Day 7 Obstetrics

Question 1

A 23-year-old primigravida woman at 36 weeks gestation presents with mild irregular labor pains in the lower abdomen.

On examination she has a firm, posterior, closed cervix.

Fetal heart tones are heard. The pain stops during the consultation.

What is the most appropriate next step?

Answer 1

Reassure and discharge

False Labor

Occurs in the last 4 weeks of pregnancy

Presentation:

• contractions felt in the lower abdomen.
• The contractions are irregular and occur every 20 minutes.
• Progressive cervical changes are absent.

Question 2

False labour features

(4)

Answer 2

False Labor

Occurs in the last 4 weeks of pregnancy

Presentation:

contractions felt in the lower abdomen.

The contractions are irregular and occur every 20 minutes.

Progressive cervical changes are absent.

Question 3

What are the stages of labour?

stage 1:

stage 2:

stage 3:

Answer 3

Labour may be divided in to three stages

stage 1: from the onset of true labour to when the cervix is fully dilated

stage 2: from full dilation to delivery of the fetus

stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Question 4

A 22-year-old woman has just had an artificial rupture of membranes in order to augment a slowly progressing labour.

Her partner is helping her move into a more comfortable position when she suddenly becomes breathless and collapses from the bed.

She is unconscious and unresponsive with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute.

What is the most likely diagnosis?

Answer 4

A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism.

The patient is clearly too unwell for this to be a simple vasovagal event.

Amniotic fluid emboli can indirectly lead to myocardial infarcts, but It is hard to arrive at a primary diagnosis of myocardial infarction without mention of preceding chest pain.

Occult bleeding and hypovolaemic shock would also typically evolve at a slower pace.

Postural orthostatic tachycardia syndrome is more common in women of a reproductive age but would not be associated with marked hypotension as present here.

Question 5

A 34-year-old woman attends the antenatal clinic at 37 + 4 weeks.

She is concerned as her other child developed an infection 2 days after being born.

The doctor offers her intrapartum antibiotics to reduce the risk of this happening again.

She has no known drug allergies.

What antibiotic should she be given prophylactically intrapartum?

Answer 5

Benzylpenicillin is the antibiotic of choice for Group B Strep prophylaxis

IV benzylpenicillin is the correct answer. When a woman has previously had a baby with early or late GBS disease, they should be offered intrapartum prophylaxis in subsequent pregnancies.

75% of cases of early-onset sepsis in the UK are caused by GBS, so the assumption can be made that her older child had GBS sepsis.

Question 6

Risk factors for cord prolapse include:

(6)

Answer 6

Risk factors for cord prolapse include:

• prematurity
• multiparity
• polyhydramnios
• twin pregnancy
• cephalopelvic disproportion
• abnormal presentations e.g. Breech, transverse lie

Question 7

Around 50% of cord prolapses occur when? (1)

How is the diagnosis of cord prolapse made? (2)

Answer 7

Around 50% of cord prolapses occur at artificial rupture of the membranes

The diagnosis is usually made when the

• fetal heart rate becomes abnormal and the cord is palpable vaginally
• the cord is visible beyond the level of the introitus

Question 8

Management of cord prolapse

(5)

Answer 8

1. the presenting part of the fetus may be pushed back into the uterus to avoid compression
2. if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
3. the patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out or the left lateral position is an alternative
4. tocolytics may be used to reduce uterine contractions
5. retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
   * although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.*

Question 9

A 31-year-old woman G3P1 at 28 weeks gestation attends maternity triage with bright red vaginal bleeding.

She reports not being in any pain.

On examination, her uterus is non-tender.

Cardiotocography (CTG) monitoring shows no evidence of uterine contractions or foetal compromise.

What is the most likely diagnosis?

Answer 9

Pain is usually absent in patients with placenta praevia

The clinical features described in this scenario are typical of placenta praevia: painless vaginal bleeding and a non-tender uterus.

Threatened miscarriage is incorrect, as this is defined as painless vaginal bleeding occurring before 24 weeks gestation. Bleeding occurring after 24 weeks of pregnancy is an antepartum haemorrhage.

Question 10

placenta praevia features

Answer 10

painless vaginal bleeding and a non-tender uterus.

Question 11

A 24-year-old female who is 10 weeks in to her first pregnancy presents for review. Her blood pressure today is 126/82 mmHg.

What normally happens to blood pressure during pregnancy?

Answer 11

Falls in first half of pregnancy before rising to pre-pregnancy levels before term

Question 12

High risk groups of pre-eclampsia

(4)

Answer 12

• hypertensive disease during previous pregnancies
• chronic kidney disease
• autoimmune disorders such as SLE or antiphospholipid syndrome
• type 1 or 2 diabetes mellitus

Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby

Question 13

Treatment plan for women who are at risk of developing preeclampsia

(3)

Answer 13

Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby

Question 14

Hypertension in pregnancy in usually defined as (2)

Answer 14

Hypertension in pregnancy in usually defined as:

systolic > 140 mmHg or diastolic > 90 mmHg

or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Question 15

Describe Wood’s screw manoeuvre

Answer 15

Put your hand in the vagina and attempt to rotate the foetus 180 degrees

In this maneuver the anterior shoulder is pushed towards the baby’s chest, and the posterior shoulder is pushed towards the baby’s back, making the baby’s head somewhat face the mother’s rectum.

Question 16

Key risk factors for shoulder dystocia

(4)

Answer 16

Key risk factors

fetal macrosomia (hence association with maternal diabetes mellitus)

high maternal body mass index

diabetes mellitus

prolonged labour

Question 17

Management of shoulder dystocia

(2)

Answer 17

Senior help should be called as soon as shoulder dystocia is identified and McRoberts’ manoeuvre should be performed:

• this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.

Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.

Question 18

A 27-year-old woman who is 22-weeks pregnant presents to the emergency department after noticing a vesicular rash on her torso this morning. Upon further questioning you ascertain that her 4-year-old son developed chickenpox last week and the patient does not remember if she has had the condition before. She appears comfortable at rest.

You perform serological testing for varicella zoster virus which shows the following:

Varicella IgM = Positive

Varicella IgG = Negative

Which is the most appropriate management?

Answer 18

Chickenpox exposure in pregnancy > 20 weeks

if not immune give either oral antivirals or VZIG

Question 19

A 32-year-old primigravida at 37 weeks attends the antenatal unit complaining of abdominal pain which is worse on the right side. She has also been vomiting. Her blood pressure is 148/97 mmHg. She denies any abnormal discharge and reports that fetal movements are still present. Her blood results are shown below.

Hb = 93 g/l

Platelets = 89 * 109/l

WBC = 9.0 * 109/l

Urate = 0.49 mmol/l

Bilirubin = 32 µmol/l

ALP = 203 u/l

ALT = 190 u/l

AST = 233 u/l

What is the most likely diagnosis?

Answer 19

HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), a serious manifestation of pre-eclampsia.

Question 20

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications.

It is classically a triad of 3 things:

Answer 20

1) new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
2) proteinuria
3) other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Question 21

Potential complications of pre-eclampsia

(5)

Answer 21

Eclampsia

other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata

Fetal complications

• intrauterine growth retardation
• prematurity

Liver involvement:

• (elevated transaminases)

Haemorrhage:

• placental abruption
• intra-abdominal
• intra-cerebral

Cardiac failure

Question 22

Features of severe pre-eclampsia

(8)

Answer 22

Features of severe pre-eclampsia

1. hypertension: typically > 160/110 mmHg and proteinuria as above
2. proteinuria: dipstick ++/+++
3. headache
4. visual disturbance
5. papilloedema
6. RUQ/epigastric pain
7. hyperreflexia
8. platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Question 23

High risk factors for preeclampsia (5)

Moderate risk factors for preeclampsia (6)

Answer 23

High risk factors

• hypertensive disease in a previous pregnancy
• chronic kidney disease
• autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension

Moderate risk factors

• first pregnancy
• age 40 years or older
• pregnancy interval of more than 10 years
• body mass index (BMI) of 35 kg/m² or more at first visit
• family history of pre-eclampsia
• multiple pregnancy

Question 24

Pharmacological management of preeclampsia

(3)

Answer 24

Further management

• oral Labetalol is now first-line following the 2010 NICE guidelines.
• Nifedipine (e.g. if asthmatic) (calcium channel blocker)
• Hydralazine may also be used (vasodilator)

Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Question 25

A 26 year-old lady presents complaining of persistent itching. She has a history of eczema and uses emollients daily but this has not helped. She is currently 30 weeks pregnant. On examination there is evidence of excoriation on the hands but no obviously visible dermatitis.

Which of the following tests is the most important investigation to request and why?

(3)

Answer 25

Liver function tests

Pruritus is extremely common in pregnancy, affecting as many as a quarter of women.

Causes include exacerbations of eczema, polymorphic eruption of pregnancy, or simply just as the result of skin stretching and changes in circulation.

Pruritus in the absence of a rash should raise the possibility of obstetric cholestasis.

This potentially serious condition increases the risk of complications such as prematurity, passage of meconium, post partum haemorrhage, and possibly stillbirth.

Liver function tests and bile acids are therefore the most important tests to check.

Iron deficiency anaemia can also cause pruritus so full blood count would also be relevant.

Question 26

Intrahepatic cholestasis of pregnancy features:

(3)

Answer 26

pruritus, often in the palms and soles

no rash (although skin changes may be seen due to scratching)

raised bilirubin

Question 27

Intrahepatic cholestasis of pregnancy management:

(3)

Answer 27

Management

ursodeoxycholic acid is used for symptomatic relief

weekly liver function tests

women are typically induced at 37 weeks

Question 28

When does acute fatty liver of pregnancy occur?

(2)

Answer 28

Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.

Question 29

Acute fatty liver of pregnancy features

(6)

Answer 29

Features

• abdominal pain
• nausea & vomiting
• headache
• jaundice
• hypoglycaemia
• severe disease may result in pre-eclampsia

Question 30

Investigations for acute fatty liver of pregnancy

(2)

Answer 30

Investigations

• ALT is typically elevated e.g. 500 u/l
• HELLP syndrome

Question 31

A 32-year-old woman presents to the antenatal clinic at 41-weeks gestation. She is concerned that she has not yet gone into labour.

She reports normal foetal movements and denies recent illness. This is her first pregnancy and there is no other past medical history of note.

On examination, her abdomen is soft with a palpable uterus in keeping with a term pregnancy.

Her Bishop’s score is calculated as 5.

What is the most initial step in the management of this patient?

Answer 31

A membrane sweep is a useful adjunct, prior to formal induction of labour, that may be done in the antenatal clinic

Question 32

A 28-year-old woman presents the Emergency Department at 35-weeks gestation with lower abdominal pain and vaginal bleeding. She is alert and responsive. Physical examination revealed a heart rate of 115 bpm, blood pressure of 90/60 mmHg and O2 saturation of 99%. On neurological exam, her pupils were dilated and her reflexes were brisk.

