GOSH 4 Flashcards
What is the most common single chromosomal abnormality causing miscarriage?
45X
When would you refer a woman to EPAU:
a) <6 weeks gestation
b) >6 weeks gestation
a) Bleeding AND pain
b) Bleeding
In a uterine pregnancy, how will the hCG change?
How does this differ for an ectopic or miscarriage?
Uterine –> hCG will DOUBLE every 48h
Ectopic/miscarriage –> will not be the case:
- fall in hCG >50% –> miscarriage
- fall 50% –> ectopic
What vitamin may need to replaced in hyperemesis gravidarum?
Thiamine (B1)
At what mean gestational sac diameter is a foetal pole expected?
≥25mm
At what foetal pole/crown rump length is a foetal heartbeat expected?
≥7mm
What are 3 key features in early pregnancy that appear sequentially on a transvaginal US (i.e. as each appears, the previous becomes less relevant in assessing viability of pregnancy)?
1) Mean gestational sac diameter
2) Foetal pole and crown-rump length
3) Foetal heartbeat
How can a molar pregnancy lead to thyrotoxicosis?
As hCG can mimic TSH
What US characteristic appearance can be seen in a molar pregnancy?
‘Snowstorm’ appearance
When should Rhesus negative women having an abortion have anti-D prophylaxis?
1) ALL surgical abortions
2) Medical abortion if >10w gestation
What PUQE score indicates SEVERE hyperemesis gravidarum?
> 12
How is an abortion confirmed as complete?
Urine pregnancy test 3 weeks later
What is the latest gestational age that an abortion can be carried out?
24 weeks
When there is a crown-rump length of 7mm or more, without a fetal heartbeat, when is the pregnancy diagnosed as non-viable?
The scan is repeated after one week before confirming a non-viable pregnancy.
Note - can have a pregnancy of unknown viability where size may be 7mm but too small to see foetal heartbeat yet.
But if >7mm with no heartbeat, this is diagnostic of loss of pregnancy.
Why should products of conception be removed in a miscarriage?
Retained products of conception can result in cervical shock due to vagal stimulation (bradycardia & hypotension).
How many weeks gestation must women be to undergo manual vacuum aspiration (abortion)?
Must be below 10 weeks gestation
When is the combined test offered?
11 to 13+6
What is 1st line DMARD for RA in pregnancy?
Hydroxychloroquine
When can you fly up until in a single pregnancy?
37 weeks
When can you fly up until in a twin pregnancy?
32 weeks
Mx of gestational diabetes if fasting glucose ≥6mmol/l + macrosomia?
Insulin +/- metformin
When should anti-D be given in a sensitisation event?
Within 72 hours
When should those with previous gestational diabetes be screened?
1) Women with previous gestational diabetes should have OGTT soon after booking clinic
2) 2nd test at 24-28 weeks if the first test is normal.
What can be suggested as an alternative for women who decline insulin or cannot tolerate metformin in pregnancy?
Glibenclamide (a sulfonylurea)
Anti-D injections are given routinely on what two occasions?
1) 28 weeks gestation
2) Birth (if baby found to be rhesus +ve)
What are 3 classes of HTN drugs that can cause congenital abnormalities?
1) ARBs
2) ACEi
3) Thiazide like diuretics e.g. indapamide
Is GDM managed with short or long acting insulin?
Short acting
When is the Kleinhauer test performed?
In women >20 weeks gestation who are rhesus -ve.
Performed after any sensitisation event.
When should women with grade III/IV be offered a c-section?
37-38 weeks
COCP and BMI?
BMI 30-34 –> UKMEC 2
BMI ≥35 –> UKMEC 3
Features of a ‘missed’ miscarriage?
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is CLOSED
N.B when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
When can you attempt ECV for transverse lie in labour?
If the amniotic sac has not rupture AND the patient is not in active labour (i.e. cervical dilation is <3cm).
What is 1st line for treating magnesium sulphated induced respiratory depression?
