O&G Flashcards

Question

Miscarriage types

Answer 1

1) Threatened - Mild symptoms/closed os - 75% will settle, rest advice - Associated with subsequent risk of PROM and preterm delivery 2) Inevitable - Severe symptoms/ Os open - Incomplete miscarriage, but most of products of conception have passed 3) Missed miscarriage: - Foetus dies but is retained - PC: Bleeding - Uterus is small for dates - Confirm with US Mx: Medical if uterus small; surgical if uterine products >5cm in transverse plane 4) Mid-trimester MC: - usually due to mechanical causes eg. cervical incompetence, uterine abnormalities or chronic maternal disease - Incompetent cervix can be strengthened by a cervical cerclage suture at 14 weeks 5) Miscarriage with infection: - Presents as acute salpingitis Rx: Broad spectrum Abx eg. coamoxiclav + Metro 6) Septic miscarriage - contents of uterus infected causing endometritis Sx: Offensive vaginal D/C + Tender uterus

Answer 2

3 or more consecutive miscarriages before 24wks Affects 1% of women Causes: - APS - Chromosomal defects - Uterine abnormalities - Infection - Obesity - Smoking - PCOS - Excess caffeine intake - Higher maternal age - Thrombophilia - Alloimmune causes Ix: APS antibodies screen - karyotyping of both parents - Pelvic US - hysterosalpingogram

Answer 3

``` Dmg to tubes (Salpingitis, previous surgery) Previous ectopic Endometriosis IUCD POP ``` Site: Tubal 97% isthmus 25% Ovary/cervix/peritoneum 3%

Answer 4

Sx: D+N+V Dark/fresh PV blood Tubal colic causes abdo pain Gradually increasing PV bleeding and bleeding into peritoneum producing shoulder tip pain due to diaphragmatic irritation and pain on defecation/urination Rupture - sudden severe pain, peritonism and shock OE: Faint, tender abdo, enlarged uterus, cervical excitation, adnexal mass Mx: Anti-D prophylaxis - Urinary/serum B-HCG US expectant management: option in those without acute symptoms/falling bHCG Early ectopics - medical mx: Methotrexate Surgical Mx: Salpingectomy/salpingotomy (Creating an opening in the tube to remove ectopic) via laparoscopy/laparotomy

Answer 5

Complete hydatidiform mole 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 Features 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* may be seen - B-HCG resembles TSH. Thyrotoxic storm can occur at evacuation Management urgent referral to specialist centre - evacuation of the uterus is performed effective contraception is recommended to avoid pregnancy in the next 12 months Around 2-3% go on to develop choriocarcinoma 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

Answer 6

2-3% of molar pregnancies go onto develop choriocarcinoma ``` Sx: May be yrs after pregnancy general malaise Uterine bleeding Sx from mets Nodules on CXR Pulmonary artery obstruction due to tumour emboli ``` Rx: Methotrexate based chemo

Answer 7

Red ring around the os as endocervical epithelium has extended over the ectocervical epithelium Due to eversion Occurs temporarily under hormonal influence during puberty, with the COCP and during preggers Prone to bleeding, excess mucus production and infection Normal finding in young women, particularly if pregnant or on COCP Rx: No Tx usually, cryocautery can be used after taking a smear

Answer 8

Mucus retention cysts found on cervix Harmless Rx: cryotherapy if discharging

Answer 9

CIN - preinvasive cervical cancer --> Atypical cells present within the squamous epithelium CIN I - mild dysplasia - lower basal 1/3 of cervical epithelium. Commonly regress. Assoc. with HPV 6,11 ``` CIN II (Moderate dysplasia) - 2/3 of thickness of epithelium. Associated with HPV 16/18 --> Less likely to regress, and significant number develop into invasive SCC of cervix. ```

Answer 10

1st smear taken aged 25 3 yearly from 25 yr, 5 yearly from 50 – 64 yr Only screen after 65 if one of last 3 was abnormal HIV +ve should have annual smears Borderline/mild dyskaryosis - original sample tested for HPV - -ve - routine recall +ve - refer to colposcopy Moderate dysk - consistent with CIN II. refer to colposcopy Severe dysk - Consistent with CIN III - refer to colposcopy Suspected invasive cancer - refer for urgent colposcopy (within 2 weeks) Inadequate - repeat smear. If 3 inadequete samples, colposcopy

Answer 11

1 Gardasil targets HPV 6, 11, 16 & 18 3 IM does, 0.5mL (deltoid/lateral thigh). Age range: 9–18yrs (9–26 ). Dose 2 is ≥1 month after dose 1, and dose 3 ≥4 months after dose 1. CI: pregnancy, bleeding disorders Cervarix (bivalent; HPV16 & 18).

Answer 12

