Antenatal care - done Flashcards

Question

How much vitamin D supplement should be taken in pregnancy?

Answer 1

**Vitamin A** and eating liver or pate (teratogenic at high doses)

Answer 2

Unpasteurised dairy or blue cheese (risk of **listeriosis**) Undercooked or raw poultry (risk of **salmonella**)

Answer 3

Continue moderate exercise but **avoid contact sports**

Answer 4

Above and below the bump (not across it)

Answer 5

**First 3 months** of pregnancy

Answer 6

Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 7

**Microchephaly** (small head) **Thin upper lip** **Smooth flat philtrum** **Short palpebral fissure** (short horizontal distance from one side of the eye to the other) **Behavioural difficulties** **Hearing** and **vision problems** **Cerebral palsy**

Answer 8

**Fetal growth restriction** Misscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palete **Sudden infant death syndrome** (SIDS)

Answer 9

**37 weeks in a single pregnancy** **32 weeks in a twin pregnancy**

Answer 10

**28 weeks gestation**

Answer 11

- What to expect at different stages of the pregnancy - Lifestyle advice in pregnancy e.g. not smoking - Supplements (folic acid and vit D) - Plans for birth - Screening tests (e.g. Downs) - Antenatal classes - Breastfeeding classes - Discuss mental health

Answer 12

- Blood group - Antibodies and rhesus D status - FBC for anaemia - Screening for **thalassaemia** (all women) and **sickle cell disease** (those at risk)

Answer 13

HIV Hep B Syphilis

Answer 14

- Weight, height and BMI - Urine for protein and bacteria - Blood pressure - Discuss female genital mutilation - Discuss domestic violence

Answer 15

**Rhesus negative** (book anti-D prophylaxis) **Gestational diabetes** (book oral glucose tolerance test) **Fetal growth restriction** (book additional growth scans) **Venous thromboembolism** (provide prophylactic LMWH if high risk) **Pre-eclampsia** (provide aspirin if high risk)

Answer 16

**Trisomy 21**

Answer 17

To establish whether more invasive testing is needed

Answer 18

Using: - **Measurements** from the fetus using ultrasound - Mother's **age** - Mother's **blood results**

Answer 19

**Nural translucency** - thickness of the back of the neck of the fetus (greater than 6mm indicates Down's)

Answer 20

**Beta-human chorionic gonadotrophin** (beta-HCG) - higher result indicates a greater risk **Pregnancy-associated plasma protein-A** (PAPPA) - lower result indicates a greater risk

Answer 21

Between 11 and 14 weeks gestation

Answer 22

Screening at 14 to 20 weeks gestation involving only **maternal blood tests**: - **Beta-HCG** - higher result indicates a greater risk - **Alpha-feroprotein** (AFP) - a lower result indicates a greater risk - **Serum oestriol** (female sex hormone) - a lower result indicates a greater risk

Answer 23

Similar to the triple test (also at weeks 14 to 20 gestation) - Also includes maternal blood testing for **inhibin-A** (higher indicates greater risk)

Answer 24

A risk score - if it is greater than 1 in 150 (occuring in 5% of women) then the woman is offered **amniocentesis** or **chorionic villus sampling**

Answer 25

Ultrasound-guided **biopsy** of the **placental** tissue (used earlier in pregnancy - before 15 weeks)

Answer 26

**Ultrasound-guided aspiration** of **amniotic fluid** using a needle and syringe - used later in pregnancy when there is enough amniotic fluid to make a sample

Answer 27

New test for detecting fetal abnormalities - involves a simple blood test from the mother. Contains fragments of **DNA from the fetus** which can be tested. Used as an alternative to invasive testing (CVS and amniocentesis)

Answer 28

Jointly by the obstetric team and the specialist in their health condition

Answer 29

- Miscarriage - Anaemia - SGA - Pre-eclampsia)

Answer 30

**Levothyroxine** (T4)

Answer 31

**25-50mcg** (30-50%)

Answer 32

**ACE inhibitors** **Angiotensin receptor blockers** (e.g. losartan) **Thiazide and thiazide-like diuretics** (e.g.indapamide)

Answer 33

**Labetalol** (a beta-blocker - although other beta blockers may have adverse effects) **CCB**s (e.g. nifedipine) Alpha-blockers (e.g. doxazosin)

Answer 34

5mg daily to reduce the risk of **neural tube defects**

Answer 35

Additional **stress** **Lack** of **sleep** **Hormonal changes** **Altered medication** **regimes**

Answer 36

No, only the risk of physical injury

Answer 37

With a single epileptic drug

Answer 38

**Levetiracetam** **Iamotrigine** **Carbamazepine**

Answer 39

**Sodium valporate** (causes neural tube defects and developmental delay) **Phenytoin** (causes cleft lip and palete)

Answer 40

**Programme to prevent pregnancy** in epileptic patients on sodium valporate (**due to it's teratogenic effects**)

Answer 41

**Autoimmune condition** which causes **chronic inflammation** of the **synovial lining** of the **joints, tendon sheaths** and **bursa** INFLAMMATORY ARTHRITIS

Answer 42

Disease modifying anti-rheumatic drug (DMARD)

Answer 43

**3 months**

Answer 44

Improve but may flare up after delivery

Answer 45

**Methotrexate** (teratogenic, causing miscarriage and congenital abnormalities)

Answer 46

**Hydroxychloroquine** (often the first-line choice) **Sulfasalazine** (safe during pregnancy)

Answer 47

**Corticosteroids**

Answer 48

**Iburprofen** **Naproxen**

Answer 49

They **block** prostaglandins

Answer 50

Maintaining the **ductus arteriosus**

Answer 51

They **soften** the **cervix** and stimulate **uterine contractions**

Answer 52

Avoided in the **third trimester** as they can cause **premature closure of the ductus arteriosus** in the fetus. They can also **delay labour**.

Answer 53

Hypertension Cardiac conditions Migraine

Answer 54

**Fetal growth restriction** **Hypoglycaemia** in the neonate **Bradicardia** in the neonate

Answer 55

ACE inhibitors and ARBs

Answer 56

- Affect the **kidneys** causing reduced production of urine (and therefore amniotic fluid) - **Hypoclavaria** (incomplete formation of the skull bones)

Answer 57

**Oligohydraminos** (reduced amniotic fluid) Miscarriage or fetal death **Hypocalvaria** (incomplete formation of the skull bones) Renal failure in the neonate Hypotension in the neonate

Answer 58

**Withdrawal symptoms** in the neonate after birth, called **neonatal abstinence syndrome** which presents between 3 - 72 hours after birth with **irritability**, **tachypnoea** (fast breathing), **high temperatures** and **poor feeding**

Answer 59

Younger patients with **recurrent venous thrombosis**, **atrial fibrillation** or **metallic mechanical heart valves**

Answer 60

**Teratogenic**, causes: - Fetal loss - Congenital malformations, particularily craniofacial problems - Bleeding during pregnancy, PPH, fetal harmorrhage and intracranial bleeding

Answer 61

**Neural tube defects** **Developmental delay**

Answer 62

Mood stabilising agent for patients with bipolar disorder, mania, recurrent depression.

