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O+G 4 Flashcards

1
Q

Second dose of anti-D prophylaxis to rhesus negative women, following NICE guidance, should take place at what point during routine antenatal care?

A

34 weeks

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2
Q

What happens at 28 weeks gestation?

A
  • second screen for anaemia and atypical red cell alloantibodies
  • first dose of anti-D prophylaxis to rhesus negative women
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3
Q

When is the anomaly scan done?

A

18 - 20+6 weeks

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4
Q

When is the scan done to confirm dates?

A

10 - 13+6 weeks

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5
Q

When is Downs syndrome nuchal screening done?

A

11 - 13+6 weeks

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6
Q

Which contraceptives are effective after 7 days?

A
  • Depo Provera (injectable contraceptive)
  • intrauterine system (e.g. Mirena)
  • combined oral contraceptive pill
  • Nexplanon (implantable contraceptive)
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7
Q

Which contraceptives are effective after 2 days?

A

POP

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8
Q

A woman who is 10 weeks pregnant presents with vaginal bleeding. Ultrasound shows no fetus but a ‘snowstorm’ appearance. The B-hCG is markedly elevated is a stereotypical history of:

A

Hidatiform mole

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9
Q

Booking visit with midwives, following NICE guidance, should take place at what point during routine antenatal care?

A

8-12 weeks <10 ideally

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10
Q

If not started on the first day of the menstrual cycle, the intrauterine device (copper coil) takes how many days before being effective?

A

Immediately

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11
Q

First dose of anti-D prophylaxis to rhesus negative women, following NICE guidance, should take place at what point during routine antenatal care?

A

28 weeks

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12
Q

Offer external cephalic version if indicated, following NICE guidance, should take place at what point during routine antenatal care?

A

36 weeks

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13
Q

When do you refer for routine colposcopy?

A
  • third inadequate smear
  • borderline (HPV positive)
  • mild dyskaryosis (HPV positive)
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14
Q

When do you refer for urgent colposcopy?

A
  • suspected invasive cancer
  • severe dyskaryosis
  • moderate dyskaryosis
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15
Q

Smoking is associated with which gynaecological cancer?

A

Cervical

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16
Q

When is a urine culture done as part of antenatal care?

A

8 - 12 weeks (ideally < 10 weeks)

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17
Q

When should a second screen for anaemia and atypical red cell alloantibodies be done as part of antenatal care?

A

28 weeks

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18
Q

A teenage girl is investigated for primary amenorrhoea, despite having developed secondary sexual characteristics. On examination she has well developed breasts with scanty pubic hair and blind-ending vagina is a stereotypical history of:

A

Androgen insensitivity syndrome

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19
Q

A 30-year-old nulliparous woman presents with severe dysmenorrhoea, heavy & irregular bleeding, pain on defecation and dyspareunia is a stereotypical history of:

A

Endometriosis

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20
Q

Which drugs must be avoided when breast feeding?

A

BLA(2)S(2)T CCC

benzodiazepines
lithium
aspirin
amiodarone
sulphonylureas
sulphonamides
tetracyclines
carbimazole
ciprofloxacin
chloramphenicol
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21
Q

What is a complete hydatiform mole? How does it occur?

A

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

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22
Q

What are the features of hydatiform mole?

A
  • bleeding in first or early second trimester
  • exaggerated symptoms of pregnancy e.g. hyperemesis
  • uterus large for dates
  • very high serum levels of human chorionic gonadotropin (hCG)
  • hypertension and hyperthyroidism (hCG can mimic thyroid-stimulating hormone (TSH)) may be seen
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23
Q

How do you manage a complete hydatiform mole?

A
  • urgent referral to specialist centre - evacuation of the uterus is performed
  • effective contraception is recommended to avoid pregnancy in the next 12 months
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24
Q

What proportion of hydatiform moles go on to develop choriocarcinoma?

A

2-3%

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25
Q

What is a partial mole?

A

In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen.

