Day 11 Obstetrics Flashcards
A 24-year-old primagravida patient is being treated on the ward for antenatal haemorrhage.
In the course of her management, she receives a Kleihauer test.
What is the purpose of the Kleihauer test? (3)
- The Kleihauer test is performed in rhesus D -negative women to gauge the dose of anti-D immunoglobulin required
- The Kleihauer test is used to quantify the dose of Rh-D antigen in maternal circulation.
In significant sensitising events (events during which Rh-D antigen enters the maternal Rh-negative circulation), a Kleihauer test can guide the amount of anti-D IG needed to prevent maternal sensitisation
A 30 year old woman has just given birth on the labour ward at 41 weeks gestation.
The birth was an uncomplicated vaginal delivery but the midwife had noticed the presence of some green coloured liquor during delivery.
At initial assessment, the newborn has noisy breathing, expiratory grunting and is using his accessory respiratory muscles.
The APGAR score at 5 minutes is 7.
Heart rate is 95 beats per minute, respiratory rate is 70 breaths per minute and the neonate appears pink.
Given the likely diagnosis, what is the most appropriate management plan?
Admission to NICU for oxygen and antibiotic therapy.
This is the most appropriate management. This neonate is showing signs of meconium aspiration syndrome (respiratory distress on a background of meconium-stained liquor and postdates delivery) and thus should be transferred to a specialist unit oxygen, antibiotics and close monitoring.
A 30 year old woman who is pregnant with her second child presents to the antenatal clinic.
In her previous pregnancy she had an elective Caesarean section due to breech presentation.
This was carried out at 38 weeks and left her with a low transverse scar.
Otherwise, her pregnancy was uncomplicated.
She is currently 18 weeks pregnant and her scans and bloods so far have been normal.
This time round, she is keen to have a vaginal delivery at home and seeks advice.
What advice should be given to this mother?
She will be able to try for a vaginal delivery, but there is still a chance she will require an emergency Caesarean section
Classical Caesarean section and previous uterine rupture are both contraindications to VBAC. Other contraindications may include contraindications to any vaginal delivery such as major placenta praevia.
A 31-year-old woman presents at 4 weeks of pregnancy with some minor vaginal bleeding.
She has no tenderness on abdominal examination.
Pelvic examination reveals some cervical motion tenderness.
She is referred for a pelvic ultrasound which does not identify any masses or active pregnancy.
A serial serum beta-human chorionic gonadotropin (B-hCG) measurement is taken at 0h and 48h:
0h: 24 IU/L
48h: 56 IU/L
What is the most appropriate next step in management of this patient? (2)
The pregnancy is likely intrauterine, order another ultrasound to confirm at a later date
- The high proportional increase in B-hCG (more than double over 48 hours) is suggestive that the embryo is successfully growing and is most likely to be located within the uterus.
- Another ultrasound at a later date when the fetus should be larger and easier to identify would confirm this result.
- An ectopic pregnancy would be likely if there was only a slight increase in B-hCG over 48 hours.
A 36-year-old woman presents to her GP. She is distressed as she has recently had a miscarriage at 9 weeks.
This is her 3rd miscarriage; the previous two were at 7 and 8 weeks gestation.
Her past medical history includes two episodes of deep vein thrombosis.
On examination, there is a net-like, mottled, purplish discolouration of her left leg.
What is the most appropriate treatment to increase the chance of future pregnancies surviving to term?
Aspirin
- The description of her leg is suggestive of livedo reticularis.
- The change occurs when reduced blood flow leads to cyanotic areas of skin which are furthest from sites of ascending arterioles.
- The most likely diagnosis is antiphospholipid syndrome, an autoimmune condition which is associated with recurrent miscarriage and thromboses.
- The formation of thromboses is thought to lead to miscarriages, and thus by thinning the blood using aspirin there is an increased chance of prevention of clots, and hence a successful pregnancy.
A 30 year old woman arrives in antenatal clinic to receive the results of her 18 week ultrasound scan.
This is her second pregnancy and her first baby was delivered three years ago via an emergency caesarean section for obstructed labour.
The ultrasound reports that there are no fetal or amniotic fluid abnormalities.
The placenta is in a fundal position and the villi have penetrated fully through the myometrium.