``` Prolonged COCP use High parity > 4 sexual partners Early first coitus HIV other STDs smoking ```

Answer 13

Sx: post-coital bleeding, offensive DC, intermenstrual/PMB. Later features: involvement of ureters, bladder, rectum and nerves cause uraemia, haematuria, rectal bleeding and pain O/E: Ulcer/mass may be visible/palpable on cervix

Answer 14

Mx of pre-invasive cancer: - Colposcopy - Abnormal epithelium has characteristic blood vessel patterns and stains white with acetic acid - take punch biopsies for histology CIN I - observe CIN II & III - destroyed by cryotherapy, laser, cold coagulation or large loop excision of transformation zone (LLETZ) - Annual smears for atleast 10 years - If the squamo-columnar junction cannot be seen or if small-volume invasive carcinoma is found on histology, the abnormal tissue is removed by cone biopsy which may be curative nb. Colposcopy does not detect adenocarcinoma

Answer 15

Staging: most are SCC, 15-30% are Adenocarcinoma Stage I - confined to cervix Stage IIaextended locally to upper 2/3 of vagina Stage IIb Extended locally to parametria Stage III - IIIa - lower 1/3 of vag, IIIb to pelvic wall Stage IV - IVa: Bladder or rectum IVb: spread to distant organs MX Stage Ia: cervical cone biopsy/cold knife excision Stage Ia2/Ib1 - radical hysterectomy with pelvic lymphadenectomy or radiotherapy Stage II/III/IV: Chemoradiation

Answer 16

Uterine infection possibly involving fallopian tubes and ovaries Uncommon Usually seen after miscarriage, TOP, childbirth, IUCD insertion or surgery Often secondary to STIs Sx: lower abdominal pain, fever, uterine tenderness on bimanual palpation Ix: cervical swabs and blood cultures Rx: Abx doxycycline & metronidazole

Answer 17

TVUS gives better resolution than transabdominal If thickness >5mm, consider endometrial Ca

Answer 18

Usually squamous Commonest in the upper third of the vagina Sx: bleeding Spread: local by lymphatics Rx: radiotherapy

Answer 19

5% associated with VIN, 4% have cancer in 12.5 yrs, 1/3 assoc with sq cell hyperplasia Most- post-menopasual but can affect children and young women Classical lesion- fig of 8 crinkled parchment like appearance (around vulva and anal region) Pruritis, irritation, ulceration Bx may be needed to confirm diagnosis and rule out VIN/ invasion Rx- testosterone propionate/ cypropionate 2%/ colbetasol propionate

Answer 20

Average age 40 years, increasing incidence in last 20 years (particularly in under 35s) VIN1 mild, VIN2 mod, VIN3 severe 30% associated with invasion Ix: Colposcopy, 5% acetic acid or 1% toluidene blue, biopsy Associated with HPV DNA- 16, 18, 31, 33, 35, 51 Mx May be multifocal Surgical excision/ laser Rx

Answer 21

Uncommon cancer - mostly postmenopausal women (mean = 65) SCC accounts for 90% of cases Dual aetiology; HPV vs chronic irritation (lichen sclerosus) Sx: vulval lump/mass Long history pruritis, vulval bleeding, Discharge , dysuria

Answer 22

Benign smooth muscle tumours of the uterus Often multiple Start as lumps in the wall of the uterus but may grow to bulge out of the wall so that they lie under the peritoneum or under the endometrium Fibroids are common fq increases with age and in non-Caucasians Associated with mutation in gene for fumarate hydratase Oestrogen dependence – enlarge in pregnancy, on the COCP and on HRT; atrophy after the menopause May enlarge or degenerate gradually or suddenly Red degeneration: pain and uterine tenderness; haemorrhage and necrosis occur May calcify – womb stones May undergo sarcomatous change rarely – causes pain, malaise, bleeding and increase in size Cause heavy periods due to increased endometrial surface, dysfunctional endometrium, impaired uterine contractility.