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26
Q

What are the features of PCOS?

A
  • subfertility and infertility
  • menstrual disturbances: oligomenorrhea and amenorrhoea
  • hirsutism, acne vulgaris, alopecia (due to hyperandrogenism)
  • obesity
  • acanthosis nigricans (due to insulin resistance)
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27
Q

How is PCOS diagnosed?

A

PCOS should be diagnosed if 2/3 of the following criteria are present:

  • Infrequent or no ovulation
  • Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone (no mention of ‘low levels of oestrogen’)
  • Polycystic ovaries on ultrasonography or increased ovarian volume
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28
Q

Incidence of PCOS

A

5-20% of women of reproductive age

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29
Q

What investigations are done for PCOS?

A
  • pelvic ultrasound: multiple cysts on the ovaries
  • FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
  • check for impaired glucose tolerance
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30
Q

A 26-year-old woman presents to her GP with a 5 week history of worsening dull pelvic pain and smelly discharge. She has had a hormonal intrauterine device in situ for one year and does not menstruate with this. She has had the human papilloma virus vaccine but has not yet had any smear tests. What is the most likely diagnosis?

A

PID

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31
Q

What organisms cause PID?

A
  • Chlamydia trachomatis - the most common cause
  • Neisseria gonorrhoeae
  • Mycoplasma genitalium
  • Mycoplasma hominis
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32
Q

What are the features of PID?

A
  • lower abdominal pain
  • fever
  • deep dyspareunia
  • dysuria and menstrual irregularities may occur
  • vaginal or cervical discharge
  • cervical excitation
  • perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in around 10% of cases. It is characterised by right upper quadrant pain and may be confused with cholecystitis
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33
Q

Investigations for PID

A

screen for Chlamydia and Gonorrhoea

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34
Q

Management of PID

A
  • due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
  • oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
  • RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
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35
Q

Complications of PID

A
  • infertility - the risk may be as high as 10-20% after a single episode
  • chronic pelvic pain
  • ectopic pregnancy
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36
Q

What proportion of babies born to mothers taking anti-epileptics have birth defects?

A

3-4% compared to 1-2% of mothers not on medication

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37
Q

A 34-year-old female with a history of primary generalised epilepsy presents to her GP as she plans to start a family. She currently takes sodium valproate as monotherapy. What advice should be given regarding the prevention of neural tube defects?

A

5mg folic acid/day

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38
Q

Which anti-epileptic is considered the least teratogenic?

A

Carbamazepine 1-3% risk
Lamotrigine 1-5% risk
Levetiracetam

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39
Q

What defect is phenytoin associated with?

A

Cleft palate

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40
Q

What’s the risk of using sodium valproate in pregnancy?

A

Risk of neurodevelopmental delay/impaired childhood cognition 4-9%

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41
Q

What is antepartum haemorrhage?

A

Bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus.

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42
Q

What are the features of placental abruption?

A
  • shock out of keeping with visible loss
  • pain constant
  • tender, tense uterus*
  • normal lie and presentation
  • fetal heart: absent/distressed
  • coagulation problems
  • beware pre-eclampsia, DIC, anuria
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43
Q

What are the features of placenta praevia

A
  • shock in proportion to visible loss
  • no pain
  • uterus not tender*
  • lie and presentation may be abnormal
  • fetal heart usually normal
  • coagulation problems rare
  • small bleeds before large

*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

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44
Q

What is olighydraminos?
How can it present?
What is the amniotic fluid derived from?

A
  • deficiency of amniotic fluid during pregnancy
  • less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile
  • often present as smaller symphysiofundal height.
  • foetal urine
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45
Q

What are the causes of olighydraminos?

A
  • premature rupture of membranes
  • fetal renal problems e.g. renal agenesis
  • intrauterine growth restriction
  • post-term gestation
  • pre-eclampsia
46
Q

If a woman has a BP of 162/110 mmHg should you deliver the baby?

