Day 10 Obstetrics Flashcards
A 29-year-old woman has recently given birth to a healthy baby girl but has suffered a perineal tear as the consequence of a difficult birth.
Upon examination, the patient has their internal anal sphincter completely torn
What degree of tear has the patient suffered from? (1)
What is the most appropriate next step in management? (2)
Third-degree perineal tears require repair in theatre by a suitably trained clinician
A 26-year-old woman at 10 weeks gestation arrives at the emergency department after suffering from severe bouts of vomiting and diarrhoea, which have lasted for the past 10 days.
This has begun to have a significant impact on her day-to-day lifestyle.
She is unable to keep down fluids and despite being prescribed oral cyclizine, there has been no improvement.
When her weight was checked she suddenly realises she has lost a significant amount of weight.
A urine sample is taken and reveals high levels of ketones in her urine.
What is the next most appropriate step in management?
(3)
Admit for hydration
Nausea and vomiting in pregnancy: admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics
The correct thing to do in this case is to admit for hydration the patient for possible IV hydration. This is considered a medical emergency due to ketonuria and weight loss.
A 23-year-old patient who is 22 weeks pregnant attends your GP clinic concerned about a high reading on a blood pressure machine at home.
She is asymptomatic and has no past medical conditions.
You take her blood pressure at the clinic which is 162/114 mmHg.
There is no evidence of proteinuria on urine dipstick testing.
- *What is the most appropriate management?
(3) **
Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
The patient might be given labetalol along with aspirin but this would have to be initiated by the obstetric department.
A multiparous woman at 29 weeks gestation is admitted to the maternity ward with painless, bright red vaginal bleeding.
The placenta is found to be wholly in the lower uterine segment.
The child is also in breech presentation with a transverse lie.
All of the patient’s previous pregnancies had remained uncomplicated.
What complication of pregnancy is this likely to be?
(2)
The correct answer is placenta praevia.
- the painless vaginal bleeding is characteristic of this complication making this the correct option.
Vasa praevia is the incorrect answer as fetal bradycardia is commonly seen in association. It may also present with blood that is darker in colour rather than bright red vaginal bleeding in this case. These factors make this option less likely.
Potentially sensitising events in pregnancy:
(10)
Potentially sensitising events in pregnancy:
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)
A 32-year-old woman comes to surgery for her blood results.
She is 25 weeks pregnant and has had her glucose tolerance test.
The results are as follows:
Fasting glucose = 7.1 mmol/L
2-hour glucose = 8.2 mmol/L
What would be the most appropriate next step?
If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started
A woman at 32 weeks gestation comes into maternity assessment unit for reduced fetal movements (RFM).
She reports that she has not felt her baby move for the last 12 hours.
She has not noticed any vaginal bleeding or experienced any pain.
The midwife cannot detect a heart beat with the handheld Doppler.
What would be done next to investigate the reduced fetal movements?
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
Contraindications to the use of epidural anesthesia:
(4)
- active maternal hemorrhage
- septicemia
- infection at or near the site of needle insertion
- clinical signs of coagulopathy
A 26-year-old woman was admitted at 34 weeks gestation with preterm labour.
On examination she has a blood pressure of 175/105 mmHg.
Urinalysis reveals 3+ proteinuria. She is commenced on magnesium sulphate and labetalol.
She is now complaining of reduced foetal movements.
A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute.
What should be the next step in the management?
(3)
Emergency caesarian section
A diagnosis of pre-eclampsia can be made due to the heavy proteinuria and hypertension.
Magnesium sulphate is given to reduce the risk of development of eclampsia, and labetalol is given to control the blood pressure.
Late decelerations and foetal bradycardia on cardiotocography (CTG) is a worrying sign and would justify an emergency caesarian section.
Induction would be inappropriate with an abnormal CTG.
A 32-year-old woman presents to the obstetric department in the early stages of labour.
She is 36+4 weeks gestation and the current pregnancy has been complicated by polyhydramnios.
On examination, the foetal head can be palpated at the right side of the maternal pelvis and the buttocks can be palpated at the left side of the maternal pelvis.
The amniotic sac is intact.
What is the most appropriate next step in the management of this patient?
