicus: 18-20 weeks |
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How long is the sac making amniotic fluid?
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until about week 16, after than the baby is making it.
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what changes occur in the cervix during pregnancy?
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- softening
- cyanosis - shortening - proliferation of glands - formation of mucus plug |
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What changes occur in the vagina during pregnancy?
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- increased vaginal discharge
- changes colour - becomes more vascular - thickening of vaginal mucosa - loosening of connective tissue - hypertrophy of smooth muscle |
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What skin changes occur during pregnancy?
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1. stria gravidarum
2. diastasis recti 3. pigmentaion |
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Cervical changes in pregnancy
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Reduction in cervical collagen towards term enables its dilatation.
Hypertrophy of cervical glands leads to the production of profuse cervical mucus and the formation of a thick mucus plug or operculum that acts as a barrier to infection. Vaginal discharge ↑ due to cervical ectopy and cell desquamation |
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Breast changes in pregnancy?
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- tenderness
- antenatal secretion of clostrum - increase from week 8 - areolar becomes more pigmented |
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Metabolic changes in pregnancy?
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1. weight changes: uterine hypertropy & contents, fet deposition, fluid retention
2. fluid retention: - decreased plasma osmolality - increased maternal blood volume - pitting oedema |
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Haematological changes in pregnancy? (6)
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Prothrombotic state:
1. blood volume up by 40-45% 2. RBC increase by 33% 3. increased platalets 4. increased ESR 5. increased fibrinogen 6. decreased fibrinogen |
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Cardiovascular changes in pregnancy?
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- HR up 10-15bpm
- increased SV & CO - decreased peripheral resistence - decreased BP for first 20 weeks - exaggerated splitting of the first heart sound. - systolic ejection murmur |
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What percentage of pregnant woman have a systolic ejection murmur?
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90%
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Respiratory changes in pregnancy?
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There aren't actually any, but they may be perceived due to the baby pressing up against the diaphragm
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Renal changes in pregnancy?
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- increased renal size
- increased renal blood flow - increased GFR - decreased serum creatinine and urea |
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GI changes in pregnancy?
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Displacement
Delayed gastric emtpying and intestine transit times Reflux & heart burn are common Constipation/ haemorrhoids |
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What are some minor disorders of pregnancy?
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1. nausea
2. vomiting 3. oesophageal reflux 4. constipation 5. epistaxis (nose bleed) |
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What is the standard antenatal visit schedule in a normal low risk pregnancy?
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First visit: 12-16 weeks
4 weekly till 28 weeks 2 weekly till 36 weeks weekly until term |
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When is nuchal translucency investigated?
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11-14 weeks
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When is the foetal morphological scan undertaken?
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18-20 weeks
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When are routine FBC's done?
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First visit
week 28 week 36 |
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When is Anti-D given
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to rhesus -ve mothers
week 28 week 36 |
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when is glucose testing done?
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28 weeks
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How do you test for Group B strep?
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Low vaginal swab
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What are the phases of labour in the first stage?
How long does the first stage last on average? |
Latent phase & active phase (when cervix is >3cm dilated)
Nulliparis: 12 hours Multiparis: 6 hours |
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How long does the second stage last on average?
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Nulliparis: 20-120 minutes
Multiparis: 10-60 minutes |
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When is oxcytocin administered in the 2nd stage, and why?
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Administered with the delivery of the anterior shoulder and helps with the delivery of the placenta.
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How long should the 3rd stage of labour last?
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less than 30 minutes.
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prevalence of ovarian cysts worldwide?
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7%
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What genetic mutations are associated with ovarian cancer?
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BRCA-1
BRAC-2 Lynch II syndrome |
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What are the two common functional ovarian cysts?
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follicular cysts
corpus luteum cysts |
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What is most common type of ovarian cyst?
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Follicular
24% |
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What makes a follicular cyst?
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An unruptured Graddian follicle that continues to secrete fluid
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Are follicular cysts generally bilateral?
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Nope, usually unilateral.