A

It depends…

Women with severe hypertension in pregnancy (160/110mmHg or higher) should be treated with labetalol as first time treatment. Delivery should not be offered to women before 34 weeks unless:

  • severe hypertension remains refractory to treatment
  • maternal or fetal indications develop as specified in the consultant plan

At 34 weeks delivery should be offered to women with pre-eclampsia once a course of corticosteroids has been completed.

47
Q

If a mother gets chicken pox when pregnant what is she more at risk of?

A

5 times greater risk of pneumonitis

48
Q

If a pregnant lady gets chickenpox what is the risk the foetus will get fetal varicella syndrome (FVS) and what is FVS?

A
  • risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
  • studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
  • features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
49
Q

What are the foetal risks if the mother gets chickenpox?

A
  • shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
  • severe neonatal varicella: if mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
50
Q

How do you manage chickenpox exposure of a pregnant lady?

A
  • if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
  • if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
  • consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
51
Q

A 28-year-old woman who is P1 G2 is 30 minutes post-partum of an uncomplicated delivery. She suddenly begins gasping for breath with a blood pressure of 83/65mmHg, heart rate of 120bpm and a respiratory rate of 33/min. She appears cyanosed. She becomes unresponsive. What is the most likely diagnosis?

A

Amniotic fluid embolism

52
Q

When do amniotic fluid embolisms usually occur?

A

during or within 30 minutes of labour

53
Q

What are signs and symptoms of an amniotic fluid embolism?

A

Signs:

  • respiratory distress
  • hypoxia
  • hypotension
  • cyanosis
  • bronchospasms
  • tachycardia
  • arrhythmia
  • MI

Symptoms include:

  • chills
  • shivering
  • sweating
  • anxiety
  • coughing
54
Q

Intracranial haemorrhage is often preceded by…..

A

A severe headache

55
Q

What’s the incidence of amniotic fluid embolisms?

What are the risk factors?

A

Rare complication of pregnancy associated with a high mortality rate.

Incidence 2/ 100,000 in the U.K

maternal age and induction of labour

56
Q

What are the classic presenting features of an ectopic pregnancy?

A

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

  • lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm
  • vaginal bleeding: usually less than a normal period, may be dark brown in colour
  • history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
  • peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
57
Q

A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound reveals a 24mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She says she would like a follow-up appointment following her treatment. What is the first line treatment?

A

Methotrexate

The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up.

58
Q

When is a laparoscopic salpingectomy indicated for an ectopic pregnancy?

A

Offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500.

There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.

59
Q

What are the causes of primary amenorrhoea?

A
  • Turner’s syndrome
  • testicular feminisation
  • congenital adrenal hyperplasia
  • congenital malformations of the genital tract
60
Q

What are the causes of secondary amenorrhoea?

A
  • hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
  • polycystic ovarian syndrome (PCOS)
  • hyperprolactinaemia
  • premature ovarian failure
  • thyrotoxicosis (hypothyroidism may also cause amenorrhoea)
  • Sheehan’s syndrome
  • Asherman’s syndrome (intrauterine adhesions)
61
Q

Initial investigations for amenorrhoea

A
  • exclude pregnancy with urinary or serum bHCG
  • gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
  • prolactin
  • androgen levels: raised levels may be seen in PCOS
    oestradiol
  • thyroid function tests
62
Q

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.

What is the most appropriate management for prophylaxis of Rhesus sensitisation?

A

One dose of Anti-D immunoglobulin followed by a Kleihauer test

Antepartum haemorrhage is associated with fetomaternal haemorrhage (FMH) and therefore an increased risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies.

A Kleihauer test is a test for FMH which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.

Kleihauer test: add acid to maternal blood, fetal cells are resistant

63
Q

When is a foetal heartbeat established?

A

4-5 weeks (visible on TVUS a week later)

64
Q

Miscarriage rate

A

15%

65
Q

What is a heterotopic pregnancy?

A

One ectopic and one not ectopic.