You can attempt external cephalic version for a transverse lie if the amniotic sac has not ruptured
A 33-year-old woman who is 34 weeks pregnant with twins presents to you with a 3-day history of intense pruritis which has been affecting her sleep. You can see multiple excoriations but no obvious skin rash. Other than this the pregnancy has been going well, and foetal movements are normal.
Bloods are taken:
Bilirubin = 41 µmol/L(3 - 17)
ALP = 213 u/L(30 - 100)
ALT = 189 u/L(3 - 40)
An abdominal ultrasound was normal.
What is the most likely diagnosis? (1)
What is the most likely management plan? (3)
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth;
therefore induction of labour is generally offered at 37-38 weeks gestation
Also:
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
You are urgently bleeped to the labour ward to see a 22-year-old woman who has recently undergone an artificial rupture of membranes.
She is at 40-weeks gestation and has so far, had an uncomplicated pregnancy.
The midwife informs you that the foetal heart rate is abnormal.
On examination, you can palpate the umbilical cord.
What is your management plan?
What drug can you administer whilst waiting to prevent complications?
- Emergency C-section
- Terbutaline - Tocolytics may be useful in umbilical cord prolapse to reduce uterine contractions
A 32-week gestation woman attends for a repeat ultrasound scan after her 20-week scan showed a low lying placenta.
The repeat ultrasound in the department shows a placenta that is partially covering the top of the cervix.
She is counselled by the obstetric consultant on her mode of delivery.
She has had 4 previous pregnancies which she delivered vaginally and has no other past medical or surgical history.
What is the appropriate offer she should be given regarding recommended mode of delivery?
Women with grade III/IV placenta praevia should be offered an
- elective caesarean section
- at 37-38 weeks
A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding.
On examination blood pressure is 90 / 60 mmHg
What is the most likey diagnosis?
Placental abruption
A 31-year-old woman presents with painless vaginal bleeding at 15 weeks gestation.
She has not yet had any antenatal care despite suffering from severe vomiting.
On examination the uterus is large for dates.
What is the most likey diagnosis?
Hydatidiform mole
A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding.
Her last period was 8 weeks ago.
On examination her cervix is tender to touch
Ectopic pregnancy
A 26-year-old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 39 weeks.
Urinalysis shows +++ protein.
Which of these is the most appropriate way to manage her hypertension?
Administer intravenous labetalol
with target blood pressure < 135/85 mmHg
When is aspirin taken in pregnancy? (2)
Which groups are at risk? (4)
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.
High risk groups include:
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
Nancy is a 25-year-old woman who is 30 weeks pregnant with her first child.
She has not felt the baby kick for 3 hours.
Her pregnancy has been unremarkable, however, her baby is slightly small for gestational age.
She presents to the obstetric emergency walk-in unit at her local hospital.
What is the next best step in the management of this patient?
If a pregnant woman reports reduced fetal movements then handheld Doppler should be used to confirm fetal heartbeat as a first step
Then ultrasound
After how many weeks is same-day delivery an option?
After 34 weeks, same day delivery is an option.
What is the cure for eclampsia?
What is the purpose of magnesium sulfate?
Delivery is the only cure for pre-eclampsia.
IV magnesium sulphate is used for eclampsia (seizure) prophylaxis.
What effect would an epidural anesthetic have on the patient’s blood pressure?
epidural anesthesia should reduce blood pressure.
A 36-year-old multiparous woman is in advanced labour at 37 weeks gestation.
An ultrasound confirms a breech presentation.
She is fully dilated and has been pushing for an one and a half hours, however the buttocks are still not visible.
How should this situation be managed?
Due to the foetal presentation and station, vaginal delivery is likely to be difficult.
Breech extraction is not recommended for singleton pregnancies and requires considerable skill.
Therefore Caesarean section should be advised.
Which direction should the fetus be facing during delivery?
Occiput anterior to the mother
A 32-year-old woman who is 30+2 weeks pregnant, G3 P2+0, presents to the maternity triage unit.
Her past deliveries were both elective Caesarean sections.
Her pregnancy has been uneventful up to this point but she presents to the maternity triage unit this morning with an episode of vaginal bleeding.
She describes the amount as about a tablespoon.
There is no associated pain.
What should be done next to determine the diagnosis?
