Maternal medicine Flashcards
A black multigravid woman who underwent a CS for failure to progress after an induction for PET complicated by endometritis, comes to see you 5/52 post partum with fatigue/dyspnoea/orthopnoea. O/E HR 110, BP 140/95, pretibial oedema, RUQ tenderness, fine crackles at both bases, CXR cardiomegaly, temp 36.7. What is Dx?
a) post partum cardiomyopathy
b) mitral stenosis
c) pulmonary hypertension
d) bacterial endocarditis
A - post partum cardiomyopathy
At routine cardiovascular examination in pregnancy, which of the following may be normal:
a) diastolic murmur
b) 3rd heart sound
c) ejection click
d) renal bruit
b - third heart sound
perceptible in 80% of pregnant women
A woman with severe idiopathic cardiomyopathy is having an atonic PPH. EBL 800-1000ml. You have given 10 units Syntocinon but she is still bleeding. Next agent should be?
a) further 10 units oxytocin IV
b) oxytocin 40units in 1L Hartman’s over 4 hours
c) prostaglandin F2-alpha 1.5mg intramyometrially
d) ergometrine 0.25mg intravenously
e) misoprostol 200-400mcg orally
d) ergometrine 0.25mg intravenously
O
**Note if infusion ideally in 500mL of fluid and rate is reduced by half
Oxytocin in slow infusion is recommended (as per O&G magazine)
https: //www.ogmagazine.org.au/22/3-22/maternal-heart-disease-in-labour/
- also see NICE guideline: https://www.nice.org.uk/guidance/ng121/chapter/Recommendations#heart-disease
Misoprostol is OK
Carboprost (PGF analogues) increases pulmonary vascular resistance therefore not suitable
- not recommended in significant cardiac disease
Avoid ergometrine in HTN as causes vasoconstriction, exam answer says it is OK if context of cardiomyopathy
Risk of cardiac disease in a patient aged 35 who undergoes surgical castration (BSO) compared to a normal woman of the same age
a) < control
b) equal to control
c) x2 control
d) x3 control
e) x4 control
c) x2 control
Doubles cardiovascular risk
39 yo woman had elective repeat GA LSCS and developed pleuritic chest pain and tachypnoea 3 days postop. WCC 11.000, CXR showed R lower lobe atelectasis. ABG showed pO2 65mmHg. Next most appropriate step:
A - pulmonary angiogram
B - ventilation perfusion lung scan
C - chest physio and deep breathing exercises
D - IV antibiotics
E - Pulmonary CT scan
B - ventilation perfusion lung scan
College of radiologists suggests VQ first line for PE postpartum
37yo African-American multi 5 weeks following LUSCS for FTP with PET and postpartum endometritis. 4/7 history of progressive fatigue, SOB and orthopnoea. O/E pulmonary rales, third heart sound audible, tender liver, pretibial oedema. Afebrile, BP increase, tachypnoeic, tachycardic. ECG shows sinus tachycardia, CXR shows cardiomegaly. The most likely diagnosis is:
A - mitral stenosis
B - peripartum cardiomyopathy
C - pericarditis
D - pulmonary HTN
E - bacterial endocarditis
B - peripartum cardiomyopathy
O
Mother has anti Ro detected. What is the risk of congenital complete heart block in the fetus?
a - <5%
b - 10%
c - 20%
d- 30%
e - 40%
a - <5%
Regarding Bell’s Palsy:
a - it is caused by compression of the facial nerve in the pterygopallatine fossa
b - it responds to NSAID’s
c - it causes a sensory nerve deficit
d - it is most common in late pregnancy
d - it is most common in late pregnancy
Most cases in the 3rd trimester and 1st post-partum week
Which is the most incorrect statement regarding the management of ITP?
a - LUSCS is of no benefit to fetus with known severe thrombocytopaenia
b - fetal risk increases if the mother has a past history of splenectomy
c - fetal scalp sampling shouldn’t be used because of the risk of bleeding
d - maternal steroids should be given if the platelet count drops below 100
e - fetal risk can be determined by maternal antibody titre
e - fetal risk can be determined by maternal antibody titre
Diagnosis of exclusion, we don’t do antibody titre
Which of the following is most normal in a normal pregnancy?