Only really happens following IVF

66
Q

What is mifepristone?

A

An oral anti-progesterone used for medical management of ectopic pregnancy

67
Q

What are the complications of surgically removing an ectopic pregnancy?

A
  • Damage to the endometrium causing Asherman’s syndrome

- Uterine perforation 1%

68
Q

If a foetal heartbeat is detected at 8 weeks what proportion will not miscarry?

A

90%

69
Q

What is recurrent miscarriage?
What proportion of couples are affected?
Risk of miscarriage in 4th

A
  • 3 or more miscarriages
  • 1%
  • 40%
70
Q

What complication are antiphospholipid antibodies associated with?
What is the mechanism?
Treatment

A
  • Miscarriage
  • Thrombosis in the uteroplacental circulation
  • Aspirin and low-dose low molecular weight heparin
71
Q

Miscarriage beyond 16 weeks would indicate?

A
  • anatomical factors such as cervical incompetence

- infection

72
Q

What proportion of mothers are rhesus negative?

A

15%

73
Q

Regarding rhesus status, what is done to try and prevent haemolytic disease of the newborn?

A
  • test for D antibodies in all Rh -ve mothers at booking
  • NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
  • the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’
  • anti-D is prophylaxis - once sensitization has occurred it is irreversible
  • if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
74
Q

Following which situations should Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours)?

A
  • delivery of a Rh +ve infant, whether live or stillborn
  • any termination of pregnancy
  • miscarriage if gestation is > 12 weeks
  • ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
  • external cephalic version
  • antepartum haemorrhage
  • amniocentesis, chorionic villus sampling, fetal blood sampling
75
Q

What test should be done for all babies born to rh negative mothers?

A
  • all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
  • Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
76
Q

What are the features of haemolytic disease of the newborn and how would you treat it?

A
  • oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
  • jaundice, anaemia, hepatosplenomegaly
  • heart failure
  • kernicterus
  • treatment: transfusions, UV phototherapy
77
Q

What are risk factors for miscarriage?

A
  • Age
    Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is about 40 percent. And at age 45, it’s about 80 percent.
  • Previous miscarriages
    Women who have had two or more consecutive miscarriages are at higher risk of miscarriage.
  • Chronic conditions
    Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage.
  • Uterine or cervical problems
    Certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies)
  • Smoking, alcohol and illicit drugs
    Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and illicit drug use also increase the risk of miscarriage.
  • Weight
    Being underweight or being overweight has been linked with an increased risk of miscarriage.
  • Invasive prenatal tests
    Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage.
78
Q

Which condition is a contraindication for using epidural anaesthesia during labour?

A

Coagulopathy

79
Q

Define labour

A

The onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

80
Q

What are the signs of labour?

A
  • regular and painful uterine contractions
  • a show (shedding of mucous plug)
  • rupture of the membranes (not always)
  • shortening and dilation of the cervix
81
Q

What are the stages of labour?

A
  • stage 1: from the onset of true labour to when the cervix is fully dilated
  • stage 2: from full dilation to delivery of the fetus
  • stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
82
Q

What monitoring should be done in labour?

A
  • FHR monitored every 15min (or continuously via CTG)
  • Contractions assessed every 30min
  • Maternal pulse rate assessed every 60min
  • Maternal BP and temp should be checked every 4 hours
  • VE should be offered every 4 hours to check progression of labour
  • Maternal urine should be checked for ketones and protein every 4 hours
83
Q

Which oral hypoglycaemics should be avoided during pregnancy?

A
  • Sulfonylureas (gliclazide) should be avoided when breastfeeding due to theoretical risk of neonatal hypoglycaemia.
  • liraglutide
  • exenatide
  • sitagliptin
84
Q

What are the risk factors for gestational diabetes?

A
  • BMI of > 30 kg/m²
  • previous macrosomic baby weighing 4.5 kg or above
  • previous gestational diabetes
  • first-degree relative with diabetes
  • family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
85
Q

Who and when are women screened for gestational diabetes?

