AKT O&G 2 Flashcards
What is antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus
Antepartum haemorrhage can indicate various complications during pregnancy.
What are the characteristics of placental abruption?
- Shock out of keeping with visible loss
- Constant pain
- Tender, tense uterus
- Normal lie and presentation
- Fetal heart: absent/distressed
- Coagulation problems
- Beware pre-eclampsia, DIC, anuria
Placental abruption is a serious condition that requires immediate medical attention.
What are the characteristics of placenta praevia?
- Shock in proportion to visible loss
- No pain
- Uterus not tender
- Lie and presentation may be abnormal
- Fetal heart usually normal
- Coagulation problems rare
- Small bleeds before large
Placenta praevia typically poses different risks compared to placental abruption.
True or False: In cases of suspected antepartum haemorrhage, a vaginal examination should be performed in primary care.
False
Vaginal examinations can exacerbate bleeding in women with placenta praevia.
Fill in the blank: In placental abruption, the fetal heart may be _______.
absent/distressed
This indicates potential fetal distress which may require urgent intervention.
Fill in the blank: In placenta praevia, the uterus is usually _______.
not tender
A tender uterus may indicate placental abruption rather than praevia.
What complications should be considered with placental abruption?
- Pre-eclampsia
- Disseminated intravascular coagulation (DIC)
- Anuria
These conditions can complicate the clinical picture and management of placental abruption.
What does the shock level indicate in placental praevia?
Shock is in proportion to visible loss
This is an important distinguishing feature from placental abruption.
What is a common pattern of bleeding in placenta praevia?
Small bleeds before large
This pattern can help in identifying placenta praevia during assessments.
What is antepartum haemorrhage?
Bleeding after 24 weeks of pregnancy
Antepartum haemorrhage can indicate serious complications and requires prompt evaluation.
List three causes of bleeding in the 1st trimester of pregnancy.
- Spontaneous abortion
- Ectopic pregnancy
- Hydatidiform mole
Each of these conditions presents with different clinical features.
List three causes of bleeding in the 2nd trimester of pregnancy.
- Spontaneous abortion
- Hydatidiform mole
- Placental abruption
These conditions can have significant implications for maternal and fetal health.
List four causes of bleeding in the 3rd trimester of pregnancy.
- Bloody show
- Placental abruption
- Placenta praevia
- Vasa praevia
These conditions require immediate medical assessment.
What conditions should be excluded alongside pregnancy-related causes of bleeding?
- Sexually transmitted infections
- Cervical polyps
These conditions can also cause bleeding and need to be ruled out.
What is a threatened miscarriage?
Painless vaginal bleeding typically around 6-9 weeks
It indicates a risk of pregnancy loss but does not always result in miscarriage.
What characterizes a missed (delayed) miscarriage?
Light vaginal bleeding and symptoms of pregnancy disappear
This type of miscarriage can go undetected until a routine scan.
What are the features of an inevitable miscarriage?
Complete or incomplete depending on whether all fetal and placental tissue has been expelled
It often involves heavier bleeding and cramping.
What are the symptoms of an incomplete miscarriage?
Heavy bleeding and crampy, lower abdominal pain
It may require medical intervention to manage bleeding.
What describes a complete miscarriage?
Little bleeding
The body has expelled all pregnancy tissue.
What is a common presentation of ectopic pregnancy?
History of 6-8 weeks amenorrhoea with unilateral lower abdominal pain and later vaginal bleeding
Shoulder tip pain and cervical excitation may also be present.
What is a hydatidiform mole associated with?
Bleeding in first or early second trimester with exaggerated pregnancy symptoms
High serum hCG levels and an enlarged uterus for dates are common.
What are the signs of placental abruption?
Constant lower abdominal pain, tender tense uterus, and fetal heart distress
Visible blood loss may not correlate with maternal shock.
What characterizes placenta praevia?
Vaginal bleeding without pain and a non-tender uterus
The lie and presentation of the fetus may be abnormal.
What occurs in vasa praevia?
Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia is classically seen, indicating fetal distress.
What is one bonding advantage of breastfeeding for the mother?
Bonding with the baby
What is a physiological benefit of breastfeeding related to the uterus?
Involution of uterus
Breastfeeding offers protection against which types of cancer?
Breast and ovarian cancer
What is an economic advantage of breastfeeding?
Cheap, no need to sterilise bottles
What contraceptive effect does breastfeeding have?
Contraceptive effect (unreliable)
Which immunological component in breast milk protects mucosal surfaces?
IgA
What is the role of lysozyme in breast milk?
Bacteriolytic enzyme
What does lactoferrin do in breast milk?
Ensures rapid absorption of iron so not available to bacteria
Breastfeeding reduces the incidence of which types of infections?
Ear, chest, and gastro-intestinal infections
What skin condition is less common in breastfed infants?
Eczema
Breastfeeding is associated with a reduced incidence of which chronic condition?
Type 1 diabetes mellitus
What syndrome has a reduced incidence in breastfed infants?
Sudden infant death syndrome
Who is in control of how much milk it takes during breastfeeding?
The baby
What is a disadvantage of breastfeeding related to drug transmission?
Transmission of drugs
What infection can be transmitted through breastfeeding?
HIV
What nutrient inadequacy may result from prolonged breastfeeding?
Vitamin D deficiency
What deficiency can occur in breastfed infants related to vitamin K?
Vitamin K deficiency
What condition can arise due to breast milk?
Breast milk jaundice
What is a common misconception about frequent feeding in a breastfed infant?
Frequent feeding is not alone a sign of low milk supply.
What may cause nipple pain in breastfeeding?
A poor latch may cause nipple pain.
What is a blocked duct also known as?
‘Milk bleb’.
What should be done if experiencing a blocked duct?
Breastfeeding should continue and advice on positioning should be sought.
What treatment is recommended for nipple candidiasis while breastfeeding?
Miconazole cream for the mother and nystatin suspension for the baby.
What percentage of breastfeeding women are affected by mastitis?
Around 1 in 10 breastfeeding women.
When should mastitis be treated according to the BNF?
If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal, or if culture indicates infection.
What is the first-line antibiotic for treating mastitis?
Flucloxacillin for 10-14 days.
What may develop if mastitis is left untreated?
A breast abscess.
What is breast engorgement?
A condition causing breast pain in breastfeeding women, usually occurring in the first few days postpartum.
What complications can arise from breast engorgement?
Blocked milk ducts, mastitis, difficulties with breastfeeding, and reduced milk supply.