Hb = 115 g/l

Platelets = 250*109/l

WBC = 5*109/l

PT = 12 seconds

APTT = 30 seconds

Which of the underlying condition would most likely explain the findings on the physical exam?

Answer 32

The scenario described in this question is consistent with that of placental abruption.

Cocaine abuse, pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia.

Cocaine Maternal risks

• hypertension in pregnancy including pre-eclampsia
• placental abruption

Cocaine Fetal risk

• prematurity
• neonatal abstinence syndrome

Question 33

A 22-year-old woman who is 14 weeks pregnant presents to her GP as she thinks she has been exposed to an infectious disease. Her friend’s daughter has a crusty rash and a fever.

She has no past medical history and when questioned, doesn’t know whether she has had chickenpox as a child.

What is the first action to perform?

What is the next step?

Answer 33

Chickenpox exposure in pregnancy - first step is to check antibodies

If a pregnant patient >20 weeks gestation is found to not be immune to varicella-zoster after antibody testing, they should be prescribed varicella-zoster immunoglobulin or they should be given oral acyclovir 7-14 days post-exposure.

Question 34

Oral acyclovir vs Varicella-zoster immunoglobulin

indications

Answer 34

Varicella-zoster immunoglobulin is indicated if the patient is shown to not be immune on antibody testing if they can receive it within 10 days of exposure. It provides rapid protection but is short-lived.

Oral acyclovir is indicated if a pregnant patient >20 weeks gestation develops chickenpox. It can also be used in caution in a patient <20 weeks gestation.

Question 35

Fetal varicella syndrome (FVS)

What is the relevant time frame of gestation? (2)

What are the features? (5)

Answer 35

Fetal varicella syndrome (FVS)

risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation

features of FVS include

• skin scarring
• eye defects (microphthalmia)
• limb hypoplasia
• microcephaly
• learning disabilities

Question 36

A 23-year-old woman is reviewed in the labour suite following a worrying cardiotocography (CTG) tracing. This is her first pregnancy, she has been in active labour for 70 minutes, and is receiving a spinal epidural for pain relief and IV oxytocin.

The CTG shows the following:

Foetal heart rate = 90 bpm(110 - 160)

Variability = 12 bpm(5 - 25)

Decelerations = absent

Contractions = 6-7 per 10 minutes (3 - 4)

This has been the case for 11 minutes. The mother’s heart rate is 62 bpm.

What is the most appropriate immediate next step?

(3)

Answer 36

This CTG is worrying and represents foetal compromise.

Whilst accelerations/decelerations and variability are both considered normal, a foetal bradycardia of under 100 bpm is considered pathological.

The first step is to consider whether it is the mother’s heart rate being picked up by the CTG pads. However, since we are told her heart rate is 62 bpm, we know that the heart rate given must be from the foetus.

There are many causes of foetal bradycardia, but in this case, it is likely due to too many contractions which are not allowing the foetus adequate perfusion.

A foetal bradycardia of over 10 minutes is an obstetric emergency and warrants immediate caesarean section, also known as a category 1 caesarean section.

Examples indications for a category 1 caesarean section include:

• suspected uterine rupture
• major placental abruption
• cord prolapse
• fetal hypoxia
• persistent fetal bradycardia

Question 37

Indications for caesarian section

(11)

Answer 37

1. cephalopelvic disproportion ABSOLUTE
2. placenta praevia grades 3/4 ABSOLUTE
3. pre-eclampsia
4. post-maturity
5. IUGR
6. fetal distress in labour/prolapsed cord
7. failure of labour to progress
8. malpresentations: brow
9. placental abruption: only if fetal distress; if dead deliver vaginally
10. vaginal infection e.g. active herpes
11. cervical cancer (disseminates cancer cells)

Question 38

Categories of C-section

(4)

Answer 38

Caesarean sections may be categorised by the urgency

Category 1

• an immediate threat to the life of the mother or baby
• examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
• delivery of the baby should occur within 30 minutes of making the decision

Category 2

• maternal or fetal compromise which is not immediately life-threatening
• delivery of the baby should occur within 75 minutes of making the decision

Category 3

• delivery is required, but mother and baby are stable

Category 4

• elective caesarean

Question 39

A 26-year-old primary school teacher has come to see you 4 days after contact with a child who had a vesicular rash on his head and trunk. She is currently 16 weeks pregnant and apart from some morning sickness, has felt completely well in herself. Blood tests reveal she is non immune to varicella zoster virus.

What would be the next step in your management plan?

Answer 39

A single dose of varicella-zoster immunoglobulin (VZI)

If the pregnant woman is not immune to varicella zoster virus and she has had a significant exposure, she should be offered varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG is effective when given up to 10 days after contact (in the case of continuous exposures, this is defined as 10 days from the appearance of the rash in the index case).

Question 40

Tina is a 30-year-old woman who has recently given birth to a baby girl 6 weeks ago. At the 6 week check, you can see from her records that she has previously been on citalopram for moderate depression, however, this was stopped before her pregnancy. She tells you that she is finding it difficult to cope and is feeling extremely low. On examination, she is tearful and has a flat affect. She denies any thoughts to harm herself or her baby but is keen to try a medication that would be safe to use with breastfeeding.

Which of the following medications may be appropriate for her to start?

Answer 40

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women

Question 41

Which SSRIs can be taken by breastfeeding women?

Answer 41

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women

Question 42

A 28 year old lady who is 20 days post-partum attends your surgery feeling hot and feverish for the past 2 days and reports a red, swollen, painful left breast.

On examination her temperature is 37.5 degrees, and there is erythema and firmness to the left lower quadrant of the left breast.