A - MCV 105
B - WCC 12
C - Platelets 100,000
D - Reticulocytes 15%
B - WCC 12
Which of the following features is helpful in distinguishing HELLP syndrome from TTP?
A - TTP requires immediate delivery of fetus
B - DIC occurs more commonly with HELLP than TTP
C - Liver dysfunction is more common with TTP
B - DIC occurs more commonly with HELLP than TTP
Alloimmune thrombocytopenia, management, correct option:
a - IV immunoglobulin
b - Plasmapheresis
c - Prednisolone
d - Betamethasone
e - Fetal platelet transfusion
a - IV immunoglobulin (IVIGs)
TTP and HELLP, incorrect option
A - TTP more correlated with DIC
B - HELLP more associated with neurological abnormality
C- HELLP more associated with haemolysis
A - TTP more correlated with DIC
ITP, correct option:
a - caesarean section is not helpful in known severe fetal thrombocytopenia
b - FBS should not be attempted due to risk of bleeding from puncture site
c - Splenectomy decreases the likelihood of correlation between maternal and fetal platelet counts
d - Maternal antiplatelet ab levels correlate with incidence of neonatal platelet levels
b - FBS should not be attempted due to risk of bleeding from puncture site
*CHECK
Similar question from M implies C would be correct.
Mainstay of treatment for TTP
a - steroids
b - plasmapheresis
c - Ig infusion
b - plasmapheresis
TTP results from defective ADAMST13 enzyme. Test for the same confirms.
Reduction of ADAMTS13 enzyme - poor cleavage of von willebrand factor - hyperactive so higher plt aggregation to endothelial surfaces. Microthrombi in capillaries and arterioles. Diffuse endothelial insult.
Aggressive treatment with FFP and plasmapheresis removes and replaces defective ADAMST13 with effective enzyme to limits vascular injury and improve prognosis. Corticosteroids may be of benefit. Delivery does not affect course of TTP
M
32 yo G4P3 with 3 previous uneventful pregnancies and deliveries arrives in labour at term and if found to have platelet count of 85. Otherwise NAD. Most acceptable management is:
a- normal delivery and neonatal platelet count
b- notification of blood bank to have platelet packs available for maternal transfusion
c- LUSCS rather than mid-cavity forceps to minimise fetal trauma
d- Fetal platelet count (by scalp sampling)
a- normal delivery and neonatal platelet count
O
Mainstay of treatment of neonatal alloimmune thrombocytopaenia is:
a - steroids
b - intrauterine platelet transfusion
c - maternal immunoglobulin
c - maternal immunoglobulin (IVIGs)
In comparing HELLP to TTP, which is not true?
a. liver dysfunction is more common with HELLP
b. DIC is more common with HELLP
c. Delivery of fetus in not mandatory with HELLP
c. Delivery of fetus in not mandatory with HELLP
PG at 32/40 with BP 130/90, headache and epigastric pain. VE cervix long and closed. LFT’s reveal elevation of ALT?? And plt count of 70 000. MX?
a. observe
b. IOL
c. Platelet transfusion
d. LUSCS
d. LUSCS
MG presents unbooked in early labour. Platelet count is incidentally noted to be 90, 000. Management?
a. allow to labour and anticipate vaginal delivery
b. LUSCS
c. Assess fetal platelet count (scalp or cordocentesis)
d. Plasmapheresis
a. allow to labour and anticipate vaginal delivery
A MG presents unbooked at 38 weeks with a Hb of 6.8. If untreated the most likely cord Hb is
a - 10
b - 14
c - 16
d - 20
c - 16
No correlation between maternal anaemia and fetal Hb
Normal 14-22
What compound is at the greatest concentration in blood in physiological conditions?
a- carbon dioxide
b - bicarbonate
c - carbonic acid
d - all are at equal concentrations
b - bicarbonate
Carbon dioxide and carbonic acid are in equilibrium in the blood
Bicarbonate ions and carbonic acid are present in the blood in a 20:1 ratio if the blood pH is within the normal range
Which congenital coagulation disorder improves in pregnancy?
a - anti-thrombin 3 deficiency
b - vWB disease
c - protein C deficiency
d - protein S deficiency
e - haemophilia
b - vWB disease
vWF and FVIII both increase in pregnancy
A patient has an FBE with HB 10.4, MCV 70 and MCHC 28 (30-36). Which is true?
