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Specialties Active > ICSM Year 5 Obstetrics > Flashcards

ICSM Year 5 Obstetrics Flashcards

1
Q

What is an amniotic fluid embolism?

A

Amniotic fluid and foetal cells enter maternal circulation leading to cardiorespiratory collapse

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2
Q

How does the amniotic fluid embolism cause a maternal emergency?

A

Embolism –> anaphylactic reaction/ complement cascade

Complement –> pulmonary artery spasm

Pulmonary artery pressure and RVP increases

Myocardial and pulmonary capillaries are hypoxically damaged

LVF failure

Death

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3
Q

What are the signs and symptoms of Amniotic fluid embolism?

A

Sudden onset of SOB and cyanosis

Seizures

DIC

Hypotension

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4
Q

What would be seen on examination in amniotic fluid embolism?

A

Tachypnoea

Tachycardia

Pulmonary oedema

Uterine atony

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5
Q

What are some appropriate investigations to do in amniotic fluid embolism, and what would they show?

A

ABG (hypoxaemia, raised pCO2)

FBC (low Hb)

Clotting (DIC: low platelets, raised PT/APTT, decreased fibrinogen)

CROSS MATCH

CXR (cardiomegaly?? Pulmonary oedema)

ECG (right heart strain, rhythm abnormalities)

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6
Q

How should amniotic fluid embolism be managed?

A

ABC and refer to ITU

Circulation: 2 large bore cannulae, fluid resus

Pharmacological: ionotropics, correct the coagulopathy (FFP, platelets etc) PPH management of uterine atony

Consider delivery +/- hysterectomy

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7
Q

What is the survival rate of amniotic fluid embolism?

A

75%

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8
Q

What are the Hb values indicative of anaemia in each trimester?

A

1st TM: <110

2nd TM: <105

3rd TM: <105

Postpartum: <100

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9
Q

What is the characteristic blood film appearance of iron deficiency anaemia, folate deficiency and B12 deficiency?

A

IDA: hypochromia, microcytes, pencil cells

Folate deficiency: megaloblastic picture: hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia

B12 deficiency: also megaloblastic - as above

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10
Q

What is the cause of IDA in pregnancy?

A

Increased use of iron and decreased intake/ absorption - may also be caused by blood loss/ haemolysis

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11
Q

What is the cause of folate/B12 deficiency during pregnancy?

A

Lack in diet can cause both folate and B12 deficiency

Folate deficiency may also be caused by increased demand/ drugs

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12
Q

Recall some B12-specific symptoms of anaemia

A

Glossitis, depression, psychosis/ dementia, paraesthesia, peripheral neuropathy

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13
Q

What is the dose of iron given in IDA?

A

100 -200mg OD

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14
Q

Recall some side effects of giving ferrous sulphate

A

Black stools, constipation, abdo pain

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15
Q

When should oral folic acid not be given?

A

If cause of anaemia is not known - as it could exacerbate symptoms in a B12 anaemia

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16
Q

What is the treatment for B12 deficiency?

A

IM hydroxycobalamin

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17
Q

When is asthma most likely to be exacerbated in pregnancy?

A

24-36 weeks

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18
Q

What is the cause of asthma in pregnancy?

A

Pregnancy itself can’t cause it so it must have been present beforehand

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19
Q

What are the PEFR values that define severe and life-threatening asthma attacks?

A

Severe = 50-33%

Life-threatening = <33%

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20
Q

What are the appropriate investigations to do in asthma in pregnancy?

A

Peak flow, pulse oximetry, ABG, FBC (WCC infection?), CRP, UandEs, blood and sputum cultures, daily PEFR monitoring

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21
Q

How should chronic asthma be managed in pregnancy?

A

Continue medications throughout labour

Avoid bronchoconstrictors

Monitor foetal movements daily after 28 weeks

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22
Q

How should an acute asthma attack be managed in pregnancy?

A

High flow O2

Nebulised salbutamol

Ipratropium 0.5mg QDS

Steroids (IV hydrocortisone/ PO prednisolone)

IV magnesium

Summon senior help

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23
Q

What is the risk of oral corticosteroid use in first TM?

A

Cleft lip risk increased

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24
Q

What is the difference between the baby blues and post-natal depression?

A

Baby blues = mild, self-limiting low mood <2 weeks

PND = pervasive low mood in the PN period > 2 weeks

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25
Q

What is the perinatal period defined as?

A

Pregnancy + 1 year postpartum

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26
Q

Which class of drugs can increase risk of post natal depression?

A

Antipsychotics (ironically)

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27
Q

What scoring system is used for post natal depression?

A

Edinburgh Post Natal Depression Scale

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28
Q

Recall 2 breast-feeding safe antidepressants

A

Sertraline

Paroxetine

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29
Q

What is peripartum cardiomyopathy?

A

New-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum

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30
Q

What is the pathophysiology of peripartum cardiomyopathy?

A

40% rise in blood volume during pregnancy by 28w causing strain

Women with cardiac disease cannot increase CO –> uterine hypoperfusion –> increased pulmonary oedema

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31
Q

What classification system is used for cardiac disease in pregnancy?

A

NYHA classification

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32
Q

Recall some cardiovascular system abnormalities that are normal in pregnancy

A

ESM 3rd heart sound

Peripheral oedema (more volume)

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33
Q

In which patients should anticoagulation be used during pregnancy, and what is an appropriate anticoagulant to use?

A

Patients with:

  • CHD
  • Pulmonary HTN
  • Artificial valves
  • Increased risk of AF

Warfarin is teratogenic in 1st TM - so use LMWH instead

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34
Q

How can maternal cardiac disease be managed in labour?

A

Advise epidural to reduce pain-related cardiac strain

2nd stage can be kept short with elective forceps/ ventouse - reduces maternal effort for an increased cardiac output

Do a C-section where any effort is dangerous

Do not use ergometrine in 3rd stage (only syntocinon)

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35
Q

How does insulin resistance change throughout pregnancy?

A

Increases throughout

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36
Q

How does pregnancy affect pre-existing diabetes?

A

Increase in insulin dose requirements in second half of pregnancy

Increased risk of severe hypoglycaemia

Risk of deterioration of any diabetic retinopathy/ nephropathy

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37
Q

How does diabetes affect pregnancy?

A

Increases risk of miscarriage

Risk of spina bifida

Risk of macrosomia

Also increases risk of: pre-eclampsia, still birth, infection

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38
Q

Recall the pre-conception checks in diabetes

A
  1. Tight glucose control (HbA1c)
  2. Renal testing (UandEs, creatinine)
  3. BP checks
  4. Retinal checks
  5. Stop statins
  6. Stop folic acid
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39
Q

What is the risk of poor glycaemic control to the baby during pregnancy?

A

It’s teratogenic - can cause midline deformities like spina bifida

It can also cause the baby to be for large for dates

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40
Q

Why does diabetes increase still birth risk?

A

Placental damage by over-glycosylation of proteins means it may not be able to supply baby

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41
Q

What is the biggest risk to the neonate after the cord is cut when there is maternal DM?

A

Hypoglycaemia

Foetus has been producing high levels of insulin in utero because of high glucose load from mother, so when the cord is cut they keep producing lots of insulin which prediposes them to hypoglycaemia

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42
Q

Why does diabetes increase risk of macrosomia?

A

Excess maternal glucose –> foetus produces IGF-1 –> growth factor cause macrosomia

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43
Q

How often are antenatal diabetes clinics?

A

Every 2 weeks

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44
Q

What precaution should be taken when a diabetic mother requires antenatal steroids?

A

Insulin therapy is required to maintain normoglycaemia as steroids increase glucose release

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45
Q

What are the indications for testing for gestational diabetes in a pregnant woman?

A

Glycosuria on dipstick, previous GDM, any RF on clerking

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46
Q

What is the main investigation to do for GD?

A

2 hour 75g OGTT

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47
Q

What are the values that indicate diagnosis of GD?

A

5678 Fasting plasma glucose >5.6 2-hour OGTT >7.8

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48
Q

What should be the first thing you do if you diagnose GD?

A

Offer a review at a joint diabetes and antenatal clinic within 1 week

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49
Q

Recall the stepwise management of GD

A

1st line = changes in diet and exercise (CDE) - Only use this if fasting glucose is <7

2nd line - if targets are not met by 1st line in 2 weeks, still <7 fasting glucose = metformin as well as CDE (go straight to insulin if metformin contra-indicated)

3rd line (if >7 fasting glucose or 2nd line ineffective)
= CDE, metformin and insulin
Offer 3rd line straight away if fasting glucose is 7 or 6-6.9 with complications

4th line - consider glibenclamide

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50
Q

What should be done postnatally in mothers with GD?

A

Immediate discontinuation of blood-glucose lowering treatment GP should perform a fasting plasma glucose at 6-13w pp

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51
Q

What is by far the most common site of ectopic pregnancy?

A

Fallopian tubes - usually ampulla

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52
Q

Where is the site of ectopic pregnancy with highest chance of rupture?

A

Isthmus

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53
Q

What is the cause of ectopic pregnancy?

A

Tube damage due to infection (eg PID), endometriosis, previous tubal surgery, Depo-Provera injection

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54
Q

What are the signs and symptoms of ectopic pregnancy?

A

Abdo pain, diarrhoea, shoulder tip pain, back pain

Amenorrhoea with PV scanty blood

Dizziness if ruptured - with circulatory collapse

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55
Q

What will be seen on examination in ectopic pregnancy?

A
  1. Abdomen - rebound tenderness, guarding 2. Vaginal - cervical excitation, adnexal tenderness + mass
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56
Q

What are the appropriate investigations for an ectopic?

A

Pregnancy test

Speculum + bimanual

TVUSS

Bloods: FBC, X match, clotting

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57
Q

What signs on TVUSS are indicative of ectopic pregnancy?

A

Tubal: ‘blob’ sign, ‘bagel’ sign

Cervical: ‘barrel’ cervix, negative sliding sign

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58
Q

How does a located ectopic appear?

A

Empty uterus, adnexal mass with GS and YS, free fluid in uterine cavity

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59
Q

What should be done in the case of a pregnancy of unknown location (PUL)?

A

Depends on increase in serum beta-hCG (taken at 0 and 48 hours)

  1. >63% –> developing prenancy: rescan at 7-14 days
  2. <63% –> review in EPAU <24 hours
  3. <50% –> miscarriage –> expectant management
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60
Q

How should all early-pregnancy emergencies first be managed?

A

Call the on-call gynae

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61
Q

When should ectopics be managed expectantly?

A

Only permissable in stable, asymptomatic patient with falling levels of beta-hCG

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62
Q

What are the indications for medical management of an ectopic?

A

Stable

Normal LFT and UandEs

Beta-hCG <3000

Ectopic <35mm

No blood in pouch of douglas

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63
Q

What is the medical management of ectopic?

A

ONCE IM methotrexate

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64
Q

What advice should be given following medical management of an ectopic?