A
  • women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
  • women with any of the other risk factors should be offered an OGTT at 24-28 weeks
86
Q

What are the diagnostic thresholds for gestational diabetes?

A

fasting glucose is >= 5.6 mmol/l

2-hour glucose is >= 7.8 mmol/l

87
Q

How do you manage gestational diabetes?

A
  • newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
  • women should be taught about selfmonitoring of blood glucose
  • advice about diet (including eating foods with a low glycaemic index) and exercise should be given
  • if the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
  • if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
  • if glucose targets are still not met insulin should be added to diet/exercise/metformin
  • if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
  • if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
  • glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
88
Q

How do you manage pre-existing diabetes during pregnancy?

A
  • weight loss for women with BMI of > 27 kg/m^2
  • stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  • tight glycaemic control reduces complication rates
  • treat retinopathy as can worsen during pregnancy
89
Q

What are the blood sugar targets for pre-existing and gestational diabetes?

A
  • Fasting 5.3 mmol/l
  • 1 hour after meals 7.8 mmol/l, or:
  • 2 hour after meals 6.4 mmol/l
90
Q

What is lochia and when would you do an US?

A

Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium*. This should be expected to cease after 4-6 weeks. Continue vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.

  • Puerperium is the period of approximately six weeks after childbirth during which time the woman’s reproductive organs return to normal. Lochia is a normal part of this process.
91
Q

Which antihypertensives can be used in pregnancy?

A

Labetalol
Hydralazine
Nifedipine

92
Q

How do you treat red or ‘carneous’ degeneration?

A

Analgesia and rest. Should resolve by 4-7 days

93
Q

How do you treat moderate to severe depression in pregnancy or the post natal period?

A

The National Institute for Health and Care Excellence recommends that for women without previous history of severe depression, the first line treatment for moderate to severe depression in pregnancy or the post-natal period should be a high intensity psychological intervention (such as CBT).

If this is refused, or symptoms do not improve, then an antidepressant should be used. NICE suggests a selective serotonin re-uptake inhibitor (SSRI) or tricyclic antidepressant (TCA). Mindfulness may be useful for women with persistent subclinical depressive symptoms.

94
Q

What are the features of chorioamnionitis?

A
  • uterine tenderness
  • rupture of the membranes with a foul odour of the amniotic fluid
  • maternal signs of infection (for example tachycardia, pyrexia, and leukocytosis)
95
Q

What LFTs would you expect with intrahepatic cholestasis of pregnancy?

A
  • high ALP and GGT, with a lesser rise in ALT

- Patients may also be jaundiced with right upper quadrant pain and steatorrhoea

96
Q

What LFTs/blood count would you expect with acute fatty liver of pregnancy?

A
  • ALT/AST greater than that of ALP,
  • a raised white cell count
  • potential clotting abnormalities
97
Q

Why should women who have migraine with aura should stop the pill immediately?

A

The oestrogen component of the COCP can increase the risk of the women having an ischaemic stroke.

98
Q

What counselling should be given to women before taking the COCP?

A

Potential harms and benefits, including

  • the COC is > 99% effective if taken correctly
  • small risk of blood clots
  • very small risk of heart attacks and strokes
  • increased risk of breast cancer and cervical cancer

Advice on taking the pill, including

  • if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
  • should be taken at the same time everyday
  • taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
  • advice that intercourse during the pill-free period is only safe if the next pack is started on time

Discussion on situations here efficacy may be reduced*

  • if vomiting within 2 hours of taking COC pill
  • if taking liver enzyme inducing drugs

Other information
- discussion on STIs

  • Concurrent antibiotic use
  • for many years doctors in the UK have advised that the concurrent use of antibiotics may interfere with the enterohepatic circulation of oestrogen and thus make the combined oral contraceptive pill ineffective - ‘extra-precautions’ were advised for the duration of antibiotic treatment and for 7 days afterwards
  • no such precautions are taken in the US or the majority of mainland Europe
  • in 2011 the Faculty of Sexual & Reproductive Healthcare produced new guidelines abandoning this approach. The latest edition of the BNF has been updated in line with this guidance
  • precautions should still be taken with enzyme inducing antibiotics such as rifampicin
99
Q

What cervical dilation indicates labour is active?