Given the diagnosis of puerperal mastitis, which of the following represents the best advice to give her?

Answer 42

Advise her to continue breast feeding

Lactation mastitis is inflammation in the interlobular connective tissue of the breast, which may or may not be associated with infection. It occurs in around 10% on breast feeding women and is most common six weeks post-partum.

The woman should be encouraged to continue breast feeding as this improves milk removal and prevent nipple damage. If pain prevents the woman from breast feeding she should be encouraged to express breast milk by hand or pump until breastfeeding can be resumed.

Question 43

A neonate is born at 32 weeks gestation after prolonged premature rupture of membranes (PROM).

Approximately 12 hours after birth the neonate presents with temperature instability, respiratory distress and lethargy.

Sepsis is confirmed by blood cultures.

What is the most likely infectious agent?

Answer 43

Risk factors for Group B Streptococcus (GBS) infection:

prematurity

prolonged rupture of the membranes

previous sibling GBS infection

maternal pyrexia e.g. secondary to chorioamnionitis

Question 44

At what week is the initial booking visit with midwife?

Answer 44

8 - 12 weeks

Question 45

At which week would a doctor offer external cephalic version if baby is breech?

Answer 45

36 weeks

Question 46

At which week is down’s syndrome screening where nuchal scanning is available?

Answer 46

11 - 13+6 weeks

Question 47

A 24-year-old primigravida attends her booking visit at 12 weeks. She is concerned because her mother had a condition in pregnancy that resulted in a seizure. She has no past medical history and her BP is 125/85 mmHg at this appointment. No abnormalities are detected on her urine dipstick. Her BMI is 38 kg/m².

What is the most appropriate management?

Answer 47

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth

Question 48

A 34-year-old primiparous woman is 33+6 weeks pregnant. During a recent antenatal visit she had a blood pressure of 152/101 mmHg.

She reports some swelling of her hands and feet but no other symptoms. Urinalysis is negative for protein.

She has a past history of asthma for which she uses a salbutamol inhaler PRN and depression but she stopped her antidepressant medication when she became pregnant.

What is the best management?

Answer 48

Oral nifedipine

Gestational hypertension is new onset hypertension diagnosed after 20 weeks without significant proteinuria. This woman has moderate gestational hypertension as her systolic blood pressure is between 150-159 mmHg and her diastolic blood pressure is between 100-109 mmHg.

Question 49

A 32-year-old pregnant woman of South Asian origin is 10+0 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other previous pregnancies. Since she has a strong family history of type 2 diabetes mellitus, she is offered a fasting glucose test at her booking visit. Her fasting glucose level is 7.2 mmol/L.

What is the most appropriate initial management given her fasting glucose level?

Answer 49

Insulin

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

Question 50

A 25-year-old female comes to see her GP with a positive pregnancy test following a missed period. Given her last menstrual period it is estimated that she is 4-5 weeks pregnant. Although the news is unexpected, she is happy to continue with the pregnancy, however she is a known epileptic and is concerned about her medication.

Which medications are recommended for epileptics in pregnancy?
(3)

Answer 50

Lamotrigine, carbamazepine and levetiracetam are known to have the smallest effects on the developing foetus, however all epileptics who are either pregnant or are planning to become pregnant should be referred to specialist care as soon as possible.

Question 51

A 25-year-old female who is 39+0 weeks pregnant has an artificial rupture of membranes in an attempt to expedite slow labour. Shortly after this is performed, foetal bradycardia is noted on cardiotocography (CTG) and the umbilical cord can be palpated at the vaginal introitus.

What is the most appropriate initial step in the management of this patient?

Answer 51

The correct position for women who have a cord prolapse is on all fours, on knees and elbows

Question 52

A 28-year-old woman who is 6 weeks postpartum and breastfeeding presents with a history of a painful, erythematous breast for the past 12 hours.

Her blood pressure is 120/80 mmHg, her heart rate is 75 beats per minute and her temperature is 37.0 degrees celsius. On examination her right breast is tender and erythematous and warm to touch. There is no palpable lump and no visible fissure.

You take a sample of breast milk to send for culture.

What is the most appropriate first line management?

Answer 52

Advise to continue breastfeeding and use simple analgesia and warm compresses

The correct answer is to continue breastfeeding and use simple analgesia and warm compresses.

Milk stasis is often the initiating factor for lactational mastitis, therefore if breastfeeding is too painful women are advised to express milk by hand or using a pump.

Question 53

A 32-year-old woman is referred to the joint antenatal and diabetic clinic after being diagnosed with gestational diabetes mellitus. She is currently 25 weeks pregnant and this is her first pregnancy. There is no history of any pregnancy-related problems in her family but her father has type 1 diabetes mellitus. The examination is normal, other than a raised BMI of 32 kg/m².

What are the diagnostic criteria for this woman’s condition?

Answer 53

Gestational diabetes can be diagnosed by either a:

fasting glucose is >= 5.6 mmol/L, or

2-hour glucose level of >= 7.8 mmol/L

Question 54

A 36-year-old pregnant patient is admitted to the labour ward after her waters break and she begins to experience contractions.

She is 39 weeks pregnant and was diagnosed with gestational hypertension at 25 weeks.

The doctor decides to continuously monitor the foetus throughout labour.

After seeing the CTG tracing, he tells the mother that he must call for senior obstetrician review due to a potentially worrying feature which has persisted for 20 minutes.

Which of the following is he most likely to have seen on the CTG?

Answer 54

Normal CTG:

• accelerations present
• variability >5bpm
• no decelerations
• HR 110-160

Question 55

A 27-year-old nulliparous woman is diagnosed with gestational diabetes during her current pregnancy via an oral glucose tolerance test (OGTT). She asks whether her diagnosis will impact future pregnancies.