A

Go home and come back for repeat blood tests (hCG)

No intercourse for 3 months

Don’t drink alcohol

Avoid excessive sun exposure

Expect side effects of pain, nausea and diarrhoea

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65
Q

What are the indications for surgical management of ectopic pregnancy?

A

Significant pain

Ectopic with foetal heartbeat

Adnexal mass >35mm

beta-hCG >5000

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66
Q

What is the surgical management of ectopic pregnancy?

A

Laparoscopic salpingectomy

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67
Q

When can a salpingostomy be used to treat ectopic pregnancy?

A

If bleeding is minimal and occlusion is viable to be removed (eg at fimbriae) and the patient only has one viable tube left (as high future risk of ectopics)

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68
Q

What type of prophylaxis is required for surgical management of an ectopic?

A

Anti-D prophylaxis

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69
Q

What form of contraception should be avoided following a lap salpingectomy?

A

Copper IUD

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70
Q

How should all seizures in second half of pregnancy be managed?

A

Immediate treatment for eclampsia until a definitive diagnosis is made

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71
Q

How should epilepsy medication be managed in pregnancy?

A

Minimum possible dose - levetiracetem and lamotrigene are safest agents

Reduce to monotherapy where possible

Explain risk of congenital malformation, as well as risk of recurrent seizures

Pre-conceptional folic acid 5mg, and vit K in last month of pregnancy

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72
Q

What congenital abnormalities are associated with anti-epileptic drugs?

A

Neural tube defects

Facial clefts

Cardiac defects

Valporate is teratogenic

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73
Q

What is the main risk of phenytoin use in pregnancy?

A

Cleft palate

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74
Q

Which anti-epileptic drugs are most appropriate in pregnancy?

A

Lamotrigine

Levetiracetem

Carbamazepine (least teratogenic of the old antiepileptics)

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75
Q

What extra source of support and advice could you refer someone to when counselling an epileptic expectant mother in PACES?

A

Invite to register to the UK Epilepsy and Pregnancy Register

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76
Q

What is a hyatidoform mole?

A

A benign tumour of the trophoblastic tissue

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77
Q

What is the aetiology of a hyatidoform mole?

A

Abnormal fertilisation leads to either a ‘complete’ mole (empty egg fertilised by 2 sperm) or a partial mole (normal egg fertilised by 2 sperm)

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78
Q

What are the signs and symptoms of a hyatidoform mole?

A

Painless PV bleeding (ie miscarriage)

Uterus larger than expected for GA

Hyperemesis

Often seen on USS before symptoms

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79
Q

What are appropriate investigations to do to diagnose hyatidoform mole?

A

Bloods: Beta-HcG grossly elevated

hCG shares an alpha subunit with TSH, therefore (due to negative feedback) there should be a low TSH and a high T4

Imaging: pelvic USS

  • Complete mole: snowstorm/ ‘cluster of grapes’
  • Incomplete mole = foetal parts, no snowstorm/ cluster of grapes
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80
Q

How should hyatidoform mole be managed?

A

Urgent referral to a specialist centre

1st line = surgical: ERPC (evacuation of retained products of contraception) = suction curettage

Then: monitor serum BhCG, use methotrexate if rising/ stagnant levels, avoid pregnancy until 6 months of normal BhCG

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81
Q

What are the main complications of hyatidoform mole to be aware of?

A

May progress to malignancy (20% of complete moles, 2% of partial)

This would be either an invasive mole or a choriocarcinoma

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82
Q

How can the diagnosis of hyatidoform mole be explained in PACES?

A

When foetus doesn’t form properly, and a baby doesn’t develop, instead there is an irregular mass of pregnancy tissue

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83
Q

What is the main risk when gestational trophoblastic disease progresses to malignancy?

A

Rapid metastasis all over the shop

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84
Q

What are the forms of malignant gestational trophoblastic disease?

A
  1. Invasive mole (Hyatidoform mole invades myometrium –> necrosis and haemorrhage)
  2. Choriocarcinoma (cytoctrophoblast and synctiotrophoblast without formed chorionic villi invade myometrium)
  3. Placental site trophoblastic tumour
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85
Q

Recall 4 things that choriocarcinoma might arise from

A

50% = molar pregnancy

22% = viable pregnancy

25% = miscarriage

3% = ectopic pregnancy

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86
Q

What are the signs and symptoms of malignant gestational trophoblastic disease?

A

Persistent PV bleeding

Hyperemesis gravidarum

Lower abdo pain

Symptoms of mets to:

  • Lung (haemoptysis, dyspnoea, pleuritic pain)
  • Bladder/ bowel (haematuria/ PR bleeding)

On examination: excessive uterine size for GA

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87
Q

What are the appropriate investigations to do for malignant gestational trophoblastic disease?

A

Bloods: serum BhCG, FBC, LFT (mets)

Imaging: pelvic USS, CXR, CTP, MRI brain

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88
Q

How is malignant gestational trophoblastic disease managed?

A

Methotrexate, hysterectomy for placental site trophoblastic tumour

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89
Q

What % of women get hyperemesis gravidarum?

A

1%

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90
Q

What % of pregnant women get emesis gravidarum?

A

80%

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91
Q

What lifestyle factor is protective against hyperemesis gravidarum?

A

Smoking

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92
Q

What factors increase risk of hyperemesis gravidarum?

A

Increased oestrogen (Nulliparity, obesity, multiple pregnancies)

Hyperthyroid

Gestational trophoblastic disease (more BhCG)

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93
Q

What are the RCOG diagnostic criteria for hyperemesis gravidarum?

A

MUST HAVE ALL 3 OF:

>5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

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94
Q

When does hyperemesis gravidarum begin?

A

Between 4th and 7th gestational week

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95
Q

When does hyperemesis gravidarum peak?

A

Week 9

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96
Q

When does hyperemesis gravidarum resolve?

A

By 20th week

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97
Q

What investigations should be done in hyperemesis gravidarum?

A

Body weight (for measuring dehydration)

Urine dipstick (to check ketones)

UandE

Basic obs

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98
Q

What scoring system is used to assess the severity of hyperemesis gravidarum, and what score means admission?

A

PUQE-24

13 or above

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99
Q

How should hyperemesis gravidarum be managed?

A

Always VTE prophylaxis (LMWH) , IV saline with KCl and thiamine supplementation

1st line: antihistamines (eg IV promethazine/ cyclizine)

2nd line: antiemetics (eg IV ondansteron, metoclopramide, domperidone) Metoclopramide is 2nd line due to EPS 3rd line

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100
Q

What are the major possible maternal complications of hyperemesis gravidarum?

A

VTE

Wernicke’s

Hypokalaemia

Hyponatraemia

Acute renal tubular necrosis

Mallory-Weiss tear

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101
Q

What are the main risks to the foetus from hyperemesis gravidarum?

A

IUGR

Pre-term labour

Termination

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102
Q

What BP is considered hypertensive, and what is the threshold for ‘severe hypertension’ during pregnancy?

A

HTN: 140/90

Severe HTN: >160/110

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103
Q

When is HTN considered to be gestational, rather than chronic?

A

Appearing after 20 weeks

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104
Q

What are the features of pre-eclampsia?

A

New HTN present after 20 weeks

Proteinuria

AND/OR Maternal organ dysfunction

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105
Q

What is HELLP syndrome?

A

Haemolysis, Elevated Liver enzymes, Low Platelets Severe form of pre-eclampsia

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106
Q

How is eclampsia defined?

A

1 or more seizures in someone with pre-eclampsia

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107
Q

How is decision to give aspirin for HTN in pregnancy (not pre-eclampsia, just HTN) guided?

A

Guided by presence of high/ moderate risk factors

Always give aspirin if 1 or more of the following is present:

  • Previous pre-eclampsia
  • CKD
  • AI disease
  • DM
  • Chronic HTN

Give aspirin if they have any two of:

  • Primigravidity
  • Age >40
  • Pregnancy interval >10 years
  • BMI >35
  • Pos FHx
  • Multiple pregnancy
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108
Q

What are the signs and symptoms of pre-eclampsia?

A

Often asymptomatic

Can give: severe headache, visual disturbances, epigastric/ RUQ pain, vomiting, breathlessness, sudden swelling of face/ feet/ hands

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109
Q

What investigation is most useful in pre-eclampsia?

A

Urine dip (proteinuria) - if 1+ on dip or protein creatinine ratio quantification >30mg/mmol

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110
Q

How should pre-eclampsia be managed?

A

1st line: labetolol (100mg, BD) - contraindicated in asthma

2nd line: nifedipine

3rd line: methyldopa

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111
Q

How is eclampsia managed?

A

IV magnesium sulphate (it’s a potent cerebral dialator)

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112
Q

What is the threshold for admission for gestational HTN?

A

Severe HTN (>160/110)

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113
Q

What is the target BP for those who have gestational HTN?

A

135/85

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114
Q

How should gestational HTN be managed?

A

1st line labetolol, 2nd line nifedipine

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115
Q

How often should mothers with gestational HTN be monitored, and what checks should be done?

A

BP measurement: weekly for moderate HTN, every 15-30 mins in severe HTN when mother is admitted

Dipstick: once or twice a week in moderate, daily whilst admitted FBC, LFT and

UandE once at presentation

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116
Q

What foetal monitoring should be done in mothers with HTN?

A

USS for foetal growth

Amniotic fluid assesment

Umbilical artery doppler

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117
Q

How does BP usually vary during pregnancy?

A

Tends to fall in first half of pregnancy before rising back to pre-pregnancy levels before term

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118
Q

How often are LFT, FBC and renal fx repeated in pre-eclampsia, eclampsia and gestational HTN?

A

Done twice a week in moderate pre-eclampsia or 3 times per week in eclampsia - only done once in gestational HTN

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119
Q

Describe the planning of birth timing in pre-eclampsia

A

If birth <34 weeks - offer antenatal steroids and MgSO4

If birth 34-36 weeks, continue surveillance unless delivery indicated in care plan

If birth >37 weeks, initiate birth within 24-48 hours

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120
Q

What should be monitored intrapartum in pre-eclampsia?

A

CTG (continuous) BP monitoring + continue antihypertensives

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121
Q

When should anticonvulsants be considered for women with pre-eclampsia?

A
  1. Previous eclamptic fits
  2. Birth planned in next 24 hours
  3. Features of severe pre-eclampsia present
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122
Q

What are the features of severe pre-eclampsia?

A

Severe headaches

Epigastric pain

Visual scotomata

Oligouria and severe HTN

Nausea and vomitimng

Deteriorating biochemistry

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123
Q

What is the first line anticonvulsant to use in eclampsia, and what is its reversing agent?

A

IV MgSO4

Calcium gluconate (10mls. 10%, over 10 mins)

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124
Q

Recall the MgSO4 dosing used to treat severe htn/pre-eclampsia/ eclampsia

A

Loading dose of 4g IV over 5 mins, followed by an infusion of 1g/hour for 24 hours

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125
Q

What are the discharge criteria following eclampsia?