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What are the most common types of benign ovarian neoplasms?
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serous cystadenoma & mucinous cytadenomas make up 40% and are the most common.
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Follicular cysts, features:
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unilateral
<5cm secrete oestrogen may result in longer menstrual cycle |
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40 year old with bilateral moderately sized cyts, and no disruption of her cycle. What is it?
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Serous cystadenoma
- 30% bilateral - moderate size - 35-55yrs - secrete a thin watery fluid |
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35 yr old women with a large multilocular ovarian cyst. What is it most likely?
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Mucinous cytadenoma
- big and multilocular - usually unilateral - secretes mucin |
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What causes pseudomyxoma pertonei?
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when a mucinous cytadenoma
ruptures and mucinous cells attach to the peritoneum and omentum. |
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What are chocolate cysts?
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endometriomata
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A 30yr old presents with bilateral ovarian cysts or moderate size, which contains atypical tissue. What is it likely?
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Benign teratoma
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What is a fibromata?
characteristics? |
a connective tissue neoplasm of mesenchymal origin.
- usually small - 10% are bilateral |
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How many women presenting with polycystic ovaries have PCOS?
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1/3
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What are s/s of polcystic ovaries? (4)
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Pelvic pain
Bloating Early saitey Palpable adnexal mass |
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what are risk factors of polycystic ovaries? (7)
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pre-menopausal
early menarche 1st trimester of pregnancy PCOS increased intrinsic/extrinsic gonadotropins tamoxifen therapy |
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What is the equation for the risk of malignancy index?
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RMI= UxMxCA125
U: ultrasound score M: menopausal CA-125: serum CA-125 measurement as marker of epithelial ovarian ca. |
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US signs that increase the risk of an ovarian cyst having malignant potential?
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1. multi-locular cyst
2. evidence of solid areas 3. evidence of metastases 4. presence of ascites 5. bi-lateral lesions |
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How to treat polycystic ovaries?
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Observe with repeat US
Suppress with OCP Laparoscopic ovarian cystectomy Laparoscopic oviectomy |
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Fibroids: details?
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Aka. leimyomata, fibromyomas
Most common pelvic tumour in women (30-70%) Malignant changes are rare Related to E and P Shrink after menopause |
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Most common pelvic tumour in women (30-70%)
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Fibroids
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When do you treat fibroids?
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When the symptoms are unpleasant (intramenstrual bleeding, miscarriage, compression of bladder, pain, constipation)
when it is affecting fertility |
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What are some drugs therapies for fibroids?
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NSAIDs, tranexamic acid
OCP, mirena IUD, progestins GnHR agonist/antagonists |
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what is preterm?
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<37 weeks
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what is postterm?
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>42 weeks
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low birth weight=
very low birth weight= extreme low birth weight= |
LBW=<2500gm
VLBW=<1500gm ELBW= <1000gm |
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Risk factors for small babies (both small for gestational age and premature)
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Socioeconomic: poverty, teenage mums, single mothers, smoking, drug use
Medical: hypertension, renal, autoimmune Placental/uterus: infection, multiple gestation, placental abruptio, placenta praevia Foetal: chromosomal abnormalities, cardiac problems, etc. |
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What are the broad issues involved with preterm delivery for the feotus?
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1. Asphyxia
2. Thermal instability 3. Pulmonary disease: respiratory distress syndrome/ hyaline membrane disease 4. Metabolic disturbances 5. GI: jandice, necrotising enerocolitis 6. Renal immaturity 7. Cardiac: patent ductus arterosus 8. Haematological 9. Infections 10. Neurological/ neurosensory 11. Retinopathy of prematurity 12. Sensori-neural hearing loss |
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How do manage potential metabolic disturbances in a premature baby?
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Monitor blood sugars and electrolytes
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When do babies get their suck reflex?
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36 weeks
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What is a potential serious neurological result of prematurity?
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Intraventricular haemorrhage: bleeding into the ventricles which results in hydrocephalus and potentially a stroke.