Calcium gluconate
What procedure carries a high risk of haemorrhage of the newborn in cases of ITP?
Prolonged ventouse delivery
What is the mechanism of action of metformin in PCOS?
Increases peripheral insulin sensitivity
Next step in a suspected PE in the presence of a CONFIRMED DVT?
Start LMWH therapeutic dose 1st.
Which steroid is used in prematurity?
Dexamethasone
what should be corrected before starting bisphosphonates?
Vit D & calcium deficiencies
What is the gold standard investigation for mycoplasma genitalium?
NAATs
Stepwise mx of PPH caused by uterine atony?
1) Catheterise, left lateral position & rub fundus of uterus (attempting to stimulate contraction)
2) Pharmacological: IV oxytocin, carboprost (careful in asthma), ergometrine (careful in HTN)
3) Surgical: intrauterine balloon tamponade
Mx of Factor V Leiden in pregnancy?
LMWH antenatally + 6 weeks postpartum
What is the the most effective method of contraception available?
Implant
When should women wait until post-partum for a smear?
12 weeks postpartum
1st line mx of 1ary dysmenorrhoea?
NSAIDs such as mefenamic acid
What normally happens to blood pressure during pregnancy?
Fall in first half of pregnancy, before rising to pre-pregnancy levels before term.
During pregnancy, when is the 2nd screen for anaemia and atypical auto red cell antibodies?
28 weeks
What 3 medications are associated with an increased risk of miscarriage?
1) Ibuprofen
2) Methotrexate
3) Retinoids
Role of the Kleihauer test?
Detects fetal cells in the maternal circulation which can estimates the volume of foetomaternal haemorrhage to allow calculation of additional anti-D immunoglobulin.
It is required for any sensitising event after 20 weeks gestation.
Mx of non-reassuring CTG findings (which are persistent in nature)?
Prepare for a category 2 c-section.
Delivery of baby should occur within 75 minutes
1st line mx of postnatal depression?
CBT (can offer SSRI if symptoms are severe, or have history of severe depression).
What is an intrauterine balloon tamponade also known as?
Intrauterine Bakri catheter
What type of organism is GBS (S. aglactiae)?
Gram-positive coccus (round-shaped bacterium)
What is adenomyosis?
The presence of endometrial tissue within the myometrium.
Who is adenomyosis more common in?
Multiparous women towards the end of their reproductive years.
Features of adenomyosis?
- dysmenorrhoea
- menorrhagia
- enlarged, boggy uterus
1st line investigation in adenomyosis?
TV US
Stepwise mx of PMS?
1) Mild –> lifestyle
2) Mod –> COCP
3) Severe –> SSRI
How can ACEi and ARBs during pregnancy affect amniotic fluid?
Can cause renal dysgenesis –> oligohydramnios due to reduced production of urine.
2 key side effects of ACEi during pregnancy?
1) Renal dysgenesis
2) Hypocalvaria (incomplete formation of skull bones)
What is a key side effect of ergometrine?
Coronary artery spasm
3 adverse effects of beta blockers during pregnancy?
1) Neonatal hypoglycaemia
2) Neonatal bradycardia
3) Foetal growth restriction
What can co-amoxiclav during pregnancy lead to?
Increased risk of NEC
How do NSAIDs impact other antihypertensives?
Reduce the therapeutic effects of other antihypertensives.
Abx management of chorioamnionitis?
Cefuroxime + metronidazole
Delivery
Abx mx of endometritis?
Co-amoxiclav
When the chickenpox rash starts in pregnancy, what is given?
What is the criteria for this?
Oral aciclovir:
1) presented within 24h
2) >20w gestation
What 3 Abx are typically used in UTIs in pregnancy?
1) nitrofurantoin
2) amoxicillin
3) cefalexin
VZV virus infection during pergnancy can cause a more serious presenation that normal in the mother.
What can it lead to?
- pnuemonitis
- hepatitis
- encephalitis
Impact of listeriosis on the pregnancy?