Answer 23

Premature labour Malpresentations Transverse lie Obstructed lie PPH Red degeneration common

Answer 24

Intramural Subserosal Submucosal Pedunculated submucosal 5% are submucous, hysteroscopic resection is tx of choice Type 0 – pedunculated without intramural extension Type 1 – sessile fibroid w intramural extension 50%

Answer 25

Sx: Asymptomatic, menorrhagia, dysmenorrhoea, fertility problems, pain, mass, frequency, urinary retention Ix: US, MRI, hysteroscopy/hysterosalpingogram Mx: Menorrhagia: Tranexamic acid, mefanamic acid or progestogens Surgical resection: - pretreatment with GnRH analogues can shrink fibroids and make resection easier Myomectomy Hysterectomy

Answer 26

Presence of endometrial tissue within the myometrium Age: 40 Cause: endometrium grows into the myometrium; pockets of menstrual blood can be seen in the myometrium Sx: asymptomatic; painful, regular, heavy menstruation OE: uterus is mildly enlarged and tender Ix: MRI ``` Mx: IUS or COCP with or without NSAIDs for menorrhagia Mefanamic acid Tranexamic acid COCP Mirena IUS Endometrial ablation Uterine artery embolisation Hysterectomy ```

Answer 27

Usual PC = Postmenopausal bleeding - initially scanty and occasional, and then heavy and frequent. May also PC as intermenstrual bleeding or menorrhagia. - Most are adenocarcinomas of columnar endometrial gland cells - Others are adenosquamous carcinomas (poorer prognosis) - Related to excessive exposure to oestrogen unopposed by progesterone Risk factors: - Obesity - Unopposed oestrogen (PCOS) - FH of breast, ovary or colon Ca - Nulliparity - LAte menopause - DM - Tamoxifen, tibolone - Pelvic irradiation - Lynch syndrome type II (HNPCC)

Answer 28

Ix: Cervical smear, uterine ultrasound, uterine sampling/curettage, hysteroscopy ``` Staging: I = body of uterus only II = body + Cervix III = advancing beyond uterus but not beyond pelvis IV = extending outside pelvis ``` Mx: stage I/II - total hysterectomy + bilateral salpingo-oopherectomy +- radiotherapy Stage III and IV: radiotherapy and/or high dose progestogens Recurrent disease: Medroxyprogesterone, surgical exoneration & radiotherapy

Answer 29

Physiological cysts (functional cysts) 1) Follicular cysts commonest type of ovarian cyst due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle commonly regress after several menstrual cycles 2)Corpus luteum cyst during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst more likely to present with intraperitoneal bleeding than follicular cysts Benign germ cell tumours 1) Dermoid cyst also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth most common benign ovarian tumour in woman under the age of 30 years median age of diagnosis is 30 years old bilateral in 10-20% usually asymptomatic. Torsion is more likely than with other ovarian tumours Benign epithelial tumours Arise from the ovarian surface epithelium 1) Serous cystadenoma the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) bilateral in around 20% 2) Mucinous cystadenoma second most common benign epithelial tumour they are typically large and may become massive if ruptures may cause pseudomyxoma peritonei

Answer 30

Follicular cyst

Answer 31

Dermoid cyst

Answer 32

Serous cystadenoma

Answer 33

1) Surface derived tumours (65%) - Serous cystadenoma (B) - Serous cystadenocarcinoma (M) - Mucinous cystadenoma (B) - Mucinous cystadenocarcinoma (M) - Brenner tumour (B) 2) Germ cell tumours (15-20%) - Teratoma (Mature - B, immature M) - Dysgerminoma (M) - yolk sac tumour (M) - Choriocarcinoma (M) 3) Sex cord-stromal tumours - Granulosa cell tumour (M) - Sertoi-leydig cell tumour (B) - Fibroma (B) - Meig's 4) Mets - Krukenberg tumour (M) - Mets from a GI tumour result in a mucin-secreting signet ring cell adenocarcinoma, most commonly from pylorus. 80% bilateral