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What causes retinopathy of prematurity?
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vessels being grown too fast in response to oxygen, leads to retinal detachment resulting in blindness
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What is the accepted cut off for potential survival of premmie?
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23 weeks
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When is a preterm baby considered viable? ie. parents can't decide to withdraw care
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25 weeks
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Preterm babies between 23-25 weeks suffer what complications?
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1. chronic lung disease: 50-70%
2. infection: 30-50% 3. intraventricular haemorrhage:10-30% 4. retinopathy of prematurity: 10-50% 5. necrotising enterocolitis: 5-10% |
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What are some long term respiratory problems associated with premature birth?
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Asthma
Chronic lung disease Home oxygen therapy Increased risk of infection |
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Do respiratory problems associated with premature birth persist?
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overt lung abnormalities resolve over 1-2 years
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Do premature babies catch up in terms of growth?
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Yes, over 1-3 years with additional nutrition
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When are vaccinations given to a preterm baby?
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According to chronological age, not gestational.
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What % of extreme low birth weight babies require hearing aids?
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2-4%
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what is the relationship between birth weight and cerebral palsy?
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ELBW: 50/1000
LBW: 8/1000 NmBW: 1.5/1000 |
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Is cerebral palsy detected at birth?
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Nope. May not be picked up on neurological exam until 8-12 months.
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What % of miscarriages have a chromosomal abnormality?
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50%
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What % of still births have a chromosomal abnormality?
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5%
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What % of live births have a chromosomal abnormality?
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0.5%
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What is the best early screening test for chromosomal abnormalities?
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NT+biochemistry
Detect 90-94% 2.5-5% false positives 7 unnecessary tests |
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What is NT? When is it done?
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nuchal translucency testing
11-13 weeks |
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Can you use maternal age as a screening tool for T21?
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No, 45% of DS babies are born to mothers <35yrs.
Only detect 55%, get 18-22% false positives, do 79 unnecessary tests. |
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Why do you do first trimester tests?
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Do look for foetal death, multiple pregnancies, or morphological abnormalities.
Early detection give parents privacy to make difficult decisions. |
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What percentage of NT tests come back low risk?
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95%
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Where is it harder to get NT?
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The country, as you require a very skilled sonographer
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NT 3.9 at 12 weeks: high or low risk T21?
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High, if maternal age is 31:
went from 1/528 to 1/24 |
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First trimester screening: what should to look for chromosomal abnormalities?
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Combined test:
11-13+6 weeks: Pregnancy-associated plasma protein A (PaPP-A) + free B-hCG- risk calculation Nuchal thickness (increase=+ve) Performance ˜90% detection for 5% FPR . May detect other abnormalities such as anencephaly. Acceptable detection of all trisomies. Disadvantage: expensive and difficult to perform nuchal scan |
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Should you do T1 testing or T2 testing?
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both is best, increases detection rate from 90 to 96.3%
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Beyond NT, what else can be picked up on US to suggest T21?
(3) |
1. Nasal bone (5-6weeks) will be shorter and less mineralised in T21
2. Abnormal ductus venosus 3. Tricuspid regurg |
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What is CVS and when is it performed?
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It is sampling of chorionic vili, and chromosomes are analysed from cultured cells.
11-14 weeks EARLIER than amniocentesis |
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What is amniocentisis, and when is it performed?
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Sampling of amniotic fluid (20mls). Chromosomes analysed from cultured cells.
15+ weeks |
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Why is fetal blood sampling done? When is it done? Is it common?
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Uncommon now
Done from 18 weeks Is done when there is risk of foetal transfusion (like in rhesus mothers). |
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What is the gold standard for analysis of chromosomes in samples (CVS, amnio)?
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Classic cytogenics- but is expensive, and slow, and highly operator dependent.
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What is the miscarriage risk with CVS?
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<1%
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What is the miscarriage risk with amnio?
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<0.5%
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What is the miscarriage risk with feotal blood sampling
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2% is foetus is well
20% if hydrophobic foetus |
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What normally happens to BP in pregnancy?