A

No symptoms of pre-eclampsia

BP <150/110

Blood test results stable/ improving

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126
Q

Recall some anti-hypertensives that are not recommended whilst breastfeeding

A

ARBs

ACE inhibitors

Amlodipine

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127
Q

What drugs for HTN are safe when breastfeeding?

A

Labetolol, nifedipine, enalapril, captopril, atenolol

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128
Q

What is the aetiology of eclampsia?

A

Impaired trophoblastic invasion of spiral arteries –> high resistance flow –> poor placental perfusion –> release of factors from placenta into circulation –> factors cause symptoms

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129
Q

What is TORCH syndrome?

A

Toxoplasmosis, Other agents, Rubella, CMV, HSV

Cluster of symptoms caused by congenital infection with the above

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130
Q

Recall the 4 signs and symptoms of congenital toxoplasmosis

A

Chorioretinitis

Hydrocephalus

Convulsions

Intracranial calcifications

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131
Q

How should congenital toxoplasmosis be managed?

A

Pyrimethamine

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132
Q

What pathogens come under the ‘other’ section of TORCH?

A

Syphillis, Parvovirus B19, hepatitis, VZV, HIV

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133
Q

What are the signs and symptoms of congenital syphilis?

A

Rash (soles and palms)

Bloody rhinitis

Nose deformity

Saber shins

Hutchinson’s teeth

Clutton’s joints

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134
Q

What condition does congenital parvovirus B19 cause?

A

Hydrops fetalis - causes heart failure

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135
Q

When does congenital HIV present?

A

6 months

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136
Q

What are the signs and symptoms of congenital rubella?

A

Cataracts (from chorioretinitis)

PDA heart defect

Microcephaly

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137
Q

What are the signs and symptoms of congenital CMV?

A

Chorioretinitis –> cataracts

Intracranial calcifications

Microcephaly

Hepatosplenomegally

Jaundice

Purpura/ petichiae

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138
Q

How should congenital CMV be managed?

A

Ganciclovir

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139
Q

What disease is caused by congenital HSV?

A

SEM (skin eyes mouth) disease/ disseminated disease

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140
Q

What other organisms can cause neonatal sepsis?

A

GBS. Listeria monocytogenes

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141
Q

How should congenital GBS be treated?

A

Benzylpenicillin

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142
Q

How should congenital listeria be managed?

A

Amoxicillin/ ampicillin

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143
Q

What is the organism responsible for toxoplasmosis and how is it spread?

A

Protozoon toxoplasma gondii

Parasite excreted in cat faeces - transmission is faeco-oral route (from infected meat and cat faeces)

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144
Q

What are the maternal signs and symptoms of toxoplasmosis?

A

Often asymptomatic but may have fever, malaise, arthralgia

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145
Q

What are the signs and symptoms of congenital toxoplasmosis?

A

60% are asymptomatic but may develop deafness, low IQ and microcephaly

40% have classic ‘4 Cs of toxoplasmosis’:

  • Chorioretinitis
  • hydroCephalus
  • intracranial Calcifications
  • Convulsions
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146
Q

What is the test for toxoplasmosis?

A

Sabin Feldman Dye test

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147
Q

How should toxoplasmosis be managed in pregnancy?

A

Prophylaxis: mother should avoid eating raw/ rare meat and handling cats/ cat litter

If +ve mother and -ve baby: spiramycin (prevents vertical transmission)

If +ve mother and +ve baby: pyrimethamine and sulfadiazine with prednisolone adjunct

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148
Q

What is the name, shape and gram status of the organism causing syphillis?

A

Treponema pallidum: gram neg spirochete

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149
Q

What are the symptoms of primary syphillis?

A

Painless chancres and local lymphadenopathy

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150
Q

What is the difference bwtween early and late latent syphillis?

A

Early = signs/symptoms <2 years, late = >2 years

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151
Q

What are the different types of tertiary syphillis?

A

Gummatous, cardiovascular and neurosyphilis

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152
Q

What is the most useful treponomal test?

A

EIA

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153
Q

How is syphillis treated?

A

Benzathine-penicillin OR doxycycline

Early: Benzathine-penicillin STAT or doxy BD 14/7

Late: Benzathine-penicillin IM once weekly 3/52 OR doxy BD 28/7

Neurosyphilis: Benzathine-penicillin IV 4-hourly, 14/7

Prednisolone used as an adjunct to avoid Jarish-Herxheimer reaction

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154
Q

For how long is parvovirus B19 infectious?

A

From 10 days prior to the rash to 1 day after the rash appears

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155
Q

How is parvovirus transmitted?

A

Aerosol/ blood-borne

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156
Q

How does the parvovirus rash usually appear?

A

Slapped cheek’ appearance

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157
Q

What symptoms are to be expected in an infant with parvovirus?

A

Coryzal symptoms + headache + rash

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158
Q

What is the risk of parvovirus in pregnancy?

A

Crosses placenta at 4-20w GA, destroying RBCs and –> hydrops foetalis (10% infant mortality)

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159
Q

How is hydrops fetalis managed?

A

Blood transfusion

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160
Q

If a baby is born to a HepB + mother, how should they be managed?

A
  1. Vaccination - at birth, 1 month and 6 months
  2. HBV IV Ig within 12 hours of birth
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161
Q

Is Hep B transmitted by breastfeeding?

A

No

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162
Q

How can Hep C infection be confirmed?

A

PCR

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163
Q

How should hep C be treated in pregnancy?

A

It shouldn’t as it is contraindicated (ribavarin and interferon)

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164
Q

What is the danger of having Hep E in pregnancy?

A

If contracted in third TM can cause a severe reaction and a fulminant hepatitis

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165
Q

What should pregnant mothers avoid eating to avoid hep E?

A

Pork and shellfish

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166
Q

For how long is VZV infectious?

A

From 48 hours before rash until the vesicles crust over

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167
Q

How does congenital varicella syndrome appear?

A

Chorioretinitis

Cutaneous scarring

Microcephaly

IUGR

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168
Q

In which period is VZV infection considered ‘neonatal’?

A

Maternal infection 7 days before or after birth

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169
Q

How does neonatal VZV present?

A

Mild disease: pneumonua, disseminated skin lesions and visceral infections (ie hepatitis)

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170
Q

How should antenatal chickenpox be managed?

A

VZIg within 10 days of exposure (before 20/40 gestation)

Once symptoms have developed, VZIg cannot be given

If after 20/40 weeks gestation –> Aciclovir 800mgs QDS

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171
Q

What should be done if there is doubt about whether a mother has previously had VZV?

A

Maternal blood checked urgently for VZ Ig

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172
Q

What are the possible complications of delivery during viraemic period in varicella zoster infection?

A

Haematological: bleeding, DIC, thrombocytopaenia

Hepatitis

VZV infection of new born

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173
Q

When should an HIV test be done antenatally?

A

Routinely in antenatal booking

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174
Q

How is HIV diagnosed in children?

A

Direct viral amplification by PCR carried out at birth, on discharge, at 6 , 12 and 18 weeks if mother is HIV+

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175
Q

How should maternal ARVs be managed during pregnancy?

A

Don’t change them they’re continual

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176
Q

How should the babies of HIV + mothers be treated?

A

First 2-4w of life: ARVs - zidovudine monotherapy

If viral load is undetectable or less than 50: vaginal delivery

If viral load >50 at 36 weeks: ELCS at 38 weeks

If viral load is detectable: intrapartum zidovudine

One of the only infections where avoidance of breastfeeding should be advised - offer cabergoline to suppress lactation

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177
Q

What are the S/S of rubella?

A

Coryzal symptoms + arthralgia + maculopapular rash

Soft palate lesions (NO koplik spots though)

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178
Q

Describe the spread of the rash in Rubella

A

Starts behind ears, spreads to head and neck and then to rest of body

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179
Q

At what point during gestation is there highest risk of congenital rubella syndrome?

A

<12 weeks GA

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180
Q

What are the features of congenital rubella syndrome?

A

Chorioretinitis, sensorineural hearing loss

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181
Q

At what point in gestation does maternal rubella become very low risk?

A

20 weeks

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182
Q

What investigations are appropriate for rubella?

A

Blood serology

USS for foetal abnormalities

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183
Q

How should maternal rubella be managed?

A

Rest, fluids and paracetamol (no treatment)

Offer TOP if <16w GA

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184
Q

What are the possible sites of latent CMV infection?

A

Dorsal root ganglion

B cells

Monocytes

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185
Q

At what stage of pregnancy is CMV most likely to transmit vertically?

A

Unlike other infections during pregnancy, CMV just as likely (30- 40%) to vertically transmit at any point

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186
Q

How does congenital CMV present?

A

90% are asymptomatic, although some will go on to develop sensorineural hearing loss

10% are symptomatic: Sensorineural hearing loss, pre-ventricular calcification, chorioretinitis, ‘blueberry muffin rash’

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187
Q

What investigations are appropriate when a pregnant woman has CMV?

A

Maternal serology

USS of foetus

Amniocentesis

PCR

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188
Q

How should maternal CMV be managed?

A

Do not treat, but if evidence of CNS damage to foetus –> offer TOP

Foetal USS every 2w following diagnosis

Can offer foetal MRI at 28wGA

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189
Q

How should congenital CMV be managed?

A

IV ganciclovir

Audiology follow-up

Ophthalmology follow-up

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190
Q

Which type of HSV is which?

A

HSV1 = oral, HSV2 = genital

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191
Q

What are the features of SEM disease?

A

Blistering vesicular rash, chorioretinitis

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192
Q

What are the possible presentations of congenital HSV infection?

A
  1. CNS disease + SEM (seizures, lethargy, poor feeding + skin/eye/mouth disease)
  2. Disseminated infection - encephalitis, CNS abnormalities
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193
Q

How is congenital HSV diagnosed?

A

Clinically + STI screen + PCR

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194
Q

How should congenital HSV infection be managed?

A

Acute infection –> Aciclovir Oral for mother, IV for child

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195
Q

When should a C section be done in maternal HSV?

A

If first episode <6 weeks prior to EDD

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196
Q

What antigen characterises the Group B Strep pathogen?

A

Group B Lancefield antigen

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197
Q

Is group B strep gram pos or neg?

A

Pos (cocci in chains)

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198
Q

What causes group B strep infection?

A

Commensal in vagina and rectum carried by 25% of women

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199
Q

What are the signs/symptoms of GBS?

A

Often asymptomatic until incidental finding

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200
Q

How should maternal group B strep be managed?

A

Intrapartum IV benzylpenicillin (or vancomycin if penicillin allergy) if pyrexial

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201
Q

In what situations would group B strep prophylaxis be given?

A

When there are RFs for an early-onset neonatal sepsis:

  • intrapartum fever/ chorioamnionitis
  • prolonged rupture of membranes (PROM)
  • Pre-term birth
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202
Q

How should sepsis monitoring occur in neonates?