Answer 34

Ascites , pleural effusion + ovarian fibroma

Answer 35

Rare In ~80% it causes few symptoms until it has metastasized 5 year survival

Answer 36

``` Sx: Initially vague or asymptomatic persistent abdo distention Early satiety/loss of appetite Pelvic or abdo pain Increased urinary urgency/frequency Similar to Sx of IBS ``` Ix: Histology, ascites, ultrasound/CT, CA-125 Risk of malignancy index (US score, menopausal status & CA125 levels) - if RMA>250 refer to MDT Pattern of spread: - Transcoelomic - Lymphatic spread to pelvic and paraaortic nodes

Answer 37

Staging: I - disease limited to 1 or both ovaries II - Beyond ovaries but in pelvis III - ovary and peritoneal implants outside pelvis/ +ve retroperitoneal or inguinal nodes IV - distant mets Rx: Adenocarcinomas (89%) - Curative surgery - total hysterectomy + bilateral salpingo-oppherectomy + partial omentetomy + Chemo --> unless very early disease with low grade histology Follow up levels of Ca125 and CT

Answer 38

90% sexually acquired - mostly chlamydia 10% follow childbirth/instrumentation Acute Salpingitis - Pain, fever, spasm of lower abdo muscles, cervicitis, purulent/bloody vag DC MX: endocervical & urethral swabs IV ABx : Ceft + Doxy followed by doxy + Metro Complications: - Abscess - chronic infection - Long term tubal blockage - Increased rate of ectopic pregnancy

Answer 39

Unresolved acute salpingitis - Inflammation leads to fibrosis leading to adhesions - Tubes may be distended with pus/fluid Sx: Pelvis pain, menorrhagia, sexondary dysmenorrhoea, discharge, deep dyspareunia Ix: Laparascopy

Answer 40

Endometrial glandular tissue occuring outside uterine cavity eg. on ovary - If foci found in uterine wall muscle - adenomyosis 10% of all women, 35-50% of women with subfertilitiy Foci are under hormonal influence with waning in pregnancy and menopause and bleeding during menstruation.

Answer 41

Asymptomatic, pelvic pain (particular at the time of periods. Constant if adhesions), secondary dysmenorrhea, deep dyspareunia, thigh pain, pain on defecation, menorrhagia (especially with adenomyosis), subfertility OE: VE - tenderness or thickening behind uterus/adnexa, fixed retroverted uterus or uterosacrl ligament nodules and general tenderness. Retroverted uterus Everything stuck together

Answer 42

Ix: Laparoscopy ``` Rx: Medical - analgesia NSAIDs hormonal therapy: COCP/progestogens GnRH analogues IUS ``` Surgical: - surgical excision or laser ablation - Total hysterectomy & bilateral salpingo-oopherectomy - -> Important to do medical first as endometriosis can recur after excision Complications: - Obstruction - Ovarian endometroid and clear cell cancers - Hodgkin's lymphoma - Melanoma

Answer 43

Defined as failure to get pregnant after 2 years of regular (2-3wk) UPSI) ``` Offer investigation after 1 year of trying to conceive In subfertile couples consider: Production of ova Production of sperm Meeting of ova and sperm Implantation of embryo ``` ``` Ix: Blood tests for anovulation Serum mid-luteal progesterone Day 5 FSH & LH TFT Prolactin Semen analysis Volume Sperm count/morphology Infection Hysterosalpingogram Rx: intrauterine insemination, ``` bromocriptine for hyperprolactinaemia, Pulsed GnRH/clomifene/IVF for anovulation, surgery for tubal problems, IUI/IVF with or without ICSI for male infertility NB. NO FERTILITY TX ON NHS IF STILL SMOKING

Answer 44

Descent of uterus and/or vaginal walls beyond normal anatomical confines Occurs as a result of weakness in supporting structures Types: Urethrocoele – prolapse of lower anterior vaginal wall involving urethra only Cystocoele – prolapse of upper anterior vaginal wall involving the bladder Apical prolapse – prolapse of uterus, cervix and upper vagina Enterocoele – prolapse of the upper posterior wall of the vagina; resulting pouch usually contains loops of small bowel Rectocoele – prolapse of the lower posterior wall of the vagina involving the anterior wall of the rectum

Answer 45

Delivery (large infants, prolonged second stage & instrumental delivery) Ehlers danlos Menopause Chronically raised intra-abdominal pressure eg. obesity, chronic cough, constipation, heavy lifting or pelvic mass, pelvic surgery eg. hysterectomy or continence procedures

Answer 46

Sx: asymptomatic, heavy dragging sensation/sensation of a lump Worse at the end of day or when standing up May interfere with intercourse, urinary frequency or incomplete bladder emptying Sims speculum Ix: Pelvic ultrasound, urodynamic testing Mx: Conservative: lose weight, treat chest problems eg. quit smoking Pessaries - ring/shelf pessary if pt unfit for surgery Surgery: Hysteropexy; hysterectomy ; sacrocolpopexy