a - her film will show microcytosis
b - she should have a trial of folate
c - she will have target cells on film
d - reticulocyte count will be 10%
a - her film will show microcytosis
Iron studies show decreased ferritin, TIBC greatly increased.
a - transferrin will be low
b - reticulocyte count will be 15%
b - reticulocyte count will be 15%
transferrin goes up in iron deficiency
normal retic count is 10%
Which of the following is associated with intrahepatic cholestasis of pregnancy?
a - RUQ pain
b - High risk of recurrence in future pregnancies
c - Bilirubin levels >10
d - Excessive use of antacids
b - High risk of recurrence in future pregnancies
Intrahepatic cholestasis associated with all except:
A - neonatal jaundice
B - pruritis with onset of jaundice
C - 3rd trimester
D - increase premature delivery
A - neonatal jaundice
Premature delivery is iatrogenic
A 32 yo presents at 35/40 with recent onset malaise. BP 130/84, AST + ALT elevated, bilirubin 80, plt 60. O/E cervix long and closed. Mx?
a - IOL
b - LUSCS
c- Upper abdominal US for gallstones
d - Bed rest
b - LUSCS
high bilirubin in HELLP with haemolysis
Regarding Vitamin D and pregnancy - true or false for the following:
a - Insufficiency is a more serious state than deficiency
b - Deficiency can be corrected by daily administration of 10 mcg per day
c - Deficiency is detected by measuring levels of 1,25 dihydroxyvitamin D
d - Inadequate levels are associated with gestational diabetes
e - Vitamin D supplements help to prevent childhood rickets
a - Insufficiency is a more serious state than deficiency - FALSE
b - Deficiency can be corrected by daily administration of 10 mcg per day - FALSE 400IU OD recommended as supplement
c - Deficiency is detected by measuring levels of 1,25 dihydroxyvitamin D - FALSE - serum 25 hydroxyvitamin D levels
d - Inadequate levels are associated with gestational diabetes - TRUE
e - Vitamin D supplements help to prevent childhood rickets- TRUE
A 22 year old primigravida develops HELLP syndrome at 34 weeks of gestation with acute renal and liver dysfunction. After delivery she is transferred to Critical Care. Which of the following are true?
A - Intravenous N-acetylcysteine may be of benefit
B - Renal replacement therapy is not required until serum creatinine concentration exceeds 1000 micromol/L
C - Central venous access and arterial line placement is prevented by a platelet count of 75x109/L
D - Magnesium sulphate as seizure prophylaxis should not be given because of her renal impairment
E - Clotting factors such as fresh frozen plasma may be required
E - Clotting factors such as fresh frozen plasma may be required
A woman is pregnant after bromocriptine treatment of a pituitary macroademoma. Management during pregnancy should include:
A - continue bromocriptine
B - visual field assessment
C - xray sella turcica
D - neurosurgery
B - visual field assessment
No significant tumour:
- Stop treatment
- No follow up needed
Significant tumour:
- Usually stop treatment
- Follow up with regular radiological assessment
- Regular formal visual field checks
A multiparous woman presents 8 weeks post partum complaining of tiredness, palpitations and tremor. She has been losing weight and is unable to sleep. Pulse is 100 bpm, BP 160/90. The most likely diagnosis is:
A - HIV
B - Anxiety
C - Drug abuse
D - Thyrotoxicosis
D - Thyrotoxicosis
What woman has the best reproductive future?
A - PG Eclamptic fit with DIC, BP normal at 6/52
B - Multi with severe preeclampsia, BP normal at 3 months
C - Preeclampsia with diastolic BP 100mmHg at 3 months
D - Woman with essential hypertension
E - Woman with chronic renal failure, currently stable
D - Woman with essential hypertension
Prev PET - RR 7.2
Chronic HTN - RR 3.7
*CHECK as other answer says A…
1st ANC visit, 22yo primip, mother is NIDDM.