High risk of miscarriage or foetal death
Triad of features in congenital toxoplasmosis?
1) Intracranial calcification
2) Hydrocephalus
3) Chorioretinitis
When is the risk of congenital toxoplasmosis highest?
Later in pregnancy
US findings in:
a) monochorionic diamniotic twins
b) dichorionic diamniotic twins
a) T sign
b) lambda sign/twin peak sign
Delivery options for:
a) monoamniotic twins
b) diamniotic twins
a) planned c-section 32-33+6 weeks
b) planned c-section 37-37+6 weeks
Note - diamniotic twins can be delivered vaginally if first baby is cephalic.
What do the foetuses share in twin-twin transfusion syndrome?
A placenta
How can the donor in twin-twin transfusion be affected?
1) anaemia
2) growth restriction
3) oligohydramnios
Women with multiple pregnancies require additional monitoring for anaemia.
When is an FBC done in these women?
Three times:
1) Booking clinic
2) 20 weeks (this is the additional one)
3) 28 weeks
What 2 measurements are used to assess foetal size?
1) Foetal abdominal circumference
2) Estimated foetal weight
When is planned birth offered for triplets?
Before 35+6
When is placenta praevia most common?
In the 3rd trimester
Describe the 4 grades of placenta praevia
Grade I - low lying placenta, >2cm from cervical opening
Grade II - marginal placenta praevia, close to cervical opening but not covering it
Grade III - partial placenta praevia, partially covering cervical opening
Grade IV - complete placenta praevia, completely covering cervical opening
What scan can tell you placental location?
20w anomaly scan
Why should patients with placenta praevia not be internally examined until the placental site has been determined?
As this may precipitate heavy bleeding
Delivery in placenta praevia?
Planned c-section from 37w (CANNOT be vaginal)
What does the Kleihauer test measure?
FHb in materanl blood –> if >5ml then give anti-D (a sensitisation event has happened)
What volume of FHb in materal blood indicates that a sensitisation event has occurreD?
> 5ml
How is anti-D given?
IM injection
Role of anti-D?
Acts to remove foetal cells within the maternal circulation.
This prevents sensitisation and therefore foetal haemolytic anaemia in future pregnancies.
Timeline of 1ary vs 2ary PPH?
1ary: up to 24h after birth
2ary: 24h to 12w after birth
What are some risk factors for uterine atony causing PPH?
- fibroids
- exhausted uterus e.g. multigravida, prolonged labour, post-dates, prolonged oxytocin use
- infection e.g. chorioamnionitis
- overdistended uterus e.g. LGA, polyhydramnios, multiple pregnancy
What is a risk factor for retained placenta?
Placenta accreta –> risk increases with increased c-sections
What may growth charts look like in SGA caused by:
1) IUGR e.g. smoking, pre-eclampsia, alcohol use
2) Chromosomal abnormalities, genetic syndromes, infection, anatomical abnormalities
3) Constitutionally small
1) Starts NORMAL but growth starts tailing around 20w (i.e. doesn’t stay on line)
2) Starts SMALL and gets smaller (doesn’t stay on line)
3) Growing along same centile at normal rate (just on a smaller centile)
Give 4 key causes of IUGR
1) smoking
2) HTN
3) IUGR previously
4) twins
SHIT
Dose of corticosteroids given if delivery <34w?
2x doses of dexamethasone 12mg IM, given 12 to 24h apart.
Maximal effect within 7 days of 2nd dose.
Is abdominal or head circumference more affected in IUGR?
Abdominal circumference
I.e. there is asymmetrical growth
What is the biggest risk-determining factor in twin-pregnancy?
Chorionicity (number of placentas)
Dichorionic is lower risk than monochorionic.
Note –> dizygous twins are ALWAYS dichorionic
Folic acid in multiple pregnancy?
High dose 5mg
Frequency of serial growth scans in monochorionic vs dichorionic twins?
Monochorionic - every 2 weeks from 16w (risk of TTTS)
Dichorionic - every 4 weeks from 20w
When & why is an OGTT indicated in multiple pregnancy?
