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130 Cards in this Set
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Definition of antepartum haemorrhage
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A significant bleed from the birth canal after 20 weeks
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Incidence of antepartum haemorrhage
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2-5%
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Risk factors for antepartum haemorrhage?
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Previous pelvic surgery
Multiparity Prior placenta previa >35yrs Asian ethnicity Smoking |
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Most common cause of antepartum haemorrhage? incidence of it?
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Placental abruption
incidence: 4% |
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indications for US in first trimester?
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Threatened abortion
History of recurrent abortion Suspected ectopic Hyperemesis gravidium |
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indications for US in the third trimester?
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Antepartum haemorrhage
Placental localisation Clinical polyhdramnios Multiple pregnancy Diabetes, renal disease Malpresentation IUGR High risk pregnancy |
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What is the definition of low lying placenta?
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~2cm away from the internal os
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Anti D: when is it given for pregnancy?
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Sensitising event or prophylaxis
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What sensitising events require the administration of AntiD in pregnancy?
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Miscarriage
Termination Ectopic pregnancy Chorionic villus sampling Amniocentesis Cordocentesis Foetoscopy Abdominal trauma Antepartum haemorrhage: concealed or revealed External cephalic version |
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what dose of Anti-D should be given after a sensitising event in the first trimester?
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250 IU (50ug)
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what dose of Anti-D should be given after a sensitising event AFTER the first trimester?
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650 IU (125ug)
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When is antenatal prophylaxis given for isomunization? what is given? dose?
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28 and 34 weeks
Anti-D 625IU (125ug) |
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When should Anti D be given prophylactically?
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All Rh -ve mothers with a Rh +ve baby
Give: 625IU (125ug) |
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How much blood transfer for 625IU (125ug) cover?
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12 mls of whole blood, or over 6mls foetal red blood cells
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Who should receive antepartum corticosteroids?
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all pregnant women between 24 and 34 weeks who are at risk of preterm delivery within 7 days
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What corticosteroids are used for women at risk of preterm labour?
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Dexamethasone 6mg IM every 12 hours for four doses
Betamethasone 12mg IM every 24 hours for two doses |
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Can a woman with placenta previa be managed out of hospital?
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Any antepartum bleeding MUST be admitted to hospital.
Once stabilised... Home based care requires close proximity to the hospital, the constant presence of a companion and full informed consent by the woman. |
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When can a placenta previa be trialled for labour?
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when the placental edge is more than 2cm away from the internal os at the time of delivery
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when should uncomplicated placenta previa be delivered?
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38-39 weeks gestation
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when should women at high risk of placenta acreta be delivered?
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36-37 weeks with steroid cover
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what is a patient with a placenta overlying a past c-section scar be at risk for?
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placenta acreta
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How common is abnormal glucose regulation in pregnancy?
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3-10%
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what happens insulin levels in normal pregnancy?
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They are maintained, despite resistance to insulin increasing normally in pregnancy. This occurs because beta cells compensate for the increased resistance.
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risk factors for gestational DM?
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1. age
2. obesity 3. smoking 4. PCOS 5. non-white ancestry 6. fx DMII 7. low-fibre and high-glycaemic index diet 8. weight gain as a young adult 9. lack of exercise 10. prior GDM |
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how often does GDM recur?
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80%
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Why is diabetes more common in pregnancy?
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products of the placenta are thought to play key roles in inducing maternal insulin resistance
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when is insulin resistance most marked in pregnancy?
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third trimester
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what foetal disturbances are associated to GDM?
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macrosomia
fetal hypoxia adrenal associated problems: HTN, cardiac remodelling, hypertrophy miscarriage birth defects |
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what is the % increase in miscarriage in GDM?
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9-14%
long standing DM: 44% |
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neonatal complications of GDM?
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hypoglycaemia
hyerbilirubinaemia: JAUNDICE hypocalcaemia |
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when do you have a IUGR baby in a diabetic mother?
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in pre-existing diabetes, not GDM
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childhood risks of GDM?
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Obesity
Metabolic syndrome: glucose intolerance, hyperinsulinaemia, THN, dyslipidaemia |
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GDM: what is the % of macrosomia?
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15-40%
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how common is GDM recurrence?
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80%
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will mother with GDM go onto have DMII?