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Drop in both SBP and DBP in first trimester
Normalises in second trimester Approaches pre pregnancy BP in third trimester |
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Prevalence of gestational HTN?
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9.8%
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Severe HTN?
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SBP > 170 mmHg
DBP>110 mmHg |
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In pregnancy a change of how much is defined as HTN? And from when?
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30/15mmHg
from BOOKING BP, not pre-pregnancy BP |
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Define gestational HTN?
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HTN after 20 weeks without associated systemic changes
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If gestational HTN is still present 15 weeks after the birth, is this normal?
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Not for gestation HTN
Not it is chronic HTN This cut off is at 12 weeks post partum |
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When is gestational HTN at risk of becoming pre-eclampsia?
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If it is present early in pregnancy, or is severe.
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What % of severe gestational HTN diagnosed <30weeks go onto PET?
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40%
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If gestational HTN is dx >37 weeks what % will go onto PET?
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10%
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HTN <20 weeks, with no known cause is?
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Essential HTN
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secondary HTN <20weeks may be caused by what?
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1. chronic kidney disease
2. renal artery stenosis 3. SLE 4. DM 5. Cushings syndrome 6. Primary hyperaldosteronism 7. coarctation of the aorta |
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What variables should be controlled when measuring BP in pregnancy?
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Right arm always
Patient sitting, relaxed |
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When should you measure BP on both arms in pregnancy? Why?
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On the first visit, to exclude coarcation of the aorta
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If you have a woman with pre-exisiting HTN, and proteinuria, what do you do?
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She is at higher risk of PET
Diagnose on other systemic/foetal features: such as IUGR |
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Define pre-ecplamsia
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HTN that occurs >20 weeks gestation with systemic signs, such as
- proteinuria - haematological involvement - liver signs: LFTs or pain - neurological involvement |
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Is a raised Alk phos of concern in pregnancy?
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Nope, it is normally raised in pregnancy
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What is the prevalence of pre-eclampsia in aus?
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4.2%
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What % of maternal deaths in low and middle income countries is due to PET?
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99%
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Risk factors for PET
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Previous PET
>10yrs since last baby Age: >40 BMI>35 Family history Underlying medical disorder |
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What can be used as prophylaxis for PET?
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Arpirin has a use
Calcium, Vit C and Vit E have been shown to NOT be useful |
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What is involved in surveillance of a woman with PET?
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1. BP measured 2-3x week in day assessment unit
2. Education about signs and symptoms 3. Blood investigations: FBC, UEC, LEFTs, Urate 4. Urinalysis: spot protein, creatinine 5. CTG and or US to monitor foetal growth |
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Education about signs and symptoms of PET for mother should include what?
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- headaches
- visual spotting - visual blurring - epigastric pain - dizziness |
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Pathology of PET
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1. immunological: foreign body reaction
2. Placental: poor implantation, poor invasion by throphoblastis |
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Is oedema a key component of PET?
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It occurs in PET, BUT is not part of the diagnosis because it is so common in pregnancy and is probably of little clinical importance.
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How do you diagnose PET>
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diagnosis of exclusion
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What are the patho-physiological changes that distinguish PET from normal pregnancy?
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1. intense vasopasm
2. intravascular coagulation |
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Why is there increased intravascular coagulation in PET?
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platelets are on hand to repair the vasculature in the placenta
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what happens to the plasma volume in women with PET?
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In normal pregnancy plasma volume increases (40-45%)
In women with PET there is slight or unchanged plasma volume Thus haemoconcentration!! |
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How does the change in blood in PET affect the kidneys?
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Kidneys are super sensitive little fellas
- protein > +1 - spot protein/creatinine ration >30mg - creatinine >90 |
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What is HELLP syndrome?
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HELLP syndrome is a group of symptoms that occur in pregnant women who have:
H -- hemolysis (the breakdown of red blood cells) EL -- elevated liver enzymes LP -- low platelet count |
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What liver enzymes are we looking at in PET?