A

If 1 risk factor: remain in hospital for 24 hours for obs

If 2 or more risk factors, or one red flag, –> Abx + septic screen Sepsis

Abx in neonate: cefotaxime, amikacin, ampicillin

Red flags: seizure, resp distress, shock

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203
Q

What are the S/S of listeriosis?

A

Often asymptomatic or non-specific

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204
Q

How can listeriosis be diagnosed?

A

Isolation of organism from blood, vaginal swabs or placenta

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205
Q

How is listeriosis managed?

A

IV amoxicillin/ ampicillin

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206
Q

What is the prognosis for listeriosis?

A

Bad unless treated (then good)

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207
Q

What is a Braxton-Hicks contraction?

A

Painless contractions with no cervical change

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208
Q

Define the 3 stages of labour

A
  1. Painful uterine contractions –> full (10cm) cervical dilatation 2. Starts with urge to push and ends with delivery of foetus 3. Delivery of placenta and foetal membranes
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209
Q

Up to how long should the 3rd stage of labour last ideally?

A

Up to 30 mins

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210
Q

What factors determine the progress of labour?

A
  1. Power (contractions) 2. Passage (dimensions of pelvis) 3. Passenger (diameter of foetal head)
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211
Q

What is a possible complication of shoulder dystocia?

A

Erb’s palsy

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212
Q

What is ‘restitution’?

A

Bringing head in line with shoulders

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213
Q

Recall the management of shoulder dystocia

A

In LESS THAN 5 MINS:

  1. Call for senior help and discourage pushing
  2. McRobert’s manoevre and suprapubic pressure
  3. Evaluate for episiomtomy
  4. Either Rubin’s manoevre or Wood’s Screw or deliver posterior arm
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214
Q

What is McRobert’s manoevre?

A

Legs up to abdomen

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215
Q

What is Rubin’s manoevre?

A

Push anterior shoulder towards baby’s chest

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216
Q

What is Wood’s Screw?

A

Rubin’s + push posterior shoulder towards baby’s back –> rotation

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217
Q

What score is used to decide how likely it is that a woman will go into labour imminently?

A

Bishop’s score

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218
Q

What is ‘effacement’?

A

Reported as a %, measure of how thin the cervix is

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219
Q

What is the ‘foetal station’?

A

Position of the baby’s head relative to the ischial spines of the maternal pelvis

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220
Q

How should the 1st stage of labour be managed?

A

One-to-one midwifery care

Vaginal exams performed 4-hourly or as clinically-indicated

Ensurance of adequate: analgesia, antacids, hydration, light diet to provide ketosis

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221
Q

What is the normal progress of the first stage of labour?

A

1cm per hour

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222
Q

How should a delayed first stage of labour be managed?

A

1st - if membranes intact - ARM (artificial rupture of membranes) 2nd (if membranes ruptured) - oxytocin

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223
Q

What is the most common cause of primary dysfunctional labour?

A

Ineffective uterine action

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224
Q

When is the second stage of labour considered ‘delayed’?

A

In nulliparous women: 3 hours with an epidural or 2 hours without

In multiparous women: 2 hours with epidural or 1 hour without

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225
Q

How should a delayed 2nd stage of labour be treated?

A

Same as delayed 1st stage with regards to ARM and oxytocin

226
Q

What is ‘crowning’?

A

When head no longer recedes between contractions

227
Q

What does the midwife do as the baby crowns?

A

Flex the foetal head and guard the perineum

228
Q

How should the woman be instructed once the head has crowned?

A

Discouraged from bearing down and should take rapid, shallow breaths

229
Q

Recall the immediate care of the neonate

A

After clamping/ cutting of the umbilical cord, baby should have an apgar scre calculated at 1 min and at 5 mins

230
Q

What apgar score is considered normal?

A

>7

231
Q

What does APGAR stand for?

A

Appearance, pulse, grimace, activity, respiration

232
Q

How quickly should initiation of breastfeeding be encouraged?

A

Within 1 hour

233
Q

What medication should be given to the baby whilst still in the delivery room?

A

Vit K

234
Q

What are the causes of PPH?

A

4 Ts: Tone (uterine atony) Tissue (retained products) Trauma (laceration) Thrombin (coagulopathy)

235
Q

What is PPH?

A

Post Partum Haemorrhage

236
Q

What is the normal duration of the 3rd stage of labour?

A

5-10 mins

237
Q

Describe the physiological management of the 3rd stage of labour

A

Associated with more bleeding (and therefore greater need for transfusions) than active management

Active Mx recommended if placenta undelivered within 60 mins or haemorrhage may occur

238
Q

Describe the active management of the 3rd stage of labour

A

10 IU syntocinon (IM)/ ergometrine

Drug can be delivered after delivery of anterior shoulder or immediately after delivery (and before cord is clamped and cut)

Remove placenta using controlled cord traction

239
Q

What are the signs of placental separation?

A

Gush of blood, cord lengthening, uterus rising, uterus becoming round

240
Q

What should be done immediately following delivery of the placenta?

A
  1. Inspection of placenta for missing cotyledone/ succenturiate lobe
  2. Inspect vulva for tears
241
Q

After how long of active management is it considered ‘prolonged’?

A

30 mins

242
Q

Recall the options for induction of labour, from 1st to 5th line

A
  1. Prior to formal induction: membrane sweeping - for nulliparous women = at 40-41 weeks - for multiparous women = at 41 weeks
  2. Prepare the cervix –> prostaglandins (Prostin/ Propress; vaginal PGE2)
    - this is the preferred formal method of induction, can be administered as a tablet, gel or pessary - max of 2 doses
    - Risk of uterine hyperstimulation
  3. Artificial Rupture of Membranes
    - ARM = amniohook
    - Should not be used first line
  4. Syntocinon
  5. C section
243
Q

At how many weeks is induction offered?

A

41 weeks

244
Q

If induction is declined when it is indicated, what should be done?

A

Twice weekly USS and CTG

245
Q

In what circumstances can labour be induced at maternal request?

A

Special circumstancs eg. If partner has to go away to serve in armed forces - only consider after 40 weeks

246
Q

What should be done in the scenario of intrauterine foetal death?

A

If membranes are intact, offer an induction

If ruptured membranes/ infection/ bleeding - immediate induction with oral mifepristone, followed by prostin/ misoprostol

247
Q

Recall 3 scenarios in which induction is not recommended

A

Breech/ transverse lie

IUGR

Suspected foetal macrosomia

248
Q

Recall 3 non-pharmacological methods of analgesia

A

TENS

Breathing techniques

Massage

249
Q

Recall 4 pharmacological analgesics used in pregnancy, with their side effects

A

Entonox (nausea, light-headed, dry mouth)

Meperidine (‘sleepy baby’, low baby RR, constipation)

Morphine/ diamorphine (‘sleepy baby’, low baby RR, constipation)

Fentanyl (‘sleepy baby’, low baby RR, constipation)

250
Q

Recall 2 surgical methods of analgesia

A

Lumbar epidural (bupivocaine, ropivacaine etc)

Combined lumbar-spinal epidural (fentanyl + bupivacaine)

251
Q

What is a partogram, and what score is based on its results?

A

Records condition of mother, foetus and progress of labour

Used to calculate a Bishop’s score

252
Q

Define puerperal pyrexia

A

>38C in first 14 days following delivery

253
Q

What is the most common cause of puerperal pyrexia?

A

Maternal endometritis

254
Q

How should puerperal pyrexia be managed?

A

Until fever has abated for >24 hours: - IV clindamycin AND IV gentamycin

255
Q

What weight at term are macrosomic babies?

A

>4/4.5kg (definition varies)

256
Q

What tools are used to diagnose LGA prenatally?

A

1st: symphisis-fundal height
2nd: abdominal circumference
3rd: estimated foetal weight

If in 90th/95th centile for GA = LGA

257
Q

What investigations should be done if a baby seems LGA prenatally?

A

OGTT (gestational diabetes? This can cause LGA)

Bloods (serum beta-hCG, as molar pregnancy can cause polyhydramnios)

USS (liquor volume, biometry)

Genetic testing

258
Q

How should LGA be managed, if detected at 18-21 weeks?

A

Repeat scan

259
Q

How should LGA be managed, if detected at 24-36 weeks?

A

If acceleration of growth, arrange

USS for foetal biometry

Offer OGTT

260
Q

How should LGA be managed, if detected at 36-40 weeks?

A

If SFH is in 90th centile, USS for foetal biometry

Perform OGTT

Care in labour + postnatally as per gestational diabetes at earlier gestation

261
Q

Recall some complications of delivery in LGA

A

Shoulder dystocia

Hypoglycaemia in GDM

Respiratory distress syndrome (baby)

Intrauterine deformations eg matatarsus adductus, (hip subluxation)

Increased mortality

Perineal tear

262
Q

Define SGA

A

<10th centile for GA

263
Q

What are the biggest risk factors for SGA?

A

Previous stillbirth, APLS, renal disease

Others include: chromosomal abnormalities, infection, multiple pregnancy, placental insufficiency

264
Q

How should SGA be investigated?

A

At booking assesment, note any minor or major RFs

If 1 major or 3 minor RFs, reassess at 20 weeks

At 20 weeks, if still at risk, consider:

  • Minor risk: uterine artery doppler (if abnormal, serial USS from 26-28 weeks)
  • Major risk: foetal size and umbilical artery doppler
265
Q

What does USS biometry measure?

A

Biparietal diameter, head circumference, abdo circumference, femur length

266
Q

How should SGA be managed?

A

Stop any smoking/ EtOH/ drugs

Low dose aspirin may have some role in preventing (not reversing) IUGR in high-risk pregnancies

Monitoring: SFH at booking and at antenatal appointment, confirm SGA with foetal biometry at 20 weeks, uterine artery doppler at 20-24 weeks

If abnormal, serial scans every week from 26w onwards

Indications for immediate delivery: abnormal CTG, reversal of end-diastolic flow

Delivery by 37 weeks is usually necessary

267
Q

What are ths symptoms of obstetric cholestasis during pregnancy?

A

Pruritis, no rash

268
Q

Recall some possible complications of obstetric cholestasis

A

PPH, foetal distress, meconium delivery, PTL, IVH

269
Q

What does IVH stand for?

A

Intraventricular haemorrhage

270
Q

Where does the pruritis usually affect the worst in obstetric cholestasis, and at what point in the day?

A

Palms and soles

Night time

271
Q

Recall some appropriate investigations in suspected obstetric cholestasis

A

Bile acids and LFTs

CTG (to check baby)

Coagulation screen (may be high if vit K deficient)

Fasting serum cholesterol (high)

Hep C serology (increased risk of OC in hep C)

272
Q

How should obstetric cholestasis be managed?

