Day 8 Obstetrics Flashcards
A pregnant woman has serum alpha feto-protein levels measured.
- *Which one of the following is associated with a low alpha-feto protein level?
(2) **
AFP
- raised in neural tubes defects
- decreased in Down’s syndrome
A 46-year-old woman has come into her GP.
She is planning on becoming pregnant, and would like advice about simple lifestyle changes and medications she should be taking, and the GP mentions that the woman should be taking the high dose (5 mg) folic acid.
What are the reasons for taking high dose folic acid?
Women are considered higher risk if any of the following apply:
- either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
- the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
Which changes would you expect to see in a healthy pregnant patient as compared to before pregnancy?
Normal laboratory findings in pregnancy:
- reduced urea
- reduced creatinine
- increased urinary protein loss
A 32-year-old gravid 3, para 2 at 24 weeks gestation attends an antenatal clinic and wishes to discuss delivery options for her pregnancy.
On history, you find that her previous pregnancies were delivered by vaginal and elective caesarean section respectively.
What is an absolute contraindication for vaginal delivery following a previous cesarean section?
(2)
Vertical (classic) caesarean scar
previous episodes of uterine rupture
A 23-year-old woman has come to the emergency department.
She is 37 weeks pregnant, and is complaining of a temperature and feeling generally unwell.
She is seen by the emergency department doctors and sent to the obstetric unit.
There, she is found to have a fever of 38ºC and to be tachycardic at 110 bpm.
The fetus is found to be tachycardic as well.
She says she has had no other symptoms, except having an episode of what she said describes as urinary incontinence 3 weeks ago, and some discharge afterwards.
What is the most likely cause of her presenting complaint?
Chorioamnionitis
You should think chorioamnionitis in women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
A 19-year-old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding.
Her ultrasound scan confirms a viable intrauterine pregnancy.
However, the high vaginal swab has isolated group B streptococcus (GBS).
How should she be managed?
Intrapartum intravenous benzylpenicillin only.
GBS is a vaginal commensal isolated in many women. It is known to be the most frequent cause of severe early-onset infection in the newborn and can cause significant morbidity and mortality.
A 28-year-old woman self-presents to the Emergency Department, extremely concerned regarding her pregnancy.
She is 33 weeks pregnant and thus far, the pregnancy has been uncomplicated.
However, several hours ago whilst out shopping, she felt a sudden gush of fluid from her vagina and a subsequent wetness of her underwear.
Her observations have already been taken by one of the triage nurses and are stable, within normal ranges.
Given the likely diagnosis, what is the first-line investigation?
(2)
Speculum examination is first line
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
Ultrasound may also be useful to show oligohydramnios.
Preterm prelabour rupture of the membranes management
(5)
Management
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
A mother brings her 6 year-old son to clinic with a widespread rash.
You diagnose chickenpox.
You know his mother, who is also a patient at the practice, is currently 20 weeks pregnant with her second child.
What action should you take, if any, regarding her exposure to chickenpox?
You should ask pregnant women exposed to chickenpox if they have had the infection before. If they say no or are unsure, varicella antibodies should be checked.
If it is confirmed they are not immune, varicella immunoglobulin should be considered. It can be given at any point in pregnancy and is effective up to 10 days after exposure.
A 27 year old woman attends her GP with breast pain.
She is 2 weeks postpartum and is exclusively breastfeeding.
She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing.
On examination, she appears well, her temperature is 38ºC.
There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
What would be the most appropriate management?
(2)
The first-line antibiotic is oral flucloxacillin for 10-14 days.
Breastfeeding or expressing should continue during treatment.
A woman has a vaginal delivery of her first child.
Although the birth was uncomplicated, she suffers a tear which extends from the vaginal mucosa into the submucosal tissue, but not into the external anal sphincter.
Which degree tear is this classed as?
- 1st degree = tear within vaginal mucosa only
- *- 2nd degree = tear into subcutaneous tissue**
- 3rd degree = laceration extends into external anal sphincter
- 4th degree = laceration extends through external anal sphincter into rectal mucosa
Sarah is a 29-year-old woman who comes to see you for a follow-up visit. You initially saw her 1 month ago for low mood and referred her for counselling. She states she is still feeling low and her feelings of anxiety are worsening. She is keen to try medication to help.
