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Y4 Exam Practice > High Yield Obs and Gynae > Flashcards

High Yield Obs and Gynae Flashcards

1
Q

Risk factors for ectopic pregnancy?

A

damage to tubes (salpingitis, surgery)
previous ectopic
IVF (3% of pregnancies are ectopic)

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2
Q

What is placental abruption? Key clinical features?

A

Placental abruption is separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Clinical features:
shock out of keeping with visible blood loss
constant pain
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems

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3
Q

Alpha-fetoprotein (AFP) is a protein produced by the developing fetus.

Give some causes of a raised AFP

A

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

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4
Q

Give some causes of a low AFP

A

Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

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5
Q

How does placenta praevia present?

A

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

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6
Q

Define antepartum haemorrhage

A

bleeding after 24 weeks

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7
Q

What are the main risk factors for breech presentation?

A

uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality
prematurity

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8
Q

How should breech presentations be managed?

A

if < 36 weeks: many fetuses will turn spontaneously
> 36 weeks (or 37 weeks if multiparous) :external cephalic version (ECV)
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery

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9
Q

What are the contraindications to ECV (pressure applied to abdomen to try and turn the baby)?

A

where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy

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10
Q

What are Category 1 C sections?

A

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

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11
Q

What are Category 2 C sections?

A

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

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12
Q

What are Category 3 and 4 C sections?

A

3 = delivery is required, but mother and baby are stable
4 = elective

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13
Q

What is normal fetal heart rate?

A

100-160 / min

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14
Q

What is fetal baseline bradycardia?

A

Heart rate < 100 /min
Causes: Increased fetal vagal tone, maternal beta-blocker use

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15
Q

What is fetal baseline tachycardia?

A

Heart rate > 160 /min
Causes: Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

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16
Q

What are early decelerations?

A

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually indicates head compression

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17
Q

What are late decelerations?

A

Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction

Indicates fetal distress e.g. asphyxia or placental insufficiency

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18
Q

What are variable decelerations?

A

Independent of contractions

May indicate cord compression

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19
Q

How does Down’s syndrome present on the combined test?

A

↑ HCG, ↓ PAPP-A, thickened nuchal translucency

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20
Q

What is pre-eclampsia?

A

condition seen after 20 weeks gestation

triad:
pregnancy-induced hypertension (140/90)
proteinuria
oedema

eclampsia is pre-eclampsia + seizures

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21
Q

How should eclampsia be managed?

A

in eclampsia an IV bolus of magnesium sulphate (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 tx

tx should continue for 24 hours after last seizure or delivery

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22
Q

What are the risks of sodium valproate and phenytoin in pregnancy?

A

sodium valproate: associated with neural tube defects

phenytoin: associated with cleft palate

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23
Q

How can neural tube defects be prevented during pregnancy?

A

all women should take 400mcg of folic acid until the 12th week of pregnancy

women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

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24
Q

Which women should take more folic acid?

A

M = Metabolic conditions e.g. T1DM, coeliacs
O = Obesity (BMI>30)
R = Relative (PMHx)
E = epilepsy (on anti-epileptics)

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25
Q

Causes of placental abruption?

A

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

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26
Q

Give some risk factors for gestational diabetes

A

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)

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27
Q

What is used to screen for gestational diabetes?

A

OGTT

women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal

women with risk factors: 24-28 weeks

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28
Q

What is diagnostic for gestational diabetes?

A

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

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29
Q

How should pre existing diabetes be managed in pregnancy?

A

weight loss for women with BMI of > 27 kg/m2

stop oral hypoglycaemic agents (bar metformin) and commence insulin, ensure tight glycaemic control

folic acid 5 mg/day from pre-conception to 12 weeks gestation

detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts

treat retinopathy as can worsen during pregnancy

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30
Q

Benzylpenicillin is the antibiotic of choice for Group B Strep intrapartum antibiotic prophylaxis (IAP). Who should be offered it?

A

women with a previous baby with GBS disease
women in preterm labour
women with a pyrexia during labour (>38ºC)

women who’ve had GBS detected in a previous pregnancy should be offered (IAP) OR testing in late pregnancy and then antibiotics if still positive

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31
Q

What is HELLP syndrome? How should it be managed?

A

Hemolysis, Elevated Liver enzymes, and a Low Platelet count

Features:
nausea & vomiting
right upper quadrant pain
lethargy

Mx = delivery of the baby

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32
Q

What modes of delivery are available to mothers with HIV?