What is the most appropriate approach to screen for gestational diabetes in future pregnancies?

Answer 55

Women with gestational diabetes in a previous pregnancy should be offered an OGTT as soon as possible after booking and subsequently at 24-28 weeks

Women who have had gestational diabetes during a previous pregnancy should first be screened with an OGTT immediately after booking.

If this test is positive, gestational diabetes is diagnosed and a further OGTT is not required. If this test is negative, then they should have a further OGTT at 24-28 weeks.

Question 56

How are pregnant women tested for gestational diabetes?

Answer 56

Women who have had gestational diabetes during a previous pregnancy should first be screened with an OGTT immediately after booking.

If this test is positive, gestational diabetes is diagnosed and a further OGTT is not required. If this test is negative, then they should have a further OGTT at 24-28 weeks.

Question 57

A 23-year-old female patient presents to her general practitioner asking for advice about getting pregnant. She has a past medical history of epilepsy for which she takes lamotrigine. She last had a seizure 2 years ago.

She wants to know if there are any supplements that she should be taking and she is concerned as she has heard that epilepsy medications should not be taken during pregnancy.

What are the important counselling points for this patient regarding her concerns?

Answer 57

Folic acid 5mg

continue lamotrigine

Question 58

A 38-year-old pregnant woman presents to antenatal clinic complaining of headaches and rapid swelling of her ankles over the last 3 days. She is 30+4 weeks pregnant, gravida 1 para 0. She has a past medical history of diabetes mellitus type II which is lifestyle controlled. On examination the fundal height is measuring small for dates and she is sent for an ultrasound scan which reveals oligohydramnios.

What can cause this patient’s oligohydramnios?

(5)

Answer 58

Pre-eclampsia is a cause of oligohydramnios

Causes

• premature rupture of membranes
• fetal renal problems e.g. renal agenesis
• intrauterine growth restriction
• post-term gestation
• pre-eclampsia

Question 59

oligohydramnios definition

Answer 59

In oligohydramnios there is reduced amniotic fluid.

Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.

Question 60

A 17-year-old primiparous woman, who is 37 weeks pregnant, attends the emergency department with a large volume of painful vaginal bleeding.

This started 30 minutes ago and presented as a sudden gush of blood. She had been feeling unwell for a few days, feeling lightheaded whenever she stood up. She has not engaged with antenatal care, apart from her initial booking visit.

On examination, her heart rate is 130 beats per minute, her respiratory rate is 21 breaths per minute and her blood pressure is 96/65 mmHg. She has a tense abdomen, with a firm, fixed uterus.

What is she suffering from?

Which of the following is most likely to put her at risk for this complication?

Answer 60

Polyhydramnios is a risk factor for placental abruption

• *ABRUPTION**:
• *A** for Abruption previously;
• *B** for Blood pressure (i.e. hypertension or pre-eclampsia);
• *R** for Ruptured membranes, either premature or prolonged;
• *U** for Uterine injury (i.e. trauma to the abdomen);
• *P** for Polyhydramnios;
• *T** for Twins or multiple gestation;
• *I** for Infection in the uterus, especially chorioamnionitis;
• *O** for Older age (i.e. aged over 35 years old);
• *N** for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Question 61

Risk factors for placental abruption

(9)

Answer 61

ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Question 62

The following drugs CAN be given to mothers who are breastfeeding:

(8)

Answer 62

• antibiotics: penicillins, cephalosporins, trimethoprim
• endocrine: glucocorticoids (avoid high doses), levothyroxine*
• epilepsy: sodium valproate, carbamazepine
• asthma: salbutamol, theophyllines
• psychiatric drugs: tricyclic antidepressants, antipsychotics**
• hypertension: beta-blockers, hydralazine
• anticoagulants: warfarin, heparin
• digoxin

Question 63

The following drugs should be avoided (8)

Answer 63

• antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
• psychiatric drugs: lithium, benzodiazepines
• aspirin
• carbimazole
• methotrexate
• sulfonylureas
• cytotoxic drugs
• amiodarone

Question 64

Conditions screened at antenatal screening

(10)

Answer 64

1. Anaemia
2. Bacteriuria
3. Blood group, Rhesus status and anti-red cell antibodies
4. Down’s syndrome
5. Fetal anomalies
6. Hepatitis B
7. HIV
8. Neural tube defects
9. Risk factors for pre-eclampsia
10. Syphilis

Question 65

A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant.

This is confirmed with a positive pregnancy test. She is known to be HIV positive.

What can be done to reduce the chance of HIV transmission?

(4)

Answer 65

Factors which reduce vertical HIV transmission (from 25-30% to 2%)

• maternal antiretroviral therapy
• mode of delivery (caesarean section)
• neonatal antiretroviral therapy
• infant feeding (bottle feeding)

Question 66

Which mode of delivery is recommended if the mother is HIV positive?

(2)

Answer 66

Mode of delivery

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended

a zidovudine infusion should be started four hours before beginning the caesarean section

Question 67

You are reviewing the blood results for a pregnant woman.

Which one of the following results would indicate the need for routine antenatal anti-D prophylaxis to be given at 28 weeks?

Answer 67

Rhesus negative mothers who are NOT sensitised

Question 68

A 37-year-old woman who is 32 weeks pregnant presents with malaise, headaches and vomiting. She is admitted to the obstetrics ward after a routine blood pressure measurement was 190/95mmHg. Examination reveals right upper quadrant abdominal pain and brisk tendon reflexes. The following blood tests are shown:

Hb = 85g/l

WBC = 6*109/l

Platelets = 89*109/l

Bilirubin = 2.8 µmol/l

ALP = 215 u/l

ALT = 260 u/l

γGT = 72 u/l

LDH = 846 u/I

A peripheral blood film is also taken which shows polychromasia and schistocytes.