No glycosuria. You advise the patient:
A - no chance that she will get diabetes
B - need GTT in 2nd trimester
C - start prophylactic insulin
D - if doesn’t get glycosuria in pregnancy, no risk of diabetes
E -monitor her by doing fasting BSL in pregnancy
B - need GTT in 2nd trimester
The CLASP trial demonstrated that aspirin 60mg daily could:
A - reduce severe early onset IUGR associated with PET
B - reduce IUGR
C - both
D - neither
D - neither
Overall, the use of aspirin was associated with a reduction of only 12% in the incidence of proteinuric pre-eclampsia, which was not significant. Nor was there any significant effect on the incidence of IUGR or of stillbirth and neonatal death. Aspirin did, however, significantly reduce the likelihood of preterm delivery (19·7% aspirin vs 22·2% control; absolute reduction of 2·5 [SD 0·9] per 100 women treated; 2p=0·003). There was a significant trend (p=0·004) towards progressively greater reductions in proteinuric pre-eclampsia the more preterm the delivery.
Low-dose aspirin may be justified in women judged to be especially liable to early-onset pre-eclampsia severe enough to need very preterm delivery.
Your 38yo 16/40 patient with no known exposures has a Mantoux reaction of 16mm induration. She is asymptomatic and CXR is negative for active tuberculosis. Which therapy is recommended?
A - No treatment
B - Isoniazid 300mg daily for 6 months
C - Isoniazid 300mg daily for 12 months
E - Bacillus Calmette-Guerin vaccination
D - Rifampicin 100 mg daily for 12 months
A - No treatment
O
Doesn’t have active pulmonary disease
Can’t make diagnosis on Mantoux alone
?Latent
16 yo primip with HIV on Western blot test and 28 weeks pregnant. Risk of transmission to the fetus is:
A - 0%
B - 10%
C - 30%
D - 60%
E - 80%
In undiagnosed and untreated women, 20-30% risk of MTCT
With ART, appropriate mode of delivery, formula feeding, baby receiving PEP, incidence of perinatal transmission <2%
Risk decreases with decreasing levels of maternal HIV RNA (e.g. <1000 copies/ml) - <1%
2/3 of MTCT occurs during delivery
Each of the following antibodies may cause HDFN except:
a. Anti s
b. Anti Jka
c. Anti K
d. Anti P
d. Anti P
O
Anti JK only RARELY cause HDFN
Also not included are Anti-Lewis (non haemolytic)
A woman in mid pregnancy develops intractable constipation which has not responded to fibre supplements. The NEXT MOST APPROPRIATE therapy is
a. Lactulose
b. Magnesium sulphate
c. Coloxyl (docusate)
d. Bisacodyl
a. Lactulose
O
1st line - dietary fibre
2nd line - increase bulk
3rd line - osmotic - lactulose (MgSO4)
4th line - stimulant - bisadocyl, Docusate
Docusate - theoretically increase risk of PTB
A G1P0 has stable Crohn’s disease, MCV normal range, B12 110 micromols (normal > 127). The NEXT step is to
a. Take no action
b. Give IM B12
c. Repeat B12 concentrations
d. Check homocysteine levels
d. Check homocysteine levels
O
if borderline vit b12, check homocysteine as will be high in true deficiency.
Crohn’s is associated with increased risk B12 deficiency
A woman who works in a childcare centre presents with flu-like symptoms at 14 weeks gestation. She has read about CMV and is worried about the risk to the baby. Which of the following statements about CMV in pregnancy is CORRECT?
a. Maternal infection is usually associated with flu-like symptoms
b. Fetal infection is associated with echogenic bowel on a 20 week ultrasound
c. Primary and secondary maternal infection carries equal risk to the fetus
d. Spiramycin is an effective treatment in pregnancy
b. Fetal infection is associated with echogenic bowel on a 20 week ultrasound
O
Most primary infections are asymptomatic
Spiramycin is the treatment for toxoplasmosis
Which is true of CMV infection in pregnancy?
a. It is the commonest known virus transmitted trans-placentally
b. It is usually symptomatic at birth
c. The usual source of infection is ingestion of undercooked meat
d. It may cause an elevation of IgG in cord blood
a. It is the commonest known virus transmitted trans-placentally
O
A 35yo primigravida presents with occasional shortness of breath and palpitations at 35 weeks. The midwife queries the “expected changes” in pregnancy. You tell her that the physiological changes in pregnancy include:
a) Blood volume increases by 10% in a normal pregnancy
b) Red cell mass and plasma volume increases by similar amounts in normal pregnancy
c) White cell count increases by 20% in normal pregnancy
d) Stroke volume increases in a normal pregnancy
d) Stroke volume increases in a normal pregnancy
O
Blood volume increases by ~50%
Red cells mass increases less so (by 20-30%)
Which of the following laboratory results are normal in pregnancy?