A

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

33
Q

What neonatal antiretroviral therapy is offered to babies of mothers with HIV?

A

zidovudine orally if maternal viral load is <50 copies/ml

Otherwise triple ART should be used

Therapy should be continued for 4-6 weeks

34
Q

Define hypertension in pregnancy

A

systolic > 140 mmHg or diastolic > 90 mmHg

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

35
Q

Indications for induction of labour?

A

prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery

prelabour premature rupture of the membranes

maternal medical problems

intrauterine fetal death

36
Q

How can the Bishop Score be interpreted?

A

a score of < 5 = labour is unlikely to start without induction

a score of ≥ 8 = cervix is ripe, or ‘favourable’ - high chance of spontaneous labour, or response to interventions made to induce labour

37
Q

What is the NICE guidance on methods used to induce labour?

A

if the Bishop score is ≤ 6:
vaginal prostaglandins or oral misoprostol
(balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean)

if the Bishop score is > 6:
amniotomy and an intravenous oxytocin infusion

38
Q

How should intrahepatic cholestasis of pregnancy be managed?

A

induction of labour at 37-38 weeks and ursodeoxycholic acid - both widely used but evidence base not clear

vitamin K supplementation

39
Q

What monitoring should be provided in labour?

A

FHR monitored every 15min (or continuously via CTG)

Contractions assessed every 30min

Maternal pulse rate assessed every 60min

Every 4 hours:
Maternal BP and temp
VE should be offered
Maternal urine should be checked for ketones and protein

40
Q

How should pre-eclampsia be managed?

A

arrange emergency secondary care assessment

oral labetalol is first-line, nifedipine (e.g. if asthmatic) and hydralazine may also be used

women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

41
Q

How should antepartum haemorrhage be investigated?

A

FBC
Clotting profile, Group and Save & Cross-match
Kleihauer test if the woman is Rhesus negative (to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required)

U&Es and LFTs
to exclude pre-eclampsia and HELLP syndrome, and any other organ dysfunction

Assess Fetal Wellbeing using CTG in women above 26 weeks gestation

42
Q

What are the fetal complications of GD?

A

Macrosomia – this can cause complications during labour, such as shoulder dystocia, obstructed/delayed labour, and/or higher rates of instrumental deliveries

Organomegaly (particularly cardiomegaly)

Erythropoiesis (resulting in polycythaemia)

Polyhydramnios

Increased rates of pre-term delivery

43
Q

Complications of obstetric cholestasis?

A

maternal - increased risk of gallstones and liver disease

fetal - increased risk of passing meconium during labour, prematurity and stillbirth

44
Q

Give some maternal complications of APH

A

anaemia
coagulopathy
maternal shock
infection
renal tubular necrosis
prolonged hospital stay
psychological sequelae

45
Q

Give some fetal complications of APH

A

hypoxia
SGA and growth restriction
prematurity
fetal death

46
Q

How can perineal tears be classified?

A

first degree:
superficial damage with no muscle involvement
do not require any repair

second degree:
injury to the perineal muscle, not involving the anal sphincter
require suturing on the ward

third degree:
injury to perineum involving the anal sphincter
require repair in theatre

fourth degree:
injury to perineum involving the anal sphincter and rectal mucosa
require repair in theatre

47
Q

Risk factors for perineal tears?

A

primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery

48
Q

What is placenta accreta? Risk factors?

A

attachment of the placenta to the myometrium, due to a defective decidua basalis

= inc risk of PPH

Risk factors:
previous caesarean section
placenta praevia

49
Q

What is placenta praevia? How can it be graded?

A

placenta lying wholly or partly in the lower uterine segment

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os

50
Q

What are the risk factors for placenta praevia?

A

Maternal age >40 years
Previous C section
Multiparity
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Curettage to the endometrium after miscarriage or termination

51
Q

Mx of placenta praevia with bleeding?

A

admit
ABC approach to stabilise the woman
if not able to stabilise → emergency caesarean section
if in labour or term reached → emergency caesarean section

in all cases of antepartum haemorrhage, give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative

52
Q

How should placental abruption be managed?

A

no fetal distress:
< 36 weeks = observe closely, steroids
> 36 weeks = deliver vaginally

fetal distress: immediate caesarean

fetus dead : induce vaginal delivery

53
Q

Complications of placental abruption?

A

Maternal:
shock
DIC
renal failure
PPH

Fetal:
IUGR
hypoxia
death

54
Q

Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery or 1000ml blood loss after C section.