Answer 63

**Avoided** in pregnant women or those **planning pregnancy** unless other options (i.e. antipsychotics) have failed

Answer 64

It's linked with **congenital**

Answer 65

Monitored closely (every 4 weeks, then weekly from 36 weeks) it also **enters breast milk** so should be **avoided in breastfeeding**

Answer 66

- **Congenital heart defects** - **Paroxetine** has stronger link with **congenital malformation**

Answer 67

**Persistent pulmonary hypertension**

Answer 68

**Withdrawal symptoms** usually only mild and **not requiring medical management**

Answer 69

**Retinoid** medication (relating to **vitamin A**) which is used to treat **severe acne** - should be prescribed and monitored by a specialist dermatologist

Answer 70

Highly **teratogenic** causing **miscarriage** and **congenital defects**. Women need very reliable contraception before, during and for one month after taking isotretinoin.

Answer 71

**German measles**

Answer 72

Maternal infection with **rubella virus** during the first 20 weeks of pregnancy

Answer 73

**Before 10 weeks gestation**

Answer 74

Women **planning on becomming pregnant** should ensure that they have **had the MMR vaccine,** if in doubt they can be **tested** for **rubella immunity** if they do not have **antibodies** to rubella they can be **vaccinated** with two doses of the MMR **three months** apart

Answer 75

No as this is a live vaccine - they should be given the vaccine **after giving birth**

Answer 76

Congenital **deafness** Congenital **cataracts** Congenital **heart disease** (PDA and pulmonary stenosis) **Learning difficulty**

Answer 77

**Varicella zoster virus** (VZV)

Answer 78

Causes more severe cases in the mother, such as **varucella pneumonitis**, **hepatitis** or **encephalitis** Fetal varicella syndrome Severe **neonatal varicella infection** (if infected around delivery)

Answer 79

**IgG** levels for **VZV** can be tested, if positive then idicated immunity

Answer 80

Treated with **IV varicella immunoglobulins** as prohylaxis against developing chickenpox, given within 10 days of exposure

Answer 81

Treament with **oral aciclovir** if presenting within 24 hours and more than 20 weeks gestation

Answer 82

Occurs in around 1% of chickenpox cases with infection in the first 28 weeks of gestation. Features include: - Fetal **growth restriction** - Microcephaly, hydrocephalus and learning difficulty - Scars and **significant skin changes** located in **specific dermatomes** - Limb **hypoplasia** (underdeveloped limbs) - Cataracts and **inflammation** in the eye (**chorioretinitis**)

Answer 83

**Gram positive**

Answer 84

**Listeriosis**

Answer 85

**Asymptomatic** or **flu-like illness** or less commonly **pneumonia** or **meningoencephalitis**

Answer 86

High rate of **miscarriage** or **fetal death** it can also cause **severe neonatal infection**

Answer 87

**Unpasteurised dairy products** **Processed meats** Contaminated food Advise *avoid blue cheese and other **high risk** fods and practice good **food hygiene***

Answer 88

CMV infection in the mother during pregnancy

Answer 89

Via infected saliva or urine of asymptomatic children

Answer 90

- Fetal growth restriction - Microcephaly - Hearing loss - Vision loss - Learning disability - Seizures

Answer 91

Caused by **infection** with the **toxoplasma gondii** parasite

Answer 92

By **contamination** with **faeces** from a cat that is a **host** of the parasite

Answer 93

- Intracranial calcification - Hydrocephalus - Chorioretinitis (inflammation of the choroid and the retina in the eye)

Answer 94

**Fifth disease**, **slapped cheek syndrome** and **erythema infectiosum**.

Answer 95

Illness is **self-limiting** and the **rash** and **symptoms** usually fade over 1-2 weeks

Answer 96

**Initally** with **non-specific** viral symptoms **After 2-5 days** the rash appears quite rapidly as a **diffuse bright red rash on both cheeks** as though they have "**slapped cheeks**" **A few days later** a **reticular** mildly erythmatous rash affecting the trunk and limbs appears which can be **raised and itchy**.

Answer 97

**7-10 days before the rash appears** (not infectious once the rash has appeared)

Answer 98

15 minutes in the **same room** or face-to-face contact with someone that **has the virus**

Answer 99

1st and 2nd trimester

Answer 100

**Miscarriage** or fetal death Severe **fetal anaemia** **Hydrops fetalis** (fetal heart failure) Maternal **pre-eclampsia**-like syndrome

Answer 101

Infection of the **erythroid progenitor cells** in the fetal **bone marrow** and **liver** (the cells which produce red blood cells) Producing **faulty red blood cells** which have a shorter life span - less red blood cells results in anaemia, this anaemia leads to heart failure, referred to as **hydrops fetalis**.

Answer 102

**Mirror syndrome**

Answer 103

**Rare complication** of severe fetal heart failure (**hydrops fetalis**) involving a triad of: - Hydrops fetalis - Placental oedema - Oedema in the mother

Answer 104

**IgM** to **parvovirus** which tests for **acute infection** within the past 4 weeks **IgG** to **parvovirus** which tests for **long term immunity** to the virus after a previous infection **Rubella** antibodies (as a differential diagnosis)

Answer 105

Supportive **Referral** to **fetal medicine** to monitor for complications and malformations

Answer 106

By host **Aedes mosquitos** in aread of the world where the virus is **prevalent** Also spread by **sex** with someone infected

Answer 107

No symptoms, minimal symptoms or mild flu-like illness

Answer 108

- Microcephaly - Fetal growth restrictions - Other intracranial abnormalities such as **ventriculomegaly** and **cerebellar atrophy**

Answer 109

**Viral PCR** **Antibodies to the zika virus**

Answer 110

Referred to **fetal medicine** for close monitoring of the pregnacy There is **no treatment** for the virus

Answer 111

Various types of **rhesus** antigens on the surface or RBCs

Answer 112

No, they are **separate**

Answer 113

**rhesus-D antigen**

Answer 114

No additional treatment needed during pregnancy

Answer 115

Consider possibility that the child will be **rhesus positive**

Answer 116

Blood from the baby will find a way into the mothers blood stream e.g. during childbirth, the **baby**'s **RBCs** display the **rhesus-D antigen** which the **mother's immune system will recognise as foreign** and produce antibodies to the **rhesus-D antigen** - the mother has then become **sensitised** to rhesus-D antigens

Answer 117

During **subsequent** pregnancies the mother's anti-rhesus-D antibodies can **cross the placenta** into the fetus. If the fetus is **rhesus-D positive**, these antibodies attach themselves to the RBC of the fetus and cause the immune system of the fetus to attack them, causing the destruction of the RBC = **haemolytic disease of the newborn**

Answer 118

**Prevention of sensitisation** - involves giving **intramuscular** **anti-D** injections to rhesus-D negative women (there is no way to reverse the sensitisation process once it has occured)

Answer 119

**Attaches** itself to the **rhesus-D antigens** on the **fetal red blood cells in the mothers circulation** causing them to be destroyed - thus **preventing** the **mother's immune system** recognising the antigen and creating it's own antibodies to the antigen - acts as a prevention of sensitisation

Answer 120

28 weeks gestation Birth (if the baby's blood group is found to be rhesus positive)

Answer 121

- **Antepartum haemorrhage** - **Amniocentesis** procedures - Abdominal trauma

Answer 122

**Within** **72 hours**

Answer 123

Test to **check how much fetal blood** has passed into the mother's during a sensitisation event Done at 20 weeks

Answer 124

To setermine whether further doses of anti-D are required

Answer 125

Involves **adding acid to a sample of the mother's blood** fetal haemoglobing is more resistant to acid (so they are protected against the acidosis that occurs around childbirth) **Fetal haemoglobin** persists in response to the added acid whilst the mothers Hb is destroyed - number of cells still containing the haemoglobin (remaining fetal cells) can then be calculated