What is the most likely diagnosis?
Placenta percreta
Placenta percreta is the most severe form of abnormal placental villous adherence. Here the placental villi extend past the normal confines of the uterine myometrium and can even adhere to other abdominal structures such as the bladder. Common risk factors include placenta praevia, previous Caesarean section or uterine surgery and structural uterine abnormalities.
A 34 year old G2P0 at 36 weeks gestation presents to the antenatal clinic complaining of a week long history of general malaise, vomiting, and anorexia. She has had a poor appetite. She also complains of abdominal pain on the right side and indigestion. She denies any visual changes, headaches, and swellings. She denies any abnormal discharge and reports presence of foetal movements. On examination, her blood pressure is 135/85 mmHg and she appears mildly jaundiced.
Her blood test results are shown below:
Hb: 129 g/l (115-160 g/l)
Platelets: 175 x 109/l (150-400 x 109/l)
WBC: 10 x 109/l (4.0 - 11.0 x 10 9/l)
PT: 16 secs (10-14 secs)
Bilirubin: 36 umol/l (3-7 umol/l)
ALP: 344 u/l (30-100u/l)
ALT: 200 u/l (3-40 u/l)
AST: 350 u/l (3-30 u/l)
What is the most likely diagnosis?
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy is a rare complication of pregnancy but important to be aware of. It commonly occurs in the third trimester or immediately following delivery and is thought to be more common in nulliparous women as in the case of this patient. A typical patient will present with a few days history of general malaise, anorexia, vomiting, and jaundice. Pain in the right upper quadrant may sometimes be present. Blood results would show marked elevation of liver enzymes, prolonged PT, raised and bilirubin.
A 34 year old woman is attending the maternity unit for an elective caesarean section at 39 weeks gestation.
She is administered spinal anaesthesia by the anaesthetist and draped and prepped for the operation.
Which of the following is the correct sequence of layers that will be dissected through to gain access to the foetus during caesarean section? (7)
- Skin
- subcutaneous fat
- rectus sheath
- rectus abdominus muscle
- peritoneum
- uterine myometrium
- amniotic sac
During a caesarean section the skin is first incised using a scalpel, subcutaneous fat is divided to reveal the tough rectus sheath. This is incised again using a scalpel to reveal the rectus abdominus muscle below. This is generally dissected using blunt dissection with pulling apart of the fibres, rather than sharp cutting, to reveal the peritoneum covering the uterus. This is dissected away and the hysterotomy (uterine incision) is performed. An incision may also need to be performed in the amniotic sac if this has not already been perforated, to allow delivery of the foetus.
A 29-year-old nulliparous woman is 34 weeks pregnant and presents to her GP with a two day history of flu-like illness and painful vesicular lesions around her vagina.
Given the most likely diagnosis, which of the following best represents the most appropriate course of action regarding further management of her pregnancy?
Offer the patient oral aciclovir and an elective Caesarian section
The most likely diagnosis here is herpes simplex virus. As such, aciclovir can be offered to treat the current presentation and a Caesarian section will greatly reduce the risk of vertical transmission to the foetus at delivery
A 25 year old primiparous woman has just given birth on the labour ward at 41 weeks gestation.
The birth was a vaginal delivery and other than the presence of green - tinged liquor there were no other complications.
At initial assessment the newborn appears to have laboured breathing, expiratory grunting and nasal flaring.
Heart rate is 90 beats per minute and the neonate appears pink.
What is the likely diagnosis in this newborn?
Meconium aspiration syndrome
- The green tinged liquor suggests that meconium is present and it is likely that this was inhaled by the infant before or during birth.
- Furthermore, the risk of meconium aspiration syndrome increases after 40 weeks gestation.
A 17 year old lady presents to the emergency department with heavy vaginal bleeding and lower abdominal pain. Her last menstrual period was eight weeks ago. She describes bits of ‘skin-like’ substance within the blood. Vaginal bleeding is ongoing.
She looks well. Her observations are normal. On examination, her abdomen is mildly tender suprapubically. On speculum examination, her cervical os is open, no products of conception are seen, and ongoing bleeding is apparent.
What is the likely diagnosis? (3)
Incomplete miscarriage
Incomplete miscarriage occurs with abdominal pain and/or vaginal bleeding following a pregnancy loss where not all of the products of conception have been expelled from the uterus.