How can discomfort from engorgement be relieved?
Hand expression of milk.
What characterizes Raynaud’s disease of the nipple?
Intermittent pain during and immediately after feeding, blanching of the nipple followed by cyanosis and/or erythema.
What lifestyle changes can help manage Raynaud’s disease of the nipple?
- Minimizing exposure to cold
- Using heat packs after breastfeeding
- Avoiding caffeine
- Stopping smoking.
What should be done if a breastfed baby loses more than 10% of their weight in the first week?
Consider the breastfeeding problems and examine the infant for underlying issues.
What does NICE recommend for monitoring poor infant weight gain?
An ‘expert’ review of feeding and monitoring weight until gain is satisfactory.
What is a non-drug contraindication for breastfeeding?
galactosaemia
Galactosaemia is a metabolic disorder that affects the body’s ability to process galactose.
What is a controversial viral infection regarding breastfeeding?
HIV
The controversy arises from the high infant mortality and morbidity associated with bottle feeding in the developing world.
Name 3 antibiotic classes drugs that can be given to breastfeeding mothers for infections.
antibiotics
Examples include penicillins, cephalosporins, and trimethoprim.
Which drug class should be avoided in high doses for breastfeeding mothers?
glucocorticoids can be given in breastfeeding but should be avoided in high doses
High doses may pose risks to the breastfeeding infant.
Identify a drug used for epilepsy that is safe for breastfeeding mothers.
sodium valproate
Another option is carbamazepine.
What is a safe asthma medication for breastfeeding mothers?
salbutamol
Theophyllines are also considered safe.
Which psychiatric drug should be avoided in breastfeeding mothers?
clozapine
Clozapine poses risks to breastfeeding infants.
Name a type of drug used to treat hypertension that is safe for breastfeeding.
beta-blockers
Hydralazine is another safe option.
What anticoagulant can be given to breastfeeding mothers?
warfarin
Heparin is also considered safe.
What is one drug that should be avoided while breastfeeding?
ciprofloxacin
Other antibiotics to avoid include tetracycline and chloramphenicol.
Which psychiatric drug is contraindicated for breastfeeding mothers?
lithium
Benzodiazepines should also be avoided.
Fill in the blank: _______ should be avoided during breastfeeding due to potential risks.
aspirin
Aspirin can have adverse effects on the breastfeeding infant.
Identify a cytotoxic drug that should be avoided while breastfeeding.
methotrexate
Other drugs to avoid include carbimazole and sulfonylureas.
True or False: Amiodarone is safe for breastfeeding mothers.
False
Amiodarone should be avoided due to potential risks to the infant.
What are risk factors for breech presentation?
Uterine malformations, fibroids, placenta praevia, polyhydramnios or oligohydramnios, fetal abnormality, prematurity
Fetal abnormalities may include CNS malformation and chromosomal disorders.
What is more common in breech presentations?
Cord prolapse
Cord prolapse can complicate labor and delivery in breech presentations.
What happens if a fetus is breech at less than 36 weeks?
Many fetuses will turn spontaneously
Spontaneous turning is common before 36 weeks of gestation.
What is the NICE recommendation for breech presentation at 36 weeks?
External cephalic version (ECV) with a success rate of around 60%
ECV is a procedure to turn the fetus from a breech position to a head-down position.
When should ECV be offered to nulliparous women according to RCOG?
From 36 weeks
Nulliparous women are those who have never given birth before.
When should ECV be offered to multiparous women according to RCOG?
From 37 weeks
Multiparous women are those who have given birth before.
What are the delivery options if the baby is still breech?
Planned caesarean section or vaginal delivery
The choice of delivery method can depend on various factors, including maternal and fetal health.
What should women be informed about regarding planned caesarean section for breech presentation?
It carries a reduced perinatal mortality and early neonatal morbidity compared to planned vaginal birth
This information is crucial for informed decision-making in childbirth.
What evidence exists regarding the long-term health of babies with breech presentation delivered at term?
There is no evidence that it is influenced by how the baby is born
This suggests that the mode of delivery may not affect long-term outcomes.
What are the absolute contraindications to ECV according to RCOG?
- Where caesarean delivery is required
- Antepartum haemorrhage within the last 7 days
- Abnormal cardiotocography
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
These contraindications ensure the safety of the mother and fetus during ECV.
What virus causes chickenpox?
Varicella-zoster virus
What condition is caused by the reactivation of dormant varicella-zoster virus?
Shingles
What is the risk to the mother associated with chickenpox in pregnancy?
5 times greater risk of pneumonitis
What is the risk of fetal varicella syndrome (FVS) following maternal varicella exposure before 20 weeks gestation?
Around 1%
List some features of fetal varicella syndrome (FVS).
- Skin scarring
- Eye defects (microphthalmia)
- Limb hypoplasia
- Microcephaly
- Learning disabilities
What is the risk of shingles in infancy if maternal exposure occurs in the second or third trimester?
1-2%
What is the risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth?
Around 20% fatality risk to the newborn
What should be checked if there is doubt about a mother’s previous chickenpox infection?
Maternal blood should be urgently checked for varicella antibodies
What is the first choice of post-exposure prophylaxis (PEP) for pregnant women?
Oral aciclovir (or valaciclovir)
When should antivirals be given after exposure to chickenpox in pregnancy?
Day 7 to day 14 after exposure
What should be done if a pregnant woman develops chickenpox?
Specialist advice should be sought
What do consensus guidelines suggest for pregnant women ≥ 20 weeks presenting within 24 hours of rash onset?
Oral aciclovir should be given
How should aciclovir be considered for pregnant women < 20 weeks who develop chickenpox?
Considered with caution
What is the standard antenatal test for Down’s syndrome?
The combined test
The combined test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A) and should be done between 11 - 13+6 weeks.
What results suggest Down’s syndrome in the combined test?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Similar results can occur for trisomy 18 (Edward syndrome) and 13 (Patau syndrome), but hCG tends to be lower.
When should the quadruple test be offered if women book later in pregnancy?
Between 15 - 20 weeks
The quadruple test includes alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin, and inhibin A.
What are the possible results of the combined or quadruple tests?
Lower chance or higher chance
‘Lower chance’ is defined as 1 in 150 chance or more (e.g., 1 in 300) and ‘higher chance’ is 1 in 150 chance or less (e.g., 1 in 100).
What is offered to women with ‘higher chance’ results?
A second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or CVS)
NIPT is likely preferred due to its non-invasive nature and high sensitivity and specificity.
What does NIPT analyze?