Answer 126

Fetus which measures **below the 10th** centile for their **gestational age**

Answer 127

- **Estimated fetal weight** (EFW) - **Fetal abdominal circumference** (AC)

Answer 128

Mother's: - Ethnic group - Weight - Height - Parity

Answer 129

**Below the 3rd centile** for their gestational age

Answer 130

Birth weight less than 2500g

Answer 131

**Constitutionally small** (matching the mother and other's in the family) - growing appropriately on the growth chart **Fetal growth restriction** also known as **intrauterine growth restriction**

Answer 132

Small fetus **due to a pathology reducing** the **amount of nutrients** and oxygen being delivered to the fetus through the placenta

Answer 133

**Placenta mediated** growth restriction **Non-placenta mediated growth restriction**, where the baby is small due to a genetic or structural abnormality

Answer 134

Conditions which affect the transfer of nutrients across the placenta: **Idiopathic** **Pre-eclampsia** Maternal **smoking** Maternal **alcohol** **Anaemia** **Malnutrition** Infection Maternal health conditions

Answer 135

**Genetic** abnormalities **Structural** abnormalities **Fetal infection** **Errors of metabolism**

Answer 136

**Reduced amniotic fluid** volume **Abnormal Doppler** studies **Reduced fetal movements** **Abnormal CTGs**

Answer 137

Fetal **death or stillbirth** ## Footnote **Birth asphyxia** **Neonatal hypothermia** **Neonatal hypoglycaemia**

Answer 138

**Cardiovascular disease**, particularly hypertension **Type 2 diabetes** **Obesity** **Mood** and behavioural **problems**

Answer 139

Previous SGA baby Obesity Smoking **Diabetes** **Existing hypertension** **Pre-eclampsia** **Older mother** (over 35 years) **Multiple pregnancy** **Low** pregnancy‑associated plasma protein‑A (**PAPPA**) **Antepartum haemorrhage** **Antiphospholipid syndrome**

Answer 140

At the booking clinic

Answer 141

**Monitoring** of the **symphysis fundal height** (SFH) at **every antenatal appointment** from **24 weeks onwards** to identify potential SGA

Answer 142

**Serial growth scans** with **umbilical artery doppler**

Answer 143

**Three or more minor** risk factors **One or more major** risk factors **Issues with measuring the symphysis fundal height** (e.g. large fibroids or **BMI \> 35**)

Answer 144

**Estimated fetal weight** (EFW) and abdominal circumference (**AC**) to **determine the growth velocity** **Umbilical arterial pulsatility index** (UA-PI) to measure flow through the umbilical artery **Amniotic fluid volume**

Answer 145

**Identifying those at risk** of SGA **Aspirin** is given to those at risk of **pre-eclampsia** Treating **modifiable risk factors** (e.g. **stop smoking**) **Serial growth scans** to monitor growth **Early delivery** where growth is static, or there are other concerns

Answer 146

**Blood pressure and urine dipstick** for **pre-eclampsia** **Uterine artery doppler scanning** **Detailed fetal anatomy scan** by fetal medicine **Karyotyping** for chromosomal abnormalities **Testing for infections** (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

Answer 147

Growth is statis on the charts or abnormal doppler results ## Footnote **Reducing the risk of stillbirth**

Answer 148

**Corticosteroids** particulary when delivered by C-Section

Answer 149

**Macrosomia**

Answer 150

\>4.5kg at birth (weight above 90th centile in pregnancy)

Answer 151

**Constitutional** **Maternal diabetes** **Previous macrosomia** **Maternal obesity** or rapid weight gain **Overdue** **Male baby**

Answer 152

**Failure to progress** Perineal **tears** **Instrumental delivery** or caesarean Postpartum **haemorrhage** **Uterine rupture** (rare)

Answer 153

**Shoulder dystocia** **Birth injury** (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal **hypoglycaemia** **Obesity in childhood** and later life **Type 2 diabetes** in adulthood

Answer 154

**Ultrasound to exclude polyhydramnios** and estimate the fetal weight **Oral glucose tolerance test** for gestational diabetes

Answer 155

**Delivery on a consultant lead unit** Delivery by an **experienced midwife or obstetrician** **Access to an obstetrician** and **theatre** if required **Active management of the third stage** (delivery of the placenta) **Early decision for caesarean section** if required Paediatrician attending the birth

Answer 156

Pregnancy with **more than one fetus**

Answer 157

**Identical** twins (from a **single zygote**)

Answer 158

**Non-identical** (from two different zygotes)

Answer 159

**Single amniotic sac**

Answer 160

**Two separate** amniotic sacs

Answer 161

Those that share a **single placenta**

Answer 162

Those which have **two separate placentas**

Answer 163

**Diamniotic, dichorionic** - each fetus has their own nutrient supply

Answer 164

Booking ultrasound scan, along with: - Gestational age - Number of placentas (**chorionicity**) and **amnionicity** - Risk of **Down's syndrome** (as part of the combined test)

Answer 165

**Dichorionic diamniotic** twins have a **membrane between the twins**, with a lambda sign or twin peak sign **Monochorionic diamniotic** twins have a **membrane between the twins, with a T sign** **Monochorionic monoamniotic** twins have **no membrane** separating the twins

Answer 166

The triangular appearance, where the **membrane** **between** the **twins** meets the **chorion** as the chorion blends **partially into the membrane**, indicating a **dichorionic twin pregnancy** (separate placenta)

Answer 167

Where the membrane between the twins abruptly meets the chorion giving a T appearance - indicating a **monochorionic twin pregnancy** (single placenta)

Answer 168

**Anaemia** **Polyhydramnios** **Hypertension** **Malpresentation** **Spontaneous preterm birth** **Instrumental delivery** or caesarean Postpartum **haemorrhage**

Answer 169

**Miscarriage** **Stillbirth** **Fetal growth restriction** **Prematurity** **Twin-twin transfusion syndrome** **Twin anaemia** polycythaemia sequence Congenital **abnormalities**

Answer 170

When **fetuses share a placenta** called **feto-fetal transfusion syndrome** in pregnancies with **more than two fetuses** **One fetus** (the recipient) may receive the majority of the blood from the placenta whilst the other (the donor) is starved of blood **Recipent** = Heart failure and polyhydraminos **Donor** = Growth restriction, anaemia and oligohydraminos Discrepancy between the size of the fetuses

Answer 171

Referred to a tertiary specialist fetal medicine centre **Laser treatment** may be used to destroy the connection between the two blood supplies

Answer 172

Similar to twin-twin transfusion syndrome but **less acute**, one twin becomes **anaemic** whilst the **other develops polycythaemia** (raised Hb)

Answer 173

Multiple pregnancy obstetric team

Answer 174

**Anaemia** with an **FBC** at **booking clinic**, **20 weeks** gestation and **28 weeks gestation**

Answer 175

Monitor for **fetal growth restriction**, **unequal growth** and **twin-twin** **transfusion syndrome**

Answer 176

**2 weekly scans from 16 weeks** for **monochorionic twins** **4 weekly scans from 20 weeks** for **dichorionic twins**

Answer 177

**32 and 33 + 6 weeks** for **uncomplicated mono**chorionic **mono**amniotic twins **36 and 36 + 6 weeks** for **uncomplicated mono**chorionic **diamniotic** twins **37 and 37 + 6 weeks** for **uncomplicated dichorionic diamniotic twins** **Before 35 + 6 weeks** for triplets