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not necessarily, only 30%
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Do most women require insulin for GDM?
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Nope. 50% control by diet and exercise alone
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Target blood glucose in GDM
a. fasting b. 1hr postprandial c. 2hr postprandial |
fasting: <5.3 mmol/l
1hr: <7.8 mmol/l 2hr: <6.7 mmol/l |
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what drug therapies are available for GDM?
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Insulin: very short acting best
Metformin: no widely used, 50% still require insulin as well. |
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how often should a GDM mother check her BG?
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initially: 4x day
reduce the frequency when glycaemic control is satisfactory |
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Is metformin contraindicated in pregnancy?
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no
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what are the most common types of tumours of the uterus?
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fibroids: leiomyoma
BENIGN |
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what is the structure of a typical fibroid?
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round
firm well circumscribed nodule |
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Risk factors for fibroids?
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Age
Obesity infertility alcohol african ethnicity |
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is smoking a risk factor for fibroids?
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no, it appears to be the opposite
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what are the three types of uterine fibroids?
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subserosal
intramural submucosal |
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can fibroids exist outside the uterine cavity?
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they can occur in ligaments and in the cervix
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when do you treat fibroids?
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when they cause symptoms
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symptoms of fibroids?
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Menorrhagia (if submucosal)
Pelvic pain/ pressure Dysmenorrheoa Bloating Infertility constipation urinary incontinence |
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medical treatment of fibroids, fertility not desired
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GnRH agonist
mifepristone Mirena NSAIDs COCP |
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which treatment for fibroids is restricted to 6 months, why?
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GnRH agonists: causes osteoporosis
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which contraception option can causes reversible osteoporosis?
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depoprovera
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surgical options for treatment of fibroids, and which is preferred by patients?
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myomectomy
uterine artery embolisation hyesterctomy- pt preference |
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how do you diagnose dysfunctional uterine bleeding?
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diagnosis of exclusion
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symptoms of DUB?
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menorrhagia, is the cause in 50-60% of women
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what is the age cut off for investigating DUB with a scan before treatment?
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40yrs
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first line medical mgt's of regular DUB?
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1. antifibrinolytics: tranexamic acid
2. Mirena 3. COCP 4. NSAIDs |
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first line medical mgt's of irregular DUB?
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same as regular, with the addition of cyclical progesterone therapy, which is useless in regular DUB
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when first line medical therapies have failed in DUB, what further medical treatment may be used?
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GnRH agonist: limit to 6-12 months
High-dose progesterone: time limited as well due to side effects |
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surgical management of DUB?
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1. endometrial ablation
2. hysterectomy |
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Causes of day 1 jaundice
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Haemolytic anaemia
Extravasation of blood Polycythaemia ABO mismatch Rhesus disease Sepsis |
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describe physiological jaundice
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day 3 -10
usually benign |
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serum bilirubin
>150- mgt? >500- mgt? |
>150: phototherapy
>500: exchange transfusion |
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serum bilirubin >500, concern?
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Kernicterus (auditory nerve, basal ganglia, cerebral palsy)
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factors that are likely to make physiological jaundice worse?
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prematurity
bruising- cephalohematoma polycythaemia delayed passage of meconium breast feeding being chinese |
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What is involved in an antenatal exam?
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General appearance
Cardio exam - pulse, bp Resp exam Thyroid exam Abdomen |
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How do you do a palp?
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dont forget fundal height too and auscultate from 12 wks
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What do you start thinking about at 36 wks?
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Lie, presentation, position (mostly in labor), engagement
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When should you do a vaginal exam?
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only if need smear or discharge, active bleeding
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What are the risks of smoking? how common is it to smoke in pregnancy?
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Major risks of heroin/opiates?
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Are there any effects of cannabis on development?
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supposedly cognitive at 3 years, shorter at 6 years and hyper at 10...
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What are the adverse effects of cocaine in pregnancy?
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Effects of amphetamines?
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What are the risks of alcohol?
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spontaneous abortion
IUGR Dev delay Fetal alcohol syndrome only proven for >12 std drinks/day but dont know so abstain if can |
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What are the features of fetal alcohol syndrome?
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How do babies get Hep B from mum, what can we do about it?
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How common is vertical transmission of hep c? How is it managed?
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What are the two types of NAS?
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What is the timing of presentation for heroin vs methadone?