Small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
This analysis allows for early detection of certain chromosomal abnormalities.
What is the sensitivity and specificity of NIPT for trisomy 21?
> 99%
NIPT also has similarly high sensitivity and specificity for other chromosomal abnormalities.
At what gestational age can private companies offer NIPT screening?
From 10 weeks gestation
Companies such as Harmony provide this service.
Interpreting the results of quadrapule tests
Downs: Only one with raised inhibin A and HCG. AFP and unconjugated oestriol low
Edward’s: (everything low), Inhbin A normal
Neural tube defects : AFP raised everything else normal
What is the general consensus regarding the risks of uncontrolled epilepsy during pregnancy versus the risks of medication to the fetus?
The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus.
What should epileptic women thinking about becoming pregnant be advised to take to minimize the risk of neural tube defects?
Folic acid 5mg per day.
What percentage of newborns born to non-epileptic mothers have congenital defects?
1-2%.
What is the percentage of congenital defects in newborns if the mother takes antiepileptic medication?
3-4%.
What is the recommended approach regarding antiepileptic medication during pregnancy?
Aim for monotherapy.
Is there an indication to monitor antiepileptic drug levels during pregnancy?
No indication.
Which antiepileptic drug is associated with neural tube defects?
Sodium valproate.
Which older antiepileptic is often considered the least teratogenic?
Carbamazepine.
What congenital defect is phenytoin associated with?
Cleft palate.
What does current research suggest about lamotrigine and congenital malformations?
The rate of congenital malformations may be low.
What may need to be increased during pregnancy for epileptic women taking lamotrigine?
The dose of lamotrigine.
Is breastfeeding considered safe for mothers taking antiepileptics?
Generally safe, with exceptions for barbiturates.
What supplement is advised for pregnant women taking phenytoin?
Vitamin K in the last month of pregnancy.
What significant risk is associated with maternal use of sodium valproate according to the November 2013 Drug Safety Update?
Significant risk of neurodevelopmental delay in children.
What conclusion does the Drug Safety Update reach regarding the use of sodium valproate during pregnancy?
Sodium valproate should not be used during pregnancy unless clearly necessary.
What should epileptic women of childbearing age not do without specialist neurological or psychiatric advice?
Start treatment with sodium valproate.
What is folic acid converted to?
tetrahydrofolate (THF)
Folic acid is essential for various biochemical processes in the body.
What are good dietary sources of folic acid?
green, leafy vegetables
These foods are rich in folate and contribute to overall health.
What key role does THF play in the body?
transfer of 1-carbon units for DNA & RNA synthesis
1-carbon units include methyl, methylene, and formyl groups.
Name a medication that can cause folic acid deficiency.
phenytoin
Phenytoin is an anticonvulsant that can interfere with folate metabolism.
What is another medication that can lead to folic acid deficiency?
methotrexate
Methotrexate is used in cancer treatment and autoimmune diseases.
Which lifestyle factor can contribute to folic acid deficiency?
alcohol excess
Excessive alcohol consumption can impair the absorption of folate.
What are the consequences of folic acid deficiency?
- macrocytic, megaloblastic anaemia
- neural tube defects
These conditions can have serious health implications, especially in pregnancy.
What is the recommended folic acid intake for all women during pregnancy?
400mcg until the 12th week of pregnancy
This recommendation aims to reduce the risk of neural tube defects.
What is the folic acid dosage for women at higher risk of conceiving a child with a neural tube defect?
5mg from before conception until the 12th week of pregnancy
Higher risk factors include previous NTD-affected pregnancies and certain medical conditions.
List one factor that classifies a woman as higher risk for NTD.
- either partner has a NTD
- previous pregnancy with NTD
- family history of NTD
- taking antiepileptic drugs
- coeliac disease
- diabetes
- thalassaemia trait
- obesity (BMI of 30 kg/m2 or more)
Identifying these risk factors is crucial for preventive health strategies.
What is the prevalence of gestational diabetes in pregnancies?
Affects around 4% of pregnancies
Gestational diabetes is the second most common medical disorder complicating pregnancy after hypertension.
List six risk factors for gestational diabetes.
- BMI of > 30 kg/m²
- Previous macrosomic baby weighing 4.5 kg or above
- Previous gestational diabetes
*first-degree relative with diabetes
*family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
*unexplained stillbirth in a previous pregnancy
What is the test of choice for screening gestational diabetes?
Oral glucose tolerance test (OGTT)
NICE recommends early self-monitoring of blood glucose as an alternative to OGTTs.
When should women with risk factors for gestational diabetes be offered an OGTT?
At 24-28 weeks
This applies to women with any of the specified risk factors.
What are the diagnostic thresholds for fasting glucose to diagnose gestational diabetes?
EITHER OF THE TWO BELOW
Fasting glucose is >= 5.6 mmol/L
2hours post challenge >= 7.8 mol/L
This is one of the criteria updated by NICE.
What should newly diagnosed women with gestational diabetes do within a week?
Be seen in a joint diabetes and antenatal clinic
This is part of the management plan.
What dietary advice should be given to women with gestational diabetes?
Advice about diet including eating foods with a low glycaemic index
This is part of the management strategy.
What should be done if fasting plasma glucose is < 7 mmol/L?
A trial of diet and exercise should be offered
This is an initial management step.
What is the next step if glucose targets are not met within 1-2 weeks of diet/exercise alteration?
Metformin should be started
This is part of the stepwise management approach.
What type of insulin is used to treat gestational diabetes?
Short-acting insulin
Long-acting insulin is not used in this context.
When should insulin be started for gestational diabetes?
If the fasting glucose level is >= 7 mmol/L
This indicates a need for insulin therapy.
What should be offered if plasma glucose levels are between 6-6.9 mmol/L with complications?
Insulin should be offered
Complications may include macrosomia or hydramnios.
Under what conditions should glibenclamide be offered?
For women who cannot tolerate metformin or those who fail to meet glucose targets with metformin but decline insulin treatment
This is a specific management option.
What is the recommended weight loss for women with pre-existing diabetes and a BMI of > 27 kg/m²?
Weight loss
This is part of the management to improve diabetes control.
What should be done for women with pre-existing diabetes regarding insulin?
Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
This is necessary for effective diabetes management.
What is the recommended dose of folic acid for women with pre-existing diabetes?
5 mg/day from pre-conception to 12 weeks gestation
This is to prevent neural tube defects.
What type of scan is recommended at 20 weeks for women with pre-existing diabetes?
