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MRCOG part 2 > Antepartum Care > Flashcards

Antepartum Care Flashcards

1
Q

Incidence of placenta praevia

A

1 in 200 pregnancies

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2
Q

Resolution rate of placenta praevia at 32 weeks

A

90%

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3
Q

Resolution rate of placenta praevia at 36 weeks

A

50%

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4
Q

Cervical length of less than ________ predicts antepartum haemorrhage and emergency c/s

A

31mm

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5
Q

Risk factors for placenta praevia

A

Smoking
ART
Caesarean birth

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6
Q

Timing of steroids for placenta praevia

A

34+0 to 35+6

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7
Q

Timing of delivery in placenta praevia

A

34+0 - 36+6 if vaginal bleeding/other risk factors

36+0 - 37+0 if uncomplicated

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8
Q

Risk of bleeding by gestation with placenta praevia

A

4.7% by 35 weeks
15% by 36 weeks
30% by 37 weeks
59% by 38 weeks

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9
Q

Risk of MOH requiring blood transfusion with placenta praevia c/s

A

12 x higher

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10
Q

Risk factors for PAS

A

C/S
Previous uterine surgery
Placenta praevia
IVF
Maternal age
Bicornuate uterus
Adenomyosis
Submucous fibroids
Myotonic dystrophy

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11
Q

Rate of PAS with praevia and 3 or more c/s

A

50-67%

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12
Q

Proportion of PAS undiagnosed

A

1/3 to 2/3rds

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13
Q

USS signs of PAS

A

Abnormal uterus-bladder interface
Abnormal vasculature on colour Doppler
Abnormal Placental lacunae vascularity
Increased vascularity of the placental bed
Loss of clear zone
Myometrial thinning
Placental bulge
Focal exophytic mass
Bridging vessels

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14
Q

MRI signs of PAS

A

Abnormal uterine bulging
Dark intraplacental bands
Heterogenous signal intensity in placenta
Disorganised vasculature of placenta
Disruption of uteroplacental zone

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15
Q

Gestation for delivery with PAS

A

35+0 to 36+0

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16
Q

Risk of urinary tract injury during PAS surgery

A

16% of uterus preserved
57% with standard hysterectomy

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17
Q

Risks of conservative management of PAS (placenta in situ)

A

Infection
Bleeding
Septic shock
Peritonitis
Uterine necrosis
Fistula
Pulmonary oedema
Acute renal failure
VTE
Injury to adjacent organs

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18
Q

Emergency cerclage can be considered up from ______ to _____ gestation

A

16+0 to 27+6

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19
Q

Risk of preterm birth with cervical length of <25mm and history of PTB

A

14%

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20
Q

Indications for serial cervical length scans

A

Previous PTB/2nd trimester loss 16-34 weeks
Previous PPROM <34 weeks
Previous cerclage
Intrauterine adhesions
Known uterine variant
History of trachelectomy

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21
Q

Indication for trans abdominal cerclage

A

Previous failed vaginal cerclage

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22
Q

Risks of cervical cerclage

A

Cervical laceration
Bladder injury
Membrane rupture
Fistula formation
Removal under anaesthetic required if performed with bladder mobilisation

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23
Q

Removal of cervical suture should be at

A

36+1 to 37+0 unless pt undergoing c/s

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24
Q

History indicated cerclage

A

Singleton, 3 or more preterm births
Singleton, history of second trimester loss

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25
Q

Gestation at which you MUST remove cervical cerclage after PPROM

A

Less than 23 weeks
More than 34 weeks

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26
Q

Incidence of PPROM

A

3%

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27
Q

PPROM occurs in what percentage of PTB

A

30-40%

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28
Q

Median latency after PPROM

A

7 days

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29
Q

Management of PPROM

A

Delivery if septic
Erythromycin (penicillin if allergic) 10 days or established labour
Offer steroids between 24+0 to 33+6
Consider steroids 34+0 to 35+6

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30
Q

Benefit of abx in PPROM

A

Reduce babies born within 48 hours and within 7 days
Reduce risk of chorio
Reduces risk of neonatal infection, surfactant use, oxygen therapy and abnormal cerebral USS

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31
Q

Most helpful marker of chorioamnionitis

A

CRP (77% specificity)