A

Ursodeoxycholic acid (reduces itching and improves LFTs)

Vit K if deficient

Sedating antihistamines

273
Q

How should mothers with obstetric cholestasis be monitored?

A

Weekly LFTs until delivery, two-weekly doppler and CTG until delivery

274
Q

How should delivery be managed in mothers with obstetric cholestasis?

A

Offer induction at 37 weeks

275
Q

What are the main possible complications of obstetric cholestasis?

A
  1. Intrauterine death (due to intracranial haemorrhage)
  2. PPH (due to low vit K)
276
Q

Describe the epidemiology of Acute Fatty Liver of pregnancy

A

Rare

277
Q

What is the aetiology of Acute Fatty Liver of pregnancy?

A

Probably a mitochondrial disorder affecting fatty acid oxidation

278
Q

What is the main differential diagnosis in Acute Fatty Liver of pregnancy?

A

HELLP (haemolysis, elevated liver enzymes, low platelets)

279
Q

Recall the S/S of AFL of pregnancy

A

Normally 3rd TM Nauea/ vomiting/ abdo pain Jaundice, bleeding, ascites, manifestations of coagulopathy 50% have proteinuric HTN

280
Q

How can AFL of pregnancy be differentiated from OC?

A

Pruritis absent in AFL

281
Q

What investigations are appropriate in AFL of pregnancy?

A

ALT typically very elevated

Low blood glucose

Elevated uric acid

USS to show fatty liver

282
Q

How should AFL of pregnancy be managed?

A

Supportive care to stabilise

Once stabilised, delivery is the definitive management to prevent deterioration

283
Q

What is the prognosis of AFL of pregnancy?

A

Maternal mortality of 10-20%, perinatal of 20-30%

284
Q

What % of pregnancies are breech at term?

A

3-5%

285
Q

Recall some signs of breech delivery

A

Palpable head at fundus, soft breech in pelvis

Vaginal: soft presenting part, ischial tuberosities, anus or genitalia may be felt

Footling breech: foot felt or seen through cervix

286
Q

What are the different types of breech presentation?

A

Frank breech

Footling breech

Complete breech

287
Q

Recall some antenatal features of vaginal breech birth being high risk

A

Hyperextended neck

High EFW

Also Low EFW?!?!

288
Q

How information should be given at term in breech presentation?

A
  1. Offer ECV (exteral cephalic version) at 36w if nulliparous, 37w if multiparous:
    - 50-60% success rate
    - Foetal distress –> emergency CS
  2. If ECV unsuccessful/ declined –> council risks for CS
289
Q

What is the most dangerous form of breech delivery?

A

Footling

290
Q

How should a breech delivery be managed?

A

‘Hands off’ approach (baby hopefully will deliver self - if handling - put thumbs on sacrum and fingers on ASIS - Pinard manoevre may be needed)

291
Q

What is a Pinard manoevre?

A

Poke the baby in the popliteal fossa - this makes the bend their knees

292
Q

How will you tell if the baby’s head is stuck after the body is delivered in breech delilvery?

A

Winging of scapulae

293
Q

How should a stuck head be managed in breech delivery?

A

Loveset’s manoevre: rotate baby into transverse position and pull anterior arm down

If it stays stuck: perform Mauriceau-Smellie-Veit manoevre - you basically just haul them out resting baby on forearm and pulling head downwards

294
Q

Recall 3 types of unstable lie

A

Transverse, face, brow, breech (longitudinal)

295
Q

How should unstable lie be investigated?

A

USS to confirm the lie

296
Q

How should unstable lie be managed?

A

If already in labour, CS

Transverse lie can be altered by ECV with 50% success rate

Brow lie should –> CS if persistent/ 2nd stage labour

Face:mentoposteroir –> CS, mentoanterior = SVD is oky

297
Q

Define miscarriage

A

Loss of pregnancy at <20 weeks gestation

298
Q

What is a ‘threatened’ miscarriage?

A

PV bleed with foetal heartbeat present: the cervical os must be closed

299
Q

What is an incomplete miscarriage?

A

Passage of products of conception but uterus not empty on USS

300
Q

What is a missed miscarriage?

A

USS diagnosis of miscarriage in absence of symptoms

301
Q

What is recurrent miscarriage?

A

>3 consecutive miscarriages

No cause found in 50%

302
Q

What is the most common cause of miscarriage?

A

Chromosomal abnormalities in the embryo (eg trisomy 16)

303
Q

What causes must be considered in recurrent miscarriage?

A

Structural abnormalities (fibroids, bicornate/ septate uteri)

Cervical incompetence

Medical conditions (diabetes, SLE)

Clotting abnormalities (eg FVL, ATIII deficiency, APLS)

304
Q

What measure is used to date pregnancies <14 weeks?

A

CRL (crown rump length) using USS

305
Q

What measure is used to date pregnancies >14 weeks?

A

Head circumference is the main one

306
Q

What is needed to identify a IUP (rather than a PUL)?

A

Yolk sac and gestational sac

307
Q

Recall the process of TVUSS dating of pregnancies

A

1st. Look for foetal heartbeat
2nd. Find foetal poles for CRL (crown rump length)
3rd. If not foetal pole, look for gestational sac

308
Q

How would a miscarriage be identified on TVUSS?

A

Absence of foetal HR and CRL >7mm

OR

Growth Sac > 25mm + no foetus

Also need 2 opinions - one USS alone is not enough

309
Q

What happens if a TVUSS shows no FH and CRL <7mm?

A

PUV (pregnancy of unknown viability)

Repeat TVUSS in 7 days

310
Q

What investigations should be done in recurrent miscarriage?

A

Cytogenic analysis of products of conception, pelvic USS, anti- phospholipid antibodies, screen for BV

Explain that cause is often never found

311
Q

Recall the management of PV bleeding during pregnancy

A

If signs of an ectopic or severe bleeding: admit to surgeons

If more than 6w pregnant: GDR/EPU referral

If a viable pregnancy: go home and follow expectant management

If a complete miscarriage: council and go home

If <6w pregnant, expectant mx: no USS

312
Q

How should miscarriage with retained products be managed?

A

1st line is expectant management for 7-14 days: if the bleeding/ pain settle, have a pregnancy test after 3 weeks.

Return if +ve.

If pain/ bleeding persist, go to follow up clinic in 4 weeks.

2nd line is medical or surgical management - depends on patient

Medical: misoprostol

Surgical: Suctioned RPC

313
Q

How should thrombophilia/ anti-phospholipid syndrome be managed in pregnancy?

A

Low-dose aspirin and LMWH (clexane (enoxaparin))

314
Q

What is the ‘chorion’ and ‘amnion’?

A

Chorion = outermost foetal membrane

Amnion = membrane closely covering embryo

315
Q

What % of monozygotic twins are dichorionic diamniotic - and what sign on USS shows this?

A

2 placenta and 2 amniotic sacs = 25%

Lambda sign

316
Q

What % of monozygotic twins are monochorionic diamniotic - and what sign on US is useful for identifying this?

A

75% - 1 shared placenta

T sign

317
Q

What is lambda sign?

A

In dichorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be a triangular placental tissue projection into the base of the membrane

318
Q

What is the T sign?

A

In monochorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be no placental tissue projection into the base of the membrane

319
Q

How should multiple pregnancy be managed antenatally?

A

FBC at 20-24 weeks

BP (as increased risk of eclampsia)

GTT (Increased likelihood of diabetes)

TTTS monitoring/ growth scans - every 2w starting at 16w for shared placentas, every 4w starting at 20w for no shared placenta

Serial USS for foetal growths

320
Q

How can a breech baby be turned in a multiple pregnancy when the other baby is cephalic?

A

Internal pedalic version

321
Q

Recall some possible foetal complications of multiple pregnancy

A

IUGR

Downs

Structural abnormalities

Twin to twin transfusion syndrome (TTTS)

322
Q

Recall 3 possble maternal complications to multiple pregnancy

A

Pre-eclampsia, hyperemesis gravidarum, GDM

323
Q

In what type of pregnancy does TTTS occur?

A

Monochorionic twins

324
Q

What are the symptoms of TTTS?

A

Sudden increase in abdominal size, SOB

325
Q

How should TTTS be managed?

A

If <26w, foetoscopic laser ablation of vascular anastomoses

If >26w, delivery

326
Q

What is the pathogenesis of TTTS?

A

Direct arterial to venous flow in placenta

  • Donor baby = SGA + oligohydramnios
  • Recipient baby = LGA + polyhydramnios
327
Q

What is the diagnostic criterion for TTTS?

A

>25% difference between EFW

328
Q

What are the risks to the recipient baby in TTTS

A

More blood –> more cardiac strain –> hydrops fetalis

329
Q

What BMI is classified as obesity?

A

>30

330
Q

What should be considered pre-delivery in obese mums?

A

Assess risk of giving birth vaginally and whether there needs to be induction/CS

331
Q

How is oligohydramnios defined?

A

<5th centile

Deepest pool <2cm

332
Q

Recall the risk factors for oligohydramnios

A

Reduced input fluid: placental insufficiency, pre-eclampsia

Reduced output fluid: structural pathology, medications

Lost fluid: ROM, IUGR, post-term pregnancy carry, TTTS

Chromosomal abnormalities

333
Q

What are the signs and symptoms of oligohydramnios?

A

Hx of fluid leak PV

Abdo exam - decreased fundal height, foetal parts easily palpable

Speculum - assess for membrane rupture

334
Q

What are the risk factors for polyhydramnios?

A

Congenital infections

Foetal polyuria

Any failure of foetal swallowing

335
Q

What investigations are useful in polyhydramnios?

A

Liquor volume, foetal growth, UA doppler, exclude foetal abnormalities

Also exclude maternal DM

336
Q

How should polyhydramnios be managed?

A

Antenatal foetal monitoring and DM monitoring

Amnioreduction - if gross reduction COX inhibition

Internal pedalic version - to decrease foetal urine output

337
Q

What is placenta praevia?

A

Low-lying placenta = placental edge <2cm from internal os on TVUSS - placenta lies over internal os

338
Q

After what GA can placenta praevia be diagnosed?

A

32w

339
Q

Recall 2 signs/symptoms of placenta praevia

A

Painless PV bleeding

Potential signs of shock

340
Q

What is the first line investigation for diagnosis of placenta praevia?

A

TVUSS

341
Q

What other investigations should be done in placenta praevia?

A

Kleihauer test/ Rhesus test

If mother RhD -ve –> Kleihauer test (check level of blood in maternal circulation).

Administer RhD

Do not perform a bimanual

342
Q

How should placenta praevia be managed when there is minimal bleeding?

A

Symptomatic management - if bleeding settles, they should be admitted for 48 hours for observation

343
Q

How should a low-lying placenta at 20w scan be managed?

A

Rescan at 32w as only 10% go on to have a low-lying placenta later in pregnancy

If still present and grade I/II at 32 weeks, rescan at 36w –> if still low, recommend CS

If still present and grade III/IV, admit at 34w and CS 37 weeks USS at 36w to decid

344
Q

How should PP be managed (with and without bleeding/ labour or no labour)?