On speculum examination, the cervical os may be open or closed, or there may be products seen within the os. On ultrasound, products of conception are seen persisting within the uterus.
Patients with incomplete miscarriage may be managed with ‘watchful waiting’, medical management with Misoprostol, or surgical management with dilatation and curettage
A 45 year old woman presents to the GP at 15 weeks gestation after finding out that she is pregnant.
This is her first pregnancy and she has read on the internet that Down’s syndrome is common in women over the age of 40.
She would like to find out what her risk is of having a child with Down’s syndrome.
Which test should she be offered?
(3)
The quadruple test
- The quadruple test is the screening test provided for pregnant women presenting after 13 weeks gestation.
- It involves blood tests to measure levels of the hormones B-hCG, AFP, uE3 and inhibin A. It does not involve an ultrasound scan.
A 30 year old G2P0 at 38 weeks gestation presents to the antenatal clinic complaining of itchy palms and soles since two days. Her husband has commented on her skin looking yellow lately. She denies any fever, malaise, rash, visual disturbances, and headaches. Blood test reveals elevated bilirubin of 35 umol/l (3-17 umol/l) but all other liver function and clotting tests are normal.
What is the most likely diagnosis?
Intrahepatic cholestasis of pregnancy
- Intrahepatic cholestasis generally seen in third trimester.
- There is accumulation of bile salts in the serum.
- As a result it often involves pruritus in the palms and soles.
- Liver enzymes rarely rise above 250 u/l along with elevated bilirubin.
A 28-year-old woman (para 1, gravida 3) presents to birth options clinic to create a delivery plan for her current dichorionic twin pregnancy.
She has no significant medical history other than a previous classical Caesarean section three years ago.
Which of the following is the best advice to offer?
Recommend a Caesarean section at 37 weeks gestation
A previous classical Caesarean section is an absolute contraindication to normal vaginal delivery. There is a risk of uterine rupture and the foetus may be expelled into the peritoneal cavity. Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days.
A 25 year primigravida at 14 weeks gestation presents to the Accident and Emergency complaining of severe nausea and vomiting.
She is unable to keep fluids down.
A diagnosis of hyperemesis gravidarum is suspected.
Which other symptoms might be found in this diagnosis? (3)
Evidence of hypokalaemia on the ECG
Vomiting causes potassium loss leading to hypokalaemia, which would show signs on an ECG such as the U waves, small or absent T waves, prolonged QT and PR intervals along with ST depression. They are usually a later finding in the course of the disease.
Ketonuria
Early signs include ketonuria and/or weight loss of up to 5% of overall pre-pregnancy weight. Ketonuria is caused by the lack of nutrition and starvation mode brought on to the body by persistent vomiting. Treatment is usually with electrolyte rehydration therapy and anti-emetics. Admission may be necessary for IV hydration.
Weight loss of more than 5% of overall body weight despite treatment with oral antiemetics
A baby is born at term to a 28 year old primigravida, who has had no prenatal screening.
The baby has a very large head and after 2 days has a tense fontanelle.
He undergoes a CT scan which shows enlargement of the lateral and third ventricles.
What is the most likely cause?
Maternal rubella infection.
Rubella can cause aqueductal stenosis leading to congenital hydrocephalus.
A 23 year old primigravida woman attends her local maternity unit at 40+2 weeks gestation for induction of labour.
Her midwife examines her and finds her cervix difficult to reach as it is very posterior.
It is long, closed and firm to the touch.
What medication is appropriate to prescribe at this time?
Vaginal prostaglandin E2 pessary
- Prostaglandins are administered into the vagina and act to ‘prime’ the cervix, allowing it to become softer and shorter in preparation for labour.
- The pessary is inserted by a suitably experienced person, and left in situ for 24 hours before reassessment of the cervix.
A 30 year old primiparous woman presents to the labour ward at 33 weeks gestation with regular painful uterine contractions occurring every 15 minutes.
A vaginal examination reveals that she is 3cm dilated.
Her observations are normal and fetal cardiotocogram is reassuring.
There have been no known complications with the pregnancy so far.
The obstetric consultant decides to offer tocolytic intervention to delay the delivery to allow time for maternal corticosteroids to take effect.
