Day 9 Obstetrics Flashcards
A 31-year-old female presents to the antenatal clinic for a booking appointment.
What are the risk factors for pre-eclampsia?
(9)
- Aged 40 years or older
- Nulliparity
- Pregnancy interval of more than 10 years
- Family history of pre-eclampsia
- Previous history of pre-eclampsia
- Body mass index of 30kg/m^2 or above
- Pre-existing vascular disease such as hypertension
- Pre-existing renal disease
- Multiple pregnancy
A 26-year-old woman presents to her GP with a 5 week history of worsening dull pelvic pain and smelly discharge.
She has had a hormonal intrauterine device in situ for one year and does not menstruate with this.
She has had the human papilloma virus vaccine but has not yet had any smear tests.
What is the most likely diagnosis?
How should she be managed?
Pelvic inflammatory disease is the most likely diagnosis in this patient.
Her pain has developed over a long duration, and she has presented to her GP suggesting that the pain is not severe.
She also complains of smelly discharge that may be a sign of a sexually transmitted infection.
This patient has an intrauterine device suggesting that there may be no barrier method in use to prevent sexually transmitted infections.
Abnormal bleeding (post-coital, inter-menstrual, menorrhagia) may be also present.
High vaginal swabs should be taken, and antibiotics prescribed if appropriate. A smear test can be taken opportunistically in this patient.
A woman who is 8 weeks pregnant presents with abdominal pain and vaginal bleeding.
On examination she is tender in the right iliac fossa and suprapubic region.
Speculum examination shows an open cervical os.
Ultrasound confirms an intrauterine pregnancy.
What is the most likely diagnosis?
This lady is likely to be having an inevitable miscarriage.
A woman who is 22 weeks pregnant presents with abdominal pain on the right side of her abdomen.
On examination she has abdominal tenderness on the right side and urine dipstick is normal.
White blood cells are raised at 18.5 * 109/l
The correct answer is: Appendicitis
A woman who is 33 weeks pregnant presents with vaginal bleeding, which she describes as being like a period.
She also has constant, lower abdominal pain. On assessment, her blood pressure is 90/60 mmHg and her pulse is 110/min
What is the likely diagnosis?
Placental abruption
*Placental praevia would not usually present with abdominal pain.
A 28-year-old pregnant woman wishes to receive the measles, mumps and rubella (MMR) vaccination.
She has never received any MMR vaccination and is worried that her baby may be infected as a result.
She is currently 12-weeks pregnant and there are no sick contacts around her.
Which of the following is the correct response in this scenario?
Refrain from giving her any MMR vaccination now and at any stage of her pregnancy
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant; to avoid becoming pregnant for 28 days after receipt of MMR vaccine (CDC 2013)
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
The bleeding associated with placenta praevia is painless and usually bright red.
Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red.
The pattern of previous bleeding also favours placenta praevia. Though vasa praevia can also present with painless vaginal bleeding other expected features would include fetal bradycardia and membrane rupture.
A 32-year-old woman presents to the obstetric clinic at 30 weeks gestation.
She has been diagnosed with gestational diabetes and was started on metformin two weeks previously.
Despite a well controlled diet and maximum dose metformin, her blood glucose levels remain too high.
What is the next most appropriate step to control blood glucose in this woman?
(2)
What are the potential complications? (3)
Add on insulin therapy
In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added
This woman has gestational diabetes and hyperglycaemia associated with this can result
- macrosomia
- premature birth
- stillbirth
A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy.
Her baby is known to currently lie in a breech presentation.
What is the most appropriate management?
Refer for external cephalic version
*if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
A 23-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents after fainting and has severe abdominal pain.
Blood pressure = 92/58 mmHg and heart rate = 132/min.
On examination she is cold and her fundal height is 37 cm; the cervical os is closed and there is no vaginal bleeding.
Which is the most appropriate diagnosis?
(4)
Placental abruption
- Presents with sudden abdominal pain in the third trimester.
- On examination the mother can be seen to be in extreme pain and cold to touch.
- Bleeding is present in 80% of cases - absence of visible bleeding does not rule out this diagnosis.