Sarah has a 4-month-old baby and is breastfeeding.
Which are the most appropriate medications for Sarah to commence?
(2)
Sertraline or paroxetine are the SSRIs of choice in breastfeeding women
Sertraline or paroxetine are the SSRIs of choice in breastfeeding women as whilst they are secreted in low levels in the breast milk it is not thought to be harmful to the infant.
A 28-year-old woman is admitted to the labour ward at 38+4 weeks gestation.
This is her first pregnancy and she tells you that contractions started around 10 hours ago.
On examination, her cervix is positioned anteriorly, is soft, and is effaced at around 60-70%.
Cervical dilatation is estimated at around 3-4cm and the fetal head is located at the level of the ischial spines.
She has had no interventions performed as of yet.
What intervention should be performed?
She has a bishop score of 10
No interventions required
A Bishop’s score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
What is a bishop score?
Interpretation
a score of < 5 indicates that labour is unlikely to start without induction
a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
When is Vaginal prostaglandin E2 used?
(2)
- Vaginal prostaglandin E2 is the preferred method of induction of labour but as this patient is only 10 hours into the first stage of labour
and
- she has a bishop score of 10
When is Maternal oxytocin infusion used?
(2)
Maternal oxytocin infusion can be used if labour is not progressing and other methods of induction have been tried but wouldn’t be appropriate in this scenario at this stage.
Oxytocin infusion carries the risk of uterine hyperstimulation.
When is an amniotomy performed?
(2)
Amniotomy is the artificial rupturing of membranes and can be performed if other methods have failed to induce labour or if vaginal prostaglandin E2 is contra-indicated.
Amniotomy carries the risk of infection, umbilical cord prolapse and baby moving into breech position if the fetal head is not engaged.
A woman who is at 12 weeks gestation presents to her antenatal appointment for her combined screening test.
She consents to, and undergoes, the standard screening test involving blood tests being taken and an ultrasound scan.
She is subsequently informed that her results may indicate Down’s syndrome, and is invited to discuss this further.
What results would be expected in this instance?
(3)
Down’s syndrome is suggested by
raised HCG
low PAPP-A
thickened nuchal translucency
A 29-year-old woman with her first pregnancy presents to you at 30-weeks gestation with itchiness.
There is no rash on examination and after referral to an obstetrician, she is confirmed to be suffering from intrahepatic cholestasis of pregnancy.
What should she be treated with?
The patient mentions her obstetrician said something about her labour but she was not sure.
What needs to be planned regarding this patient’s labour?
She should initially be treated with ursodeoxycholic acid.
Induction of labour at 37-38 weeks gestation
A 36-year-old woman who is currently 32 weeks pregnant has been monitoring her capillary blood glucose (CBG) at home following a diagnosis of gestational diabetes mellitus (GDM) 4 weeks ago.
She has been given appropriate dietary and exercise advice, as well as review by a dietitian.
She has also been taking metformin and has been on the maximum dose for the past 2 weeks.
Fetal growth scans have been normal with no signs of macrosomia or polyhydramnios.
She has brought her CBG diary today, which shows that her mean pre-meal CBG is 5.9 mmol/L and mean 1-hour postprandial CBG is 8.3 mmol/L.
What is the most appropriate management?
In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added
You are a male FY1 working in obstetrics. A 33-year-old female is on the ward in labour, 10 minutes ago she suffered a placental abruption and is in need of emergency care.
Her midwife comes to see you, informing you that she is requesting to only be seen and cared for by females.
What do you say?
Ask the midwife to immediately summon senior medical support, regardless of gender
While patients do have a right to choose their own doctor, this doesn’t apply in emergency situations where treatment is needed to save the life of the patient.
Hepatitis B and pregnancy
(4)
Basics
all pregnant women are offered screening for hepatitis B
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
there is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation.
On examination, the cervix is 7 cm dilated, the head is direct Occipito-Anterior, the foetal station is at -1 and the head is 2/5ths palpable per abdomen.
The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes.
How should this situation be managed?
(4)
The cardiotocogram is very concerning (the late decelerations which are a worrying sign especially in the context of foetal bradycardia) and indicates that the baby needs to be delivered immediately.