Which of the following is the most appropriate tocolytic agent?
Oral Nifedipine
Current guidelines recommend oral nifedipine as the first line tocolytic agent to use in pre-term labour.
A 28 year old G1P0 at 42 weeks gestation is undergoing vaginal delivery.
She had developed gestational diabetes at 24 weeks gestation and recent ultrasound confirmed foetal macrosomia.
During delivery, baby’s shoulders get stuck following delivery of the head.
Keeping the most likely diagnosis in mind, what is the appropriate first-line management?
Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy
Correct. Oral antibiotics are recommended in cases of asymptomatic bacteriuria to prevent progression to pyelonephritis and increased risk of preterm labour.
Women should have a routine urinalysis at booking to screen for asymptomatic bacteriuria. If this is positive for nitrites or leukocytes, it should be sent for culture.
A 30 year old primiparous woman at 37 weeks gestation is having regular uterine contractions which are 15 minutes apart.
Speculum examination shows clear fluid pooled in the vagina and a digital examination shows that the cervix is fully effaced and 5cm dilated.
The cervix has been dilating around 1cm every 2 hours.
Fetal presentation is cephalic and fetal station is -2.
Which stage of labour is this woman experiencing?
First stage – active phase
The active phase of the first stage of labour is described as cervical dilation from 3cm to 10cm.
A 30-year-old G1P1 presents to the booking visit at the antenatal clinic.
She is briefed about the antenatal care timetable.
She is wondering when the anomaly scan would be performed as she is concerned about any abnormalities in her baby.
When is the anomaly scan usually performed?
18-20 + 6 weeks
This is the timeframe for the anomaly scan to be performed.
Anomaly scan evaluates anatomical structures of the foetus, placenta, and maternal pelvic organs.
This allows for careful planning of the pregnancy as well delivery.
A 35 year old woman was seen at 28 weeks gestation in the antenatal clinic as she was worried about some abnormal discharge.
Her previous baby stayed in hospital for 2 weeks after birth for neonatal sepsis.
Endocervical and high vaginal swabs were taken which were negative for chlamydia and gonorrhoea.
However, a positive culture Group B Streptococcus was found incidentally.
In light of this finding how should this woman be managed?
She should be given antibiotics intravenously during labour and delivery to prevent newborn GBS infection
This is the most appropriate management. Intra-partum antibiotics reduce the baby’s risk of early onset GBS infection and thus perinatal mortality.
You are bleeped to a patient on labour ward who has just delivered a healthy baby.
The midwife reports that while he was performing controlled cord traction, the patient began to bleed and the uterine fundus is no longer palpable in the abdomen.
What is the most likely diagnosis?
What is the most appropriate next step in management?
Inversion of the uterus
This question is describing a case of uterine inversion.
Immediate replacement of the uterus is the best first step as the greater the delay in attempting this, the greater the likelihood the manoeuvre will fail.
General resuscitation measures should also be taken and tocolytic drugs can be used to aid replacement of the uterus if a first attempt fails.
A 27 year old patient comes in with a feeling very anxious, low in mood, and is unable to sleep at night. She delivered her first baby 6 weeks ago.
She reports feeling sad all the time and a reduced appetite.
She feels guilty about not being able to connect well with her baby either and says she feels like crying all the time.
What is the most likely diagnosis?
Postpartum depression
This is a classic presentation of post-partum depression. It affects about 10-15% of women Symptoms typically start within a month and peak at 3 months. Symptoms are similar to symptoms of depression under other circumstances such as low mood, anhedonia, anergia, difficulty sleeping and anxiety. This patient has presented with these symptoms after 6 weeks of giving birth.
A 30 year old woman is brought in by her husband to accident and emergency due to a two week history of persistent nausea and vomiting. Her husband also reports she has been more confused over the last three days. She is 10 weeks pregnant and this is her first pregnancy.
For several days now she has not been tolerating food but has been able to drink water.
On general examination she appears fatigued there is also some noticeable weakness of her ocular muscles bilaterally.
Which complication of hyperemesis gravidarum is this woman likely suffering from?
Wernicke’s encephalopathy secondary to hyperemesis gravidarum
Wernicke’s encephalopathy is the most likely cause of this woman’s confusion and ophthalmoplegia.