A

3cm or more

100
Q

When can you attempt ECV for a singleton fetus presenting in transverse lie?

A

if the membranes have not yet ruptured and the patient is not in active labour

Then in order to prevent the fetus from spontaneously reverting to a transverse lie, it is recommended that the membranes are ruptured to speed up the delivery process.

101
Q

What complications are associated with a transverse lie?

A
  • pre-term rupture of the membranes

- cord prolapse

102
Q

What antenatal care is offered?

A
  • 10 antenatal visits in the first pregnancy if uncomplicated
  • 7 antenatal visits in subsequent pregnancies if uncomplicated
  • women do not need to be seen by a consultant if the pregnancy is uncomplicated

8 - 12 weeks (ideally < 10 weeks)
Booking visit
- general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
- BP, urine dipstick, check BMI
Booking bloods/urine
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- hepatitis B, syphilis, rubella
- HIV test is offered to all women
- urine culture to detect asymptomatic bacteriuria

10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy

11 - 13+6 weeks
Down’s syndrome screening including nuchal scan

16 weeks
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick

18 - 20+6 weeks
Anomaly scan

25 weeks (only if primip)
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

28 weeks

  • Routine care: BP, urine dipstick, SFH
  • Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
  • First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip)
- Routine care as above

34 weeks

  • Routine care as above
  • Second dose of anti-D prophylaxis to rhesus negative women*
  • Information on labour and birth plan

36 weeks

  • Routine care as above
  • Check presentation - offer external cephalic version if indicated
  • Information on breast feeding, vitamin K, ‘baby-blues’

38 weeks
- Routine care as above

40 weeks (only if primip)

  • Routine care as above
  • Discussion about options for prolonged pregnancy

41 weeks Routine care as above
- Discuss labour plans and possibility of induction

103
Q

What does SFH mean?

A

Symphysio Fundal Height

104
Q

What’s the first line treatment for pregnant women with a UTI?

A

Nitrofurantoin 50mg qds or 100mg modified release bd for seven days. However this should be avoided in women at full-term due to the risk of neonatal haemolysis.

105
Q

What are the risks of smoking or cannabis during pregnancy?

A
  • Increased risk of miscarriage
  • Increased risk of pre-term labour
  • Increased risk of stillbirth
  • IUGR
  • Increased risk of sudden unexpected death in infancy
106
Q

What are the risks of alcohol use during pregnancy?

A
  • Fetal alcohol syndrome (FAS)
  • learning difficulties
  • characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures
  • IUGR & postnatal restricted growth
  • microcephaly

Binge drinking is a major risk factor for FAS

107
Q

What are the risks of taking cocaine during pregnancy?

A

Maternal risks

  • hypertension in pregnancy including pre-eclampsia
  • placental abruption

Fetal risk

  • prematurity
  • neonatal abstinence syndrome
108
Q

What are the risks of taking cocaine during pregnancy?

A

Risk of neonatal abstinence syndrome

109
Q

What are the adverse effects and drug interactions of a nexplanon insert?

A
  • irregular/heavy bleeding is the main problem
  • ‘progestogen effects’: headache, nausea, breast pain
  • enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon
  • the FSRH advises that women should be advised to switch to a method unaffected by enzyme-inducing drugs or to use additional contraception until 28 days after stopping the treatment
110
Q

When is the nexplanon insert contraincicated?

A
  • current breast cancer
  • ischaemic heart disease/stroke
  • unexplained, suspicious vaginal bleeding
  • past breast cancer
  • severe liver cirrhosis
  • liver cancer

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