Instrumental delivery is not possible because the cervix is not fully dilated and the head of the baby is high.
Oxytocin and vaginal prostaglandin are contraindicated due to foetal distress.
Therefore the safest approach in this case is an emergency caesarian section.
A 28-year-old woman rings up the surgery for the results of her oral glucose tolerance test. She is 25 weeks pregnant and had a glucose tolerance test as she has a body mass index of 34kg/m².
Her results are as below:
Fasting glucose = 5.4 mmol/L
2-hour glucose = 7.8 mmol/L
What is the single best description of these results?
Gestational diabetes due to a raised 2-hour glucose
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
- ‘5678’
Risk factors for gestational diabetes
(5)
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
A 25-year-old primigravida presents to her General Practitioner at 25-week gestation following a referral from her midwife who found glucose present during a routine urinalysis. The following results are noted:
Blood pressure = 129/89 mmHg
Fundal height = 25.5 cm
Fasting plasma glucose = 6.8 mmol/L
What intervention should be offered to this patient?
(2)
if the fasting plasma glucose is < 7 mmol/l
then
a trial of diet and exercise should be offered for 1-2 weeks
- This patient is presenting with elevated fasting plasma glucose (6.8 mmol/L) and may have gestational diabetes.*
- The most appropriate management for this is a trial of diet and exercise to attempt to control blood glucose without pharmacological intervention.*
- The patient should be advised to eat a high fibre diet with minimal foods containing refined sugars.*
- During this period, the patient will be asked to check their blood glucose regularly as there are significant risks to the foetus with gestational diabetes and the patient should contact their team if ongoing elevated readings despite lifestyle interventions.*
A 28-year-old pregnant woman with pre-eclampsia suffered an eclamptic seizure at 11 am yesterday.
She was started on magnesium, the baby was delivered an hour later at midday, but she had another eclamptic seizure at 2 pm.
She has been well since then, as is the baby.
When should the magnesium infusion be stopped?
Magnesium treatment should continue for 24 hours after delivery or after last seizure
A 35-year-old woman comes to see you, her GP, because she feels tearful and low since the birth of her son 1 month ago and she isn’t sleeping well.
She says she thinks the baby hates her and feels they aren’t bonding, though she is still breast feeding.
She has a good family network, including the baby’s father and has never suffered with depression in the past.
She does not feel suicidal and has not been abusing any substances, you do not feel the baby is at risk.
What is the most appropriate management?
(2)
Cognitive behavioural therapy may be beneficial.
Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
A 25-year-old para 1+0 presents at 36 weeks with painless vaginal bleeding.
She reports that she has had intermittent spotting over the last 4 weeks, but they have increased in volume and frequency.
Her blood pressure is 125/80mmHg and her heart rate is 85bpm.
On examination, her abdomen is soft and non-tender, and the fetal head is not engaged and high.
What examination should you perform to confirm your initial working diagnosis?
- Transvaginal ultrasound
- The findings, in this case, are classical of placenta praevia.
Investigations for placenta praevia
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
Acute viral hepatitis screen is negative. Urgent US doppler liver demonstrates steatosis with patent hepatic and portal vessels. What is the most likely diagnosis?
The most likely diagnosis is acute fatty liver of pregnancy as demonstrated by:
- jaundice
- mild pyrexia
- hepatitic LFTs
- raised WBC
- coagulopathy
- steatosis on imaging
A 32-year-old woman has given birth to a healthy baby 2 weeks ago with no known complications. She enquires about iron supplementation. Her blood tests show:
Hb = 107 g/L
Female: (115 - 160)
What haemoglobin cut-off should be used in order to commence treatment in this patient?
How should she be manged?
(3)
- 100g/L
Management
- oral ferrous sulfate or ferrous fumarate
- treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
Pregnancy: anaemia management (2)
Management
- oral ferrous sulfate or ferrous fumarate
- treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
Is short or long-acting insulin used to treat gestational diabetes?
Gestational diabetes is treated with short-acting, but not longer-acting SC insulin
You are seeing a woman for her 6-week follow up appointment following a normal vaginal delivery.
She wishes to cease breastfeeding as her baby requires specialised formula feeds.