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AST>40 U/L
ALT >40 U/L ALP will probably be up anyway as a result of pregnancy |
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What is the end-point of PET?
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ECLAMPSIA- Cerebral changes!
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What occurs with eclampsia?
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Seizures
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What are the cerebral changes associated with PET?
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hyperreflexia WITH clonus
persisting headache visual disturbances diminished level of conscoiusness |
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What haematological problems are associated with PET?
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DIC!
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What effect can PET have on the foetus?
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IUGR
Foetal hypoxia Prematurity Placental abruption Intrauterine death |
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Is an epidural recommend or illadvised in PET patients?
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Recommended, you dont want a pain related increase in BP
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What antihypertensives are first line in PET?
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Methyldopa- oldest
Oxyprenolol Labetolol |
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Second line PET meds
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Hydralazine
Nifedipine Prazosin |
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Drug therapy for severe PET?
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Jump straight to second line:
Hydralazine Nifedipine Prazosin |
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What BP meds are contraindicated in pregnancy?
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ARBs
ACEi |
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Acute Rx for SEVERE HTN in pregnancy?
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IV labetolol (50mg, repeat after 15-30mins)
IV Hydrazaline (5-10mg, repeat after 30 mins) IV Diazoxide (15-45mg, repeat after 5 mins, max 300mg) Tab Nifedipine (10-20mg, repeat after 45 mins) |
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PET indications for delivery
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GA>37weeks
Cant control the HTN Decrease in platelets- worry about DIC Decrease in LFTs, renal funct. Placental abruption Persistent neurological symptoms Pulmonary oedema Eclampsia IUGR |
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Rx for eclampsia
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Usually self limitiing seizures
If long: IV diazapan or clonazapem Magnesium sulphate- prevents further seizures! |
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MgSO4
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CNS depressant
used: - following a seizure, to prevent the next one - maintenance - in anticipation of delivery |
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MgSO4 toxicity
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hypotension
flushing slurred speech absent reflexes |
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If a baby grows normally in initially, but is growth restricted in the last trimester, what has caused this?
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placental dysfunction/ insufficiency
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Fetal growth depends on?
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1. genetics
2. nutrients (O2 and glucose esp) 3. A good foetal circulation 4. Functioning fetal pancreatic B-cells 5. a good blood supple to placental and transfer accross it |
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What is the relationship between insulin and interutero growth
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Insulin is one of the main regulators of feotal growth
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What is the most common cause of IUGR?
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maternal hypertensive disorders
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Will all hypertensive women have small babies?
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No, the degree to which this affects foetal growth depends on the amount of placental functioning reserve.
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What makes a IUGR foetus likely to die in utero?
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They are more likely to develop metabolic disorders:
- acidosis - hypoglycaemia - erythroblastosis |
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macrosomic
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large baby
DMII |
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Is being a normal for size baby in a high risk pregnancy better or the same risk wise, than being IUGR?
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Better
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What additional tests should be done to access foetal well being in a high risk pregnancy?
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>30 weeks
- foetal movement counts - cardiotocography - serial ultrasound examinations - doppler flow velocity wave forms |
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How many times should a baby kick in a day, past 30 weeks?
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10-130
<10, needs to have a cardiotographic assessment |
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Naegele's rule?
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(LMP + 1yr 7days) – 3 months
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Gravidity
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Number of pregnancies, including the current one
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Parity
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Number of births beyond 24 weeks gestation (including still births)
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Linea nigra
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dark pigmented line stretching from the xiphi sternum through the umbilicus to the suprapubic area
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striae gravidarum
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recent stretch marks are purplish in colour
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striae albicans
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Old stretch marks are silvery, white
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What is the difference between foetal lie and presentation?
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Lie: what direction the foetal pole is in
Presentation: part of foetus overlying the pelvic brim |
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polyhdramnios
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excess of amniotic fluid in the sac
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Pawlick's manoeuvre
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The presention foetal partis moved between the fingers and thumb of the examiners hand, to determine whether it is the foetal head or breech
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Naegele's rule?