It is caused by thiamine deficiency which can be precipitated in severe vomiting and reduced food intake.
- Treatment is with Vitamin B1 (thiamine) supplementation.
A 33 year old primigravida presents to the antenatal clinic at 11 weeks gestation complaining of a week long history of persistent intractable nausea and vomiting.
She is experiencing difficulty keeping liquids down and has been unable to go to work.
Her urine shows ketones ++.
She asks whether there’s a medication she can try.
What is the most appropriate pharmacological therapies?
(4)
promethazine/cyclazine
then
Ondansetron
then
Metoclapromide
Straight facts about ECV
(3)
ECV
- only 50% are successful
- For nulliparous and multiparous women, the recommended time for ECV is 36 and 37 weeks respectively
- Tocolytics can increase the success rate of ECV
What regarding the mode and timing of delivery in patients with gestational diabetes is correct?
Women with gestational diabetes should give birth no later than 40+6 weeks of gestation.
Gestational diabetes is when women develop high levels of blood sugar levels during pregnancy.
It is usually diagnosed at 24-28 weeks of gestation on the basis of elevated blood glucose levels on glucose tolerance tests.
Women with gestational diabetes have a significantly increased risk of stillbirth, because of which women are advised to deliver no later than 4o+6 weeks of gestation.
Caesarean section or elective induction is performed if spontaneous delivery has not occurred by then.
A 30 year old primiparous woman is admitted onto the labour ward for an induction of labour at 41 weeks gestation. She is placed on a synthetic oxytocin infusion with continuous cardiotocography monitoring. 60 minutes after the start of the infusion the midwife calls the obstetrician as she is worried about her CTG reading.
The fetal heart rate is 95 bpm and she is contracting six times in 10 minutes, with each contraction lasting 30 seconds. There is no vaginal bleeding present and maternal observations are stable. Only the fetal head can be palpated at the cervical opening.
Which complication of augmented labour is this woman likely to be suffering from?
Uterine hyper-stimulation is defined as greater than 5 contractions occurring within 10 minutes and is due to administration of prostaglandins or oxytocin for induction of labour.
The fetal bradycardia is likely a consequence of the increased frequency of contractions and thus increased compression on the fetal head.
Uterine hyper-stimulation can usually be reversed with tocolytic agents.
A 25 year old woman presents to the GP complaining of a two day history of thin, grey, offensive vaginal discharge.
On speculum examination there is no bleeding and the cervical os is closed.
A vaginal swab is taken which demonstrates the presence of Gardnerella Vaginalis and pH test gives an abnormally alkaline result.
She is worried about this as she is currently 30 weeks pregnant with her first baby.
The is the most likely diagnosis?
What is a potential complication?
Increased risk of pre-term delivery
This woman has bacterial vaginosis demonstrated by the vaginal swab and pH test. Although the pathogenesis is unknown, bacterial vaginosis has been shown to increase the risk of preterm delivery and late miscarriage.
A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B.
She is both HbsAg and HbeAg positive at the time of delivery.
Which of the following options represents the best management for the foetus? (3)
HBV IgG and HBV vaccination within 24 hours of delivery
This patient is positive for both Hbs and Hbe antigens, increasing the risk of vertical transmission at delivery.
Using both HBV IgG and a vaccine reduces the risk of the foetus contracting HBV at birth to ~5%
A 35 year old woman has delivered her first baby on the labour ward at 39 weeks gestation.
There were no problems during pregnancy and the baby was delivered via an uncomplicated vaginal delivery.
Following birth, the midwife noticed a perineal tear which appeared to extend through the muscle fibres of the external anal sphincter.
On examination, the internal anal sphincter appears intact.
There is some minimal bleeding coming from the tear.
How should this woman be managed?
Repair in theatre and discharge with laxatives
This is the most appropriate management option. This woman has a grade three tear involving the external anal sphincter. Perineal tears which are grade three or four require surgical repair in theatre by an experienced clinician and under regional or general anaesthetic. Laxatives are given post-operatively to prevent constipation and reduce risk of compromising the repair.