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How do you treat NAS?
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What is involved in examination of the neonate? - 3 sided card
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2 signs that jaundice is pathological?
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present on day one or lasts more than 14 days
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What causes the physiological jaundice?
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Are breastfed babies more or less likely to be jaundice?
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more
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What is conjugated vs unconjugated BR? (lab test)?
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unconjugated has conjugates SBR below 30
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Onset of unconjugated Br within 24 hrs - differential?
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Differential with onset of conjugated within 24 hrs?
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What is the ddx for unconjugated lasting more than 14 days?
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Ddx for conjugated lasting more than 14 days?
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What are the important points in a history for neonatal jaundice?
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When can jaundice be clinically detected?
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over 90mmol/l
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What are the risks of bilirubin to baby?
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What increases the risk of kernicterus?
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Causes of antepartum haemorrhage?
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obstetric
cervical vaginal GI Urinary |
Cervical
Cervicitis Neoplasm Polyp Vaginal Trauma Neoplasm GI bleed Urinary tract bleed OBSTETRIC Bloody show Placental abruption Placenta previa Vasa previa Uterine rupture |
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Risk factors for placental abruption?
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Hypertension
Smoking Alcohol use Trauma Short umbilical cord Prolonged rupture of membranes Previous abruption Age <20 or >35 |
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What is the presentation of placental abruption?
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Rapid contractions
Uterine pain Abdominal tenderness Vaginal bleeding (sometimes) Disproportionate uterine enlargement Pallor |
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Maternal consequences of placental abruption?
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Blood loss (may require transfusion)
Decreased uterine contraction |
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Fetal consequences of placental abruption?
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Foetal distress
Possible foetal death Premature delivery Low RBC count, O2 sat Possibility of brain damage |
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What are the risk factors for placenta pre via?
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Multiparity (especially closely spaced)
Age <20 or >30 Large placenta (i.e. twins) Previous placenta previa, cesarean delivery, or D&C |
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presentation of placenta pre via? is it painful?
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vaginal bleeding after 24wks
PAINLESS |
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Risk factors for vasa previa?
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velamentous cord insertion, multiparity
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Presentation of vasa pre via?
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similar to placenta previa
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Consequences of vasa pre via?
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rapid fetal exsanguination (its the babies blood)
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Risk factors for uterine rupture?
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Uterine scar from previous surgery
Dysfunctional labor Labor augmentation Multiparity |
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Presentation of uterine rupture?
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Surgical wound dehiscence
Abdominal pain Vaginal bleeding Reduced FHR |
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What are the indications for obstetric ultrasound?
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Diagnosis and confirmation of early pregnancy
Vaginal bleeding in early pregnancy Determination of gestational age and assessment of fetal size Diagnosis of fetal malformation Placental localization Multiple pregnancies Hydramnios/oligohydramnios Other areas Investigation of pathological processes Confirmation of fetal presentation Evaluating fetal movements, tone, and breathing Diagnosis of uterine/pelvic abnormalities |
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What are the effects of rhesus isoimmunisation?
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Hemolytic anemia
Jaundice, kernicterus Numerous erythroblasts in fetal circulation Generalized oedema (hydrops fetalis) Enlargement of fetal liver & spleen Severe anemia may result in cardiac failure with widespread oedema, ascites and pleural effusion. |
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When do you check anti-d antibodies?
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28 and 34 wks and if mum is negative and no antibodies give anti-D at 28 and 34 wks, within 72 hrs of sensitising event and postpartum
Avoid sensitisation is the goal |
remember first baby not really at risk because IgM can't cross placenta...
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What do you do if mum is already sensitised?
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Follow maternal antibody titres:
18-20wks – q4 weeks After 34 weeks – q1-2 weeks <10 IU/ml – serial u/s, manage expectantly monitor for anaemia via middle cerebral artery doppler peak velocity If peak systolic velocity of MCA increased perform fetal blood sampling If fetal haematocrit <30, blood transfusion into umbilical vein Repeat transfusion every 2 weeks or when MCA becomes abnormal Consider induction at 38-39 weeks, if cervix favorable |
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Risk factors for Rh sensitivity?