Ultrasound scan
A 24-year-old woman attends your clinic; she is currently 22 weeks pregnant, with no complications thus far.
2 days ago, her sister and niece visited. Her niece was feeling under the weather at the time, and has since taken ill with chickenpox.
The patient is worried for her pregnancy; she has no symptoms herself, but upon questioning, cannot remember whether or not she had chickenpox as a child herself.
What should the next step be in managing this patient?
Chickenpox exposure in pregnancy > 20 weeks (if not immune): antivirals or VZIG should be given at days 7-14 post-exposure, not immediately
then oral acyclovir
A neonate is born at 38 weeks gestation via spontaneous vaginal delivery. The birth weight was 4.5kg. In the newborn postnatal check the attending doctor notes that there is adduction and internal rotation of the right arm.
What is the definition of fetal macrosomia? (1)
What is the most likely diagnosis? (1)
Why does it occur? (1)
A baby is diagnosed with foetal macrosomia if they have a birth weight >4kg regardless of their gestational age.
Erb-Duchenne paralysis
- damage to C5,6 roots, upper brachial plexus
- winged scapula
- may be caused by a breech presentation
- *What is Klumpke’s palsy?
(3) **
Klumpke injury
- due to damage of the lower trunk of the brachial plexus (C8, T1)
- as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
- associated with Horner’s syndrome
GESTATIONAL HYPERTENSION
What gestational date does it begin? (1)
What is the range of hypertension? (2)
What would constitute a diagnosis of pre-eclampsia over GH? (1)
What gestational date does it begin? (1)
- occurs after 20 weeks gestation
What is the range of hypertension? (1)
- systolic > 140 mmHg or diastolic > 90 mmHg
- or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
What would constitute a diagnosis of pre-eclampsia over Gestational Hypertension? (1)
- proteinuria
An obstetrician is preparing themselves to perform an emergency lower segmental caesarian section for a 24-year-old woman who is suffering from complications of pre-eclampsia.
After making an incision through the skin and superficial and deep fascia, what layers will the obstetrician have to cut through/traverse to reach the fetus?
Caesarian section, the following lies in between the skin and the fetus:
- Superficial fascia
- Deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
- Transversalis fascia
- Extraperitoneal connective tissue
- Peritoneum
- Uterus
A 32-year-old multiparous immigrant presents at 36 weeks gestation in established labour.
No history of prenatal care or screening tests is established.
The patient has an uneventful vaginal delivery of a 3.2kg female.
Soon after birth, the baby develops fever, tachycardia and respiratory distress.
What is the most likely cause?
Group B streptococcus infection is the most frequent cause of severe early-onset (< 7 days) infection in newborn infants.
- benzylpenicillin is the antibiotic of choice for GBS prophylaxis
A 29-year-old primiparous woman is in a prolonged labour following an induction at 41 weeks gestation.
She is 6 cm dilated and the fetal head is 1 cm above the ischial spines.
The midwife calls you to look at her CTG.
The fetal heart rate is progressively dropping, it is now below 100 beats per minute, and it has not recovered for more than 3 minutes.
What is the next best step in management?
Category 1 Caesarean section
A 23-year-old woman attends her antenatal booking appointment.
She thinks that she is 10 weeks pregnant.
This is her first pregnancy.
- *Which one of the following is not routinely performed?
(6) **
Booking visit
- general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
- BP, urine dipstick, check BMI
Booking bloods/urine
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- hepatitis B, syphilis
- HIV test is offered to all women
- urine culture to detect asymptomatic bacteriuria
A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions.
Examination reveals her cervix is 3 cm dilated and membranes are intact.
hat would be the most appropriate management?
Admit and administer tocolytics and steroids
This woman is now in premature labour, although at 3cm dilated it is still in an early stage. Therefore, it may be stopped by administering tocolytic medication. In case the labour continues and delivery is required, steroids are given as a pre-emptively to help the foetal lungs mature. Antibiotics are not required as there is no indication of an infection. Syntocinon injection contains oxytocin which strengthens the contractions of the uterus!
A 34-year-old pregnant woman comes to see you in clinic today concerned as her brother’s son has just been diagnosed with rubella.
She is 9 weeks pregnant and is unsure of her rubella status.
What is the most appropriate first step to take at this stage?
