Antenatal Care/ Early Pregnancy Bleeding/ Miscarriage/ Termination Of Pregnancy

Question 1

When are foetal movements first felt?

Answer 1

Primigravida: 17-20 weeks
Multigravida: 16-18 weeks

Question 2

What should be checked each antenatal visit?

Answer 2

Weight gain
Blood pressure
U/A (protein/ sugar)
Fundal height
Foetal HR
Foetal movements
Presentation and position of foetus
Presence of oedema

Question 3

What should the patient do if they experience reduced foetal movements?

Answer 3

If daily movements exceed 10 and the regular pattern has not changed significantly hen usually the fetus is at no risk. If the movements drop to fewer than 10 per day the patient should be referred to hospital for foetal monitoring

Question 4

What should be done about early pregnancy bleeding

Answer 4

Serial quantitative HCG (should double every 2 days).

If HCG >1500 then should show on u/s

Question 5

What should be done about early pregnancy bleeding 6-8 weeks

Answer 5

Ultrasound will exclude ectopic pregnancy

Question 6

What should be done about early pregnancy bleeding >8 weeks

Answer 6

Normal ultrasound is reassuring as miscarriage rate is only 3%

Question 7

What could a small bleed at 18-24 weeks indicate?

Answer 7

Cervical ‘weakness’ and warrants a speculum exam plus foetal assessment

Question 8

Who are high risk obstetric patients?

Answer 8

Elderly primigravida (>35)
Grand multigravida (fifth or greater pregnancy)
Those with a poor obstetric history
Previous unplanned caesarean
Severe social disadvantage
Hypertension +/- chronic kidney disease
Obesity
Short stature
Diabetes mellitus
Prolonged infertility
Heavy smoking/ alcohol
Little or no weight gain in first half of pregnancy
Pregnancy complications eg multiple pregnancy, antepartum haemorrhage, preeclampsia 
Abnormal presentation
Abnormal foetal growth

Question 9

What spot test should be done for preeclampsia?

Answer 9

Spot urinary albumin- creatinine ratio

Question 10

What antihypertensives are contraindicated in pregnancy?

Answer 10

ACE-I and diuretics

Question 11

What indications for urgent hospital referral in preeclampsia?

Answer 11

Progressing preeclampsia including development of proteinuria
Inability to control BP
Deteriorating liver, blood (platelets), renal function
Neurological symptoms/ signs (headache, drowsy and confused, twitching, rolling eyes, vomiting, visual disturbances, hyper reflexia)

Question 12

What is a normal haemoglobin in pregnancy?

Answer 12

Greater than 110g/L

Question 13

What effects can diabetes in pregnancy have in the fetus?

Answer 13

Macrosomia
Foetal abnormalities
Hypoxia and intrauterine death
Miscarriage
Mal presentation
IUGR
Preterm delivery
Early hypoglycaemia, jaundice, respiratory distress syndrome after delivery

Question 14

What effects can diabetes in pregnancy have on the mother?

Answer 14

Increased risk of preeclampsia
Diabetic ketoacidosis
Polyhydramnios
Inter current infection
First trimester miscarriage
Obstructed labour

Question 15

What sound be discussed when a woman comes in for preconception advice?

Answer 15

Optimal nutrition and diet
Weight control
Regular exercise
Discouragement of smoking, alcohol and drugs
Folic acid at least 1 (preferably 3) month prior to conception
Pap smears up to date
Check rubella serology +/- immunise 3 months prior to conception
Ask about varicella history and consider serology/ vaccination
Genetic counselling based on past obstetric/ family history, advanced maternal age.

Question 16

What follow up is required after gestational diabetes?

Answer 16

Glucose tolerance test at 6 weeks postpartum and then every 5 years.
Gestational diabetes is likely in subsequent pregnancies and there is a 30% lifetime risk of developing diabetes.

Question 17

What is the usual cause of hyperthyroidism in pregnancy?

Answer 17

Grave’s disease

Question 18

True or false: 90% of murmurs in pregnancy are physiological

Answer 18

True

Question 19

Which patient require antibiotic prophylaxis cover in labour?

Answer 19

Patients with a structural cardiac malformation eg valvular problems
Patients with an increased risk of bacterial endocarditis (especially rheumatic heart disease)

Question 20

What is acute cholestasis of pregnancy?

Answer 20

Due to oestrogen sensitivity
Symptoms of low grade jaundice and pruritis during latter half of pregnancy
Can be associated with foetal death, distress and preterm delivery
Perform LFTs and consider vit K supplements
Refer for monitoring of fetus and delivery if unfavourable
The condition clears up rapidly after delivery but often recurs in future pregnancies or if given OCP (which is contraindicated)

Question 21

What is antepartum haemorrhage?

Answer 21

Bleeding from the genital tract after the 24th week of gestation and before the onset of labour

Question 22

True or false: do not perform a vaginal examination for antepartum haemorrhage

Answer 22

True

Question 23

What are the main causes of antepartum haemorrhage?

Answer 23

Placenta praevia and placental abruption

Question 24

What is the usual presentation of placenta praevia?

Answer 24

Painless bleeding at 28-30 weeks with a high presenting part on examination

Question 25

What are risk factors for endometrial cancer

Answer 25

Age
Obesity
Nulliparity 
Late menopause
Diabetes mellitus 
PCOS
Drugs eg unopposed oestrogen 
Family history (lynch syndrome)

Question 26

What are risk factors for endometrial cancer

Answer 26

Age
Obesity
Nulliparity 
Late menopause
Diabetes mellitus 
PCOS
Drugs eg unopposed oestrogen 
Family history (lynch syndrome)