What are the causes of primary PPH?

A

Tone (uterine atony - failure of adequate contractions): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)

55
Q

Give some risk factors for primary PPH

A

previous PPH
pre-eclampsia
polyhydramnios
prolonged labour
placenta praevia, placenta accreta
macrosomia
increased maternal age
emergency Caesarean section

56
Q

What is classed as minor v major PPH?

A

minor is under 1000ml blood loss
major is over 1000ml blood loss

57
Q

How should PPH be managed?

A

escalate to senior staff members immediately

STABILISE:
two peripheral cannulae (14G), bloods including group and save
lie the woman flat
commence warmed crystalloid infusion

MECHANICAL:
palpate the uterine fundus and rub it to stimulate contractions
catheterisation to prevent bladder distension and monitor urine output

MEDICAL:
IV oxytocin (slow IV injection followed by an IV infusion) , ergometrine , carboprost IM (unless there is a history of asthma) , misoprostol sublingual

SURGICAL:
intrauterine balloon tamponade where uterine atony main cause of haemorrhage

other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
hysterectomy is sometimes performed as a life-saving procedure

58
Q

Postpartum mental health problems range from the ‘baby-blues’ to puerperal psychosis.

What score can be used to screen for this?

A

The Edinburgh Postnatal Depression Scale
maximum score of 30
score > 13 indicates a ‘depressive illness of varying severity’

59
Q

What are the potential complications of pre-eclampsia?

A

progression to eclampsia

altered mental status, blindness, stroke, clonus, severe headaches

liver involvement (elevated transaminases)

haemorrhage: placental abruption, intra-abdominal, intra-cerebral

cardiac failure

fetal complications (intrauterine growth retardation, prematurity)

60
Q

What preventative tx can be given to women at moderate or high risk of developing pre-eclampsia?

A

aspirin 75-150mg daily from 12 weeks gestation until the birth

61
Q

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

How does it present?

A

headache
abdominal pain, N+V
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia

ALT raised on investigation

62
Q

Risks of smoking in pregnancy?

A

Increased risk of miscarriage, pre-term labour and stillbirth
IUGR
Increased risk of sudden unexpected death in infancy

63
Q

What are the risks of premature delivery?

A

intraventricular haemorrhage (brain bleed)
retinopathy of prematurity
hearing problems
respiratory distress syndrome
necrotizing enterocolitis (inflamed SI)
chronic lung disease, hypothermia, feeding problems, infection, jaundice

64
Q

How should PPROM be managed?

A

admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids

65
Q

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.

What are the main causes?

A

endometritis: most common cause
UTI
wound infections (perineal tears + caesarean section)
mastitis
venous thromboembolism

66
Q

How should endometritis be managed?

A

patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

67
Q

How should shoulder dystocia be managed?

A

McRoberts’ manoeuvre should be performed:
this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

68
Q

A nuchal US scan is performed at 11-13 weeks.

Causes of an increased nuchal translucency include:

A

Down’s syndrome
congenital heart defects
abdominal wall defects

69
Q

Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia.

What are the main risk factors?

A

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

50% of cord prolapse occurs after artificial rupture of membranes

70
Q

How should cord prolapse be managed?

A

the presenting part of the fetus may be pushed back into the uterus to avoid compression

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

the patient is asked to go on ‘all fours’ until emergency C section

tocolytics may be used to reduce uterine contractions (e.g. terbutaline)

71
Q

What is the most common explanation for short episodes (< 40 minutes) of decreased variability on CTG?

A

foetus is asleep

72
Q

If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler, what should be offered?

A

immediate USS

73
Q

Management of patients on methotrexate trying to conceive?

A

must be stopped at least 6 months before conception in both men and women

74
Q

Down’s syndrome: quadruple test result?

A

↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A

75
Q

When is the booking visit?

A

8 - 12 weeks (ideally < 10 weeks)

76
Q

Test results for molar pregnancy?

A

High beta hCG, low TSH, high thyroxine

(imagine beta HCG acts like TSH)

77
Q

Risk factors for pre-eclampsia?

A

40 years or older
Nulliparity
Pregnancy interval of more than 10 years
FMH/PMH of pre-eclampsia
BMI > 30
Pre-existing vascular disease/ renal disease
Multiple pregnancy

78
Q

Indications for continuous CTG monitoring in labour?

A

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour

Y4 Exam Practice (16 decks)

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