Answer 178

Corticosteroids

Answer 179

**Elective C-Section** at between 32 and 33+6 weeks

Answer 180

Between 37 and 37 + 6 weeks **Vaginal delivery** is possible when the **first baby** has a **cephalic presentation (head first)** **Caesarean section may be** required for the **second baby after successful birth of the first baby** **Elective caesarean** is advised when the **presenting twin is not cephalic presentation**

Answer 181

Infection in the bladder, causing **cyctitis** (inflammation of the bladder)

Answer 182

Infection up to the kidneys, called **pyelonephritis**

Answer 183

Pregnant women

Answer 184

**Increased risk of** **preterm** delivery, also increased risk of low birth weight and pre-eclampsia

Answer 185

**Bacteria present in the urine** without symptoms of infection (increases risk of UTI in pregnancy)

Answer 186

At booking and **routinely throughout pregnancy** involving **sending urine sample** to the lab for **microscopy, culture and sensitivites** (MC&S)

Answer 187

**Dysuria** (pain, stinging or burning when passing urine) **Suprapubic pain** or discomfort **Increased frequency of urination** **Urgency** **Incontinence** **Haematuria**

Answer 188

**Fever** (more prominent than in lower urinary tract infections) **Loin, suprapubic or back pain** (this may be bilateral or unilateral) **Looking and feeling generally unwell** **Vomiting** **Loss of appetite** **Haematuria** **Renal angle tenderness** on examination

Answer 189

**Nitrites** produced by **gram-negative bacteria** (such as **E. Coli**) a breakdown produce of nitrates - a normal waste product in the urine **Leukocytes** refer to **WBCs** (normally a small number anyway in the urine) - dipstick tests for **leukocyte esterase** which **gives an indication** to the number of leukocytes in the urine

Answer 190

**Nitrites**

Answer 191

**Escherichia coli** (gram negative, anaerobic, rod-shaped bacteria which is part of the normal lower intestinal micobiome - found in faeces normally) **Klebsiella pneumoniae** (gram negative anaerobic rod) **Enterococcus** Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)

Answer 192

7 days of abx: **Nitrofurantoin** (avoid in the third trimester) **Amoxicillin** (only after sensitivities are known) **Cefalexin**

Answer 193

Not to be used in **third trimester** as there is a **risk of neonatal haemolysis** (destruction of the neonatal RBCs)

Answer 194

Not to be used in **first trimester** as it works as a **folate antagonist** - folate is important in early pregnancy for the **normal development of the fetus** Can cause **congenital malformations** particularly **neural tube defects** (i.e. **spina bifida**) Not known to be harmful later in pregnancy but is generally avoided

Answer 195

Low concentration of **haemoglobin** in the blood- as a result of an underlying disease, not the disease itself

Answer 196

**Ingredient** in **creating Hb**

Answer 197

**Booking** clinic **28 weeks** gestation

Answer 198

**Plasma volume increases** Causes a **reduction** in the **Hb concentration**

Answer 199

So the woman has **reasonable reserves** in case there is significant blood loss during delivery

Answer 200

Often anaemia in pregnancy is **asymptomatic**, symptoms include: - SoB - Fatigue - Dizziness - Pallor

Answer 201

Booking **bloods = \> 110 g/l** **28 weeks** gestation = \> 105 g/l **Post partum** = \> 100 g/l

Answer 202

**Low MCV** may indicate **iron deficiency** **Normal MCV** may indicate a **physiological anaemia due to the increased plasma volume** of pregnancy **Raised MCV** may indicate **B12 or folate deficiency**

Answer 203

**Thalassaemia** (all women) **Sickle cell disease** (women at higher risk)

Answer 204

**Ferritin** **B12** **Folate**

Answer 205

**Iron** = iron replacement (e.g. **ferrous sulphate** 200mg three times daily) also for if they just have low ferritin **B12** = tested for **pernicious anaemia** (checking for **intrinsic factor antibodies,** advice from a haematologist RE treatment but **includes**: Intramuscular hydroxocobalamin injections, Oral cyanocobalamin tablets **Folate** = 5mg daily if folate deficient (should already be on 400mcg daily) **Thalassaemia and sickle cell anaemia** = women with haemoglobinopathy will be managed jointly with a specialist haematologist - require **high dose folic acid** (5mg), close monitoring and transfusions when required

Answer 206

Pregnancy is a **hyper-coagulable state**

Answer 207

**Postpartum** period

Answer 208

Smoking Parity ≥ 3 Age \> 35 years BMI \> 30 **Reduced mobility** **Multiple pregnancy** **Pre-eclampsia** Gross **varicose veins** **Immobility** **Family history of VTE** **Thrombophilia** **IVF** pregnancy

Answer 209

**28 weeks** if there are **three risk factors** **First trimester** if there are **four or more of these risk factors**

Answer 210

**Hospital admission** **Surgical** procedures **Previous VTE** **Medical conditions such as cancer** or arthritis **High-risk thrombophilias** **Ovarian hyperstimulation syndrome**

Answer 211

At **booking** and again **after birth** (additionally if admitted to hospital, undergo a procedure or develop significant immobility)

Answer 212

Low molecular weight heparin (e.g. enoxaparin, dalteparin and tinzaparin)

Answer 213

Until 6 weeks postnatally

Answer 214

When woman **goes into labour** and can be started **immediately after delivery** (except with PPH, spinal anaesthesia and epidurals)

Answer 215

Mechanical prophylaxis: - **Intermittent pneumatic compression** - **Antiembolic compression stockings**

Answer 216

**Unilateral:** **Calf** or leg **swelling** **Dilated** superficial **veins** **Tenderness to the calf** (particularly over the deep veins) **Oedema** **Colour changes** to the leg

Answer 217

Measure the circumference of the calf 10cm below the **tibial tuberosity** **More than 3cm difference** between calves is significant

Answer 218

Shortness of breath **Cough** with or without blood (**haemoptysis**) **Pleuritic** chest **pain** **Hypoxia** **Tachycardia** (this can be difficult to distinguish from the normal physiological changes in pregnancy) **Raised respiratory** rate Low-grade **fever** **Haemodynamic instability** causing **hypotension**

Answer 219

Doppler ultrasound (repeated on day 3 and 7 in patients with a high index of suspicion for DVT)

Answer 220

Chest X-ray ECG

Answer 221

**CT pulmonary angiogram** **Ventilation-perfusion scan** (VQ scan)

Answer 222

Chest CT with **IV contrast** which highlights the **pulmonary arteries** to **demonstrate any blood clots** (helpful as it provides info about alternative diagnoses such as pneumonia or malignancy)

Answer 223

Involves using **radioactive isotopes** and a **gamma camera** to compare the ventilation with the perfusion of the lungs First the **isotopes are inhaled to fill the lungs** and a picture is taken to demonstate ventilation Next a **contrast containing isotopes is injected** and a picture is taken to demonstrate perfusion In a PE, the area of lung tissue will be **ventilated** but **not perfused**

Answer 224

**CTPA** is the test for choice for patients **with an abnormal chest xray** **CTPA** carries a **higher risk of breast cance**r for the mother (minimal absolute risk) **VQ** scan carriers a **higher risk of childhood cancer** for the fetus (minimal absolute risk)