Detailed anomaly scan including four-chamber view of the heart and outflow tracts
This is to check for any fetal anomalies.
What does tight glycaemic control reduce in pregnant women with diabetes?
Complication rates
Maintaining tight control is crucial for maternal and fetal health.
What should be treated in women with pre-existing diabetes as it can worsen during pregnancy?
Retinopathy
Monitoring and treatment are important to prevent progression.
What is the target fasting blood glucose level for pregnant women with PRE-XISTING diabetes?
5.3 mmol/l
This target applies to both pre-existing and gestational diabetes.
What is the target blood glucose level 1 hour after meals for pregnant women with PRE-EXISTING diabetes?
7.8 mmol/l
This target is crucial for managing blood sugar levels effectively.
What is the target blood glucose level 2 hours after meals for pregnant women with PRE-EXISTING diabetes?
6.4 mmol/l
Maintaining this level helps prevent complications during pregnancy.
What are gestational trophoblastic disorders?
A spectrum of disorders originating from the placental trophoblast including:
* complete hydatidiform mole
* partial hydatidiform mole
* choriocarcinoma
These disorders arise from abnormal growth of the trophoblastic tissue.
Define complete hydatidiform mole.
A benign tumour of trophoblastic material occurring when an empty egg is fertilized by a single sperm that duplicates its DNA, resulting in all chromosomes being of paternal origin.
This leads to a complete absence of maternal DNA.
List the features of complete hydatidiform mole.
The features include:
* bleeding in first or early second trimester
* exaggerated symptoms of pregnancy (e.g. hyperemesis)
* uterus large for dates
* very high serum levels of human chorionic gonadotropin (hCG)
* hypertension and hyperthyroidism may be seen
Hyperemesis refers to severe nausea and vomiting during pregnancy.
What is the management for complete hydatidiform mole?
Urgent referral to a specialist centre for evacuation of the uterus is performed; effective contraception is recommended to avoid pregnancy in the next 12 months.
This is crucial to prevent complications and monitor for potential choriocarcinoma development.
What percentage of complete hydatidiform moles go on to develop choriocarcinoma?
Around 2-3% go on to develop choriocarcinoma.
Choriocarcinoma is a malignant form of trophoblastic disease.
Define partial hydatidiform mole.
A condition where a normal haploid egg is fertilized by two sperms or by one sperm with duplication of paternal chromosomes, resulting in DNA of both maternal and paternal origin, usually triploid (e.g. 69 XXX or 69 XXY).
Fetal parts may be seen in this condition.
Fill in the blank: In complete hydatidiform mole, all chromosomes are of _______ origin.
paternal
This results from the fertilization of an empty egg.
True or False: Hypertension and hyperthyroidism are commonly associated with complete hydatidiform mole.
True
These conditions can be secondary effects due to elevated hCG levels.
What can human chorionic gonadotropin (hCG) mimic?
Thyroid-stimulating hormone (TSH)
This mimicry can lead to confusion in diagnosing thyroid conditions.
What is Group B Streptococcus (GBS)?
GBS is the most common cause of early-onset severe infection in the neonatal period.
What percentage of mothers are thought to carry GBS?
20-40% of mothers have GBS present in their bowel flora.
How can infants be exposed to GBS?
Infants may be exposed to maternal GBS during labour.
List risk factors for Group B Streptococcus (GBS) infection.
- Prematurity
- Prolonged rupture of membranes
- Previous sibling GBS infection
- Maternal pyrexia (e.g., secondary to chorioamnionitis)
What organization published guidelines on GBS in 2017?
The Royal College of Obstetricians and Gynaecologists (RCOG).
Should universal screening for GBS be offered to all women?
No, universal screening for GBS should not be offered to all women.
Is a maternal request an indication for GBS screening?
No, a maternal request is not an indication for screening.
What should women with a previous GBS detection be informed about?
They should be informed that their risk of maternal GBS carriage in this pregnancy is 50%.
What should be offered to women with a previous baby with early- or late-onset GBS disease?
Intrapartum antibiotic prophylaxis (IAP).
When should swabs for GBS be offered?
Swabs for GBS should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date.
Who should receive IAP regardless of GBS status?
Women in preterm labour.
What should be given to women with pyrexia during labour?
Intrapartum antibiotic prophylaxis (IAP).
What is the antibiotic of choice for GBS prophylaxis?
Benzylpenicillin.
What is offered to all pregnant women regarding hepatitis B?
Screening for hepatitis B
Early detection can help manage the health of both the mother and the baby.
What should babies born to mothers who are chronically infected with hepatitis B receive?
A complete course of vaccination and hepatitis B immunoglobulin
This is crucial for preventing hepatitis B infection in newborns.
What is currently being evaluated for use in the latter part of pregnancy for hepatitis B?
Oral antiviral treatment (e.g. Lamivudine)
This could potentially improve outcomes for mothers and infants.
Does caesarean section reduce vertical transmission rates of hepatitis B?
Little evidence suggests it does
Management strategies may focus more on vaccination than delivery method.
Can hepatitis B be transmitted via breastfeeding?
No
This is an important distinction from HIV, which can be transmitted through breast milk.
What factors reduce vertical transmission of HIV from 25-30% to 2%?
- maternal antiretroviral therapy
- mode of delivery (caesarean section)
- neonatal antiretroviral therapy
- infant feeding (bottle feeding)
These factors significantly lower the risk of HIV transmission from mother to child during pregnancy and delivery.
What do NICE guidelines recommend regarding HIV screening in pregnant women?
Offering HIV screening to all pregnant women
This recommendation aims to identify and manage HIV in pregnant women to reduce transmission risks.
Should all pregnant women be offered antiretroviral therapy?
Yes, regardless of previous treatment status
Antiretroviral therapy is crucial for managing HIV during pregnancy.
What is the recommended mode of delivery for pregnant women with a viral load less than 50 copies/ml at 36 weeks?
Vaginal delivery
If the viral load is higher, a caesarean section is recommended to minimize transmission risk.
What should be done before a caesarean section for a pregnant woman with HIV?
Start a zidovudine infusion four hours before the procedure
This is to ensure that the infant has some level of protection against HIV during delivery.
What is the recommended neonatal antiretroviral therapy if maternal viral load is <50 copies/ml?
Zidovudine administered orally
If the maternal viral load is higher, triple ART should be used instead.
How long should neonatal antiretroviral therapy be continued?
For 4-6 weeks
This duration is essential for effective management of the infant’s exposure to HIV.
What infant feeding practice is advised for women in the UK with HIV?