Which medication can be used to suppress lactation in this case?
Cabergoline is the medication of choice in suppressing lactation when breastfeeding cessation is indicated
A 27-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
The patient is at 34 weeks gestation and gravida 2, para 1. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient’s pad is partially soaked but there is no active bleeding noted on a quick inspection.
What would the most appropriate first course of action be in this scenario?
Administer corticosteroids and arrange admission to the ward
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is to admit and administer steroids
A 28-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child one week prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the left breast at the three o’clock position, 4cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 88, resp rate: 12, blood pressure: 110/70mmHg, Oxygen saturation: 98%, Temperature: 37.4 Cº.
What is the likely diagnosis, and what is the most appropriate next step in investigation?
Galactocele, no further investigation necessary
A 22-year-old female, gravidity 1 and parity 0 at 10 weeks’ gestation is involved in a high speed vehicle collision and her abdomen hits the steering wheel.
Maternal vital signs are stable.
No uterine contractions are present, and there is no vaginal bleeding.
U/S shows an intact placenta.
Which is the most appropriate next step?
(2)
Blood type and Rhesus testing
Important points:
A pregnant woman with abdominal trauma should have Rhesus testing asap because women who are Rhesus-negative should be given anti-D to prevent Rhesus isoimmunization.
Katie a 38-year-old woman who is G1P0 who is 15 weeks pregnant, comes to you to discuss her 12 weeks combined screening test results.
- HCG = raised
- PAPP-A = lower
- Nuchal translucencyThickened
Katie has googled the results and is concerned that her child has Down’s syndrome. She is very distressed. This is her first time becoming pregnant after 2 years of trying, and she is concerned she will not be able to conceive again on account of her age. However, Katie is unsure if she wants to continue with the pregnancy and is considering having a termination.
What is the best advice to give to Katie?
(3)
An amniocentesis test would give a more accurate result
- An amniocentesis is a diagnostic test that will show the fetal karyotype and will give a more accurate result than the combined test.
- Amniocentesis is usually performed from week 15 onwards, and so Katie should be booked for an amniocentesis to confirm the presence or absence of trisomy 21.
A 25-year-old woman who is 35 weeks pregnant attends the Emergency Department with fever, abdominal pain and anxiety. She says that she has been waking at night with soaked bed sheets for the past few days. She has been sexually active throughout pregnancy. She reports a history of uterine fibroids.
On examination there is marked uterine tenderness and an offensive brown vaginal discharge is noted. Blood pressure is 134/93 mmHg and the maternal heart rate is 110 beats per minute. Blood results are significant for a white cell count of 18.5 * 109/l. The baseline fetal heart rate is 170 beats per minute.
(3)
What is the most likely diagnosis?
Chorioamnionitis
- Chorioamnionitis is a clinical diagnosis and is suggested by uterine tenderness and foul-smelling discharge.
- Baseline fetal tachycardia supports the diagnosis.
- The aetiology in this case is likely to involve prolonged premature rupture of membranes.
The mention of previous uterine fibroids is a distractor - fibroids may undergo red degeneration during pregnancy, which can present with fever, pain and vomiting, but usually in the first or second trimester.
You have a telephone consultation with a 26-year-old female who wants to start trying to conceive.
She has a history of epilepsy and takes levetiracetam 250mg twice daily.
Which of the following would be most important to advise?
Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy
Women on antiepileptics, who try to conceive, should receive folic acid 5mg instead of 400mcg OD
A 34-year-old female who is 16 weeks pregnant is found to have a raised serum alpha-feto-protein (AFP) and is concerned as to what may be the cause of this.
Which of the following may cause this patient to have a raised AFP?
AFP - raised with fetal abdominal wall defects
(e.g. omphalocele)
A 35-year-old woman is found at her dating ultrasound scan (8-14 weeks) to be pregnant with monochorionic twins.
Her midwife explains that she will need regular scans throughout her pregnancy.
For this pregnancy, what is the main pathology that ultrasound monitoring performed between 16 and 24 weeks gestation aims to detect?
Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic twin pregnancies.
The two fetuses share a single placenta, meaning that blood can flow between the twins.