Answer 225

No as the **treatment for DVT and PE are the same**

Answer 226

No and pregnancy is a cause of raised D-Dimers

Answer 227

LMWH e.g. enoxaparin, dalteparin and tinzaparin, dose is based on the **woman's weight** at the **booking clinic** or **from early pregnancy**

Answer 228

Immediately **before confirming** the diagnosis, treatment can be stopped when investigations **exclude** the diagnosis

Answer 229

**Remainder of pregnancy** plus 6 weeks **3 months in total** (whichever is longer)

Answer 230

**Oral anticoagulation** (e.g. warfarin or a DOAC)

Answer 231

**Unfractionated heparin** **Thrombolysis** **Surgical** embolectomy

Answer 232

New high blood pressure in pregnancy **with end organ dysfunction** notably proteinuria (protein in the urine)

Answer 233

After 20 weeks gestation, when the **spiral arteries** of the placenta form abnormally leading to a **high vascular resistance** in these vessels

Answer 234

**Maternal organ damage** **FGR** **Seixures** **Early labour** **Death**

Answer 235

Hypertension Proteinuria Oedema

Answer 236

High blood pressure **existing before 20 weeks gestation** and is longstanding - not classified as pre-eclampsia

Answer 237

Hypertension occuring after 20 weeks gestation, **without proteinuria**

Answer 238

Pregnancy induced hypertension associated with organ damage - **notably proteinuria**

Answer 239

When **seizures** occur as a result of pre-eclampsia

Answer 240

Pathophysiology is poorly understood, by simplified: - When the **blastocyst** implants on the **endometrium ,** the outermost later called the **syncytiotrophoblast** grows into the endometrium forming finger-like projections called **chorionic villi,** these villi contain **fetal blood vessels** - **Trophoblast** invasion of the endometrium sends signals to the **spiral arteries** in that area of the endometrium, reducing their **vascular resistance** making them more fragile, blood flow to these areas **increases** and eventually they break down forming pools of blood called **lacunae** **-** Maternal blood flows from the uterine arteries into the lacunae and back out through the uterine veins- these **form at around 20 weeks gestation** - When the process of forming lacunae is inadequate then the woman can develop pre-eclampsia - **Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta** causinf oxidative stress in the placenta and the release of inflammatory chemicals into the systemic circulation leadind to a **systemic inflammation** and **impaired endothelial function** in the blood vessels

Answer 241

**Pre-existing hypertension** **Previous hypertension in pregnancy** **Existing autoimmune conditions** (e.g. systemic lupus erythematosus) **Diabetes** **Chronic kidney disease**

Answer 242

**Older than 40** **BMI \> 35** **More than 10 years** since previous pregnancy **Multiple pregnancy** **First pregnancy** **Family history of pre-eclampsia**

Answer 243

Women with **one high-risk factor** or **more than one moderate risk factor** from 12 weeks gestation until birth

Answer 244

**Headache** **Visual disturbance** or blurriness **Nausea and vomiting** **Upper abdominal or epigastric pain** (this is due to liver swelling) **Oedema** **Reduced urine output** Brisk reflexes

Answer 245

Systolic blood pressure above **140 mmHg** Diastolic blood pressure above **90 mmHg** PLUS **Proteinuria** (1+ or more on urine dipstick) **Organ dysfunction** (e.g. **raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia**) **Placental dysfunction** (e.g. f**etal growth restriction or abnormal Doppler studies**)

Answer 246

**Urine albumin:creatinine ratio** (above 30mg/mmol is significant) **Urine protein:creatinine ratio** (above 8mg/mmol is significant)

Answer 247

Recommended for use on one occasion during pregnancy in women suspected of having pre-eclampsia **Placental growth factor** is a protein released by the placenta which functions to stimulate the development of new blood vessels. In pre-eclampsia the levels of PIGF are low NICE recommends using PIGF between 20 and 35 weeks gestation to **rule out pre-eclampsia**

Answer 248

Blood pressure Symptoms Urine dipstick for proteinuria

Answer 249

Treating to **aim** for a blood pressure below **135/85** mmHg **Admission** for women with a blood pressure **above 160/110 mmHg** **Urine dipstick testing at least weekly** **Monitoring of blood tests weekly** (full blood count, liver enzymes and renal profile) **Monitoring fetal growth** by serial growth scans **PlGF** testing on **one occasion**

Answer 250

Similar to gestational hypertension, except: **Scoring systems** are used to determine **whether to admit** the woman (**fullPIERS or PREP‑S**) **Blood pressure is monitored closely** (at least every 48 hours) **Urine dipstick testing** is **not routinely necessary** (the diagnosis is already made) **Ultrasound monitoring of the fetus, amniotic fluid and dopplers** is performed two weekly

Answer 251

**Labetolol is first-line** as an antihypertensive **Nifedipine** (modified-release) is commonly used second-line **Methyldopa is used third-line** (**needs to be stopped within two days of birth**) **Intravenous hydralazine** may be used as an antihypertensive in critical care in **severe pre-eclampsia or eclampsia** **IV magnesium sulphate** is given **during labour and in the 24 hours afterward**s to **prevent seizures** **Fluid restriction is used during labour** in severe pre-eclampsia or eclampsia, to avoid fluid overload

Answer 252

Blood pressure cannot be controlled or complications occur

Answer 253

**Enalapril** (first-line) **Nifedipine or amlodipine** (first-line in black African or Caribbean patients) **Labetolol or atenolol** (third-line)

Answer 254

The seizures associated with pre-eclampsia **IV magnesium sulphate** is used to help manage the seizures

Answer 255

Combination of features with occur as a complication of pre-eclampsia: **H**aemolysis **E**levated **L**iver enzymes **L**ow Platelets

Answer 256

Diabetes triggered by birth, caused by **reduced insulin sensitivity** during pregnancy and **resolves after birth**

Answer 257

**Large for dates fetus** and **macrosomia** leading to **shoulder dystocia** and **longer term** women are at a higher risk of developing **type 2 diabetes after pregnancy**

Answer 258

**Oral glucose tolerance test** at **24-28 weeks gestation** women with previous gestational diabetes also have an OGTT soon after the booking clinic

Answer 259

**Previous gestational diabetes** Previous **macrosomic** baby (≥ 4.5kg) **BMI \> 30** **Ethnic origin** (black Caribbean, Middle Eastern and South Asian) **Family history of diabetes** (first-degree relative)

Answer 260

**Large for dates fetus** **Polyhydramnios** (increased amniotic fluid) **Glucose** on urine **dipstick**

Answer 261

Performed **in the morning** after a fast (they can drink plain water) Patient **drinks** a **75g** **glucose** drink at the start of the test Blood **sugar level** is measured before the sugar drink (**fasting)** and then at **2 hours**

Answer 262

Fasting: \< 5.6 mmol/l At 2 hours: \< 7.8 mmol/l (5, 6, 7, 8)

Answer 263

**- Joint diabetes and antenatal clinics** with input from a dietician - Careful explanation about the condition and to learn how to monitor and track their blood sugar levels - Four weekly ultrasound scans to **monitor the fetal grwoth** and **amniotic fluid volume from 28 to 36 weeks gestation**

Answer 264

**Fasting glucose less than 7 mmol/l:** trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin **Fasting glucose above 7 mmol/l**: start insulin ± metformin **Fasting glucose above 6 mmol/l plus macrosomia** (or other complications): start insulin ± metformin

Answer 265

**Glibenclamide** (a sulfonylurea)

Answer 266

**Fasting:** 5.3 mmol/l **1 hour post-meal:** 7.8 mmol/l **2 hours post-meal:** 6.4 mmol/l **Avoiding levels of 4 mmol/l or below**