A

No bleeding, no labour, preterm: Monitoring, possibly in hospital, steroids if pre term, anti-D if Rhesus negative

No bleeding, labour, preterm: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative

No bleeding, at term: Normally C-section after 35 weeks

Bleeding: Stabilise the mother haemodynamically. The secondary goal is to ensure foetal survival

  • Not stabilized by resus: Emergency C-section
  • Stabilised, not in labour: MDT discussion with seniors, corticosteroids if less than 34 weeks
  • Stabilised, pre-term labour: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative

Stabilised at term or labour: Emergency C-section

345
Q

What are the complications for the mother in PP?

A

Haemorrhage, antepartum haemorrhage and postpartum haemorrhage, DIC, hysterectomy

346
Q

Recall the pathophysiology of vasa praevia

A

Foetal vessels course through membrane over the internal cervical os and below foetal presenting part, unprotected by placental tissue or umbilical cord. When baby descends they can rupture the vessels.

347
Q

What is the difference between type 1 and 2 VP?

A

Type 1 = velamentous cord insertion in a single/ bilobed placenta

Type 2 = foetal vessels running between lobes of placenta with at least 1 accessory lobe

348
Q

What is the haemorrhage of blood called when the vessels rupture in vasa praevia?

A

Benckaiser’s haemorrhage

349
Q

What are the signs and symptoms of VP?

A

ROM –> fresh PV bleeding + foetal bradychardia

350
Q

What symptoms of vasa praevia are seen in the foetus?

A

HR abnormalities - decelerations, bradycardia, sinusoidal trace

351
Q

What investigations should be done in suspected vasa praevia?

A

Kleihauer test: measures amount of foetal Hb in a mother’s bloodstream

Hb electrophoresis: identify if foetal or maternal blood (takes a wee while)

Doppler USS

352
Q

How should vasa praevia be managed?

A

C section

353
Q

What are the complications of vasa praevia?

A

No major maternal risk but dangerous for foetus

Foetus loses relatively small amounts of blood, which can have major implications

Need to rapidly deliver and aggressively resuscitate including transfusion if necessary

354
Q

What is placental abruption?

A

Separation of the placenta from the uterine wall before delivery (>24w, if <24w = miscarriage)

355
Q

What is the pathophysiology of placental abruption?

A

As placenta separates, retroperitoneal bleeding results in further detachment

356
Q

What are the signs and symptoms of placental abruption?

A

Constant abdo pain +/- PV bleeding, SUSTAINED contractions

OE: shock, speculum can show bleeding, abdomen reveals woody, tender uterus, vaginal exam (NOT IN PRAEVIA) shows cervical dilatation

357
Q

How can placental abruption and placenta praevia be distingiushed clinically?

A

Need to distinguish so that you don’t inappropriately do a vaginal exam on someone with placenta praevia

PP - bleed, no pain

Abruption = bleed and pain

358
Q

How should mild placental abruption be managed?

A

If preterm and stable: conservative management with close monitoring

Admit for at least 48 hours or until bleeding stops

Anti-D Ig followed by Kleihauer test

359
Q

How should severe placental abruption be managed?

A

ABC

Emergency CS

2 x wide bore cannulae, fluids, blood transfusions, correct coagulopathies

FBC/X match/ Kleihauer test/ anti-D if needed, steroids

CTG if >27w, consider IOL if foetal compromise, TVUSS if query PP

360
Q

What are the possible maternal complications of placental abruption?

A
  • Haemorrhage (APH/PPH)
  • DIC
  • Renal failure
  • Couvelaire uterus (it goes rock solid because of blood that has extravasated into the myometrium and beneath the peritoneum)
361
Q

What are the possible foetal complications of placental abruption?

A

Birth asphyxia, death

362
Q

Define PPH

A

Blood loss >500 mls SVD or >1000mls at CS

363
Q

What is a secondary PPH?

A

24 hours to 12w PP

364
Q

What are the causes of PPH?

A

Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)

Tone = Uterine atony

Tissue = related to placental products (membranes, cotyledon, succenturiate lobe)

Trauma

Thrombin = coagulopathy (existing or acquired)

365
Q

How can uterine atony be avoided?

A

Giving oxytocin with delivery of anterior shoulder or placenta

366
Q

Recall 4 causes of secondary PPH

A

Endometritis

Retained products

Abnormal involution of placental site

Trophoblastic disease

367
Q

What are the signs and symptoms of primary PPH?

A

General (shock)

Abdomen will have atonic uterus above umbiloicus

Speculum: exclude trauma

Vaginal - evacuate clots from cervix

368
Q

What classifies as a ‘major PPH’?

A

>1000mls blood loss or signs of shock

369
Q

How should PPH be managed?

A

If major - ring emergency buzzer

  1. Bimanual compression (rub up a contraction if in theatre)
  2. IM/IV Syntocinon (oxytocin)
  3. IM Ergometrine (not in HTN/ asthmatics)
  4. IM Carboprost
  5. Balloon tamponade
  6. B-lynch suture, ligate
370
Q

What is placenta accreta?

A

Strong attachment of placenta - but not into the muscle wall

371
Q

What is placenta increta?

A

Strong attahment of placenta into uterine wall

372
Q

What is placenta percreta?

A

Strong attachent of placenta, through the uterine wall

373
Q

What is the biggest risk factor for placenta accreta/increta/percreta?

A

Previous CS or uterine surgery

374
Q

What investigations should be done in placenta accreta/increta/percreta?

A

TVUSS

MRI to assess depth of invasion

375
Q

How should placenta accreta/increta/percreta be managed?

A

Managed delivery +/- caesarean hysterectomy

376
Q

What is the difference between PROM and PPROM?

A

PROM = pre-labour rupture at TERM, PPROM = premature rupture

377
Q

What is the cause of PROM?

A

Just physiological - but only affects <10% of women

378
Q

What is the cause of PPROM?

A

Can be caused by weakening of membranes due to infective cause (often subclinical)

379
Q

What are the signs and symptoms of (P)PROM?

A

Sudden gush of fluid leading to a constant trickle

380
Q

What investigations should be done in (P)PROM?

A

DO NOT DO A BIMANUAL (like in PP)

1st: speculum: amniotic fluid pooling is diagnostic

  • If >30w, contractions and os closed, TVUSS for cervical length
  • If is >15mm it is unlikely to be a PTL

2nd: IGFBP-1/PAMG-1: these are suuuper sensitive so if a negative result, there is a v low chance of PROM
3rd: Foetal Fibronectin (FFN) may be present - positive in PROM

381
Q

How should PPROM be managed?

A

Admission and expectant management until 37w

Do not offer tocolysis

Erythromycin and CS (24hours) and MgSO4 (if <30w)

Carefully monitor for chorioamnionitis

382
Q

How should PROM be managed?

A

If clear liquor: expectant management for 24 hours, if >24 hours –> IOL

If meconium, induce labour asap

383
Q

Define PTL, very PTL and extremely PTL

A

PTL = 32-37w GA

Very PTL = 28-32w GA

Extremely PTL = <28w GA

384
Q

What is the biggest risk factor for PTL?

A

Infection

385
Q

What is the biggest maternal lifestyle risk factor for PTL?

A

Smoking

386
Q

How should PTL be investigated?

A

CTG monitor

Urine dip +/- MCandS if indicated

387
Q

How should PTL be managed?

A

If membranes rupture –> PPROM management

If membranes not ruptured:

Medication:

  • Tocolysis (if less than 34w: 1st line is nifedipine, 2nd line is atosiban)
  • 24 hours of corticosteroids
  • MgSO4 if less than 30w

Surgery:

  • Emergency ‘rescue’ cerclage
388
Q

What is the indication for surgical management for PTL?

A

16-28w

Dilated cervix

Exposed unruptured membranes

389
Q

Give 3 contraindications of surgical management of PTL

A

Infection, bleeding, uterine contractions

390
Q

What PTL prophylaxis be given?

A

Vaginal progesterone

Cervical cerclage

391
Q

Which women are offered prophylaxis for PTL?

A

If they have a hx of PTL and any of:

  • cervical length <25mm
  • >16w GA miscarriage
  • Cervical length <25mm and hx of PPROM
  • cervical trauma
392
Q

What are the ‘big four’ complications of pre-term birth?

A

Respiratory distress syndrome

NEC

Intrvascular haemorrhage

Periventricular leukomalacia

393
Q

What % of the population are Rh negative?

A

15%

394
Q

Describe the process of Rhesus disease development

A

Rh neg mother has a Rh pos child

Sensitising event mixes blood (Simple SVD is not a sensitising event)

Mother develops IgM anti-Rh Abs

Mother delivers or miscarries child

*Time passes*

Mother has a second Rh+ child –> Mother’s IgG anti-Rh crosses the placenta

–> hydrops fetalis

395
Q

Why does Rhesus disease never occur in first primoparous mothers?

A

IgM cannot cross the placenta - IgG (produced later) can

396
Q

What test should be done in a known Rh neg mother?

A

cffDNA testing - tests for the child’s Rh status

397
Q

Recall the pathophysiology of hydrops fetalis in Rh disease

A

IgG anti-Rh Abs against foetal RBCs –> HDN = anaemia + high BR –> hydrops fetalis, foetal anaemia + kernicterus

398
Q

What is the Kleiheur test?

A

It measures the amount of foetal Hb that passes into the mother’s bloodstream

399
Q

Recall the indication and management for routine anti-D prophylaxis

A

Indication: Rh neg mother

Management: Indirect antigobulin test at booking

Either 2 doses of 500IU at 28 + 34w, or 1 dose of 1500IU at 28w

Foetal cord bloods post-delivery and prophylaxis in 72 hours if baby pos with Kleiheur

400
Q

Recall the prophylaxis protocol following a sensitising event

A

Needs to be done within 72 hours of the event

If <20w –> 250IU

If >20w –> 500IU

401
Q

How can a baby be monitored when a mother has anti-D antibodies?

A

Middle cerebral artery dopplers

402
Q

What are the 5 skin diseases of pregnancy?

A

Pemphygoid gestationis

PUPPP

Prurigo of pregnancy

Pruritis folliculitis A

atopic eczema

403
Q

Recall some physiological changes in the skin during pregnancy

A

Pre-existing conditions worsen

Increased pigmentation

Spider naevi affecting face, arms and upper torso

Broad pink linear striae - striae gravidarum common over lower abdo + thighs

Hand and nipple eczema post-partum

Psoriasis

404
Q

What is pemphigoid gestationis?

A

Rare pruritic autoimmune bullous disorder

405
Q

When does pemphioid gestationis present?

A

2nd or 3rd trimester

406
Q

What are the signs and symptoms of pemphigoid gestationis?

A

Widespread clustered blisters, sparing face: usually begin on abdomen

407
Q

How should pemphigoid gestationis be managed?