Risk factors include: maternal hypertension (common), cocaine, trauma, uterine overdistension, tobacco and previous placental abruption
A pregnant woman is brought to the Emergency department with nausea, severe itching and lethargy.
She is 37 weeks pregnant and this is her second pregnancy.
On examination she is clinically jaundiced but observations are normal.
Her blood tests are as follows:
Hb = 121 g/l
Platelets = 189 * 109/l
WBC = 8.7 * 109/l
Bilirubin = 90 µmol/l
ALP = 540 u/l
ALT = 120 u/l
γGT = 130 u/l
Albumin = 35 g/l
INR = 1.0
Acute viral hepatitis screen is negative. What is the most likely diagnosis?
Cholestasis of pregnancy
Clinically, cholestasis of pregnancy is characterised by severe pruritis,
whereas
acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea).
When does the foetal anomaly scan occur?
18 - 20+6 weeks
When is the first dose of anti-D prophylaxis to rhesus negative women?
28 weeks
When is the “early scan” to confirm dates?
10 - 13+6 weeks
A 32-year-old female presents at 28 weeks gestation in her third pregnancy.
An ultrasound scan at 12 weeks had confirmed a dichorionic diamniotic twin pregnancy.
She was admitted complaining of bleeding per vaginum.
The bleeding was bright red in nature and painless.
She has a history of two previous caesarian sections.
What is the most likely diagnosis? (1)
What is the key clinical feature? (1)
What are the risk factors? (4)
Placenta praevia is a complication of pregnancy where the placenta is attached to the lower part of the uterus.
The key clinical feature is painless bleeding after 24 weeks of gestation.
Risk factors include:
- previous placenta praevia
- previous caesarean section
- endometrium damage
- multiple pregnancies
Placenta praevia is often associated with a high presenting part or abnormal lie as a direct consequence of the low lying placenta.
A 29-year-old woman presents with dysuria and frequency four weeks after giving birth. The antenatal period and delivery were unremarkable. She is exclusively breastfeeding her child at the current time. Abdominal examination is unremarkable and she is apyrexial. A urine dipstick shows blood +, protein +, leucocytes +++ and nitrites positive.
What is the most appropriate management?
(3)
Trimethoprim in breastfeeding is considered safe to use
penicillins, cephalosporins, trimethoprim are SAFE to use in breastfeeding
A 26-year-old pregnant woman with type 1 diabetes asks you how often she should test blood glucose levels throughout her pregnancy?
(4)
- Daily fasting
- pre-meal
- 1-hour post-meal
- bedtime tests
A woman gives birth via normal vaginal delivery. The midwife notices the baby has an umbilical hernia, a large, protruding tongue, flattened face, and low muscle tone.
Which of the following results is most likely to have been those of this woman’s combined screening test at 12-weeks-pregnant with this child?
increased HCG
decreased PAPP-A
thickened nuchal translucency
According to guidelines on shoulder dystocia management:
(5)
According to guidelines on shoulder dystocia management:
Immediately after shoulder dystocia is recognised, additional help should be called.
Fundal pressure should not be used.
An episiotomy is not always necessary.
Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes.
McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases
A 36-year-old woman suffers from a major postpartum haemorrhage after delivering twins.
The obstetric consultant examines her and suspects uterine atony to be the cause.
The protocol for major PPH is initiated.
Bimanual uterine compression fails to control the haemorrhage.
- *Which drug is an appropriate next step in the management of uterine atony?
(6) **
The following management should be initiated in sequence:
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine
- intramuscular carboprost
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade
You are the obstetric SHO on call. A 32/40 primip has attended the maternity triage reporting a ‘gush of fluid down below’ earlier on in the day. She is otherwise well.
You suspect premature prelabour rupture of membranes (PPROM).
A sterile speculum examination is performed but do not note any fluid in the vaginal vault.
What other investigation could you perform to diagnose PPROM?
(2)
When investigating suspected PPROM, if there is no fluid in the posterior vaginal vault then an
ultrasound may be used to look for oligohydramnios
A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant.
The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide.
- *What advice should you give her about potential changes to her medication during pregnancy?
(2) **
Patient may continue on metformin but gliclazide must be stopped
The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped.
In the management of type 2 diabetes in pregnancy ‘women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin’.