What is the most likely diagnosis?

Answer 68

HELLP syndrome is a severe form of pre-eclampsia whose features include:

Haemolysis (H)

Elevated liver enzymes (EL)

Low platelets (LP)

A typical patient might present with malaise, nausea, vomiting, and headache.

Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.

Question 69

A 25-year-old G1P0 woman who is 30 weeks pregnant presents to her GP complaining of intense itching of her palms.

She also complains of fatigue but has been struggling with this throughout her pregnancy.

On examination, you cannot see any rash on her hands.

What is the likely diagnosis?

What management should be offered?

Which of the following is she at an increased risk of?

Answer 69

Intrahepatic cholestasis of pregnancy

increases the risk of stillbirth;

therefore induction of labour is generally offered at 37-38 weeks gestation

N.B.A miscarriage is the loss of a pregnancy at less than 24 weeks gestation. As this patient is past this point in her pregnancy she can no longer have a miscarriage and a loss of her pregnancy would instead be classed as a stillbirth.

Question 70

A pregnant woman asks for advice about alcohol consumption during pregnancy. Which one of the following is in line with current NICE guidelines?

Answer 70

They cant drink at all

Question 71

A 28-year-old pregnant woman presents to the antenatal clinic for her 12 week booking appointment.

She is nulliparous with no past medical history of note.

The midwife takes a blood sample to be screened for HIV, rubella and syphilis.

A midstream urine sample is sent for culture to screen for asymptomatic bacteriuria.

Which other infectious disease is routinely screened for in pregnancy?
(9)

Answer 71

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down’s syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Syphilis

Question 72

A young woman of 28 weeks gestation presents to the emergency department with painless vaginal bleeding, she appears well and is haemodynamically stable.

Which investigation is most likely to help confirm the diagnosis?

Answer 72

Abdominal ultrasound with colour flow doppler

searching for placenta praevia

Question 73

A 30-year-old woman at 32 weeks gestation presents to the Emergency Department with a small amount of painless vaginal bleeding that came on spontaneously. Obstetric examination finds a cephalic presentation with high presenting part. The uterus is non-tender. The cervical os is closed and the cervix appears normal. Which of the following diagnoses is most likely?

Answer 73

Clinical features

• shock in proportion to visible loss
• no pain
• uterus not tender
• lie and presentation may be abnormal
• fetal heart usually normal
• coagulation problems rare
• small bleeds before large

Placenta praevia refers to a pathological positioning of the placenta in the lower segment of the uterus, either wholly or partly. If the placenta overlies the internal cervical os then this is classed as ‘major praevia’, whereas in ‘minor’ or ‘partial’ praevia it does not. Bleeding from the placenta can occur spontaneously, as a result of trauma, or at the onset of labour as the cervix opens.

Question 74

Clinical features of placenta praevia

(7)

Answer 74

Clinical features

• shock in proportion to visible loss
• no pain
• uterus not tender
• lie and presentation may be abnormal
• fetal heart usually normal
• coagulation problems rare
• small bleeds before large

Question 75

Investigations for placenta praevia (2)

Answer 75

Investigations

placenta praevia is often picked up on the routine 20 week abdominal ultrasound

the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Question 76

A 32-year-old woman attends for advice as she has recently found out she is pregnant for the first time.

She has a family history of diabetes (mother, aunt, grandmother).

She is otherwise fit and well and does not take any regular medications other than folic acid.

What is the most appropriate screening to offer her?

Answer 76

Pregnant women who have a first degree relative with diabetes should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks

Oral glucose tolerance test (OGTT) at 24-28 weeks is the correct answer her mother has diabetes. This puts her at risk of gestational diabetes.

Question 77

Samantha is a G2P1 27-year-old female who comes to you, a locum general practitioner, because she has just found out she is pregnant. You notice that Samantha is on a number of medications for a variety of medical conditions. Samantha’s medical history includes asthma, gastro-oesophageal reflux, constipation and a recent deep vein thrombosis.

Her current medications include :

• senna
• over the counter ranitidine,
• budesonide
• salbutamol inhalers
• rivaroxaban

None of her medications have yet been altered due to her pregnancy status.

Which one of Samantha’s medications must be changed and what should it be changed to?

(2)

Answer 77

rivaroxaban

Novel oral anticoagulants are contraindicated for use in pregnancy and therefore women already on NOACs should be changed over to low molecular weight heparin

Question 78

A 30-year-old woman delivers twins vaginally after being induced.

A blood loss of 800ml is recorded and the patient continues to bleed but remains haemodynamically stable.

What is the cause of her bleeding?

What is the next step in management ?

Answer 78

The cause of PPH in this case is uterine atony.

The risk factors which indicate uterine atony in this question include induction of labour and the multiple pregnancy, which affects the tone of the uterus.

Uterine massage is the first step in management if the cause is uterine atony

Question 79

Management of PPH

Medical and Surgical

(6)

Answer 79

Start with medical management

1. ABC including two peripheral cannulae, 14 gauge
2. IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
3. IM carboprost (prostaglandin analogue)

If medical options failure to control the bleeding then surgical options will need to be urgently considered

1. the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
2. other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
3. if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Question 80

A 34-year-old woman of Chinese Han ethnicity telephones her GP to discuss her pregnancy which was planned and is at an estimated 6-weeks gestation.