(3)
Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
If you are suspecting a case of rubella in pregnancy then this should be discussed with the local Health Protection Unit immediately as they can advise on which type of investigations to perform in each individual case.
Guidelines currently recommend that the MMR vaccine is given in the post-natal period if the mother is non-immune to rubella. It is unclear whether there is a risk of transmission in this case.
If transmission has occurred, especially at this stage of pregnancy, advise there is a high risk of damage to the fetus.
There is no indication for urgent hospital admission at this stage.
When is the first screen for anemia and atypical red cell alloantibodies?
8 - 12 weeks
When is the early scan to confirm dates?
`
10 - 13+6 weeks
When is the first dose of anti-D prophylaxis to rhesus negative women?
28 weeks
A 35-year-old nulliparous lady with Factor V Leiden has come for her first antenatal appointment; she has previously had an unprovoked venous thromboembolism (VTE).
The attending doctor discusses thromboprophylaxis with her due to her history.
- *Based on her risk, which treatment pathway should be used?
(2) **
What is the aetiology of Factor V Leiden?
- Low molecular weight heparin (LMWH) antenatally
- 6 weeks postpartum
Factor V Leiden (activated protein C resistance) is the most common inherited thrombophilia, being present in around 5% of the UK population.
- The result of the mis-sense mutation is that activated factor V (a clotting factor) is inactivated 10 times more slowly by activated protein C than normal.
A 35 year old primiparous woman presents to the maternity unit in a small community hospital with regular painful uterine contractions occurring every 20 minutes and lasting for 60 seconds each.
She is currently 34 weeks pregnant and suffers from gestational hypertension.
A vaginal examination reveals that the cervix is 3cm dilated.
Her membranes rupture during the digital examination.
What is the next most appropriate step in her management?
Give maternal dexamethasone
transfer to nearest hospital with a neonatal unit
A 30 year old woman who is 32 weeks pregnant presents to the day assessment unit complaining of a headache and feeling general unwell for the last day or so.
On examination there is mild oedema in her hands and feet and tenderness in the right upper quadrant of her abdomen. symphysis-fundal height is 32cm and fetal heart rate is normal.
Her blood pressure is 160/110 mmHg and pulse rate is 90 bpm.
er booking blood pressure was 115/85 mmHg. Urinalysis is negative.
Her bloods show the following abnormalities:
- low haemoglobin
- low platelets
- raised ALT raised bilirubin
What is the most likely diagnosis?
(3)
What is the treatment?
(1)
HELLP syndrome
She fits the diagnostic criteria as there is suggested
- haemolysis
- elevated liver enzymes
- low platelet count.
Furthermore, she also has;
- headache
- right upper quadrant pain
- peripheral oedema
- hypertension
Treatment
- delivery of the baby
A 20 year old woman on the postnatal ward is experiencing fresh, painless vaginal bleeding.
She delivered her first baby 2 hours ago at 36 weeks gestation.
The delivery was instrumented with a Ventouse due to failure to progress.
On examination, the uterus is palpable at the level of the umbilicus and there is presence of striae gravidarum.
The baby is healthy and has a birthweight of 2.7kg.
What are the risk factors of postpartum haemorrhage?
(4)
CAUSES CAN BE REMEBERED FROM THE 4 Ts
Tone
- The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.
Trauma
- This risk is increased in instrumented deliveries.
Tissue
Thrombin
A 30 year old woman presents to her GP at 35 weeks gestation with an itchy, papular rash.
She says she first noted it on her abdomen but now her legs are itchy too.
She is otherwise well and is not known to have any dermatological conditions.
Her bloods show no derangement in renal or liver function.
What is the most likely diagnosis?
(3)
- Polymorphic eruption of pregnancy
- also known as pruritic urtical purpural plaques of prenancy (PUPPP)
Commonly occurs in the third trimester
A 38 year old woman is in labour at 37 weeks gestation for a VBAC.
She has been having contractions every 5 minutes lasting 50 seconds for the last hour.
The midwife calls the obstetrician as following a spontaneous rupture of membranes fifteen minutes ago the cardiotocograph became non-reassuring due to presence of variable decelerations.
No cord prolapse is found on vaginal examination.
A fetal blood sample is taken, which shows the following results:
- pH 7.2
- lactate 4.4mmol/l
How should these results be interpreted?