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32
Q

Tocolysis in PPROM is not recommended because

A

Associated with lower APGAR scores (<7) and increased need for ventilatory support
Increased risk of chorio below 34 weeks

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33
Q

Timing of Delivery following PPROM

A

37+0

From 34+0 if GBS pos

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34
Q

MgSO4 for PPROM

A

Offer when Planned or established labour 24+0 to 29+6
Consider between 30+0 and 33+6

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35
Q

Average time to delivery after PPROM

A

8-10 days at 24+0 to 28+0
5 days at 31+0

May be sooner if there is oligo

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36
Q

Factors leading to worse outcomes for PPROM

A

Oligo
Non-cephalic presentation
Occurring <26+0

Consider hospital care

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37
Q

Benefits of antenatal steroids

A

Reduce NND
Reduce NEC
Reduce RDS
Reduce intraventricular haemorrhage
Reduce risk of infection in first 48 hours of life
Reduces risk of ITU admission/respiratory support
Reduce developmental delay

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38
Q

Optimal Timing of steroids

A

Greatest benefit with delivery within 48 hours of first dose

Benefit seen within 24 hours of delivery
Benefit for up to 7 days of giving

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39
Q

Dose and type of steroids

A

Dexamethasone phosphate 12mg 24 hours apart or 4 doses of 6mg given 12 hourly (better risk reduction for IVH)

Betamethasone phosphate/acetate mix - 12mg 24 hours apart

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40
Q

Gestations to give steroids

A

Offer between 24+0 to 34+6

Consider 35+0 to 36+6

Consider between 22+0 to 23+6

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41
Q

Harms of steroids

A

Affects maternal glycaemic control for 5 days
Neonatal hypoglycaemia
Reduced birth weight with repeat courses
Neurodevelopmental affects if baby born at term

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42
Q

Stillbirth rate

A

32 in 10, 000 (white)
72 in 10, 000 (black)
51 in 10, 000 (Asian)

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43
Q

Consider Prophylactic vaginal progesterone when

A

History of PTB up to 34+0/2nd trimester loss OR cervical length is <25mm on TV USS

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44
Q

Offer either cerclage or vaginal progesterone when

A

History of PTB/2nd trimester loss AND cervical length <25mm

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45
Q

Gestation to give vaginal progesterone

A

Start between 16+0 and 24+0
Continue until 34+0

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46
Q

Offer prophylactic cerclage when

A

History of cervical trauma OR
History of PPROM

AND cervical length <25mm

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47
Q

Contraindications for emergency cerclage

A

Uterine contractions
Active vaginal bleeding
Signs of infection

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48
Q

Diagnosis of PTB at 30+0 or more

A

15mm cervical length on TV USS (preferred)
OR
Fetal fibronectin >50

Treat for PTB if above tests not available

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49
Q

Tocolysis should be given at what gestation?

A

Consider between 24+0 and 26+0
Offer PTB between 26+0 and 33+6

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50
Q

Tocolysis medication

A

Nifedipine
Oxytocin receptor antagonists if nifedipine is contraindicated (atosiban)

Do not use betamimetics

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51
Q

Monitoring of FH in established PTB

A

Offer IA or CTG if no other risk factors

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52
Q

Fetal scalp electrode monitoring should not be used below _____ gestation

A

34+0

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53
Q

FBS should not be used below ______ gestation

A

34+0

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54
Q

Cord clamping technique in preterm babies

A

60 seconds
Hold baby below the level of the placenta

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55
Q

Incidence of PTB

A

7.3% of live births

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56
Q

Gestation for amniocentesis

A

15+0

Higher risk of low DNA quantity prior to 16+0

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57
Q

Risks of amniocentesis

A

Miscarriage 0.5%
Second sample required 6%
Blood stained sample 0.8%
Maternal cell contamination 1-2%
Rapid test failure 2%
Failed cell culture 0.5-1%
Severe infection
Fetal injury
Maternal visceral injury

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58
Q

Risks of CVS

A

Miscarriage 0.5%
Second sample required 6%
Confined placental mosaicism 2%
Failed cell culture 0.5-1%
Severe infection
Fetal injury
Maternal visceral injury