OGTT at 28w
Muliple pregnancy is a risk factor for GDM.
Effect on recipient twin in TTTS?
- polycythaemia
- HTN
- cardiac hypertrophy
- oedema
- polyhydramnios
What EFW difference indicates TTTS?
> 18% difference in their TTTS
Delivery date:
a) dichorionic diamniotic
b) monochorionic diamniotic
c) monochorionic monoamniotic
a) 37-37+6
b) 36-36+6
c) 32-33+6
When does a deceleration become foetal bradycardia?
Prolonged deceleration >3 minutes = foetal bradycardia.
3 mins - call for help
6 mins - move to theatre
9 mins - prepare for assisted delivery
12 mins - aim to deliver
How does 1 late deceleration affect CTG interpretation?
1 late decel = abnormal (even if others are variable)
What makes a ‘pathological’ CTG?
1 abnormal feature
or
2 non-reassuring features
Mx of a pathological CTG?
1) Commence conservative measures e.g. LL position
2) Escalate
3) Assess for underlying cause
4) Crash call
5) Action –> check if fully dilated:
- if fully dilated –> attempt forceps delivery
- not fully dilated –> counsel for cat 1 c-section
Mx of deceleration >3 minutes?
3 mins - crash call for help
6 mins - move to theatre
9 mins - prepare for assisted delivery
12 mins - aim to deliver baby
What are variable decelerations on a CTG caused by?
usually caused by umbilical cord compression
What do late decelerations on a CTG indicate?
Insufficient blood flow to uterus and placenta, leading to foetal hypoxia and acidosis.
E.g. uterune hyperstimulation, pre-eclampsia
Mechanism of umbilical cord compression causing variable decelerations on a CTG?
1) The umbilical VEIN is often occluded first causing an ACCELERATION of the fetal heart rate in response.
2) Then the umbilical ARTERY is occluded causing a subsequent rapid DECELERATION.
3) When pressure on the cord is reduced another acceleration occurs and then the baseline rate returns.
What is the most common cause of puerperal pyrexia?
Endometritis
Impact of smoking on cervical cancer risk?
Women who smoke are at a two-fold increased risk of developing cervical cancer than women who do not
Laparotomy vs laparoscopic exploring in ectopic pregnancy?
Surgical therapy may be provided either via open laparotomy or via the laparoscopic route.
Laparoscopy has become the recommended approach in most cases.
Laparotomy is usually reserved for patients who are hemodynamically unstable.
Mx of a complex ovarian cyst (i.e. multi-loculated)
Should be biopsied with high suspicion of ovarian malignancy
What are useful adjuncts to topical oestrogen as first-line treatment of atrophic vaginitis?
Lubricants and moisturisers
What should be assessed prior to IoL?
Bishop score
What is a preferable alternative to anticholinergics for urge incontinence in elderly?
Mirabegron
Assuming the Pearl Index of the combined oral contraceptive pill is 0.2, what does this mean?
For every 1000 women using this form of contracption for 1 year, 2 would get pregnant.
If a semen sample is abnormal (in fertility testing), what is the next step?
Arrange a repeat test, ideally 3 months later
What is the most risky form of breech presentation?
Footling presentations
What is the most common benign ovarian tumour in women <25 y/o?
Dermoid cyst (teratoma)
What is the most common cause of ovarian enlargement in women of a reproductive age?
Follicular cyst
1st line for ALL patients with 2ary dysmenorrhoea?
Referral to gynae for further investigations
What is required for a diagnosis of PCOS?
2/3 features:
1) oligomenorrhoea
2) clinical and/or biochemical signs of hyperandrogenism
3) polycystic ovaries on US
Is anti-D effective if a woman has already been sensitised?
No
When is vaginal bleeding in pregnancy a potentially sensitising event?
> 12 weeks
<12 weeks, only if painful, heavy or persistent
Histopathological analysis of an ovarian cyst reveals Rokitansky’s protuberance.