A

Potent topical steroids to relieve pruritis, oral prednisolone to stop new blisters forming

408
Q

What does PUPPP stand for?

A

Pruritic Urticarial Papules and Plaques of Pregnancy

409
Q

Where does Polymorphic Eruption of Pregnancy (PEP) tend to present?

A

Abdomen - umbilicus sparing - then extending to thigh/ buttock etc

410
Q

When does Polymorphic Eruption of Pregnancy present?

A

3rd trimester/ immediately post-partum

411
Q

How should Polymorphic Eruption of Pregnancy be managed?

A

Symptomatic management only

412
Q

What % of normal pregnancies are affected by prurigo?

A

20%

413
Q

When does prurigo present?

A

Beginning in 3rd trimester and resolves upon delivery

414
Q

What does prurigo look like?

A

Excoriated papules on extensor limbs, abdomen and shoulder

415
Q

How should prurigo be managed?

A

Symptomatic treatment + topical steroids and emollients

416
Q

Where does pruritis folliculitis affect?

A

Trunk, can involve limbs

417
Q

When does pruritis folliculitis present?

A

2nd/3rd TM, may resolve on delivery

418
Q

Describe the appearance of pruritis folliculitis

A

Apears like acne (consider a type of hormone-induced acne)

419
Q

How should pruritis folliculitis be treated?

A

Topical steroids

420
Q

What are the main complications of maternal EtOH use at delivery?

A

Miscarriage, still birth, congenital abnormalities, LBW, SGA

421
Q

What is the main area of development affected by maternal EtOH use?

A

Neurodevelopmental

422
Q

How does smoking affect pregnancy?

A

Damages umbilical cord structure

Increased risk of ectopic/ placental abruption/ miscarriage

423
Q

How does smoking affect the neonate?

A

LBW/ PTL

424
Q

How does smoking affect the baby in the longterm

A

Less likely to have a long term effect

425
Q

How does cannabis affect pregnancy?

A

Increases NICU admission, as well as chance of LBW, SGA and PTL

426
Q

How does maternal cannabis use affect child development?

A

Adverse consequences of growth of foetal and adolescent brains

Reduced attention and executive funtioning skills

Poor academic achievement

Behavioural problems

427
Q

How does maternal cocaine use affect pregnancy?

A

Increases chance of PROM, PTL, LBW, SGA and placental abruption - due to vasospasm of uterine vessels

428
Q

How does maternal opioid use affect pregnancy?

A

Can cause 3rd TM bleeding and SGA

429
Q

How does maternal opioid use affect the neonate?

A

SIDS, toxaemia, microcephaly

430
Q

What is the name of the withdrawl syndrome from opioids in babies?

A

Neonatal abstinence syndrome

431
Q

Recall the presentation of neonatal opioid withdrawl

A

Irritability, hypertonia, seizures, emesis, respiratory distress

432
Q

What investigation should be done in a suspected DVT?

A

Duplex USS

433
Q

What investigation should be done in a suspected PE?

A

CXR, duplex USS - if both neg then do CTPA (better than V/Q scan as delivers smalled dose to baby)

434
Q

How should DVT be managed?

A

LMWH + elevate leg, apply graduated elastic stockings

435
Q

How should PE be managed in the longterm?

A

LMWH until 6w post-partum or 3m total treatment - whichever is greater

436
Q

How should minor PE be managed?

A

LMWH ie enoxaparin treatment dose

ECG + CXR –> If CXR is abnormal and clinical suspicion of PE –> CTPA

437
Q

How should massive PE be managed?

A

1st line = unfractionated heparin 2nd line = thrombolytic therapy, thoracotomy or surgical embolectomty

438
Q

How should unfractionated heparin be monitored?

A

APTT

439
Q

When is central venous sinus thrombosis most common?

A

Post-partum

440
Q

What are the signs and symptoms of central venous sinus thrombosis?

A

Headache and varying neurology

441
Q

How should suspected central venous sinus thrombosis first be investgated?

A

MRI

442
Q

How should central venous sinus thrombosis be managed?

A

IV unfractionated heparin –> thrombolysis –> 3-6m anticogulation

443
Q

Recall 2 possible side effects of heparin

A

Heparin-induced thrombocytopaenia

Heparin allergy

444
Q

How should VTE at term be managed?

A

IV unfractionated heparin –> thrombolysis –> 3-6m anticogulation

445
Q

How long before a planned delivery should LMWH be stopped?

A

24 hours prior to planned delivery

446
Q

How long after the last LMWH dose can an epidural be given?

A

24 hours

447
Q

How long after the epidural catheter removal can LMWH be given again?

A

4 hours after

448
Q

What drug is used to reverse IV unfractionated heparin?

A

Protamine sulphate

449
Q

By what route is clexane given?

A

Subcut

450
Q

How is VTE prevented in high-risk patients?

A

Prolonged use of LMWH and graduated elastic compression stockings

451
Q

In women of extremes of weight, how should VTE prophylactic treatment be measured?

A

Anti Xa levels

452
Q

What change in the thyroid fx is expected in pregnancy?

A

Fall in TSH and rise in T4 in 1st TM

453
Q

How should pre-existing thyroid medication be managed during pregnancy?

A

Thyroxine should be increased by 25 nanograms, even if currently euthyroid - helps to mimic physiological rise in T4 in 1st TM

454
Q

What thyroid disorder is associated with pregnancy?

A

Post-partum thyroiditis

455
Q

What are the diagnostic criteria for post-partum thyroiditis?

A

THREE criteria:

  • Less than 12 months since pt gave birth
  • Clinical manifestations are suggestive of hypothyroidism
  • TFTs alone (no need to measure TPO Ig)
456
Q

Describe the progression of postpartum thyroiditis

A

Stage 1 = thyrotoxicosis

Stage 2 = hypothyroidism

Stage 3 = Euthyroid

457
Q

What is the cause of postpartum thyroiditis?

A

It’s autoimmune - anti-TPO is present in 90%

458
Q

How should postpartum thyroiditis be managed?

A

Thyrotoxic phase = propranolol

Hypothyroid phase: thyroxine

459
Q

How should hyperthyroidism during pregnancy be managed?

A

Treat medically - no surgery, at lowest possible dose

Propylthiouracil in 1st TM

Carbimazole in 2nd/3rd TM

460
Q

What are the potential side effects of hyperthyroidism treatment on the foetus?

A

Foetal hypothyroidism - from high doses crossing the placenta

Agranulocytosis (do regular checks of maternal WCC)

461
Q

How should mild hyperparathyroidism be managed in pregnancy?

A

Adequate hydration and low calcium diet

462
Q

How should major hyperparathyroidism be managed in pregnancy?

A

Parathyroidectomy may be indicated for severe cases

463
Q

What are the signs and symptoms of UTI/ bacteruria in pregnancy?

A

FUNDHIPS

464
Q

How frequently is urinalysis and urine MCandS during pregnancy?

A

Urinalysis at every antenatal visit

MSU sent at booking visit

465
Q

What is the most likely causative organism in asymptomatic bacteriuria?

A

GBS (group B strep) - which is streptococcus agalactiae

466
Q

How should asymptomatic bacteriuria be managed?

A

Nitrofurantoin - but AVOID AT TERM

OR

Amoxicillin

OR

Cephalexin

467
Q

How should symptomatic UTI in pregnancy be managed?

A

MCandS showing GBS –> Abx

Do MSU before Abx starts

7 days nitrofurantoin

Amox/ cephalexin is 2nd line

468
Q

How should pyelonephritis be managed in pregnancy?

A

Cephalexin/ cefuroxime

469
Q

What common abx used in UTI is contraindicated in pregnancy?

A

Trimethoprim is contraindicated in 1st TM

470
Q

Recall 4 generic complications of ERPC

A

Bleeding, infection, procedural failure, necessity to repeat

471
Q

Recall 2 specific complications of ERPC

A

Intrauterine adhesions, perforation of uterus

472
Q

What is ECV?

A

External Cephalic Version

External manipulation of foetus through maternal abdomen to achieve a cephalic presentation

473
Q

What is the success rate of ECV?

A

50-60%

474
Q

When should ECV be offered?

A

If nulliparous - at 36 weeks

If multiparous - at 37 weeks

475
Q

How can the success rate of ECV be improved?

A

Add tocolysis and beta agonists

476
Q

Recall 3 drugs that can be used for tocolysis

A

Nifedipine

Atosiban (oxytocin receptor antagonist)

Terbutaline (beta agonist so not in asthma)

477
Q

What is the main contraindication for ECV?

A

Ruptured membranes

478
Q

What are the possible complications for ECV?

A

V low complication rate, but there may be procedural failure, placental abruption, uterine ruption

479
Q

What is CTG?

A

Cardiotocography

Continuous monitoring of the foetal heart and uterine activity, used in labour

480
Q

When is the booking appointment?

A

12 weeks

481
Q

When is the anomaly scan?

A

20+6w

482
Q

How is a foetal doppler done?

A

Used to monitor foetal HR and should be placed over the anterior shoulder of foetus

483
Q

How is foetal blood sampling done?

A

Blood withdrawn from umbilical vein

484
Q

What is foetal blood sampling used for?

A

Determine if severe anaemia caused by Rh sensitisation

485
Q

Recall a systemic method for interpreting CTGs

A

DR C BRAVADO:

DR = define risk - why are they on a CTG monitor? Previous CTGs?

C - contractions - normal is 5 contractions in 10 mins

BRA - baseline rate: 110-160bpm

V - variability: 5-25 bpm

A - accelerations: at least 2 every 15 mins

D - deceleratons: present? variable? Early? Late?

O - overall impression

486
Q

What is an acceleration?

A

Rise in foetal HR of >15bpm lasting >15s

Occurs in response to foetal movements

487
Q

What is a deceleration?

A

Drop of foetal HR of >15 bpm lasting >15 s

Late decelerations are much worse than early decelerations

488
Q

Define the baseline values for foetal bradycardia and tachycardia

A

<110bpm, >160bpm

489
Q

What counts as a loss of baseline variability, and what might cause it?

A

<5bpm (5-25 is normal)

May be caused by prematurity or hypoxia

490
Q

What is an early deceleration?

A

Deceleration that commences with onset of contraction and returns to normal with completion of contraction

491
Q

Recall one cause of early deceleration

A

Head compression (innocuous)

Generally not of concern

492
Q

What is a late deceleration?

A

Lags the onset of a contraction and does not return to normal until after 30s following end of contraction

493
Q

What is the cause of late decelerations?

A

Reduced uroplacental flow

494
Q

What is the cause of variable decelerations?

