Obstetrics in Flow Charts - Revision Summary

This slide show should be an easy way to cover almost all of the obstetric information you will need for your final exams.

Transcript

1. Obstetrics by Flow Diagrams Summary Jacob Matthews jake04030@hotmail.com Please share via @JakeMat91 – And get in touch! 06/05/2015 1
2. • Contents • Pregnancy – medical conditions • Emergencies • Infections • Miscarriages + still births • TOP • Induction • C-sections • Normal Labour • Antenatal care • Post natal care 06/05/2015 2
3. Obstetric hx ICE Any questions? Patient details Age + parity + Current preg weeks First? Surprise? Attitude to pregnancy? Menstrual LMP + bleeding days + regular + length + Normal Contraception Hx Present Preg General health, smoking Antenatal care? Fetal movements? Past Obstetric hx How many? Date + place Mode, problems, length Baby sex, weight, health 3rd stage problems? PMHx + PSHx FHx + SHx Smoking drugs drinking Hereditary conditions = HT diabetes Occupation + Partner Drug Hx Chronic, otc, allergies Ex general abdo Lie, vertex, Presentation, Position, engage SFH + doppler 06/05/2015 3
4. Pregnancy Conditions Pre-eclampsia HELLP Obstetric Cholestasis Diabetes Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple pregnancies 06/05/2015 4
5. HT Pre-existing HT (rBP) <20/52 BP> 140/90 STOP ACEi, Labetalol, nifedipine Deliver <40/52 Gestational HT >20/52 >140/90 Labetalol, Aspirin <16/52 BP weekly, USS 2-4 weekly Pre-elampsia HT, Proetinuria >0.3g, Oedema + IUGR Aspirin, delivery 37/52 Uterine artery Doppler 23/52 ? Admission Crap spiral arteries – thinks bleeding >160/110 Severe Headache, N+V, Epigastric pain, Sudden Oedema ? Admit <34/52 Steroids+ C- section >34/52 induce labour Monitor 24h – fluid, discharge on B-blocker Seizure, HELLP, Pain MgSO4 iv infusion Delivery ASAP, steroids 06/05/2015 5 BP should reduce 2nd trimester Cardiac output+ blood volume + GFR + Tidal Volume increases by 40%
6. Pregnancy Conditions Pre-eclampsia Obstetric Cholestasis Diabetes Pre-Existing 1 Increase insulin >resistance HbA1c <48 mmol/mol (6.5%) Stop ACEi + Statins Methyldopa, Labetalol, nifedipine Aspirin >4kg C-section <39/52 Screen Retina + kidneys Blood glucose 2/52 <34/52 Then weekly 2 Metformn aspart / lispro Short isophane insulin Long Stop Oral hypoglycaemics Gestational Fasting >7 mmol 18, 24, 28/52 OGTT 2h >7.8 Metformin Insulin Stop at birth OGTT 3/12 Urine dip Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple pregnancies 06/05/2015 6
7. Pregnancy Conditions Pre-eclampsia Obstetric Cholestasis Diabetes Epilepsy Cardiac Valve Repair > pregnancy Failure Pregnancy caution Stop ACEi, diuretics, warfarin LMWH > warfarin Forceps delivery reduce strain Eisenmenger’s Pregnancy Contra-Indicated Arrhythmia Physiological changes Anaemia Hypothyroidism Asthma VTE Multiple pregnancies 06/05/2015 7 http://www.patient.co.uk/doctor/eisenmengers-syndrome
8. Pregnancy Conditions Pre-eclampsia Obstetric Cholestasis Diabetes Epilepsy Anaemia Thyroid Hypo Anovulation Prem, Miscarriage, low IQ, pre-eclampsia Thyroxine TSH monitor 6/52 Hyper anovulation Foetal thyrotoxicos, goitre Thyroid storm propylthiouracil Neonatal hypo Are NOT altered TSH increased 1st trimester PP thyroiditis Post natal depression Asthma VTE Multiple pregnancies 06/05/2015 8