Answer 267

They should take **5mg folic acid from preconception until 12 weeks gestation**

Answer 268

Aim for the **same target insulin levels** as with gestational diabetes

Answer 269

Using metformin and insulin (other oral diabetic medications should be stopped)

Answer 270

Shortly after booking and at 28 weeks gestation in pregnancy Involves **referral** to an **ophthalmologist** to check for **diabetic retinopathy**

Answer 271

Planned delivery between 37 and 38 + 6 weeks

Answer 272

Up to 40+6

Answer 273

**Sliding-scale insulin regime** A dextrose and insulin infusion is titrated to blood sugar levels according to the local protocol. Also considered for women with **poorly controlled blood sugars** with gestational or type 2 diabetes

Answer 274

Immediately after birth with follow up testing for their fasting glucose at least 6 weeks after

Answer 275

Lower their insulin dose and be wary of **hypoglycaemia** in the postnatal period - insulin sensitivity will increase after birth and with breast feeding

Answer 276

**Neonatal hypoglycaemia** **Polycythaemia** (raised haemoglobin) **Jaundice** (raised bilirubin) **Congenital heart disease** **Cardiomyopathy**

Answer 277

**Neonatal hypoglycaemia** - babies have been accustomed to a large supply of glucose during the pregnancy Neonates need close monitoring for this with regular blood glucose checks and **frequent feeds** aiming to **maintain thier blood sugar** above 2 mmol/l and if it falls they may need **IV dextrose** or **nasogastric feeding**

Answer 278

**Intrahepatic cholestasis** **of pregnancy**

Answer 279

**Reduced outflow of bile acids** from the liver - resolving after delivery of the baby

Answer 280

Increased **oestrogen** and **progesterone** levels

Answer 281

South asian ethnicity

Answer 282

Breakdown product of cholesterol **produced in the liver**

Answer 283

**From the liver** to the **hepatic ducts** past the gallbladder and out of the **bile duct** into the intesting

Answer 284

**Increased risk of stillbirth**

Answer 285

Later in pregnancy, **particularly in the third trimester**

Answer 286

**Itching** (pruritis) on the **palms of the hands** and **soles of the feet** ## Footnote **Fatigue** **Dark urine** **Pale, greasy stools** **Jaundice**

Answer 287

No rash, if this is present then an alternative diagnosis should be considered e.g. **polymorphic eruption of pregnancy** pr **pemphigoid gestationis**

Answer 288

Obstetric chilestasis Gallstones Acute Fatty liver Autoimmune hepatitis

Answer 289

**LFTs** (deranged ALT, AST and GGT) **Bile acids** (raised)

Answer 290

Yes as the **placenta produces alkaline phosphatase**, so normal if the only enzyme to rise

Answer 291

**Ursodeoxycholic acid** - improves LFTs, bile acids and symptoms

Answer 292

**Emollients** (i.e. calamine lotion) to soothe the skin **Antihistamines** (e.g. chlorphenamine) can help sleeping (but does not improve itching)

Answer 293

**Water-soluble vitamin K** if clotting (prothrombin time) is deranged Vitamin K is a fat-soluble vitamin, bile acids help absorb fat soluble vitamins - a lack of bile acids can lead tp vitamin K deficiency (this is an impostant part of the clotting system)

Answer 294

Weekly and at least 10 days after delivery to ensure condition does not worsen

Answer 295

After 37 weeks, particularly when **the LFTs and bile acids are severely deranged**

Answer 296

Rare condition which occurs in the **third trimester of pregnancy** with **rapid accumulation of fat** within the liver cells (**hepatocytes**) causing **acute hepatitis** High risk of **liver failure** and **mortality** for both the mother and fetus

Answer 297

Impaired processing of **fatty acids** in the **placenta** result of a genetric condition in the fetus which impairs fatty acid metabolism Most common cause is **long-chain 3-hydroxyacyl-CoA dehydrogenase** (**LCHAD**) deficiency in the fetus which is an **autosomal recessive** condition The **LCHAD** enzyme is important in **fatty acid oxidation** breaking down fatty acids to be used as fuel **Fatty acids then enter maternal circulation** and accumulate in the liver causing **inflammation and failure**

Answer 298

Vague symptoms associated with hepatitis: General **malaise and fatigue** **Nausea** and **vomiting** **Jaundice** **Abdominal pain** **Anorexia** (lack of appetite) **Ascites**

Answer 299

**Elevated ALT and AST** (liver enzymes) **Raised bilirubin** **Raised WBC** **Deranged clotting** (raised prothrombin time and INR) **Low platelets**

Answer 300

**HELLP syndrome** rather than acute fatty liver of pregnancy (HELLP syndrome is much more common)

Answer 301

**Obstetric emergency** which requires prompt admission and delivery of the baby - most patients recover after delivery

Answer 302

**Acute liver failure** - consider liver transplant

Answer 303

Itchy rash which tends to **start in the 3rd trimester** Also known as **pruritic and urticarial papulaes and plaques of pregnancy** Usually **begins of abdomen** and particularly assocuated with **stretch marks** (striae)

Answer 304

**Urticarial papules** (raised itchy lumps) **Wheals** (raised itchy areas of skin) **Plaques** (larger inflamed areas of skin)

Answer 305

Control the symptoms: **Topical emollients** **Topical steroids** **Oral antihistamines** **Oral steroids** may be used in severe cases

Answer 306

Eczema which flares up during pregnancy (and in those without history of eczema) Presents in the **first and second trimester** of pregnancy

Answer 307

**E-type or eczema type** with eczematous inflamed, red and itchy skin, inside of elbows and knees, face and chest **P-type or prurigo-type** intesely itchy papules (spots) typically affecting the abdomen, back and limbs

Answer 308

**Topical emollients** **Topical steroids** **Phototherapy with ultraviolet light** (UVB) may be used in severe cases **Oral steroids** may be used in severe cases

Answer 309

**Mask of pregnancy**

Answer 310

**Increased pigmentation** to patched of the skin on the face - usually symmetrical and flat, affecting sun-exposed areas

Answer 311

**Increased female sex hormones** associated with pregnancy Also occurs with the COCP and HRT Associated also with **sun exposure, contraceptive pill and HRT**

Answer 312

No active management if the appearance is acceptable to the woman, otherwise: **Avoiding sun exposure** and using suncream **Makeup** (camouflage) **Skin lightening cream** (e.g. hydroquinone or retinoid creams), **although not in pregnancy** and only under specialist care **Procedures such as chemical peels** or laser treatment (not usually on the NHS)

Answer 313

Lobular capillary haemangioma

Answer 314

**Benign** rapidly growing tumour of capillaries

Answer 315

Discrete lump with a red / dark appearace **Occuring more often in pregnancy** can also be associated with hormonal contraceptives, minor trauma or infection

Answer 316

Rapidly growing lump which develops **over days** up to 1-2cm in size (but can be larger) Often occur on the **fingers** or on the upper chest, back, neck or head. **May cause profuse bleeding and ulceration if injured**

Answer 317

Malignancy (**nodular melanoma**)

Answer 318

Usually resolve in pregnancy without any further treatment after delivery Treatment is with **surgical removal** with **histology** to confirm the diagnosis

Answer 319

Rare **autoimmune skin condition** in pregnancy **Autoantibodies** are created with **damage the connection** between the **epidermis and dermis** creating a space with can fill with fluid, resulting in large fluid-filled blisters (bullae)