Answer 47

Uterus not felt until 12 wks 16 weeks - Fundus halfway between symphysis pubis and umbilicus 20-24wks: fundus reaches umbilicus 36 wks: Fundus under ribs From 16wks SFH increases 1cm/wk nb. Foetal HS heart from doppler from 12 weeks & Pinard from 24

Answer 48

Inaccurate menstrual history Multiple gestation Fibroids Polyhydramnios Adnexal mass Maternal Size Hydatidiform mole

Answer 49

1st noted by mothers at 18-20 weeks Increase until 32 weeks and then plateau Average 31/h Foetuses sleep for 20-40min cycles day and night Reduced foetal movements: advise lying semi-recumbent for 2h; if

Answer 50

1) Descent, with head in left/right lateral position. Flexion 2) Further descent and internal rotation of head 3) Complete internal rotation of head, beginning extension due to sacral curve 4) Complete extension as head delivered 5) Restitution (external rotation of head) 6) internal rotation + delivery of anterior shoulder 7) Delivery of posterior shoulder

Answer 51

1) Flexed fetus descends - head very flexed on spine, descends and engages 2) Internal rotation: Whole fetus internally rotates its facing towards maternal back - head at level of ischial spines 3) Extension of head - head extends around pubis symphysis due to sacral angle until delivered 4) Restitution (external rotation) - after head delivered, fetus rotates back to its original position (Shoulders AP) 5) Delivery of shoulders - Anterior shoulder comes out first, then rest in pelvic axis (ie. anteriorly)

Answer 52

CTG - US detects fetal heart beats + tocodynamometer over uterine fundus recording any contractions Normal trace: - Baseline: 110-160 - Variability: >5bpm - Accelerations: >2 of 15bpm over 15 minutes

Answer 53

DR C BRaVADO DR - Define risk C - Contractions per 10 min - hyperstimulation = >5 contractions in 10 mins BRa - Baseline rate (should be 110-160bpm) V - Variability > 5BPM A - Accelerations of the foetal heart with contractions/movement is reassuring D - Decels: - Early - synchronous with contractions - normal response to head compression - Late - persist after contraction - suggestive of fetal hypoxia - Variable: reflect cord compression O - overall assessment

Answer 54

- Aims to detect patterns known to be associated with fetal distress - diagnosis supported by fetal hypoxia on blood sampling - Intermittent auscultation at the end of contractions with doppler/Pinard used for low risk labours - 1st stage - every 15 mins - 2nd stage - every 5 mins Continuous FHR monitoring only if abnormality noted or intrapartum problems occur - -> poor predictive value - -> over diagnosis of fetal distress

Answer 55

High risk pregnancy Use of oxytocin Decelerations noted after a contraction (Late) Rate 160 Fresh meconium passed Maternal pyrexia Fresh bleeding in labour Maternal requests

Answer 56

Management of a poor trace Lie mother on left side and give O2 Stop oxytocin If there is uterine hypercontractility -> terbutaline 0.25mg SC Take foetal blood sample Foetal blood sampling Used to check for hypoxia in presence of pathological CTG trace Not used in acute compromise Take with mother lying in left lateral position Foetal acidosis reflects hypoxia pH >7.25 – normal; repeat in 1 hour if CTG remains pathological pH 7.21 7.2 – call consultant obstetrician and deliver immediately

Answer 57

Baseline variability of >5 beats/min shows response to vagal tone, sympathetic stimuli, and catecholamines in a well-oxygenated fetal brainstem Loss of baseline variability may reflect a preterm fetus who is asleep, drug effects (e.g. diazepam, morphine, phenothiazine), or hypoxia.

Answer 58

Heart rate >170 beats/min is associated with maternal fever, or β- sympathomimetic drug use, chorioamnionitis (loss of variation too), and acute/subacute hypoxia Persistent rates >200 are associated with fetal cardiac arrhythmia

Answer 59

Rarely associated with fetal hypoxia (except in placental abruption) It may reflect ↑ fetal vagal tone, fetal heart block, or, if spasmodic, cord compression

Answer 60

Early decelerations Coinciding with uterine contractions reflect increased vagal tone as fetal intracranial pressure rises with the contraction Late decelerations When the nadir of the deceleration develops some 30sec after the peak of the uterine contraction, reflect fetal hypoxia, the degree and duration reflecting its severity Variable decelerations, Both in degree and relation to uterine contractions, may represent umbilical cord compression around the limbs or presenting part