A

Cord compression

495
Q

Recall 2 indications for emergency CS that could be seen on CTG

A

Terminal braycardia: FHR <100bpm for more than 10 mins

Terminal deceleration: FHR drops and does not recover for more than 3 mins

496
Q

Recall the FHR, BV, decelerations and accelerations that typify a normal CTG

A

FHR: 110-160bpm

BV: 5-25

Dec: absent/early

Acc: 2 in 20 mins

497
Q

Recall the FHR, BV, decelerations and accelerations that typify a ‘non- reassuring’ CTG

A

FHR: 100-110, 161-180

BV: <5/

Late decelerations in >50% of contractions for >90 mins

Variable decelerations:

  • Alone for >90 mins
  • With <50% of contractions for >30 mins
  • With >50% of contractions for <30 mins
498
Q

What characterises as a pathological CTG?

A

<100bm/ >180bpm

Late decelerations >30 mins

Loss of BV/ too much BV

Acute bradycardia/ a single prolonged deceleration lasting >3 mins

SINUSOIDAL RHYTHM

499
Q

How should a sinusoidal rhythm seen on CTG be managed?

A

Immediate cat 1 emergency c section

500
Q

If a CTG is borderline, what is the next test you should do and why?

A

Foetal blood sampling - check for acisosis, which is a LATE marker of reduced oxygen delivery

501
Q

How many ‘non-reassuring’ features of CTG should there be for it to be considered pathological?

A

2

502
Q

How does foetal head compression affect the CTG?

A

Causes a baroreceptor reflex that leads to a uniform deceleration

503
Q

What should be the first course of action when a late deceleration is detected?

A

Immediate foetal blood sampling

504
Q

How should a non-reassuring CTG be managed?

A
  1. Left lateral position
  2. Stop oxytocin and consider tocolysis - exclude an acute event (like cord prolapse or uterine rupture), correct any underlying causes and give fluids (IV/ oral)
  3. Digital foetal scalp stimulation (this accelerates the HR)
505
Q

Recall 4 indications for IUD

A

Long-term contraception

Endometriosis

Menorrhagia

HRT

506
Q

Recall 7 requirements for forceps delivery

A

FORCEPS

Fully dilated cervix

OA position

Ruptured membranes

Cephalic presentation

Engaged presenting part

Pain relief

Sphincter (bladder) empty

507
Q

What are the 4 categories of CS

A

Cat 1 = immediate threat to life of woman/ foetus

Cat 2 = immediate threat to life of woman/ foetus

Cat 3 = requires early delivery

Cat 4 - elective CS

508
Q

What is the main complication risk with forceps delivery?

A

3rd degree perianal tears

509
Q

Which type of instrumental delivery is more dangerous for the foetus?

A

Ventouse

510
Q

What is the main risk of a prolonged ventouse delivery?

A

Haemorrhage in the newborn

511
Q

What are the possible complications of ventouse delivery?

A

Cephalohaematoma

Intracerebral haemorrhage

Retinal haemorrhage

Jaundice

512
Q

What is the main risk to the foetus from forceps deliveries?

A

Facial nerve palsies eg. Erb’s palsy from shoulder dystocia

513
Q

Recall 3 absolute contradicitions for vaginal birth after C section (VBAC)

A

Previous uterine rupture

Classical (vertical) C section scar

Other non-C section contraindications (eg maor placenta praevia)

514
Q

Which has fewer complications: elective repeat CS or vaginal birth after CS?

A

VBAC

515
Q

What are the main benefits of elective repeat C section?

A

No risk of rupture

Able to plan recovery

516
Q

What are the main risks of elective repeat CS?

A

Pelvic adhesions

Longer recovery

Risk of bladder/ bowel injury (rare)

Placenta praevia/ accreta

Neonatal respiratory morbidity

517
Q

After how many weeks should an elective repeat C section be performed?

A

After 39 weeks

518
Q

What two forms of prophylactic treatment should all women getting a CS receive?

A

Thromboprophylaxis

Prophylactic Abx

519
Q

Recall the 3 points of aftercare for a C section scar

A
  1. Keep it dry and get sutures taken out after 5 days
  2. No heavy lifting for 6 weeks
  3. No getting pregnant for 12-18 months
520
Q

Describe the two options for surgical sterilisation

A
  1. Hysteroscopic sterilisation - expanding springs inserted into tubal ostia via hysteroscope –> induce fibrosis
  2. Tubal occlusion - occlude fallopian tubes with Filshie chips
521
Q

What is a safer, quicker procedure for surgical contraception than sterilisation?

A

Vasectomy

522
Q

For how long after a sterilisation operation shoud women abstain from UPSI?

A

3 weeks

523
Q

What should always be done before the sterilisation procedure?

A

Pregnancy test

524
Q

For how long after sterilisation is effective contraception required?

A

If laparoscopic procedure: the next menstrual period

If hysteroscopic procedure: 3 months

525
Q

What obstetric condition are women who have been sterilised at higher risk of?

A

Ectopic pregnancy

526
Q

Recall the indications for TOP under the Abortion Act

A
  • [A] Continuation of pregnancy involves risk to pregnant woman greater than if pregnancy were terminated
  • [B] Termination necessary to prevent grave permanent injury to physical/mental health of pregnant woman
  • [C; majority] Pregnancy has not exceeded 24th week and continuance of the pregnancy would involve risk, greater than if pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
  • [D] Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing children of the family of the pregnant woman
  • [E] There is substantial risk that if the child were born it would suffer from physical or mental abnormalities
  • [EMERGENCY; F] To save the life of the pregnant woman; or
  • [EMERGENCY; G] To prevent grave permanent injury to the physical or mental health of the pregnant woman
527
Q

What is the % risk of infection from TOP?

A

10%

528
Q

What is required for a sign off of a TOP?

A

2 doctors unless an emergency

529
Q

What must be done before a TOP?

A

Abx prophylaxis

Screen for chlamydia/ other STI if indicated

Assess VTE risk

Discuss future contraceptive needs (OCP/ IUD)

Check Rh status Bloods (eg haemaglobinopathy)

530
Q

What is the max time between seeing a GP and having a TOP?

A

Less than 2 weeks

531
Q

Recall the medical option for abortion at each stage of pregnancy

A

2 pills = 200mg mifepristone, then misoprostol (prostaglandin, 24-48 hours later)

0-9w: administer at home (bleeding for 2w after abortion)

9-24w: administer in clinic and repeat misopristol 3-hourly until expulsion

>22w: use feticide (intracardiac KCl injection)

532
Q

Recall the surgical option for TOP

A

<14w: misoprostol (dilates) then ERPC (vacuum aspiration) + hCG level

>14w: misoprostol (dilates) then dilatation and curettage - under LA or GA

533
Q

What are the booking tests done in pregnancy?

A
  • FBC
  • MSU
  • Blood group and antibody screen
  • Rhesus status and atypical antibodies
  • Haemaglobinopathy screen if indicated
  • Infection screen (Hep B, syphilis, HIV, rubella)
534
Q

Recall a mnemonic to remember the causes of microcytic anaemia

A

TAILS

Thalassaemia

Anaemia of chronic disease

IDA

Lead poisoning

Sideroblastic anaemia

535
Q

What type of hepatitis is included within the 1st trimester infection screen?

A

Hep B and now (recently) C

536
Q

What test can be used to predict risk of trisomy 13/18/21 follwing a result of increased nuchal translucency (but isn’t yet funded by the NHS in most trusts)?

A

cffDNA

537
Q

What is the expected B-hCG and PAPP-A in trisomy 21?

A

High B-hCG and low PAPP-A

538
Q

When is the ‘triple test’ done and what does it involve?

A

14-20w

AFP, PAPP-A, b-hCG

539
Q

What does the anomaly scan look for?

A

Spina bifida

Diaphragmatic hernia

Major congenital abnormalities

Renal agenesis

540
Q

What supplementation is given to all women during pregnancy?

A

Folic acid 400micrograms (5mg in epilepsy/ BMI >30)

Vit D

541
Q

What breast changes should be expected at 12w, and why?

A

Nipples darken and breasts enlarge as this is highest oestrogen and human placental lactogen

542
Q

What is hPL and what is its role?

A

Homologue to GH:

  • Decreases insulin sensitivity
  • Increases lipolysis to increase glucose availability for baby
  • Decreases glucose utilisation
543
Q

What is B-hCG a homologue to?

A

TSH

544
Q

What steroid and dose is used antenatally?

A

2x12mg IM Betamethasone - given 24 hours apart

Alternative: 4 doses of 6mg IM dexamethosone 12 hours apart

545
Q

What is a partogram?

A

Pictorial assessment of the progress of labour, allowing rapid identification of slow/ obstructed labour

546
Q

Who needs a partogram?

A

All women in active labour (>4cm dilated, contracting >3 in 10)

All women on synctocinon

Threatened premature labour with the use of atosiban

547
Q

What is the mechanism of action of atosiban?

A

Inhibits ocytocin and vasopressin

548
Q

What are the components of a partogram?

A

Maternal HR every 30 mins

Contractions every 30 mins

Colour of liquor every 30 mins

Cervicograph

Cervical dilation every 4 hours

BP and temp every 4 hours

Abdominal descent

549
Q

What is the expected speed of cervical dilatation in a nulliparous vs a multiparous woman?

A

Nulliparous: 0.5cm/ hour

Parous: 0.5-1cm/ hour

550
Q

What speed of labour on the partogram may suggest a prolonged labour?

A

0.5cm/ hour

551
Q

What is the ‘action line’ on the partogram?

A

4 hours right of the alert line - if the cervical dilation crosses this then urgent obstetric review is needed

552
Q

What is the first point of management in cord prolapse?

A

Summon senior help (and consider baby monitoring with CTG)

553
Q

How can further cord prolapses be prevented?

A

Digital vaginal exam

Elevate the presenting part/ fill the bladder to reduce pressure

Tocolytics

Avoid handling the cord as this causes cord spasm

IF CORD PAST INTROITUS, DON’T PUSH BACK IN

Deliver ASAP

554
Q

How should the mother be positioned in cord prolapse?

A

Either on all 4s or in left lateral position

555
Q

Recall the definition of the 4 degrees of tear

A

1st degree = superficial damage with no muscle involvement

2nd degree = injury to perineal muscle, but no anal sphincter involvement

3rd degree = injury involves anal sphincter complex (3a = <50% of external anal sphincter involved, 3b = >50% of eas, 3c = involves interna sphincter)

4th degree = injury to perineum involving anal sphincter and rectal mu

556
Q

What types of tear can be managed by the GP alone?

A

1st and 2nd degree

557
Q

By how much does cardiac output input increase during pregnancy?

A

50%

558
Q

How much does stroke volume increase by in pregnancy?

A

35%

559
Q

By how much does tidal volume increase during preganancy?

A

30-50%

560
Q

How do kidneys change during pregnancy?

A

More aldosterone (fluid retention)

GFR increases in 1st TM

561
Q

What are the expected haematological changes in pregnancy?

A

Macrocytosis

Neutrophilia

Thrombocytopaenia

Dilutional Anaemia

Increased VWF, F7 F8, fibrinogen

Decreased protein S

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