9. Pregnancy Conditions Pre-eclampsia Obstetric Cholestasis Diabetes Epilepsy Anaemia Hypothyroidis m Asthma Prothrombotic VTE LWMH Anti- phospholipid Lupus anticoagulant Anti- cardiolipin Aspirin + LMWH Anti-Thrombin def LMWH Factor V Leiden Protein C/S def Multiple pregnancies 06/05/2015 9
10. Pregnancy Conditions Pre-eclampsia Obstetric Cholestasis Diabetes Epilepsy Renal Anaemia Hb <11, Severe <7 Booking , 28 + 36/52 100mg Ferrous Sulphate IV FE <9 Blood Transfusion Hyrdops Fetalis Sickel cell, Thalassemia 5mf Folic acid + Abx Treat as high risk Creatinine >200 Contra-indicated physiology GFR increases Urea + creatinine decrease UTI Prem, Pyelonephritis, Nitrofurantoin Asymptomatic Nitrofurantoin Hypothyroidism Asthma VTE Multiple pregnancies 06/05/2015 10
11. Pregnancy Conditions Pre-eclampsia Liver Acute Fatty Liver Intrahepatic cholestasis Itchy, ?jaundice, Fhx, rLFT Still birth + Prem Vit K >35/52, Ursodeoxycholic acid Obstetric Cholestasis Diabetes Epilepsy Anaemia Hypothyroidism Asthma VTE Multiple pregnancies 06/05/2015 11
12. Puerperium Placental delivery – 6/52 Uterus shrinks 4/52 – blood stained discharge Offensive? - infection Tazoscin PP thrombophilia Raised platelets + clotting factors PPH >500ml <24h, >1000ml C- section Tone, Trauma, Tissue, Thrombin Prevent - Syntometrin, Traction ABCDE, FBC, G+S, X-Match, Fluids Blood transfusion Treat the cause Bimanual compression Oxyotocin + ergometrin Rush Balloon Uterine artery embolization 2 >24h, Tissue or infection Endometritis - ABx Breast feeding Prolactin – Milk, Oxytocin – ejection Cholustrum 3/7 – Ig + Fat Foremilk = Fat, Hind = Filling Contraception IUD – same day POP - >4/52 COP > breast feeding Psych Baby blues PND Psychosis - admit 06/05/2015 12
13. Pregnancy Emergencies Pre- eclampsia HELLP Seizures ABCDE Diazepam Shoulder Dystocia HELPERR Cord Prolapse Tocolytic All fours Emergency C -section Amniotic Fluid Emboli ABCDE Crash call ITU Support/ ?delivery Uterine Rupture ABCDE Emergency Laparotomy Uterine Inversion Push it back in Emergency surgery 06/05/2015 13
14. C-Section Categories 1 Immediate threat to life of woman/ foetus <30 mins 2 Compromise not immediate threat 2 life <75 mins 3 No compromise but needs early delivery 4 elective 39/52 06/05/2015 14 http://www.nice.org.uk/guidance/cg132/chapter/guidance
15. Small for date baby <10th centile <3rd severe Constitutional 2/3 Maternal height, ethnicity Abdo circumference or estimated fetal weight x2 3/52 Umbilical artery Doppler – reduced placental blood flow IUGR 1/3 Slowed growth in utero 2xUSS Stop smoking, give aspirin >16/52 Steroids, plan delivery at 37/52 Symphysial fundal height >24/52 Low PAPP-A 1st trimester, high risk http://www.patient.co.uk/doctor/intrauterine-growth-restriction 06/05/2015 15
16. Pregnancy Drugs 24 – 34/52 Dexamethasone Salbutamol, terbutalin, nifedipine Peri-labour Oxytocin im misoprostol ARM Syntometrin - ergometrine Analgesia Anti-D <72h, baby +ve, mum - ve 06/05/2015 16
17. PROM <37/52, APH Diabetes, IUGR, Pre-eclampsia, rBP, 37/52 Induction >41/52 Bishop’s score <13 Membrane sweep Bishop’s score – cervix ripeness >8 PG pessary, Bishop’s <4 Misoprostol x3 ARM Oxytocin Still birth risk doubles 43/52 http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm 06/05/2015 17