(2)
This is an abnormal result and plans should be made for immediate Caesarean delivery.
A pH of 7.2 indicates an abnormal result.
pH:
- – normal: 7.25 or above
- – borderline: 7.21 to 7.24
- – abnormal: 7.20 or below
Lactate:
- Normal: 4.1 mmol/l or below
- Borderline: 4.2 to 4.8 mmol/l
- Abnormal: 4.9 mmol/l or above.
A 36 year old woman G3P2 with placenta praevia presents for her foetal growth scan.
How many weeks along is she?
Ultrasound scan shows the placenta involving more than half of the myometrium but has not invaded past it.
She denies any symptoms.
Her previous history includes two deliveries done via Caesarean section.
Which of the following explains the ultrasound findings?
- 28 weeks
- Placental increta
Placenta increta is a condition where there is an abnormal placentation and the placenta infiltrates into the myometrium and invades the muscle rather than being confined to the decidual layer of the endometrium in normal circumstances. It has been associated with raised levels of circulating fetoprotein and b-hCG and is confirmed by ultrasound scanning. It presents a major risk factor for post-partum haemorrhage and the patient is advised to have a caesarean section for delivery. The definitive treatment is hysterectomy.
A 46 year old woman who is 7 weeks pregnant presents to her GP with vaginal bleeding.
She also complains of severe nausea and vomiting over the last few days.
On examination, the symphysis-fundal height is 14cm.
She is referred to the Early Pregnancy Assessment Unit where she has a trans-vaginal ultrasound, which is difficult to interpret but does identify some fetal tissue in the uterus.
What is the most likely diagnosis?
Partial molar pregnancy
This is the correct answer. The constellation of symptoms of vaginal bleeding, hyperemesis, and a uterus larger than expected for gestational age, are together suggestive of gestational trophoblastic disease. As there is fetal tissue present in the uterus then this is a partial molar pregnancy.
A 35 year old primiparous woman is seen by the obstetrician following an uncomplicated vaginal delivery at 39 weeks gestation.
On examination, she has a perineal tear which extends through the perineal skin, muscles, fascia and a quarter of the thickness of the external anal sphincter.
What degree is this perineal tear classified as?
Third degree tear (3a)
A third degree tear is a perineal tear which has extended into the external anal sphincter. 3a indicates that less than 50% of the thickness is torn.
A 34 year old woman attends in her first pregnancy complaining of upper epigastric pain, mild nausea and fatigue. She is 36+2 weeks gestation.
She has no headache, visual disturbance or oedema.
Her observations are:
- Pulse 80 bpm.
- Blood pressure: 144/96.
- Respiratory rate: 17.
- Temperature 36.9.
- SpO2 99%.
Her urinalysis results are:
- Blood: +
- Leukocytes: negative
- Nitrites: negative
- Protein: ++
- Ketones: negative
- Glucose: negative
- pH: 5.1
Her blood results are as follows:
Haemoglobin: 8.9 g/dL
White cell count: 8.2 g/dL
Platelets: 55 × 10^9/L
CRP: <5
Urea: 2.8 mmol/L
Creatinine: 49 μmol/L
AST: 547 IU/L
ALT: 426 IU/L
LDH: 650 IU/L
Total bilirubin: 2.3mg/dL
Glucose: 5.6 mmol/L
What is the most accurate diagnosis for this woman?
HELLP syndrome is considered a variation of severe pre-eclampsia and requires immediate treatment including delivery of the foetus.
The three abnormalities found in HELLP syndrome are haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is managed via urgent delivery of the baby and supportive treatment of organ failure.
A 28 year old woman G2P2 with gestational diabetes presents to for her foetal growth scan at 28 weeks. Ultrasound scan shows the placenta involving more than half of the myometrium.
Which of the following explains the ultrasound findings?
Placenta increta
Placenta increta is a condition where there is an abnormal placentation, the placenta infiltrates into the myometrium and invades the muscle rather than being confined to the decidual layer of the endometrium in normal circumstances. It has been associated with raised levels of circulating fetoprotein and b-hCG and is confirmed by ultrasound scanning. It presents a major risk factor for post-partum haemorrhage and the patient is advised to have a caesarean section for delivery. The definitive treatment is hysterectomy.