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(LMP + 1yr 7days) – 3 months
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Gravidity
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Number of pregnancies, including the current one
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Parity
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Number of births beyond 24 weeks gestation (including still births)
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Linea nigra
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dark pigmented line stretching from the xiphi sternum through the umbilicus to the suprapubic area
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striae gravidarum
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recent stretch marks are purplish in colour
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striae albicans
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Old stretch marks are silvery, white
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What is the difference between foetal lie and presentation?
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Lie: what direction the foetal pole is in
Presentation: part of foetus overlying the pelvic brim |
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polyhdramnios
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excess of amniotic fluid in the sac
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Pawlick's manoeuvre
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The presention foetal partis moved between the fingers and thumb of the examiners hand, to determine whether it is the foetal head or breech
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What are the leading causes of death in indigenous women? in order
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1. cardiovascular disease
2. malignant neoplasm 3. endocrine, nutritional, metabolic 4. smoking |
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how do cervical cancer rates in indigenous women compare to their non indigenous counterparts?
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5x
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what is the prevalence of cervical cancer in indigenous women?
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10.2%
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Indigenous mothers:
Age? Delivery method? |
Younger. 24.8yrs is average
Less likely to be induces, less likely to have CS |
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What are the socioeconomic complications of teen mothers?
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<15 biologically immature
>15: poor preconception health care Poor education= financial difficulties socially vulnerable and stigmatised |
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what % of indigenous mothers smoke?
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57%
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maternal mortality, indigenous vs non-indigenous?
|
2x as many indigenous
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what is the average distance an indigenous mother travels to deliver?
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4 hours
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What % of indigenous mothers travelling to give birth, birth en route?
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12%
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Low birth rate risk factors
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socioeconomic disadvantage
size & age of mother mothers nutrition illness during pregnancy duration of pregnancy drugs: EtOH, tobacco, others |
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What is unique about STI's in indegnous women?
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1/4 of women in remote communities have an STI
They present acutely: - disseminated gonococcal infection - PID - ICU admission for the complication of sepsis |
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How much of a problem is domestic violence in indigenous populations?
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24% of ASTI>15yrs have been the victim of threatened or physical violence
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Risk factors for domestic violence?
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being young
being removed from your family unemployment poverty |
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What kind of incontinence is treated with retraining?
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urge incontinence
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How do you treat stress incontinence?
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pelvic floor exercises
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If pelvic floor muscles fail to manage incontinence, what is your next step?
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Stress incontinence:
- Uridynamics - Surgical sling |
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If you have mixed type urinary incontinence, which do you treat first?
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Treat urge first (retraining, anticholinergics) then stress
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What happened in an overactive bladder?
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detruser over activity: urge incontenence
involuntary leakage of urine |
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What are pregnancy risk factors for incontinence?
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Large baby: >4000g
3rd degree tear forcepts long second stage |
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Which routine test gives you a clinical suspicion of urge incontinence due to overactive bladder?
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stress provocation test
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What is urodynamics?
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Pressure flow study to work out detrusor pressure
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How do you work out detrusor activity in urodynamics?**
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pressure in bladder= abdominal pressure+detrusor pressure
use a abdominal line (vaginal/rectal) and a bladder line and then subtract to get the detrusor pressure |
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when is improvement seen after commencing pelvic floor muscle exercises in stress incontinence?
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1 week
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what are the drugs used to treat OAB?
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antimuscarincs/ anticholinergics:
propanthene, oxybutin, solifenacin tricyclic antidepressants |
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define premature
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born before 37 weeks
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define preterm
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not in labour
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prevalence or premature labour?
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7.5%
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risk factors for prematurity?
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Multiple births is the big one! IVF
PROM spontaneous preterm labour cervical incompetency IUGR Pre-eclampsia Antepartum haemorrhage |
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Long term effects of prematurity
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Chronic lung disease
Neurological deficit: hearing, vision, epilepsy, cerebral palsy |