Facts about Chorionic Villus Sampling
(5)
There is a risk of foetal limb abnormalities if CVS is performed before 11 weeks gestation
CVS has a higher rate of failed culture compared with amniocentesis
CVS results in miscarriage in ~1% of cases
CVS is typically offered between 11-13 weeks gestation
Amniocentesis can be performed from around 15 weeks gestation
A 32 year old G1P1 presents for a follow-up appointment 6 weeks post-delivery.
She is wondering if she can stop breastfeeding due to breast pain and engorgement and move her baby to specialised formula feeds.
She is informed and counselled about a medication which would help her stop breastfeeding.
Which of the medication is used to suppress lactation?
Cabergoline
This is the correct answer. Cabergoline is a dopamine receptor agonist, which inhibits prolactin production leading to suppression of lactation. This is the correct answer.
A 26 year old woman at 30 weeks gestation presents Accident and Emergency with bleeding that she noticed this morning. She describes the blood as fresh red following by some spotting since.
She denies any pain and the baby is moving well. Urinalysis is unremarkable and observations are stable.
Diagnosis of antepartum haemorrhage is made.
Which of the following is the most likely cause of the haemorrhage?
Placenta praevia
Placenta praevia is a condition where the placenta lies over the cervical os. It can be complete or partial depending on how much of the os it covers. It results in shearing of the placenta when stretched. It classically presents with painless bleeding after 20 weeks gestation as in the case of this woman.
A 38-year-old woman presents for her detailed ultrasound scan at 21
weeks gestation.
She has her blood pressure recorded and found to be 160/100 mmHg, compared with 125/90 mmHg at booking.
Aside from asthma, she has no other medical history.
Which of the following is the most appropriate management?
Nifedipine
Labetalol is normally considered first in gestational hypertension. Given that it is contra-indicated in this patient due to her asthma, NICE guidelines recommend nifedipine. If Nifedipine is not suitable, then methyldopa should be considered.
True statements regarding (TTTS)
(5)
The recipient twin is at risk of developing foetal hydrops
The donor twin is more likely to survive to birth
Specialist centres are able to offer treatment. Problem vessels are transected with lasers in-utero
Usually both foetuses have abnormal development
The donor twin can develop high output cardiac failure as a consequence of severe anaemia
What is a Frank breech?
Frank breech presentation is where the legs are fully extended up to the shoulders and the presenting part is the buttocks.
A 24 year old woman attends the hospital six weeks postpartum for a debrief. She had a normal vaginal delivery of a healthy baby boy, however 30 minutes later the placenta was ‘stuck’ and could not be delivered by controlled cord traction. There was a significant post-partum haemorrhage and the woman remembers being rushed to theatre where she underwent an emergency hysterectomy to control the haemorrhage.
Her first baby was born via caesarean section and she remembers being told there were higher risks opting for a vaginal delivery after caesarean section.
What is the most likely underlying cause for her post-partum haemorrhage and subsequent hysterectomy?
Placenta accreta
Placenta accreta occurs when the placenta invades into the myometrium. It is more common in women with a previous history of caesarean section. This is usually detected at routine ultrasound scans, however may not become apparent until delivery. The placenta fails to be delivered and results in significant post-partum haemorrhage and requirement for hysterectomy.
A 38 year old woman is on the postnatal ward after vaginal delivery of twins at 37 weeks gestation. The pregnancy was uncomplicated and her booking bloods were unremarkable. The lochia has been heavy since the delivery 6 hours ago, but now she is beginning to pass large clots of blood and has soaked the bed sheets with blood. There were no complications during labour and the placenta was delivered using controlled cord traction. The midwife reports that the placental membranes were complete on examination.
Her temperature is 36.5ºC, blood pressure is 110/70 mmHg and heart rate is 108 bpm. She is currently alert but looks paler than earlier. There is abdominal pain and the uterus is soft and palpable at the level of the umbilicus.
On speculum examination there are several large blood clots in the vaginal canal but no visible perineal or vaginal tears.
What is the most likely cause of her postpartum haemorrhage?
Uterine atony
The failure for the uterus to contract after delivery, otherwise known as uterine atony, is the most common cause of postpartum haemorrhage. A major risk factor for uterine atony is uterine over-distension, as seen in multiple pregnancy. The soft and high position of the uterus is also an indication that there is atony. It is important to recognise that this woman is at risk of haemorrhagic shock and thus requires immediate intervention.