a. Renal blood flow increased, urea increased, creatinine increased
b. Renal blood flow increased, urea decreased, creatinine increased
c. Renal blood flow increased, urea increased, creatinine decreased
d. Renal blood flow increased, urea decreased, creatinine decreased
d. Renal blood flow increased, urea decreased, creatinine decreased
O
Which of the following biochemical changes occurs MOST commonly in pregnancy, as compared with the non-pregnant patient
a. Increased urea
b. Increased alkaline phosphatase
c. Decreased TSH
d. Increased serum lipids
b. Increased alkaline phosphatase
O
At 27yo woman at 29 weeks gestation complains of a swollen, cold and painful right leg. On examination the leg is cool, swollen, with sluggish venous return. There is no evidence of DVT on lower limb doppler ultrasound and normal blood flow in the leg veins. The NEXT step is:
a. Organise a CT venogram of the pelvis
b. Organise MRI of the pelvis
c. Commence on prophylactic dose of clexane
d. Reassure patient and send her home
b. Organise MRI of the pelvis
O
Which statement regarding anticoagulation with warfarin is CORRECT
a. The drug effect is most rapidly reversed by FFP
b. Paracetamol in a normal therapeutic dose can cause a drug interaction
c. Treatment should be monitored with partial thromboplastin time
d. Breastfeeding is contraindicated
e. In pregnancy, warfarin is safe to use in the second trimester
a. The drug effect is most rapidly reversed by FFP
O
If fully anticoagulated and need urgent delivery:
- Reverse warfarin with prothombinase complex and FFP. Vitamin K helps to sustain the reversal effect.
- Reverse heparin and LMWH with protamine sulphate
(NB there is a study that demonstrates altered INR if regular paracetamol is ingested)
The INITIAL treatment of pulmonary embolus is:
a. 5,000 U heparin IV bolus then 30,000-35,000 U/24hour IV infusion
b. 5,000 U heparin SC every 12 hours
c. 5,000 U heparin IV bolus then 10,000-15,000 U/24hour IV infusion
d. 15,000 U heparin IV bolus then 50,000-60,000 U/24hour IV infusion
e. 20,000 U heparin SC every 8 hours
a. 5,000 U heparin IV bolus then 30,000-35,000 U/24hour IV infusion
O
NZF
- 5000 IU as bolus, then 18U/kg/hr infusion (which equals approx 25,000 U/24h if 60kg)
Which of the following congenital anomalies is most likely to be associated with diabetes mellitus?
a. Duodenal atresia
b. Posterior urethral valves
c. Isolated VSD (ventricular septal defect)
d. Gastroschisis
Think C - Isolated VSD (ventricular septal defect)
RANZCOG MCQs 2020 say VSD.
** BUT 2011 official exam answer said duodenal atresia.
?Incorrect answer on that exam
Sacral agenesis strong association with DM
Posterior urethral valves - assoc with oligo- or an-hydramnios, hypoplastic lungs
A 32yo, G2P1, Rhesus negative woman, is found to have an anti-D titre of 1:4 at 32 weeks. Ultrasound is normal. There is no evidence of hydrops. The previous pregnancy was uncomplicated. The next most appropriate course of action would be:
a. Repeat titre in a fortnight
b. Amniocentesis
c. Fetal monitoring
d. Elective delivery at 35-36 weeks gestation
a. Repeat titre in a fortnight
O
AS over 28weeks. Threshold for MFM referral is 1:16
Which statement regarding iso-immunised pregnancies is FALSE
a. MCA doppler peak systolic velocity is a sensitive predictor of fetal anaemia
b. Maternal plasmapheresis is indicated in severe cases
c. Cordocentesis may be useful in the second trimester
d. The mortality from exchange transfusion is less than that from intrauterine transfusion
b. Maternal plasmapheresis is indicated in severe cases
as per 2011 official answer
Cordocentesis is considered if strong suspicion fetus is affected (Fetal Medicine Guidelines)
Which of the following statements is INCORRECT?