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- Mismatched blood transfusion
- pregnancy - Abortion - Miscarriage - Ectopic pregnancy - Obstetric haemorrhage - Amniocentesis, cordocentesis - External cephalic version of a breech presentation, whether successful or not - Abdominal trauma, or any other suspected intra-uterine bleeding or sensitising event |
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Who should be offered antinatal steroids?
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Clinicians should offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation who are at risk of preterm birth.
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Antenatal steroids are associated with a significant reduction in rates of neonatal death, RDS and intraventricular haemorrhage and are safe for the mother.
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Are tocolytics worthwhile?
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There is no clear evidence that tocolytic drugs improve outcome and therefore it is reasonable not to use them. However, tocolysis should be considered if the few days gained would be put to good use, such as completing a course of corticosteroids or in utero transfer
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What tocolytics are used?
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Nifedipine (Ca channel blocker)
Indomethacin (prostaglandin synthesis inhibitor) Magnesium sulphate – conflicting RCT evidence |
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What is the deal with antibiotic use?
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Use in presence of ruptured membranes, <37weeks gestation
Erythromycin 250mg qid orally for 10 days Reduces chorioamnionitis (RR 0.66, CI 0.46-0.96) Reduces babies born within 48 hours (RR0.71, CI 0.58-0.87) and 7 days (RR 0.79, CI 0.71-0.89) Reduces neonatal infection, use of surfactant, oxygen therapy and abN cerebral USS prior to discharge from hospital NO difference in perinatal mortality or long term outcome (7 years follow up) |
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Why use magnesium sulphate?
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In women at risk of early preterm imminent birth, use MgSO4 for neuroprotection of fetus, infant, child
When gestational age < 30 wks When early preterm birth is planned or definitely expected within 24hrs. (when birth is planned, commence MgSO4 as close to 4 hrs before birth as possible No evidence of benefit after 34 wks gestation Reduces risk of cerebral palsy < 34 weeks gestation (RR 0.68, CI 0.54-0.87) •Reduces rate of substantial gross motor dysfunction (RR0.61, CI 0.44-0.85) •NNT to prevent one case of CP = 63 (CI 43-155) |
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What is abnormal uterine bleeding?
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What is heavy menstrual bleeding?
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HMB is defined as menstrual blood loss greater than 80 mL.
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What is anovulatory menorrhagia due to?
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unopposed estrogen
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What are the causes of pain that are potentially lethal vs not so urgent?
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What is chronic pelvic pain?
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more than 6 mths pain in lower abdo or pelvis not occuring exclusively with menstration, sex or in pregnancy
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What are some causes of chronic pelvic pain?
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Endometriosis
Adhesions (chronic PID, surgery) Adenomyosis Leiomyoma Ovarian cyst/tumour Vaginal or uterine infection/inflammation Uterine prolapse Somatisation Psychosexual dysfuction UTI / calculus / cystitis / detrusor overactivity Degenerative joint disease / osteitis pubis / scoliosis Faciitis / nerve entrapment / herniae |
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What are the guidelines for diabetes screening in pregnancy?
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What are the cut offs for BGL?
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cut offs: Fasting <5.1, 1hr <10.0, 2hr <8.5
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What is the significance of gestational diabetes after delivery?
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Repeat OGTT 6-12 wks post partum PLUS ongoing surveillance
30% chance recurrence with subsequent pregnancy 50% chance TIIDM in next 10-20 years |
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Who is at risk of GDM?
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COMMON – 1/20 PREGNANCIES!!
Previous GDM Previous raised BSL Ethnicity – Asian, Indian, **ATSI, Pacific Islander, **Maori, Middle Eastern, Non-white African Maternal age > 40 years FHx of first degree relatives with DM/GDM Obesity **BMI >35 Previous macrosomia PCOS Meds that cause metabolic derangement – steroids, antipsychotics |
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What are the complications of GDM?
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How often should you take BGL in these women in labour?
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Monitor BGLs 1-2hrly during labour. +/- insulin infusion (NB: breast feeding – measure pre and post)
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What are the treatment targets?
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FBG: =/<5.0 mmol/L
1 hr post prandial: =/<7.4 mmol/L 2 hr post prandial: =/< 6.7mmol/L |
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What additional scans should diabetic women have?
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Morphology at 18-20/40
Cardiac views at 24/40 Fetal growth 28-30/40 and 34-36/40 |
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The gist of preeclampsia?
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