Not to breastfeed
This recommendation is to prevent potential HIV transmission through breast milk.
What happens to blood pressure during the first trimester of normal pregnancy?
Blood pressure usually falls, particularly the diastolic, and continues to fall until 20-24 weeks.
What occurs to blood pressure after 20-24 weeks of pregnancy?
Blood pressure usually increases to pre-pregnancy levels by term.
What did NICE publish in 2010 regarding hypertension in pregnancy?
Guidance on the management of hypertension in pregnancy.
What should women at high risk of developing pre-eclampsia take from 12 weeks until birth?
Aspirin 75 mg od.
How is hypertension in pregnancy usually defined?
Systolic > 140 mmHg or diastolic > 90 mmHg, or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic.
What is pre-existing hypertension?
A history of hypertension before pregnancy or elevated blood pressure > 140/90 mmHg before 20 weeks gestation.
What characterizes pre-existing hypertension in pregnancy?
No proteinuria, no oedema, occurs in 3-5% of pregnancies, more common in older women.
What should be done if a pregnant woman is taking an ACE inhibitor or ARB for pre-existing hypertension?
These should be stopped immediately, and alternative antihypertensives should be started.
What is pregnancy-induced hypertension (PIH)?
Hypertension occurring in the second half of pregnancy, with no proteinuria or oedema.
What percentage of pregnancies does pregnancy-induced hypertension occur in?
Around 5-7%.
What is the typical resolution timeframe for pregnancy-induced hypertension after birth?
Typically resolves after one month.
What is the risk for women who have pregnancy-induced hypertension?
Increased risk of future pre-eclampsia or hypertension later in life.
What characterizes pre-eclampsia?
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours).
How common is pre-eclampsia in pregnancies?
Occurs in around 5% of pregnancies.
What is the first-line management for hypertension in pregnancy according to the 2010 NICE guidelines?
Oral labetalol.
What alternative medications may be used for managing hypertension in pregnancy?
Oral nifedipine and hydralazine.
What is intrahepatic cholestasis of pregnancy also known as?
Obstetric cholestasis
What percentage of pregnancies in the UK are affected by intrahepatic cholestasis of pregnancy?
Around 1%
What is the associated risk with intrahepatic cholestasis of pregnancy?
Increased risk of premature birth
What is a common symptom of intrahepatic cholestasis of pregnancy?
Pruritus
Where is pruritus typically worse in patients with intrahepatic cholestasis of pregnancy?
Palms, soles, and abdomen
What percentage of patients with intrahepatic cholestasis of pregnancy experience clinically detectable jaundice?
Around 20%
In what percentage of cases is raised bilirubin seen in intrahepatic cholestasis of pregnancy?
> 90%
What is a common management practice for intrahepatic cholestasis of pregnancy?
Induction of labour at 37-38 weeks
Is the management practice of inducing labour at 37-38 weeks evidence-based?
No, may not be evidence based
What medication is widely used in the management of intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid
Is the evidence base for ursodeoxycholic acid clear?
No, evidence base not clear
What supplementation is recommended in the management of intrahepatic cholestasis of pregnancy?
Vitamin K supplementation
What is the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
45-90%
What does Gravida (G) refer to?
The number of times a woman has been pregnant, regardless of the outcome.
Gravida counts all pregnancies, including those that ended in miscarriage or abortion.
What does Para (P) refer to?
The number of pregnancies that have resulted in the birth of potentially viable offspring, typically around 24 weeks of gestation.
Viability may vary based on local standards.
How is a pregnancy with twins counted in Gravida and Para?
The pregnancy is counted as one gestational event for Gravida and as one for Para regardless of the number of viable offspring.
For example, twins would result in G1P1.
If a woman gives birth to twins in her first pregnancy, what is her Gravida and Para designation?
G1P1.
The Para count is incremented by one for each pregnancy that results in a birth, not by the number of babies born.
True or False: Para is counted by the number of babies born.
False.
Para is counted by the number of pregnancies that result in a birth.
What does placenta praevia describe?
A placenta lying wholly or partly in the lower uterine segment
This condition can lead to complications during pregnancy and delivery.
What percentage of women will have a low-lying placenta when scanned at 16-20 weeks gestation?
5%
Most low-lying placentas resolve as the pregnancy progresses.
What is the incidence of placenta praevia at delivery?
0.5%
This indicates that most placentas rise away from the cervix by the time of delivery.
Name three associated factors of placenta praevia.
- Multiparity
- Multiple pregnancy
- Lower segment scar from previous caesarean section
These factors increase the likelihood of abnormal placental implantation.
What are the clinical features of placenta praevia?
- Shock in proportion to visible loss
- No pain
- Uterus not tender
- Abnormal lie and presentation
- Usually normal fetal heart
- Rare coagulation problems
- Small bleeds before large
These features help in assessing the condition of the mother and fetus.
Why should a digital vaginal examination be avoided before an ultrasound in cases of suspected placenta praevia?
It may provoke a severe haemorrhage
Ultrasound is the preferred method for diagnosis.
When is placenta praevia often detected?
During the routine 20 week abdominal ultrasound
This routine screening is crucial for early identification.
What does the RCOG recommend for the diagnosis of placenta praevia?
The use of transvaginal ultrasound
This method improves the accuracy of placental localization and is considered safe.
What is the classical grading of placenta praevia?
- I - placenta reaches lower segment but not the internal os
- II - placenta reaches internal os but doesn’t cover it
- III - placenta covers the internal os before dilation but not when dilated
- IV (‘major’) - placenta completely covers the internal os
This grading system helps assess the severity of the condition.
What is placental abruption?
Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space.
What is the approximate incidence of placental abruption in pregnancies?
Occurs in approximately 1/200 pregnancies.
What are some associated factors for placental abruption?
- Proteinuric hypertension
- Cocaine use
- Multiparity
- Maternal trauma
- Increasing maternal age
What are the clinical features of placental abruption?
- Shock out of keeping with visible loss
- Constant pain
- Tender, tense uterus
- Normal lie and presentation
- Fetal heart: absent/distressed
- Coagulation problems
- Beware pre-eclampsia, DIC, anuria
True or False: The cause of placental abruption is well known.
False
Fill in the blank: Placental abruption results in maternal _______ into the intervening space.
haemorrhage
What clinical sign indicates a serious condition in placental abruption?
Shock out of keeping with visible loss.
What does a tender, tense uterus indicate in the context of placental abruption?
It is one of the clinical features of placental abruption.
What should be monitored in patients suspected of placental abruption?