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59
Q

Gestation for CVS

A

10+0 minimum
Ideally after 11+0 to reduce technical difficulty

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60
Q

Pregnancy loss risk for CVS/amniocentesis in multiple pregnancy

A

1%

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61
Q

Risk of cross contamination in multiple pregnancy CVS

A

1%

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62
Q

Risks of 3rd trimester amniocentesis

A

10% risk cell culture failure
PTB 3-4%
More than one needle insertion 5%
Blood stained sample 5-10%

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63
Q

Amniocentesis/CVS considerations with blood borne viruses

A

Testing required prior to test
Ensure HIB viral load is undetectable
Ensure Hep B viral load is <6.99log10 copies/ml
No evidence for Hep C

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64
Q

Maternal mortality rates

A

11.66 per 100, 000 (white)

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65
Q

Definition of early FGR

A

Onset before 32+0
Fetal size or AC <3rd centile OR absent EDF

OR

<10th centile with uterine artery >95th or UA PI >95th centile

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66
Q

Static growth definition

A

No forward growth velocity in AC or EFW measured 14 days apart

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67
Q

Definition of late FGR

A

> 32+0
AC/EFW <3rd centile

OR (2 of the following):

AC/EFW <10th centile
AC/EFW crossing 2 quartiles
Cerebroplacental ratio <5th centile or UA PI >95th centile

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68
Q

Definition of FGR in previous pregnancy

A

Previous baby <3rd centile
PET or FGR requiring birth <34+0
EFW <10th centile with evidence of placental dysfunction

69
Q

Optimal time to start aspirin

A

11+0 to 16+6

70
Q

Incidence of early onset FGR

A

0.3%

71
Q

Timing of SFH measurement

A

First measurement between 26+0 and 28+6
No more than every 2 weeks, at each appointment

72
Q

Method to determine EFW

A

Haddlock formula

73
Q

Gestation for uterine artery Doppler

A

20+0 - 24+6

74
Q

Fetal infection accounts for what percentage of SGA?

A

5%

75
Q

Short femur length is associated with _____________

A

SGA and PTB

76
Q

Early FGR coincides with maternal hypertension in ________ of cases

A

70%

77
Q

Treatment for anaphylaxis

A

1:1000 adrenaline 500mcg IM (0.5ml)

78
Q

Incidence of cardiac arrest in pregnancy

A

1 in 36000 pregnancies

79
Q

Mortality rate of cardiac arrest

A

42%

80
Q

Commonest cause of cardiac arrest in pregnancy

A

Anaesthetic (25%)

81
Q

Commonest cause of maternal collapse

A

Vasovagal syncope
Epileptic seizures

82
Q

MOH incidence

A

6 in 1000

83
Q

Incidence of AFE

A

1.7 per 100, 000

84
Q

Mortality rate with AFE

A

67 per 1000

85
Q

Incidence of severe perioperative obstetric anaphylaxis

A

1-3.5 per 100, 000

86
Q

Mortality rate from perioperative obstetric anaphylaxis

A

1%

87
Q

Tryptase levels following anaphylaxis

A

After resuscitation has started
1-2 hours later
24 hours later

88
Q

Aortocaval compression in pregnancy reduces CPR cardiac output by _____

A

From 30% to 10%

89
Q

How to minimise aspiration pneumonitis risk? (Mendelsson syndrome)

A

Early intubation
Cricoid pressure
H1 anatagonists
Antacids

90
Q

Left lateral tilt angle

A

15-30 degrees

91
Q

Percentage cardiac output to placenta at term

A

10%

92
Q

Aortacaval compression impairs venous return by ______

A

60%

93
Q

Perimortem c/s should be done at ____ gestation and within ___ minutes of cardiac arrest

A

20+0
5 minutes

94
Q

Fluid replacement in sepsis

A

30ml/kg within 3 hours

95
Q

Target MAP in hypovolaemia

A

65mmHg

96
Q

Intralipid infusion protocol

A

Bolus 15ml/kg over 1 minute then 15ml/kg/hr
Further bolus at 5 minute intervals if no return of circulation
Increase infusion to 30ml/kg/hr if needed

97
Q

Maximum dose of intralipid

A

12ml/kg

98
Q

Anaphylaxis treatment

A

1:1000 adrenaline 0.5ml IM
Repeat after 5 minutes
50 microgram IV bolus can be given by experienced Dr