She smokes 10 cigarettes/day and has a body mass index (BMI) of 31 kg/m².

She suffers from mild asthma only, which is well-controlled with inhaled beclometasone.

The GP prescribes folic acid 5mg daily and advises the patient to continue this for the first 12-weeks of her pregnancy.

Which of the following is an indication for high-dose folic acid for this patient?

Answer 80

Pregnant obese women (BMI >30 kg/m2), should be given high dose 5mg folic acid

Question 81

Causes of folic acid deficiency:

(4)

Consequences of folic acid deficiency:

(2)

Answer 81

Causes of folic acid deficiency:

• phenytoin
• methotrexate
• pregnancy
• alcohol excess

Consequences of folic acid deficiency:

• macrocytic, megaloblastic anaemia
• neural tube defects

Question 82

What is the molecular function of folic acid

(3)

Answer 82

Folic acid is converted to tetrahydrofolate (THF)

THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups)

to the essential substrates involved in the synthesis of DNA & RNA

Question 83

Which women are most at risk of neural tube defects?

(6)

Answer 83

Women are considered higher risk if any of the following apply:

• either partner has a NTD
• the woman is taking antiepileptic drugs
• has coeliac disease
• diabetes
• thalassaemia trait.
• obesity

Question 84

A 35-year-old woman who gave birth two weeks ago is becoming very tired after walking to the shops and back. The birth was via a caesarean section and she required two units of blood to be transfused. She presents to her general practitioner and denies any chest pain, palpitations, shortness of breath, or further bleeding.

On examination, there are no signs of further active bleeding and the caesarean section scar is healing well.

What is the haemoglobin cut-off for this patient to receive iron?

Answer 84

<100 g/L is the correct answer as the cut-off to determine if iron supplementation is required for this postpartum woman.

The oral iron should be continued for 3 months after the ferritin has been normalised to ensure adequate stores for haem production and efficient oxygen delivery to the tissues.

Question 85

A 28-year-old woman attends clinic complaining of an intense itch that has developed over the past couple of weeks. She is 33 weeks pregnant and has so far had no complications. She describes the itch as being worse around the palms and soles. She otherwise feels well and denies any fever or recent illness.

Examination is unremarkable; there is no evidence of a rash. Blood tests are performed which are also unremarkable, except for the following:

Bilirubin = 35 (3-17 umol/L)

Alanine transferase (ALT) = 54 (3-40 iu/L)

Aspartate transaminase (AST) = 36 (3-30 iu/L)

Alkaline phosphatase (ALP) = 109 (30-100 umol/L)

Which of the following should be discussed with the patient?

What is the diagnosis?

Answer 85

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

Management

• induction of labour at 37-38 weeks is common practice but may not be evidence based
• ursodeoxycholic acid - again widely used but evidence base not clear
• vitamin K supplementation

Question 86

Answer 86

Question 87

A 35-year-old, 12 week pregnant, female presents to the emergency department with abdominal pain. The pain has been constant for the past 2 hours but she has had no vaginal bleeding.

What are the factors associated with an increased risk of placental abruption?

Answer 87

Increased risk of placental abruption is associated with increasing

• maternal age
• multiparity
• maternal trauma

Question 88

A woman who is 12 weeks pregnant presents as she is concerned following a recent antenatal scan. The scan has reportedly shown increased nuchal translucency.

Which conditions are most associated with this finding?

(3)

Answer 88

A nuchal scan is performed at 11-13 weeks.

Causes of an increased nuchal translucency include:

Down’s syndrome

congenital heart defects

abdominal wall defects

Question 89

What might hyperechogenic bowel represent on an ultrasound scan?

Answer 89

Causes of hyperechogenic bowel:

cystic fibrosis

Down’s syndrome

cytomegalovirus infection

Question 90

A 25-year-old woman presents for a routine antenatal appointment. She is 28 weeks pregnant. Her pregnancy has, so far, been uncomplicated and she currently feels well. Her observations show:

Respiratory rate 16 breaths/min

Heart rate 72 beats/min

Blood pressure 128/86mmHg

Temp 37.3ºC

Oxygen saturations 96% on room air

Urinalysis shows:

Protein+

Glucose-

Nitrites-

Which is the most appropriate for this patient?

Answer 90

Routine management

Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction

Question 91

A 24-year-old woman who is 33 weeks pregnant presents to the Emergency Department with sudden onset abdominal pain and some very light vaginal bleeding which has subsequently stopped. On examination her abdomen is tense and tender.

Cardiotocography (CTG) was performed and showed a foetal heart rate of 135bpm, with beat-beat variability of 2-25bpm and 2 accelerations were seen in a 20 minute period.

Ultrasound demonstrates normal foetal biophysical profile and liquor volume. There is a small collection of retroplacental blood.

Which of the following is the best course of action for this patient?

Answer 91

Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is to admit and administer steroids

Question 92

A 28-year-old woman gives birth to her first child. The baby is born via normal vaginal delivery and weighs 3.6 kg. The baby has a normal Newborn and Infant Physical Examination (NIPE) after birth and the mother recovers well following the delivery. The mother wishes to breastfeed her baby and is supported to do so by the midwives on the ward.

They are visited at home by the health visitor a week later. The health visitor asks how they have been getting on and the mother explains that she has been experiencing problems with breastfeeding and that her baby often struggles to latch on to her breast. She explains that this has made her very anxious that she is doing something wrong and has made her feel like she is failing as a mother. When her baby does manage to latch on to feed he occasionally gets reflux and vomits afterward. The health visitor weighs the baby who is now 3.2kg.