a. The commonest Kell phenotype is Kk
b. A fetus affected by anti-Kell antibodies and requiring IUT can be given red cells from it’s mother
c. A woman at 19 weeks with anti-Kell titre 1:2048 and a husband with KK phenotype should have a fetal blood sampling
d. The amniotic fluid bilirubin is less reliable in predicting severity of anaemia with anti-Kell antibodies compared with anti-Duffy antibodies
e. Anti-Kell antibodies both suppress erythropoiesis and cause haemolysis
a. The commonest Kell phenotype is Kk
O
kk most common
91% are K negative
A Rh negative woman, G2P1, is found to have anti-D antibodies with a titre 1:64 and concentration 10IU/L. Her first child was born at term and required phototherapy. The MOST APPROPRIATE surveillance for her pregnancy is?
a. Regular assessment of maternal anti-D titre
b. Regular USS assessment of the fetal MCA PSV
c. Regular amniocentesis to assess the OD 450 of the amniotic fluid
d. Regular ultrasound to exclude hydrops fetalis
b. Regular USS assessment of the fetal MCA PSV
O
A patient is found to have anti-Fya antibody titre 1:16 at 12 weeks gestation. The MOST APPROPRIATE next step in management is:
a. Quantify the antibody concentration with radioimmunoassay
b. Perform USS at 18 weeks to exclude hydrops
c. Ascertain the partners phenotype
d. Repeat the antibody test at 16 weeks
e. Reassure the patient that anti-Fya antibodies are non-haemolytic
c. Ascertain the partners phenotype
O
NB best practice is to actually ascertain the fetal genotype with non invasive testing to avoid potential non-paternity concerns
RCOG guidelines say next test at 28weeks
Which is LEAST TRUE of maternal alloimmunisation
a. Some maternal HLA subtypes facilitate the maternal immune response to HPA-1a antigen
b. Transplacental passage of > 0.1mL of Rh D positive fetal blood is associated with development of anti-D antibodies in 30% of Rh negative women
c. A mother who is AB negative, with a fetus of blood group B positive, is less likely to become isoimmunised than if the fetal blood group was O positive.
d. Dendritic cells present the peptide in association with HLA class II molecules to T helper cells, which in turn present antigen to B cells
e. In the absence of prophylaxis, approximately 15% of Rh negative women delivering a Rh positive ABO-compatible baby will develop anti-D antibodies.
c. A mother who is AB negative, with a fetus of blood group B positive, is less likely to become isoimmunised than if the fetal blood group was O positive.
O
Alloimmunisation is LESS common with ABO incompatibility
In which circumstance may the fetus have alloimmune thrombocytopenia?
a. Mother HPA-1a positive, Father HPA-1a negative
b. Mother HPA-1a positive, Father HPA-1a positive
c. Mother HPA-1a negative, Father HPA-1a negative
d. Mother HPA-1a negative, Father HPA-1a positive
d. Mother HPA-1a negative, Father HPA-1a positive
O
2% women are negative
The prevalence of HPA-1a negative women in the population is:
a. 0.005%
b. 0.02%
c. 0.1%
d. 0.5%
e. 2%
e. 2%
Of the 2% who are HPA-1a negative only a small proportion have the ability to generate anti-HPA-1a as this has a strong association with a particular HLA type
Which is the KEY mode of current therapy for fetal alloimmune thrombocytopenia?
a. Maternal Immunoglobulin infusion
b. Corticosteroid therapy with prednisolone
c. In utero platelet transfusion
d. Plasmapheresis
a. Maternal Immunoglobulin infusion
O
IVIG
- Shown to improve platelet count in fetuses at risk of FNAIT
Steroids have not be shown to improve platelet counts but could be considered for women at high risk of poor outcomes if benefits outweigh risks
Which is NOT a recognised cause of thrombophilia?
a. Prothrombin gene 20210A gene mutation
b. Lupus anticoagulant
c. Thrombin gene mutation
d. Factor V Leiden mutation
c. Thrombin gene mutation
O
- should be ANTIithrombin gene mutations
Which condition, if treated in pregnancy, might have osteoporosis and thrombocytopenia as a result of the treatment?
a. Asthma
b. Pulmonary TB
c. Graves disease
d. Antiphospholipid syndrome
d. Antiphospholipid syndrome
O
Heparin
*Similar Q gives PE as an answer instead