What is the most likely diagnosis?
Teratoma (dermoid cyst)
3 causes of an increased nuchal transluscency?
1) Down’s
2) Congenital heart defects
3) Abdominal wall defects
3 causes of a hyperechogenic bowel during US in pregnancy?
1) CF
2) Down’s
3) CMV infection
Mx of stage IA cervical cancer in women who wish to maintain their fertility?
Cone biopsy
What insulin is used in GDM?
Short acting only
Target BP in pregnancy on labetalol?
<135/85
What is the medication of choice in suppressing lactation when breastfeeding cessation is indicated?
Cabergoline (dopamine agonist)
When must HIV load be tested to determine mode of delivery in pregnancy?
36 weeks
Does NOT need to be retested after this
Mx of babies born at risk of developing hepatitis B?
Complete course of vaccination + hepatitis B immunoglobulin
Complete course –> vaccine at birth, further dose 1-2 months later, further dose at 6 months.
What is the diagnostic triad for hyperemesis gravidarum?
1) 5% pre-pregnancy weight loss
2) dehydration
3) electrolyte imbalance
Define menorrhagia
The definition of menorrhagia has changed to reflect the woman’s subjective experience rather than trying to quantify blood loss
Urge to push in occiput-anterior vs occiput-posterior?
Generally, women will experience an earlier urge to push in OP than OA.
Labour in OP vs OA presentation?
Delivery in OP position is likely to be longer and more painful.
What 3 contraceptives are unaffected by enzyme inducing drugs?
1) Copper IUD
2) Mirena IUS
3) Depot injection
Mx of newborns with only one minor risk factor for early onset sepsis?
Should remain in hospital for at least 24 hours with regular observations.
What are the only 2 diabetic medications used in pregnancy?
Insulin & metformin
When can a copper IUD be inserted after a surgial ToP?
Immediately after
What is a possible effect on baby of using ondansetron during pregnancy?
Small increased risk of cleft lip/palate in the newborn if used in 1st trimester
What is the most common risk following ToP?
Infection
The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS:
F - Fully dilated
O - OA position preferably
R - Ruptured membranes
C - Cephalic presentation
E - Engaged presenting part i.e. head at or below ischial spines, the head must not be palpable abdominally
P - Pain relief
S - Sphincter (bladder) empty (will usually require catheterisation)
What 3 criteria must be met for lactational amenorrhoea to be a reliable form of contraception?
1) Baby <6m old
and
2) Amenorrhoeic
and
3) Breastfeeding exclusively
How old must baby be for lactational amenorrhoea to be a reliable form of contraception?
<6m
Is rifampicin an enzyme inducer or inhibitor?
Inducer
Quadruple test result in Edward’s syndrome?
Decreased AFP
Decreased hCG
Decreased oestriol
Normal inhibin A
How often should urinalysis be performed in women with gestational hypertension (without proteinuria)?
Weekly
What is placental growth factor?
A protein released by the placenta that functions to stimulate the development of new blood vessels.
This is LOW in pre-eclampsia.
What are 2 key complications of severe pre-eclampsia (i.e. >160mmHg systolic or >110mmHg diastolic)?
1) Placental abruption
2) Haemorrhagic stroke
Why can women with pre-eclampsia get SOB & cough?
Due to pulmonary oedema
1st line medical management of pre-eclampsia AFTER delivery if an antihypertensive is needed?
Enalapril
What test is recommended in women suspected of having pre-eclampsia?
Placental growth factor (PlGF) testing
When does methyldopa need to be stopped in pregnancy if used as 3rd line for pre-eclampsia?
2 days before birth
Note - increased risk of PPD and suicide
How long after delivery can pre eclampsia develop?
Can develop up to 6 weeks after delivery
LMWH is used for mx of established VTE in pregnancy.
How long after birth should it be continued for?
6 weeks
PE is a significant cause of death in obstetrics.
When is the risk highest?
Postpartum period