Answer 320

Pregnant woman's immune system may produce these **antibodies** in response to **placental tissue**

Answer 321

**Second or third trimester**

Answer 322

**Itchy, red, papular or blistering rash** around the umbilicus that then spreads to other parts of the body - **over weeks** large **fluid filled blisters form**

Answer 323

Rash usually resolves without treatment after delivery, **blisters heal without scarring**, treatment can be: **Topical emollients** **Topical steroids** **Oral steroids** may be required in severe cases **Immunosuppressants** may be required where steroids are inadequate **Antibiotics** may be necessary if infection occurs

Answer 324

**Fetal growth restriction** **Preterm** delivery **Blistering rash after delivery** (as the maternal antibodies pass to the baby)

Answer 325

The palcenta is attached in the **lower portion of the uterus,** lower than presenting part of fetus

Answer 326

Used when the placenta is **within 20mm** of the **internal cervical os**

Answer 327

Term used for when the placenta is **over the internal cervical os**

Answer 328

Placenta praevia Placental abruption Vasa praevia

Answer 329

Cervical ectropion Infection Vaginal abrasions from intercourse

Answer 330

**Antepartum haemorrhage** **Emergency caesarean section** **Emergency hysterectomy** **Maternal anaemia and transfusions** **Preterm birth** and low birth weight **Stillbirth**

Answer 331

**Minor praevia, or grade I** – the placenta is in the lower uterus but not reaching the internal cervical os **Marginal praevia, or grade II** – the placenta is reaching, but not covering, the internal cervical os **Partial praevia, or grade III** – the placenta is partially covering the internal cervical os **Complete praevia, or grade IV** – the placenta is completely covering the internal cervical os

Answer 332

**Previous caesarean sections** **Previous placenta praevia** **Older** maternal **age** Maternal **smoking** Structural uterine abnormalities (e.g. **fibroids**) Assisted reproduction (e.g. **IVF**)

Answer 333

20 week anomaly scan

Answer 334

Usually asymptomatic **Painless vaginal bleeding** (around 36 weeks)

Answer 335

Repeat scans at **32 weeks** and **36 weeks** gestation (if present on the 32-week scan, to guide decisions about delivery) **Corticosteroids** given between 34 and 35+6 gestation to mature the fetal lungs **Planned delivery between 36 and 37 weeeks** to reduce the risk of spontaneous labour and bleeding **Planned C-Section** is required with placenta praevia and low-lying placenta **Ultrasound** around the time of procedure to locate placenta **Emergency C-Section** required with premature labout or antenatal bleeding

Answer 336

**Haemorrhage** before, during and after delivery

Answer 337

**Emergency caesarean** section ## Footnote **Blood transfusions** **Intrauterine balloon tamponade** **Uterine artery occlusion** **Emergency hysterectomy**

Answer 338

Condition where the **fetal vessels** are within the **fetal membranes** (chorioamniotic membranes) and travel across the **internal cervical os**

Answer 339

**Surrounding** the **amniotic cavity** and developing fetus

Answer 340

Two umbilical arteries Single umbilical vein

Answer 341

The fetal vessels are places over the internal cervical os, **before the fetus** - exposed, outside the protection of the umbilical cord or placenta - prone to bleeding, particularly when the membranes are ruptured during labour and at birth

Answer 342

Insert **directly into the placenta** (always protected by the umbilical cord or the placenta)

Answer 343

A layer of **soft connective tissue** that **surrounds** the **blood vessels in the umbilical cord** offering protection

Answer 344

**Velamentous umbilical cord** is where the **umbilical cord inserts into the chorioamniotic membranes**, and the fetal vessels **travel unprotected through the membranes** before joining the placenta. **An accessory lobe of the placenta** (also known as a **succenturiate** lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.

Answer 345

**Dramatic fetal blood loss and death**

Answer 346

**Type I vasa praevia** – the fetal vessels are exposed as a velamentous umbilical cord **Type II vasa praevia** – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 347

**Low lying placenta** **IVF** pregnancy **Multiple pregnancy**

Answer 348

**Maybe** diagnosed **by ultrasound during pregnancy** (allowing planned C-Section to reduce risk of haemorrhage) **Antepartum haemorrhage** with **bleeding during 2nd or 3rd trimester** of pregnancy **Maybe** detected on **vaginal examintation during labour** when pulsatiling vessels are seen in the membranes **Maybe** detected during labour when **fetal distress** and **dark-red bleeding occur following rupture of the membranes** carries a very high fetal mortality

Answer 349

For asymptomatic patients: - **Corticosteroids** from week 32 gestation - **Elective c-section** planned for 34 to 36 weeks gestation In **antepartum haemorrhage**: - **Emergency C-Section** is required to deliver fetus

Answer 350

Placenta is examined for **evidence of vasa praevia** as a possible cause

Answer 351

When the **placenta separates from the walls of the uterus** during pregnancy (site of attachment can bleed extensively after the placenta separates - **significant cause of antepartum haemorrhage**

Answer 352

Previous placental abruption Pre-eclampsia **Bleeding early** in pregnancy **Trauma** (consider domestic violence) **Multiple pregnancy** **Fetal growth restriction** **Multigravida** **Increased maternal age** **Smoking** **Cocaine or amphetamine use**

Answer 353

**Sudden onset severe abdominal pain** that is continuous **Vaginal bleeding** (antepartum haemorrhage) **Shock** (hypotension and tachycardia) **Abnormalities on the CTG** indicating fetal distress Characteristic **“woody” abdomen on palpation**, suggesting a large haemorrhage

Answer 354

**Spotting**: spots of blood noticed on underwear **Minor haemorrhage:** less than 50ml blood loss **Major haemorrhage**: 50 – 1000ml blood loss **Massive haemorrhage:** more than 1000 ml blood loss, or signs of shock

Answer 355

**Cervical os remains closed**, and **any bleeding that occurs remains within the uterine cavity**. The **severity** of bleeding can be **significantly underestimated** with concealed haemorrhage.

Answer 356

Where blood loss is observed via the vagina

Answer 357

No reliable test, clinical diagnosis

Answer 358

**Obstetric emergency** - urgency depends on the amount of fetal separation, extent of bleedin, haemodynamic stability of the mother and condition of the fetus (important to consider **concealed haemorrhage** where vaginal bleeding may be disproportionate to uterine bleeding)

Answer 359

Urgent involvement of a **senior obstetrician,** midwife and anaesthetist **2 x grey cannula** **Bloods include FBC, UE, LFT** and **coagulation** studies **Crossmatch 4 units** of blood **Fluid and blood resuscitation** as required **CTG monitoring** of the fetus Close **monitoring** of the **mother**

Answer 360

**Ultrasound** to **exclude placenta praevia** as a cause for antepartum haemorrhage (not good for diagnosing abruption) **Antenatal steroids** between 24 and 34 + 6 weeks gestation **Rhesus-D negative women** require **anti-D prophylaxis** when bleeding occurs - a **Kleihauer test** is used to quantify how much fetal blood is mixed with maternal blood to determine dose **Emergency C-Section** if mother is **unstable** or there is **fetal** distress **Increased risk** of **postpartum haemorrhage** after delivery in women with placental abruption - **active management of the third stage is recommended**

Answer 361

When the **placenta implants deeper**, through and past the endometrium - then difficult to separate the placenta after delivery of the baby