While it is likely that the patient will be required to switch to insulin it is not an absolute requirement.
What is Lamotrigine?
(3)
Lamotrigine is a medicine used to treat epilepsy.
It can also help prevent low mood (depression) in adults with bipolar disorder.
Lamotrigine is a member of the sodium channel blocking class of antiepileptic drugs
A 23-year-old woman at 37-week’s gestation is brought to labour ward.
She reports having been in labour for 4 hours and her uterine contractions are currently 2 minutes apart.
Her 34-week scan identified grade III placenta praevia.
On examination, her cervix is dilated to 8cm and effaced by 90%.
Foetal cartography measurements are within normal limits. There are no signs of vaginal bleeding.
What is the next step in the management of this patient?
(2)
If a woman with known placenta praevia goes into labour (with or without bleeding) an emergency caesarean section should be performed
If placenta praevia is detected on routine imaging, particularly grade III and IV placenta praevia, discussions should be made about an elective caesarean section at 37-38 weeks
A 24-year-old woman attends her booking scan and finds out that she is pregnant with monochorionic twins.
Her general practitioner asks her specifically to report any sudden increases in the size of her abdomen and/or any breathlessness.
What complication of monochorionic multiple pregnancy is the GP describing the symptoms of?
Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic pregnancy.
A 34-year-old woman who is 32 weeks pregnant presents to her local antenatal unit for a midwife check-up. Her pregnancy has also been complicated by intrahepatic cholestasis of pregnancy, which has been treated with ursodeoxycholic acid. This is her first pregnancy, and she has had no previous miscarriages. She is epileptic, and is being treated with lamotrigine.
She tells her midwife that her step-sister has just had another term stillbirth, after already having 2 prior.
This has made her worried about her own pregnancy.
Which part of her medical history puts her most at risk for this outcome?
(2)
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth;
therefore induction of labour is generally offered at 37-38 weeks gestation
A 32-year-old multiparous female at 9 weeks gestation has presented to her general practitioner to book her pregnancy. Due to her previous history of gestational diabetes, she returns the following day for an oral glucose tolerance test.
She has bloods which reveal:
Fasting glucose = 7.2 mmol/L
2-hour glucose = 8.9 mmol/L
What is the appropriate management plan following these results?
Patient to be started on 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
On routine antenatal swabs, a mother is found to be colonised with Group B Streptococcus.
However, she did not receive adequate intrapartum antibiotic prophylaxis and she delivers a healthy baby girl by vaginal delivery.
Her baby does not require any resuscitation and remains well in the post natal ward.
The mother is eager for discharge home.
What is the most appropriate course of action with regards to her child?
(7)
Regular observations for 24 hours
Two or more minor risk factor or one red flag warrant empirical antibiotic therapy with Benzylpenicillin and Gentamicin and a full septic screen:
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
- Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
- Respiratory distress starting more than 4 hours after birth
- Seizures
- Need for mechanical ventilation in a term baby
- Signs of shock
At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP).
Which procedure carries the greatest risk of haemorrhage in the newborn?
(3)
Prolonged ventouse delivery
- The high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate.
- Cephalohaematoma or more severely, subgaleal haemorrhage, can be exacerbated in the context of neonatal thrombocytopenia
Immune thrombocytopenia (ITP) is an autoimmune condition that can occasionally complicate pregnancies, especially if there is placental passage of maternal antiplatelet antibodies.
A 32-year-old pregnant lady is found to be anaemic 20 weeks gestation.
A full blood count shows:
Serum Hb = 104 g/L (115-160)
MCV = 104 fL (70-100)
A blood film shows hypersegmented neutrophils.
She has a past medical history of coeliac disease.
What does the blood film count show? (2)
What is the most likely cause of the anaemia? (2)
The full blood count demonstrates a macrocytic anaemia.
The blood films suggests that the cause of the macrocytosis is a megaloblastic anaemia which can occur due to folate or B12 deficiency.
The malabsorption associated with coeliac disease makes it particularly likely in this case.
A 23-year-old woman who is 24 weeks pregnant presents to the emergency department with a 48-hour history of epigastric pain and severe headache, that has increased in severity.