What is the next most appropriate step?

Answer 92

Refer her to a midwife-led breastfeeding clinic

If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate

Question 93

A 33-year-old woman presents to the GP as she has not had a period for 6 months. She has also noticed that she is sweating more at night and has had started to have the occasional hot flush, although she thinks this may just be due to the weather.

She does not want children and has only come today to check there is no sinister cause for her lack of periods. She has no past medical history and no family history.

Blood tests are as follows:

TSH = 2 mU/L(0.5 - 5.5)

T4 = 10 pmol/L(9 - 18)

Prolactin = 15 µg/L(<25)

FSH = 75 iu/L(<40)

Oestradiol = 45 pmol/L(>100)

Bloods repeated 6 weeks later show no change.

**What is thew diagnosis?

What is the most appropriate management?**

Answer 93

Premature ovarian insufficiency:

hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of 51 years

• Amenorrhea, climacteric symptoms (hot flushes and night sweats), lost oestradiol and raised gonadotrophins are all consistent with ovarian failure.*
• As this patient is under 40, this is premature ovarian failure. The mainstay of treatment is hormone replacement therapy (which can also be given as the combined oral contraceptive pill) which is given until the age of natural menopause (around 51 years) to prevent osteoporosis, as well as to protect against symptoms of oestrogen deficiency and possible cardiovascular complications.*
• As this patient has a uterus, she must not have unopposed oestrogen (due to the risk of endometrial cancer), so combined replacement should be given. Of the above options, the most appropriate answer is combined hormone replacement therapy until the age of 51.*

Question 94

A 31-year-old woman presents to the GP for advice after her son was diagnosed with chickenpox 8 days ago after he developed a widespread vesicular rash.

The woman feels well in herself.

However, she is 19 weeks pregnant and does not recall ever having had chickenpox.

This is confirmed with am immunoglobulin test.

What is the most appropriate management?

(3)

Answer 94

Give varicella-zoster immunoglobulin

Following chickenpox exposure in a non-immune pregnant woman, varicella-zoster immunoglobulin (VZIG) is only effective up to 10 days post-exposure

If a pregnant woman has significant exposure to chickenpox, is under 20 weeks and is not immune, she should be offered varicella zoster immunoglobulin (VZIG) as soon as possible within 10 days of the exposure. This is important both to reduce the risk of foetal varicella-zoster syndrome and because pregnant women are at greater risk of complications from chickenpox.

Question 95

A 37-year-old woman who has never been pregnant is referred to the fertility clinic after 12 months of trying to conceive.

Initial investigations show that she is ovulating and that her partner’s semen analysis is normal.

However, as the patient has a past history of menorrhagia, a transvaginal ultrasound is arranged.

This reveals a large uterine fibroid that is distorting the uterine cavity.

What is the next most appropriate step?

(2)

Answer 95

• The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future

Whilst the combined oral contraceptive pill may be used to reduce the bleeding associated with fibroids, there is no good evidence that it alters the size of fibroids, and hence it would not help in this case, where a patient has sub-fertility due to a fibroid distorting her uterine cavity. Furthermore, the patient would be unable to conceive whilst on this trial of treatment.

Question 96

A woman who gave birth 6 weeks ago presents to her local GP surgery with her husband.

She describes ‘crying all the time’ and ‘not bonding’ with her baby.

Which one of the following screening tools is it most appropriate to detect postnatal depression?

Answer 96

The Edinburgh Scale is a screening tool for postnatal depression

Question 97

A 37-year-old G3P2 woman at 14 weeks gestation presents to her general practitioner as she is concerned about a new rash that she noticed on her 4-year-old son’s abdomen 2 days ago.

The rash appears vesicular, and the mother reports that there is a chickenpox outbreak at school. The patient is uncertain if she had chickenpox as a child.

What is the most appropriate course of action?

Answer 97

Chickenpox exposure in pregnancy - first step is to check antibodies

Question 98

A 32-year-old woman presents at 34 weeks gestation in her first pregnancy.

She was admitted with a seizure following a 1 day period of severe abdominal pain, nausea, vomiting, and visual disturbance.

She has a family history of epilepsy.

On examination, hyperreflexia is noted.

What is the most likely diagnosis?

(3)

Answer 98

Eclampsia is a condition characterised by seizures in a pregnant woman with pre-eclampsia.

Early signs of pre-eclampsia include hypertension and proteinuria.

Other symptoms of pre-eclampsia include abdominal pain, nausea, vomiting and visual disturbance.

Question 99

Eclampsia management

(4)

Answer 99

Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop.

Guidelines on its use suggest the following:

should be given once a decision to deliver has been made

• in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
• urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

• treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Question 100

A 28-year-old woman who is 9 weeks pregnant comes to see you for her booking appointment.

She has a sister with Down syndrome and would like more information about the screening programme.

You counsel her about the combined test.

Along with nuchal translucency, which blood markers are measured?

(2)

Answer 100

Beta-human chorionic gonadotrophin (beta-hCG)

and

pregnancy-associated plasma protein A (PAPP-A)

Question 101

A 28-year-old woman who is 25-weeks pregnant presents to the emergency department with a tender, swollen left calf, which is confirmed as a DVT.

Before any management can be initiated, she becomes acutely short of breath and complains of pleuritic chest pain.

Given the most likely diagnosis, which of the following is the best initial management step?

(3)

Answer 101

Suspected PE in pregnant women with a confirmed DVT:

treat with LMWH first then investigate to rule in/out

Thrombolysis is contraindicated in pregnancy as it can cause catastrophic haemorrhage of the placenta and the foetus.