Answer 61

2 or more non-reassuring features: - Baseline rate 100–109 or 161–180 beats/minute - Variability 50% contractions, occurring over 90 minutes - Prolonged deceleration of 180 beats/minute Variability 50% contractions, or late decelerations, both over 90 minutes Single prolonged deceleration of >3 minutes

Answer 62

Early in pregnancy: Confirm ectopic or viable intrauterine pregnancy (4 weeks +3 days for regular 28 day cycle) with transvaginal scan Estimate gestation, ascertain viable foetus or diagnose twins Exclude hydatidiform mole Estimating gestation: Crown-rump length measured at 6-12 weeks From 12 weeks biparietal diameter can be measured From 14 weeks femur length can be measured Foetal abnormality Routine scans to find abnormality at 18-20 weeks Indications: Family history of neural tube defect Maternal diabetes Maternal epilepsy Oligohydramnios Multiple pregnancy Foetal echocardiography: Offered to high risk groups at 22-24 weeks

Answer 63

Hormonal: - Progesterone - decreased smooth muscle excitability (Uterus, gut, ureters) and raises body temp - Oestrogens (90% oestriol) - increased breast and nipple growth, water retention and protein synthesis Haemodynamic: - Blood volume - rises from week 10-32 - dilutional anaemia - WCC, platelets, ESR, cholesterol, B-globulin and fibrinogen raised - Albumin/ Y-globulin fall - Urea + creatinine fall Cardiovascular: - CO rises from 5 --> 6.5-7L/min in first 10 weeks (increased SV + HR) - BP falls during 2nd trimester, rises to non-pregnancy levels by term Aorto-caval compression - from 20wks, gravid uterus compresses IVC in supine women reducing VR. This reduces CO by 30-40% (supine hypotension) --> relieved by lying in left lateral position Other changes: - Ventilation increased by 40% - Gut motility reduced --> Constipation - GFR increases by 60^ - Skin pigmentation

Answer 64

High risk pregnancies: Maternal age >35 (chromosomal defects) Previous abnormal baby or family history of inherited condition Ultrasound: 11-13 - weeks screens for nuchal translucency (foetal heart failure) and chorionicity 18 weeks – anomaly scan AFP Amniocentesis CVS Foetoscopy

Answer 65

Combined test standard (11-13+6wks): 1) Nuchal tranlucency 2) Serum B-HCG 3) Pregnancy associated plasma protein A High risk - 1 in 150 or more If women book later, either triple or quadruple test should be offered between 15-20 weeks Triple test at 16: AFP + unconjugated oestriol + B-HCG Quadruple also has inhibin A Confirm diagnosis with amniocentesis or CVS

Answer 66

Amniocentesis Foetal loss rate is 1% at 16 weeks gestation but 5% for early amniocentesis at 10-13 weeks Amniotic fluid AFP is measured and cells in the fluid are cultured for karyotyping Chorionic villus sampling At 10 weeks the placenta is sampled by transcervical or transabdominal approach under continuous ultrasound control Use up to 20 weeks Does not detect neural tube defects, may cause foetal malformation and is not recommended in dichorionic multiple pregnancy

Answer 67

Glycoprotein synthesised by the foetal liver and GI tract Foetal levels fall after 12 weeks; maternal levels continue to rise to 30 weeks Maternal AFP measured at 17 weeks In 10% with high AFP there is a foetal malformation e.g. neural tube defect In 30% with no malformation there is an adverse outcome e.g. placental abruption or 3rd trimester death Non-specific test on its own

Answer 68

Carried out at 18 weeks with ultrasound guidance to find external malformations, do foetal blood samples or biopsy Foetal loss rate is 4%

Answer 69

Placenta lies in the lower uterine segment Risk of significant haemorrhage by mother and foetus Avoid PV examinations and advise against penetrative intercourse

Answer 70

Major placenta previa (placenta covers internal os) requires C-section Minor placenta previa (placenta in lower segment but does not cross the internal os) – aim for normal delivery unless the placenta encroaches within 2cm of the internal os Presentation may be as APH or as failure of the head to engage Problems are with bleeding and with mode of delivery as the placenta obstructs the os and may shear off during labour Poor lower segment contractility predisposes to postpartum haemorrhage After delivery: Examine placenta for abnormalities such as clots, infarcts, amnion nodosum, vasa praevia, single umbilical artery Weigh the placenta Blood taken from cord – cord gases, Hb, Coombs’ test (AIHA), LFTs and blood group

Answer 71