- Fetal heart
- Coagulation problems
- Signs of pre-eclampsia
- DIC
- Anuria
What is postpartum haemorrhage (PPH)?
Blood loss of > 500 ml after a vaginal delivery
PPH may be primary or secondary.
What is primary postpartum haemorrhage?
Occurs within 24 hours after delivery
Affects around 5-7% of deliveries.
What are the 4 Ts that cause primary PPH?
- Tone (uterine atony)
- Trauma (e.g. perineal tear)
- Tissue (retained placenta)
- Thrombin (e.g. clotting/bleeding disorder)
The vast majority of cases are due to uterine atony.
List some risk factors for primary PPH.
- Previous PPH
- Prolonged labour
- Pre-eclampsia
- Increased maternal age
- Polyhydramnios
- Emergency Caesarean section
- Placenta praevia
- Placenta accreta
- Macrosomia
- Nulliparity
The effect of parity on the risk of PPH is complicated.
What is the ABC approach in managing PPH?
- Two peripheral cannulae, 14 gauge
- Lie the woman flat
- Bloods including group and save
- Commence warmed crystalloid infusion
This approach is essential in life-threatening emergencies.
What is one mechanical management technique for PPH?
Palpate the uterine fundus and rub it to stimulate contractions
This technique is referred to as ‘rubbing up the fundus’.
What are some medical management options for PPH?
- IV oxytocin
- Ergometrine IV or IM (unless history of hypertension)
- Carboprost IM (unless history of asthma)
- Misoprostol sublingual
There is interest in the role of tranexamic acid for PPH.
What should be done if medical options fail in PPH management?
Urgently consider surgical options
The RCOG states intrauterine balloon tamponade is a first-line intervention for uterine atony.
What are some surgical options for PPH?
- B-Lynch suture
- Ligation of the uterine arteries
- Ligation of internal iliac arteries
- Hysterectomy (in severe cases)
Hysterectomy may be a life-saving procedure.
What is secondary postpartum haemorrhage?
Occurs between 24 hours to 12 weeks after delivery
Typically due to retained placental tissue or endometritis.
What is the Edinburgh Postnatal Depression Scale?
A 10-item questionnaire used to screen for depression with a maximum score of 30
It indicates how the mother has felt over the previous week, with a score > 13 suggesting a depressive illness of varying severity.
What score on the Edinburgh Postnatal Depression Scale indicates depressive illness?
Score > 13
This score indicates a depressive illness of varying severity.
What is the sensitivity and specificity of the Edinburgh Postnatal Depression Scale?
Both > 90%
This high sensitivity and specificity make it a reliable screening tool.
What are the characteristics of ‘baby-blues’?
Anxiety, tearfulness, and irritability
Seen in around 60-70% of women, typically occurring 3-7 days following birth, more common in primips.
What is the typical onset period for baby-blues?
3-7 days following birth
More common in first-time mothers (primips).
What is the recommended support for mothers experiencing baby-blues?
Reassurance and support from health visitors
Health visitors play a key role in providing support.
What percentage of women are affected by postnatal depression?
Around 10%
Most cases start within a month and peak at 3 months.
When do most cases of postnatal depression start?
Within a month after birth
Typically peaks at 3 months.
What treatments may be beneficial for postnatal depression?
Cognitive behavioural therapy, certain SSRIs such as sertraline and paroxetine
These medications are not thought to be harmful to the infant when secreted in breast milk.
What is puerperal psychosis and its prevalence?
A severe mental illness affecting approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth.
What are the features of puerperal psychosis?
Severe mood swings and disordered perception (e.g. auditory hallucinations)
Similar to bipolar disorder; often requires hospital admission.
What is the risk of recurrence for puerperal psychosis in future pregnancies?
25-50% risk of recurrence
This highlights the importance of monitoring in subsequent pregnancies.
True or False: Postnatal depression and baby-blues have similar features.
True
Both conditions require reassurance and support.
What are the three stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Recurrence rates can be significant in subsequent pregnancies.
In what percentage of patients are thyroid peroxidase antibodies found in postpartum thyroiditis?
90%
This high prevalence indicates an autoimmune component in postpartum thyroiditis.
What is the typical management for the thyrotoxic phase of postpartum thyroiditis?
Propranolol is typically used for symptom control
Anti-thyroid drugs are not usually used as the thyroid is not overactive.
How is the hypothyroid phase of postpartum thyroiditis usually treated?
Usually treated with thyroxine
Thyroxine replacement helps manage hypothyroidism effectively.
True or False: Anti-thyroid drugs are typically used in the thyrotoxic phase of postpartum thyroiditis.
False
The thyroid is not overactive, hence anti-thyroid drugs are not indicated.
What does pre-eclampsia describe?
The emergence of high blood pressure during pregnancy that may precede eclampsia and other complications
What are the three classical components of pre-eclampsia?
- New-onset hypertension
- Proteinuria
- Oedema
What is the formal definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: proteinuria, other organ involvement
What are examples of organ involvement in pre-eclampsia?
- Renal insufficiency (creatinine ≥ 90 umol/L)
- Liver
- Neurological
- Haematological
- Uteroplacental dysfunction
What are potential consequences of pre-eclampsia?
- Eclampsia
- Altered mental status
- Blindness
- Stroke
- Clonus
- Severe headaches
- Persistent visual scotomata
- Intrauterine growth retardation
- Prematurity
- Liver involvement (elevated transaminases)
- Haemorrhage (placental abruption, intra-abdominal, intra-cerebral)
- Cardiac failure
What defines severe pre-eclampsia?
- Hypertension typically > 160/110 mmHg
- Proteinuria: dipstick ++/+++
- Headache
- Visual disturbance
- Papilloedema
- RUQ/epigastric pain
- Hyperreflexia
- Platelet count < 100 * 106/l
- Abnormal liver enzymes or HELLP syndrome
What are high-risk factors for pre-eclampsia according to NICE?
- Hypertensive disease in a previous pregnancy
- Chronic kidney disease
- Autoimmune disease (e.g., systemic lupus erythematosus)
- Type 1 or type 2 diabetes
- Chronic hypertension
List moderate risk factors for pre-eclampsia.
- First pregnancy
- Age 40 years or older
- Pregnancy interval of more than 10 years
- BMI of 35 kg/m² or more at first visit
- Family history of pre-eclampsia
- Multiple pregnancy
What should women with high and moderate risk factors take to reduce hypertensive disorders in pregnancy?