On examination, she has a heart rate of 110 beats/min, a respiratory rate of 21 /min, a temperature of 36.8ºC, mild pitting oedema of the ankles and brisk tendon reflexes.
What is the likely diagnosis?
What is the most important sign to elicit?
pre-eclampsia
Brisk reflexes are commonly associated with pre-eclampsia and are more specific than the other answers, which are general clinical signs.
A 36-year-old woman comes into your GP clinic, 3 months after giving birth. She reports ongoing palpitations, weight loss of 5kg since the delivery and some tremors in her hands. She reports her baby is doing well and she is bottle feeding.
You perform thyroid function tests and the results are shown below.
TSH = 3.5 mU/L
T4 = 20 pmol/L
What is the likely diagnosis? (2)
What treatment is most appropriate? (1)
This patient has presented with symptoms of postpartum thyroiditis. This is an autoimmune condition which presents as the body transitions back from the immunosuppressed state of pregnancy to normal immunity.
Propranolol is the most appropriate treatment
A 32-year-old pregnant woman presents to the maternity department at 41 weeks gestation.
A decision is made for her to undergo an artificial rupture of the membranes.
Shortly after this procedure, during an examination, the umbilical cord is noted to be palpable vaginally.
Given this development, which of the following is the correct position for the woman to adopt?
The correct position for women who have a cord prolapse is on all fours, on knees and elbows
A 32-year-old pregnant woman presents to the GP with jaundice and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation. On examination, the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. She denies any tenderness in her abdomen during the examination.
Blood tests show the following:
ALT = 206 U/L
AST = 159 U/L
ALP = 796 umol/l
GGT = 397 U/L
Bilirubin (direct) = 56 umol/L
Bile salts = 34 umol/L (0 - 14)
What is the most likely diagnosis?
Obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy, is a condition caused by the impaired flow of bile.
This, in turn, causes a build-up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta.
It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors.
A 23-year-old woman is being reviewed on the labour ward.
She is 39 weeks gestation. She felt her waters breaking 2 hours ago.
She is G1P0, has no had no complications throughout her pregnancy and has no significant past medical history.
On examination, her Bishop’s score is calculated as 10. A vaginal exam confirms that her amniotic sac has ruptured. There is no evidence of contractions yet. Foetal heart rate is reassuring at 140/min.
What is the most appropriate next step in her immediate management?
Reassure and monitor
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
From where is HCG secreted? (2)
What is its function? (2)
At what rate does it increase?
When does its concentration peak?
- first produced by the embryo then the syncytiotrophoblast into the maternal bloodstream
where it acts to maintain the production of
- progesterone by the corpus luteum in early pregnancy
hCG levels double approximately every 48 hours in the first few weeks of pregnancy. Levels peak at around 8-10 weeks gestation
A 29-year-old woman goes into labour.
The midwife examines her and states that the
“head is now at the level of ischial spine”
What terminology is used to describe the head in relation to the ischial spine?
Station is the term used to describe the head in relation to the ischial spine.
The station is ‘0’ when the head is directly at the level of the ischial spines, if the station was describes as -2, it would be 2cm above the ischial spines, and it was +2 it would be 2cm below the ischial spine.
A 23-year-old pregnant woman presents at 16 weeks gestation.
She is complaining of painless vaginal bleeding, excessive morning sickness and shortness of breath.
Routine examination of the patient’s abdomen reveals a uterus which extends up to the umbilicus.
Ultrasound revealed a solid collection of echoes with numerous small anechoic spaces.
What is the most likely diagnosis?
(2)
Hydatidiform mole
On ultrasound, the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as ‘snow-storm’ appearance).
A 37-year-old female, who is breastfeeding, presented with an episode of mastitis. On examination there is erythema around the nipple.
Which antibiotic should be prescribed?
Which analgesic is absolutely contraindicated in this patient?
- Fluclox oral
2. Aspirin in breastfeeding must be avoided
Blood cord tests at delivery
(3)
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus.
Which of the following test results would be expected in this patient?
High beta hCG, low TSH, high thyroxine
The clinical presentation in this question is consistent with that of a molar pregnancy.
Molar pregnancies are characterised by significantly high levels of beta hCG for gestational age, and are therefore used as a tumour marker of gestational trophoblastic disease.
The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.