``` C-section Sharp curette TOP MULTIPARITY MULTIPLE PREGNANCY MOTHERs AGE >40 assisted conception Deficient endometrium Manual removal of placenta D&C Fibroids Endometritis ```

Answer 72

women with 3 or more persisting risk factors, consider antenatal and postnatal LMWH prophylaxis, starting as early in pregnancy as possible Consider normal dose prophylaxis when admitted in labour Treat for 6wks postpartum and supply compression stockings post partum Women with Past VTE +- thrombophilia: very high risk: High dose prophylactic LMWH eg. enoxaparin 40mg/12h SC if 50-90Kg

Answer 73

FBC Serum antibodies e.g. anti-D Glucose tolerance test Syphilis serology Rubella immunity HIV and hepatitis B offered Haemoglobin electrophoresis – sickle cell anaemia and thalassaemia Screening for infections involved in preterm labour (e.g. chlamydia, BV) offered to women at increased risk Urine microscopy & culture Urinalysis – glucose, protein and nitrites

Answer 74

Folic acid 0.4mg PO until 12 weeks - Women at higher risk of NTD 5mg until 12th week: (either partner has NTD, previous pregnancy NTD, FH, antiepileptic drugs, coeliac, DM or thalassemia trait, or BMI > 30) Vit D for women with BMI >30 or south asian/afro--carribean Avoidance of infection: listeriosis avoided by drinking pasteruised /UHT milk, avoiding soft/blue cheese, pate, partially cooked ready meals Sleep in lateral position

Answer 75

BP and urine checked at every visit 16 weeks: review of chromosomal abnormalities screening test and blood tests at booking 18-21 weeks: anomaly scan for structural abnormalities 25 weeks: appointment for nulliparous women to exclude early onset pre-eclampsia 28 weeks: fundal height measured, FBC & antibodies are check; glucose tolerance test (if indicated); anti-D given to rhesus D women 31 weeks: fundal height measured in nulliparous women and blood tests from week 28 are reviewed 32 weeks: repeat anomaly scan if placenta was low at 20 weeks 34 weeks: fundal height measured, FBC rechecked if Hb was previously low 36, 38 & 40 weeks: fundal height measured, foetal lie and presentation checked (refer for ECV if indicated) 41 weeks: fundal height measured, foetal lie and presentation is checked, membrane sweeping offered and induction of labour offered by 42 weeks

Answer 76

Occurs as gut motility decreases due to progesterone Treat with oral fluids and high-fibre diet Avoid stimulant laxatives - they increase uterine activity in some women

Answer 77

Ix: PCV and U&Es – to help guide fluid regimen LFTs – 50% have abnormal LFTs TFTs – abnormal in 60%; severity of hyperemesis correlates with degree of biochemical hyperthyroidism Rx: Admit VTE prophylaxis Thiamine supplements – to prevent Wernicke’s encephalopathy Mild – ginger, pyridoxine, dry bland food and carbonated drinks IV normal saline with potassium added (guided by U&Es) – rapid reversal of hyponatraemia can cause fatal central pontine myelinosis Anti-emetics may be needed if rehydration does not improve condition – cyclizine 50mg PO/IM/IV TDS