If >=1 high risk factor or >=2 moderate risk factor then Aspirin 75-150mg daily from 12 weeks gestation until birth
What is the initial management step for suspected pre-eclampsia?
Arrange emergency secondary care assessment
What blood pressure reading typically results in admission for suspected pre-eclampsia?
Blood pressure ≥ 160/110 mmHg
What is the first-line medication for managing pre-eclampsia according to 2010 NICE guidelines?
Oral labetalol
What are alternative medications to labetalol for managing pre-eclampsia?
- Nifedipine
- Hydralazine
What is the most important and definitive management step for pre-eclampsia?
Delivery of the baby
The timing of delivery in pre-eclampsia depends on what?
The individual clinical scenario
When are pregnant women screened for anaemia?
At the booking visit (often done at 8-10 weeks) and at 28 weeks
Screening is essential for early detection and management of anaemia in pregnancy.
What is the NICE cut-off for oral iron therapy in the first trimester?
< 110 g/L
This cut-off is used to identify pregnant women who may need treatment for anaemia.
What is the NICE cut-off for oral iron therapy in the second and third trimester?
< 105 g/L
This threshold helps in monitoring anaemia in later stages of pregnancy.
What is the NICE cut-off for postpartum oral iron therapy?
< 100 g/L
This measurement is critical for postpartum women to ensure recovery from potential anaemia.
What is the recommended management for anaemia in pregnant women?
Oral ferrous sulfate or ferrous fumarate
These are common forms of iron supplements used to treat anaemia.
How long should treatment for anaemia continue after iron deficiency is corrected?
For 3 months
Continuing treatment helps to replenish iron stores in the body.
What is the percentage of polyhydramnios in maternal complications during pregnancy with diabetes?
25%
Polyhydramnios may occur due to fetal polyuria.
What is the association between preterm labour and polyhydramnios in pregnant women with diabetes?
15% of preterm labour cases are associated with polyhydramnios.
What is macrosomia in the context of neonatal complications from maternal diabetes?
Macrosomia refers to larger than average babies, although diabetes may also cause small for gestational age babies.
What causes neonatal hypoglycaemia in infants born to diabetic mothers?
It is secondary to beta cell hyperplasia.
What is respiratory distress syndrome in newborns related to maternal diabetes?
Surfactant production is delayed.
What complication increases the risk of neonatal jaundice in infants of diabetic mothers?
Polycythaemia.
How much do malformation rates increase for infants born to diabetic mothers?
3-4 fold.
What types of malformations are associated with diabetes in pregnancy?
Examples include sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy).
What is a serious risk for infants born to diabetic mothers that can lead to infant mortality?
Stillbirth.
What are two mineral deficiencies that can occur in newborns of diabetic mothers?
- Hypomagnesaemia
- Hypocalcaemia
What is shoulder dystocia and its potential consequence for infants of diabetic mothers?
It may cause Erb’s palsy.
What is acute fatty liver of pregnancy?
A rare complication that may occur in the third trimester or the period immediately following delivery.
It is characterized by liver dysfunction during pregnancy.
List the features of acute fatty liver of pregnancy.
- Abdominal pain
- Nausea & vomiting
- Headache
- Jaundice
- Hypoglycaemia
- Severe disease may result in pre-eclampsia
These symptoms can indicate liver distress and require careful monitoring.
What is the typical elevation of ALT in acute fatty liver of pregnancy?
Typically elevated to around 500 u/l.
ALT (alanine aminotransferase) is an enzyme that indicates liver health.
What is the management approach for acute fatty liver of pregnancy?
- Support care
- Delivery is the definitive management once stabilised
Immediate delivery may be necessary if the mother’s condition worsens.
True or False: Gilbert’s and Dubin-Johnson syndrome may be exacerbated during pregnancy.
True
These conditions can lead to increased bilirubin levels, which may complicate pregnancy.
What does HELLP stand for?
Haemolysis, Elevated Liver enzymes, Low Platelets
HELLP syndrome is a severe form of pre-eclampsia and requires immediate medical attention.
What is the definition of obesity in the context of pregnancy?
Body mass index (BMI) >= 30 kg/m² at the first antenatal visit.
List three maternal risks associated with obesity during pregnancy.
- Miscarriage
- Gestational diabetes
- Pre-eclampsia
*venous thromboembolism
*dysfunctional labour, induced labour
*postpartum haemorrhage
*wound infections
There is also a higher caesarean section rate.
What is a common complication related to delivery for obese women?
Higher caesarean section rate.
List 7 fetal risks associated with maternal obesity.
- Congenital anomaly
- Prematurity
*prematurity
*macrosomia
*stillbirth
*increased risk of developing obesity and metabolic disorders in childhood
*neonatal death
What increased risk do children of obese mothers face?
Increased risk of developing obesity and metabolic disorders in childhood.
True or False: Women with a BMI of 30 or more should try to reduce their weight through dieting during pregnancy.
False.
What dosage of folic acid should obese women take during pregnancy?
5mg, rather than 400mcg.
At what weeks should all obese women be screened for gestational diabetes?
24-28 weeks.
If a woman’s BMI is >= 35 kg/m², where should she give birth?
In a consultant-led obstetric unit.
What should women with a BMI >= 40 kg/m² have before childbirth?
An antenatal consultation with an obstetric anaesthetist and a plan made.
List two maternal complications of obesity during pregnancy.
- Venous thromboembolism
- Postpartum haemorrhage
What is one risk factor for neonatal death associated with maternal obesity?
Stillbirth.
Fill in the blank: Women with a BMI of 30 or more should be informed about the risks to their health and the health of the unborn child during the _______.
booking appointment.
What is puerperal pyrexia?
A temperature of > 38ºC in the first 14 days following delivery
Puerperal pyrexia indicates a febrile condition after childbirth.
What is the most common cause of puerperal pyrexia?
Endometritis
Endometritis is an infection of the uterine lining commonly occurring after delivery.
Name two other causes of puerperal pyrexia.
- Urinary tract infection
- Wound infections (perineal tears + caesarean section)
- Mastitis
- Venous thromboembolism
These are additional potential sources of fever postpartum.
What should be suspected if puerperal pyrexia occurs?
Endometritis
Endometritis requires immediate attention as it can lead to serious complications.
What is the recommended management if endometritis is suspected?
Refer the patient to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
This treatment protocol aims to address the infection effectively.
Fill in the blank: Puerperal pyrexia is defined as a temperature of _______ in the first 14 days following delivery.
> 38ºC
True or False: Mastitis is a common cause of puerperal pyrexia.