18. EGG + Sperm M23Ch + F23Ch Normal zygote O +23 F 23 x2 Complete Mole Hyperemesis, bleeding Urine Preg test + bHCG, histology M23 + F23 + F23 Partial Mole Suction + Curetage, histology, bHCG Choriocarcinoma - Methotrexate http://www.patient.co.uk/doctor/gestational-trophoblastic-disease Father DNA = Parasitic No viable foetus Invasive mole Choriocarcinoma 06/05/2015 18
19. http://en.wikipedia.org/wiki/Hyperemesis_gravidarum 06/05/2015 19
20. Infections Pregnancy Teratogenic Rubella Deafness, sight, brain, heart CMV IUGR, rash, cataracts, deafness, epilepsy Toxoplasmosis Chorioretinits, Intracerebral calcification, hydrocephaly VZV Limb hypoplasia, skin scarring, deaf, delay Listeria Miscarriage, Prem, Meconium, Brain bleed, pneumonitis Any time Chlamydia BV, TV Parvovirus Haem anaemia, Fetal hydrops, IU death Birth Herpes simplex Skin, encephalitis Group B Haem Strep Septicaemia – Ben Pen HIV C-section, zidovudine, HAART, 06/05/2015 20
21. Pregnant Lateral pain + Bleeding + low BP bhCG 48h apart <50% or >63% change - refer bHCG + TV USS Anti-D Methotrexate HCG<1500, <35mm mass, no HR >3-6/12 before next pregnancy Diagnostic Lap bhCG>5000, HR, >35mm mass salpingECtomy salpingOStomy FBC, G+S, x-Match 06/05/2015 21 http://www.patient.co.uk/doctor/ectopic-pregnancy-pro
22. Down’s Screening Booking 10- 13/52 11-14/52 USS - NT PAPP-A Low BhCG – raised (3xCh21) Anomaly scan 18-20/52 <20/52 BhCG - raised Inhibin - raised AFP - low Estrodiol - low 06/05/2015 22
23. PROMS Pre-term <37/52 Admit, Temp Abx, deliver 1/3 – spontaneous delivery Steroids 2/3 delay to >34/52 Erythromycin 10/7 Do no do PV exam Pre-labour (term) Wait 24h Induce - PG GBS swab 06/05/2015 23 http://www.nice.org.uk/guidance/cg132/chapter/guidance
24. Miscarriage <12/52 Chromsomes AntiPhospholipid – placental clot Aspirin + LMWH thrombophilia >16/52 - structural Smokers Short cervix CIN – loop excision 06/05/2015 24
25. Pregnant – bleed <24/52 Threatened – closed Os Normal Birth Premature Birth Complete Miscarriage Inevitable – Open Os Compete Miscarriage 06/05/2015 25
26. Threatened miscarriage – PV bleed Expectant 7-14 days should bleed Medical Vaginal misoprostol Anti-D >12/52, again at 6/52 Anti-D any time if instruments Surgical Manual vacuum - LA 06/05/2015 26
27. A = abruption P = Praevia H = haemorrhage of Vagina Pregnant – bleed >24/52 Placenta praevia >20/52, painless <2cm 32/52, accrete, increta, percreta Planned C-section 39/52 >2cm Normal delivery Placental abruption, PAINFUL Woody 1/100, Fetal death 30% Induce labour Ex + CTG + USS A-E, Steroids, Anti-D, Conservative /C- section Still birth Dies in utero <24/52 DO NOT register Ante-partum haem 06/05/2015 27
28. Emergency contraception not covered Abortion act A <40/52 Grave risk to life of women In emergency only need 1 Dr B <40/52 Prevent grave permanent mental or physical health C <24/52 Continuing > risk than TOP to woman D <24/52 Risk to existing children E <40/52 Risk that child will be substantially handicapped Legal issues 2 registered medical practioners 06/05/2015 28
29. TOP <7/52 - Medical 200mg mifepristone Shed endometrium Misoprostol 800mcg Opens Os + contraction 7 – 15/52 Medical Suction <12/52 >15/52 Dilation + evacuation Medical + KCl Legal issues Abx + blood test 06/05/2015 29