99
Q

Incidence of maternal cardiac arrest

A

2.78 per 100 000

100
Q

Fetal survival after perimortem C/S

A

38%

101
Q

Vasa praevia type 1 definition

A

Vessel connects to velamentous umbilical cord

102
Q

Vasa praevia type 2 definition

A

Vessels connect placenta with succenturiate lobe

103
Q

Vasa praevia prevalence

A

1 in 1200 to 1 in 5000

1 in 250 with IVF

104
Q

Survival rates of vasa praevia when diagnosed antenatally with planned delivery

A

95%

105
Q

Risk factors for vasa praevia

A

Velamentous cord insertion
Placenta praevia
Bilobed placenta
Succenturiate placental lobes
ART

106
Q

What percentage of cases of vasa praevia resolve

A

20%

107
Q

Rate of spontaneous version from breech to cephalic at term (primip)

A

8%

108
Q

Rate of reversion to breech after ECV

A

3%

109
Q

Factors associated with ECV success

A

Non-Engagement of breech
Palpable fetal head
Maternal weight <65kg
AFI >10
Tocolysis
Multiparous

110
Q

Reason for c/s in labour after successful ECV

A

Slow progress
Fetal distress

111
Q

When to perform ECV

A

37+0
Primips could have from 36 weeks

112
Q

Rate of emergency c/s after ECV

A

1 in 200 within 24 hours

113
Q

Indications for emergency c/s after failed ECV

A

Vaginal bleeding
Abnormal FH

114
Q

Recurrence rate of breech presentation

A

9%

115
Q

APH definitions

A

Spotting
Minor - <50ml and settled
Major - 50-1000ml with no sign of shock
Massive - >1000ml or sign of shock

116
Q

Abruption incidence

A

Overall 0.5-1%
4.4% after 1
25% after 2

117
Q

Severe abruption definition

A

Presence of:
(Maternal) shock, DIC, RBC requirement, hysterectomy, renal failure, death

(Fetal) IUD/NND, non-reassuring status, PTB, SGA

118
Q

Risk factors for abruption

A

Previous
PET/essential HTN
FGR
PPROM
Old age
Multiparity
Smoking
Cocaine
Intrauterine infection
First trimester bleeding
Low BMI
ART
Abdominal trauma
Multiple pregnancy
Thrombophilia
Folic acid deficiency

119
Q

Complications of abruption

A

Infection
Anaemia
Shock
DIC
AKI
Couvelere uterus
PPH
Ischaemia of distal organs (adrenal glands/pituitary)
Feto-maternal haemorrhage
Psychological sequalae

120
Q

Risk of hysterectomy with placenta praevia + previous c/s

A

27 in 100

121
Q

Extra peri-operative considerations for PAS

A

Ureteric stents
Iliac artery balloon insertion, fill after delivery for haemostasis

122
Q

Risk of recurrence of uterine rupture

A

5%

123
Q

Risk factors for uterine rupture

A

Previous c/s
Previous uterine surgery
Previous rupture
High parity
Induction/augmentation
Hyper stimulation
Mal presentation
Macrosomia
Uterine anomaly
Trauma

124
Q

Uterine rupture causes CTG abnormalities in what percentage of cases

A

55-87%

125
Q

Uterine rupture maternal mortality

A

17 per 100 000

126
Q

Stage 1 DIC

A

Hypercoagulable state
Activation of clotting factors and development of microthrombi
Decreased clotting and increased platelet aggregation

127
Q

Stage 2 DIC

A

Consumptive coagulants state
Increased consumption of platelets and clotting factors
Bleeding
Increased clotting
Decreased platelets
Decreased fibrinogen

128
Q

Stage 3 DIC

A

Secondary fibrinolytic state
Formation of fibrin degradation products and plasmin
Marked bleeding
Increased thrombin time, decreased clot lysis time, increased fibrin degradation products

129
Q

Prophylaxis of PPH

A

Correct DIC
Ensure euvolaemia with CVP 5-10mmHg
Synt
Rub up uterus
Keep patient warm
Re-assess DIC status

130
Q

Iron requirement in pregnancy

A

2.5mg/day first trimester
6.66mg/day third trimester

131
Q

Iron deficiency ferritin level

A

<30

132
Q

B12 deficiency complications

A

PTB
Low birth weight

133
Q

Maternal Complications of iron deficiency anaemia

A

PPH
Sepsis
PPD
Fatigue
Maternal death globally

134
Q

Fetal complications of iron deficiency

A

Perinatal and neonatal mortality
SGA
PTB
Neurodevelopmental impairment

135
Q

Oral iron replacement regime

A

Recheck Hb 2-3 weeks
Continue for 3 months or 6 weeks post partum

136
Q

High dose folic acid for which women?