Answer 362

There is a **spectrum of severity** in how deep and broad the normal implantation extends

Answer 363

**Endometrium**, the inner layer that **contains connective tissue** (stroma), **epithelial cells and blood vessels** **Myometrium**, the **middle layer that contains smooth muscle** **Perimetrium**, the **outer layer, which is a serous membrane** similar to the peritoneum (also known as serosa)

Answer 364

The **endometrium**

Answer 365

Past the endometrium **into the myometrium and beyond**

Answer 366

**Previous uterine surgery** e.g. C-Section or curettage procedure

Answer 367

Difficult for the placenta to separate suring delivery, leading to **extensive bleeding** (post-partum haemorrhage)

Answer 368

**Superficial placenta accreta** is where the placenta implants in the surface of the myometrium, but not beyond **Placenta increta** is where the placenta attaches deeply into the myometrium **Placenta percreta** is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 369

**Previous placenta accreta** **Previous endometrial curettage procedures** (e.g. for miscarriage or abortion) **Previous caesarean section** **Multigravida** **Increased maternal age** **Low-lying placenta** or placenta praevia

Answer 370

Doesnt usually cause symptoms in pregnancy Can present with **antepartum haemorrhage** in the **third trimester** May be diagnosed on **antenatal ultrasound scans** with particular attention fiven to women with previous placenta accreta or caesarean during scanning May be diagnosed at birth when it is **difficult to deliver the placenta**

Answer 371

Antenatally by ultrasound - allowing planning for birth

Answer 372

**MRI scans**

Answer 373

May need additional management at birth due to the risk of bleeding: **Complex uterine surgery** Blood **transfusions** **Intensive care** for the mother **Neonatal intensive care**

Answer 374

**Between 35 to 36+6 weeks** gestation to reduce the risk of spontaneous labour and delivery (antenatal steroids given to mature the fetal lungs before delivery)

Answer 375

**Hysterectomy with the placenta remaining in the uterus** (recommended) **Uterus preserving surgery,** with resection of part of the myometrium along with the placenta **Expectant management,** leaving the placenta in place to be reabsorbed over time

Answer 376

Risks - bleeding and infection

Answer 377

- During an **elective C-section** the abdo can be closed and delayed whilst services are put in place - If discovered after delivery of baby then a **hysterectomy** is recommended

Answer 378

Presenting part of the fetus is the **legs and bottom**

Answer 379

**Less than 5% of pregnancies by 37 weeks gestation**

Answer 380

**Complete breech**, where the legs are fully flexed at the hips and knees **Incomplete breech,** with one leg flexed at the hip and extended at the knee **Extended breech**, also known as frank breech, with both legs flexed at the hip and extended at the knee **Footling breech**, with a foot is presenting through the cervix with the leg extended

Answer 381

**Before 36 weeks** often turn spontaneously **After 37 weeks** external cephalic version cabn be used

Answer 382

Mothers given a choice between **vaginal delivery** and **elective caesarean section**. Vaginal delivery requires experienced midwives and obstetricians with access to emergency theatre if required Vaginal birth is safer for mother, c-section is safer for baby **40% chance of needing c-section** when vaginal birth is attempted If first baby of a twin pregnancy is breech then C-section required

Answer 383

**After 36 weeks for nulliparous women** **After 37 weeks** in women that have given birth previously

Answer 384

**Tocolysis** to relax the uterus (subcutaneous terbutaline) A **beta-agonist** similar to salbutamol (**reduces the contractility of the myometrium**)

Answer 385

**Anti-D prophylaxis**

Answer 386

Birth of a dead fetus after 24 weeks gestation (result of **intrauterine fetal death**) occurs in approx 1 in 200 pregnancies

Answer 387

Unexplained (around 50%) Pre-eclampsia **Placental abruption** **Vasa praevia** **Cord prolapse** or wrapped around the fetal neck **Obstetric cholestasis** **Diabetes** **Thyroid disease** **Infections**, such as rubella, parvovirus and listeria **Genetic abnormalities** or congenital malformations

Answer 388

**Fetal growth restriction** **Smoking** **Alcohol** **Increased maternal age** **Maternal obesity** **Twins** Sleeping on the back (as opposed to either side)

Answer 389

**Risk assesment for SGA / FGR** is performed on all pregnant women Those at risk have **serial growth scans** (maybe planned early delivery when the growth is static or other concerns) **Risk assessment for pre-eclampsia** and given aspirin **Modifiable risk factors for stillbirth** are treated e.g. stopping smoking, avoiding alcohol, effective control for diabetes **Sleeping on the side** is recommended

Answer 390

**Reduced fetal movements** **Abdo pain** **Vaginal bleeding**

Answer 391

**Ultrasound scan** to **visualise the fetal heatbeat** Passive fetal movements are still possible so a repeat scan is offered to confirm situation

Answer 392

**Vaginal birth is first line** (choice of induction of labour or expectant management - provided there is no sepsis, pre-eclampsia or haemorrhage) **Expectant managment** needs close monitoring - condition of fetus will deteriorate with time **Induction of laboue** involves use of **oral mifepristone** (anti-progesterone) and vaginal or oral misoprostol (**prostaglandin analogue**) **Dopamine agonists** (e.g. **cabergoline**) can be used to **suppress lactation** after stillbirth

Answer 393

With **parental consent**, testing is carried our after stillbirth: **Genetic testing of the fetus** and placenta **Postmortem examination of the fetus (including xrays)** **Testing for maternal and fetal infection** **Testing the mother for conditions** associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Answer 394

**Thrombosis** (i.e. PE or MI) Tension **pneumothorax** **Toxins** **Tamponade** (cardiac) **Hypoxia** **Hypovolaemia** **Hypothermia** **Hyperkalaemia, hypoglycaemia**, and other metabolic abnormalities

Answer 395

Eclampsia Intracranial haemorrhage **Obstetric haemorrhage** **Pulmonary embolism** **Sepsis leading to metabolic acidosis and septic shock**

Answer 396

**Ectopic pregnancy** (early pregnancy) **Placental abruption** (including concealed haemorrhage) **Placenta praevia** **Placenta accreta** **Uterine rupture**

Answer 397

Pregnant woman lies on her back - the mass of the uterus compresses the **IVC and aorta** (compression on the IVC is most significant as it lowers cardiac output leading to hypotension) can **lead to cardiac arrest**

Answer 398

Place the owmen in the left lateral position, lying on her left side

Answer 399

**Aortocaval compression** **Increased oxygen requirements** **Splinting of the diaphragm** by the pregnant abdomen **Difficulty with intubation** **Increased risk of aspiration** **Ongoing obstetric haemorrhage**

Answer 400

**A 15 degree tilt to the left side** for CPR, to relieve compression of the inferior vena cava and aorta **Early intubation to protect the airway** **Early supplementary oxygen** **Aggressive fluid resuscitation** (caution in pre-eclampsia) **Delivery of the baby after 4 minutes**, and within 5 minutes of starting CPR

Answer 401

There is **no response after 4 minutes** to CPR when performed correctly **CPR continues for more than 4 minutes** in a woman more than 20 weeks gestation

Answer 402

Within **5 minutes of starting CPR** - performed at the site of the arrest e.g. A&E resus or on the ward

Answer 403

**Improves survival of the mother** improving the venous return to the heart, improving cardiac output and reducing oxygen consumption - also helps with ventilation and chest compressions (also increases the chances of the baby surviving, although this is secondary to the survival of the mother)