True
Fill in the blank: The management of suspected endometritis includes _______ until the patient is afebrile for greater than 24 hours.
intravenous antibiotics (clindamycin and gentamicin)
What can reduced fetal movements indicate?
Fetal distress and chronic hypoxia
Reduced fetal movements can reflect risk of stillbirth and fetal growth restriction.
What is quickening in relation to fetal movements?
The first onset of recognized fetal movements, occurring between 18-20 weeks gestation
Multiparous women may experience quickening as early as 16-18 weeks.
At what gestational week does the frequency of fetal movements typically plateau?
32 weeks gestation
How does the RCOG define reduced fetal movements (RFM) after 28 weeks gestation?
Less than 10 movements within 2 hours
What percentage of pregnancies are affected by reduced fetal movements?
Up to 15%
What are some risk factors for reduced fetal movements?
- Posture
- Distraction
- Placental position
- Medication
- Fetal position
- Body habitus
- Amniotic fluid volume
- Fetal size
How does posture affect awareness of fetal movements?
More prominent during lying down and less when sitting or standing
What types of medications can temporarily reduce fetal movements?
- Alcohol
- Sedative medications (opiates or benzodiazepines)
What is the significance of fetal size in relation to RFM?
Up to 29% of women presenting with RFM have a SGA fetus
What is the first step in investigating reduced fetal movements past 28 weeks gestation?
Use handheld Doppler to confirm fetal heartbeat
What should be done if no fetal heartbeat is detected?
Immediate ultrasound should be offered
What does CTG stand for and what is its purpose?
Cardiotocography; to monitor fetal heart rate
What is the recommended action if concern remains despite a normal CTG?
Urgent ultrasound within 24 hours
What should be assessed in an ultrasound if concerns about RFM exist?
- Abdominal circumference
- Estimated fetal weight
- Amniotic fluid volume
What should be done if fetal movements have not been felt by 24 weeks gestation?
Onward referral to a maternal fetal medicine unit
What percentage of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis?
40-55%
What is the prognosis for pregnancies with a single episode of reduced fetal movement?
70% have no onward complication
How long should CTG be carried out for reduced fatal movements >28w after heartbeat present on Doppler?
If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.
What is the most important antigen of the rhesus system?
The D antigen
The D antigen is crucial for determining Rh status in pregnancy.
What percentage of mothers are rhesus negative (Rh -ve)?
Around 15%
This statistic highlights the prevalence of Rh -ve mothers.
What happens if a Rh -ve mother delivers a Rh +ve child?
A leak of fetal red blood cells may occur
This can lead to the formation of anti-D IgG antibodies in the mother.
What do anti-D IgG antibodies do in later pregnancies?
They can cross the placenta and cause haemolysis in the fetus
This can lead to serious complications for the fetus.
Can sensitization occur during the first pregnancy?
Yes, due to leaks
Sensitization can happen even if the mother has not had prior pregnancies.
What does NICE (2008) advise for non-sensitised Rh -ve mothers?
Giving anti-D at 28 and 34 weeks
This is a preventive measure against sensitization.
What is the difference in efficacy between single-dose and double-dose regimes of anti-D?
Little difference
RCOG in 2011 advised that either regime could be used based on local factors.
What is the nature of anti-D immunoglobulin treatment?
It is prophylaxis
Once sensitization has occurred, it is irreversible.
What should be done if an event occurs in the 2nd/3rd trimester?
Give a large dose of anti-D and perform a Kleihauer test
This test determines the proportion of fetal RBCs present.
When should anti-D immunoglobulin be given within 72 hours?
In the following situations:
* Delivery of a Rh +ve infant, whether live or stillborn
* Any termination of pregnancy
* Miscarriage if gestation is > 12 weeks
* Ectopic pregnancy (surgically managed)
* External cephalic version
* Antepartum haemorrhage
* Amniocentesis, chorionic villus sampling, fetal blood sampling
* Abdominal trauma
These situations are critical for preventing sensitization.
Is anti-D required for medically managed ectopic pregnancy with methotrexate?
No
Anti-D is not required in cases managed medically.
What is rubella also known as?
German measles
What type of virus causes rubella?
Togavirus
What is the risk of congenital rubella syndrome if rubella is contracted during pregnancy?
High risk
What is the incubation period for rubella?
14-21 days
How long are individuals infectious with rubella?
From 7 days before symptoms to 4 days after rash onset
During which weeks of pregnancy is the risk of damage to the fetus from rubella as high as 90%?
First 8-10 weeks
Is damage from rubella common after 16 weeks of pregnancy?
No, damage is rare after 16 weeks
What are some features of congenital rubella syndrome? (List at least three)
- Sensorineural deafness
- Congenital cataracts
- Congenital heart disease
- Growth retardation
- Hepatosplenomegaly
- Purpuric skin lesions
- ‘Salt and pepper’ chorioretinitis
- Microphthalmia
- Cerebral palsy
What should suspected cases of rubella in pregnancy be discussed with?
The local Health Protection Unit (HPU)
What type of antibodies are raised in women recently exposed to rubella?
IgM antibodies
What is the risk of transplacental infection with parvovirus B19?
30%
What is the fetal loss risk associated with parvovirus B19?
5-10%
Since when has rubella immunity no longer been routinely checked at the booking visit?
2016
What should non-immune mothers be offered after delivery?
MMR vaccination
Should MMR vaccines be administered to women known to be pregnant?
No
Fill in the blank: The risk of congenital rubella syndrome is highest during the first _____ weeks of pregnancy.
8-10
True or False: Congenital heart disease is a feature of congenital rubella syndrome.
True
What is a common clinical challenge when diagnosing rubella?
It is difficult to distinguish from parvovirus B19
What is the symphysis-fundal height (SFH)?
Measured from the top of the pubic bone to the top of the uterus in centimetres
What should the symphysis-fundal height (SFH) match after 20 weeks?
The gestational age in weeks to within 2 cm
What is the normal SFH range for a gestational age of 24 weeks?
22 to 26 cm
Fill in the blank: The SFH should match the gestational age in weeks to within _______ cm after 20 weeks.
2
True or False: The SFH measurement can be more than 2 cm off from the gestational age after 20 weeks.
False
What is a nuchal scan?
A nuchal scan is performed at 11-13 weeks.
What are the causes of increased nuchal translucency?
- Down’s syndrome
- congenital heart defects
- abdominal wall defects
What are the causes of hyperechogenic bowel?
- cystic fibrosis
- Down’s syndrome
- cytomegalovirus infection