A

BMI >30
Taking AEDs
Previous affected pregnancy
Family history
T2DM and T1DM
Sickle cell disease
Thalassaemia

137
Q

How is HbA2 measured

A

With HPLC test

138
Q

HbA2 is _______ in sickle cell/thalassaemia carriers

A

Higher

139
Q

Complications of thalassaemia

A

Hypersplenism
Delayed puberty
Hormone problems
Cardiomyopathy
Hepatitis, fibrosis, cirrhosis
Joint pains and osteoporosis

140
Q

Chromosome deletion in alpha thalassaemia

A

16p

141
Q

Alpha thalassaemia trait

A

2 abnormal alleles
Mild anaemia - hypochromic microcytic

142
Q

Haemoglobin H disease

A

Unstable haemoglobins
Tetrameric gamma chains (Bart’s)
Tetrameric beta chains (H)

143
Q

Blood film features of haemoglobin H disease

A

Microcytic hypochromic anaemia
Target cells
Heinz bodies (precipitated HbH)

144
Q

Risk of cord prolapse with breech

A

1% footling breech (10% breech babies)

145
Q

Contraindications to VBAC

A

Previous uterine rupture
Classical incision
Other absolute contraindications

146
Q

Incidence of OASI after SVD

A

3.6% overall
Pri 5.4%
Multip 1.6%

147
Q

Incidence of OASI after instrumental delivery

A

Pri 7.8%
Multip 4.8%

148
Q

Repair of anorectal mucosa technique and suture

A

Continuous or interrupted
3-0 polyglactin

149
Q

IAS repair technique and sutures

A

Repair separately from anorectal mucosa and EAS
Interrupted or mattress sutures, do not overlap
Use 3-0 PDS or 2-0 polyglactin

150
Q

EAS repair technique and suture material

A

End to end for 3a and 3b
Can use overlapping for full thickness EAS tear
Use 3-0 PDS or 2-0 polyglactin

151
Q

Prognosis of OASI

A

60-80% asymptomatic at 12 months

152
Q

Mode of delivery after OASI

A

C/S if has symptoms after 1 year or abnormal endoanal ultrasound

153
Q

Sub-occipito bregmatic diameter is

A

9.5cm
Flexed OA

154
Q

Suboccipito-frontal diameter is

A

10cm
Incompletely flexed OA

155
Q

Occipito-frontal diameter is

A

11.5cm
OP position

156
Q

Submento-bregmatic diameter is

A

9.5cm
face presentation with head completely deflexed

157
Q

Submento-vertical diameter is

A

11.5cm
Face presentation incompletely extended

158
Q

Mento-vertical diameter is

A

13.5cm
Brow presentation
Cannot deliver vaginally

159
Q

Risk of SGA with low PAPP-A

A

25%

160
Q

BM targets in women with pre-existing diabetes

A

Fasting <5.3
1 hr Post prandial <7.8
2 hr post meal <6.4
Timing range >70% if using continuous monitoring

161
Q

Best method to measure BM for pre-existing type 1 DM

A

Continuous glucose monitoring - reduces LGA, NNU admission and hypoglycaemia

Consider for type 2 when not meeting targets

162
Q

Retinopathy screening timing

A

At booking
At 16-20 weeks of disease
28 weeks

No restrictions on treatment in pregnancy

163
Q

Risk of type 2 diabetes after GDM

A

50% in 5 years

164
Q

Offer insulin for GDM at diagnosis when

A

Fasting glucose >7
OR
Fasting 6-6.9 with fetal macrosomia or polyhydramnios

165
Q

Start merformin/insulin for GDM after trial of diet when ____

A

Fasting BM > 5.3
BM >7.8 post meal

166
Q

GDM timing of birth

A

Offer T+5 if uncomplicated
Deliver no later than T+6

167
Q

HbA1c measurement for pre-existing DM

A

At booking and each trimester

168
Q

Recommended delivery mode and timing after uterine transplant

A

37/40
Caesarean delivery

MRCOG part 2 (22 decks)

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