In TTTS, one fetus, the ‘donor’ receives a lesser share of the placenta’s blood flow than the other twin, the ‘recipient’.
This is due to abnormalities in the network of placental blood vessels.
The recipient may become fluid-overloaded whilst the donor can become anaemic.
One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems.
In severe cases, TTTS can be fatal for one or both fetuses.
A 39 year-old woman presents to her general practitioner with a grape-sized breast lump that she noticed one week ago whilst in the bath. It is firm and non-tender, with no surrounding skin changes. She feels well in herself with no temperatures, and has no history of breast disease. She stopped breastfeeding one month ago. An ultrasound scan shows a well-circumscribed lesion and aspiration yields a white fluid. What is the likely diagnosis?
Galactocele
The ultrasound findings and aspiration results make fibrocystic change, breast cancer and fat necrosis unlikely.
You are a junior doctor working in obstetrics and gynaecology. While helping to care for a patient during a vaginal delivery the delivery is suddenly complicated by shoulder dystocia.
After immediately calling for senior help you decide to perform McRobert’s manoeuvre, by moving the mother onto her back and hyper flexing and abducting her hips, bringing her thighs towards her abdomen.
Which additional measure can aid the effectiveness of the manoeuvre?
Suprapubic pressure
The Royal College of Obstetrics and Gynaecology suggest that ‘suprapubic pressure should be used to improve the effectiveness of the McRoberts manoeuvre’ in their shoulder dystocia guidelines.
CTG tracings
Definition of Baseline tachycardia
(1)
Causes of Baseline tachycardia
(4)
CTG tracings
Definition of Baseline tachycardia
- Heart rate > 160 /min
Causes of Baseline tachycardia
- Maternal pyrexia
- chorioamnionitis
- hypoxia
- prematurity
CTG tracings
Definition of Early deceleration
(1)
Causes of Early deceleration
(1)
Definition of Early deceleration
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Causes of Early deceleration
Usually an innocuous feature and indicates head compression
CTG tracings
Definition of Late decelerations
(1)
Causes of Late decelerations
(2)
Definition of Late deceleration
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Causes of Late deceleration
- Indicates fetal distress
- asphyxia or placental insufficiency
CTG tracings
Definition of Variable decelerations
(1)
Causes of Variable decelerations
(1)
Definition of Variable decelerations
decelerations which are independent of contractions
Causes of Variable decelerations
May indicate cord compression
A 40+5 week gestation primigravida presents to the maternity assessment unit for assessment following a membrane sweep 2 days ago attempting to induce labour.
She has had an uncomplicated pregnancy and has attended all prenatal appointments.
Her most recent scan showed a posterior high placenta and cephalic presentation.
She has no past medical or surgical history and takes no regular medication.
Cardiotocography is recorded as reassuring.
She has a vaginal examination performed which shows a Bishop score of 7.
What is the most appropriate management choice to attempt to induce labour in this patient?
Vaginal Prostaglandin E2 (PGE2) is the preferred method of induction of labour
This patient has a Bishop score which shows good favourability for vaginal delivery (a score of 7 or more is considered ‘favourable’ and the likelihood of vaginal delivery with induction is similar to spontaneous labour).
NICE guidelines advise that vaginal PGE2 is the induction method of choice irrespective of cervical status and parity. It is available as a tablet, gel or pessary.
This patient has no contraindications for the usage of these drugs such as acute inflammatory pelvic disease, active renal, hepatic, pulmonary or cardiac disease, foetal distress where delivery is not imminent, vaginal bleeding during pregnancy, marked cephalopelvic disproportion.
Amniotomy with an amnio hook is only appropriate if the cervix is favourable for this intervention (it is ripe and slightly dilated) and if there are specific contraindications to the use of vaginal prostaglandins.
A woman who gave birth 5 days ago presents for review as she is concerned about her mood.
She is having difficulty sleeping and feels generally anxious and tearful.
Since giving birth she has also found herself snapping at her husband.
This is her first pregnancy, she is not breast feeding and there is no history of mental health disorders in the past.
What is the diagnosis?
What is the most appropriate management?
Explanation and reassurance
This woman has the baby-blues which is seen in around two-thirds of women.
Whilst poor sleeping can be a sign of depression it is to be expected with a new baby!