Answer 78

Pregnancy worsens anaemia so increased risk of crises and acute chest syndrome Increased risk of infection and foetal growth restriction Prenatal testing for foetus at 8-10 weeks Give 75mg aspirin daily from 12 weeks – reduces risk of developing pre-eclampsia Crises affect 27-50%; admit if fever, severe or atypical pain Treat pain with morphine/diamorphine not pethidine as it risks fits Give O2 if oxygen saturation is less than 95% Give heparin thromboprophylaxis 7d post vaginal delivery and 6 weeks post caesarean

Answer 79

``` Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding) ``` Antiretroviral therapy all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation Mode of delivery vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended a zidovudine infusion should be started four hours before beginning the caesarean section Neonatal antiretroviral therapy zidovudine is usually administered orally to the neonate if maternal viral load is

Answer 80

Aim for HbA1c 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 Insulin needs increase 50-1055% as pregnancy progresses Aim for fasting level 3.5-5.3mmol/L Give glucogel and glucagon kit During labour give 1L of 5-10% glucose/8h IVI with 1-2u insulin via a pump (sliding scale)

Answer 81

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 Gestational diabetes is diagnosed if either: Fasting glucose is >= 5.6 mmol/l 2-hour glucose is >= 7.8 mmol/

Answer 82

1) Newly diagnosed should be seen in joint diabetes & antenatal clinic within a week 2) teach women about selfmonitoring of blood glucose 3) Diet advice (low GI) + exercise 4) if fasting glucose 7, insulin should be started 4c) If at diagnosis, fasting glucose between 6-6.9 + evidence of complications eg macrosomia/hydramnios - start insulin - Glibenclamide only for women who cannot tolerate metformin/ fail to meet glucose targets and decline insulin

Answer 83

Maternal complications polyhydramnios - 25%, possibly due to fetal polyuria preterm labour - 15%, associated with polyhydramnios Neonatal complications macrosomia (although diabetes may also cause small for gestational age babies) hypoglycaemia (secondary to beta cell hyperplasia) respiratory distress syndrome: surfactant production is delayed polycythaemia: therefore more neonatal jaundice malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) stillbirth hypomagnesaemia hypocalcaemia shoulder dystocia (may cause Erb's palsy)

Answer 84

Hyperthyroid - Usually Grave's - Increased risk of prematuriy, foetal loss and malformation - Propylthiouracil low does best trx - If not controlled by drugs: partial thyroidectomy in 2nd trimester - Increased levels can cause foetal hyperthyroidism after 24 weeks causing premature delivery, craniosynostosis, goitre, polyhydramnios and extended neck in labour Labour, delivery, surgery and anaesthesia can precipitate thyroid storm Hypothyroidism in pregnancy Untreated hypothyroidism risks increased rates of miscarriage, stillbirth, premature labour and abnormality Increase levothyroixine by 30% as soon as the patient is pregnant Neonatal thyrotoxicosis Seen in 1% of babies in women with past Graves’ disease as thyroid receptor antibodies cross the placenta Test thyroid function in affected babies frequently Signs: foetal tachycardia >160bpm and intrauterine growth restriction

Answer 85

Viral hepatitis and gallstones may cause jaundice in pregnancy Ix: urine bile, serology, LFTs, USS Intrahepatic cholestasis of pregnancy: Pruritus of palms and soles in the second half of pregnancy Mild elevation of liver transaminases Elevated bilirubin Risk of preterm labour, foetal distress and stillbirth Give vitamin K 10mg PO OD to the mother and 1mg IM to the baby at birth Ursodeoxycholic acid reduces pruritus and abnormal LFTs Symptoms resolve within days of delivery

Answer 86

Acute fatty liver of pregnancy: Mother develops abdominal pain, jaundice headache, vomiting and thrombocytopaenia and pancreatitis Hepatic steatosis with micro-droplets of fat in liver cells Deep jaundice, uraemia, severe hypoglycaemia and clotting disorder may develop causing coma and death Rx: Supportive treatment for liver and renal failure Treat hypoglycaemia with a CVP line Expedite delivery

Answer 87

major organ system anomalies, autism, small ears, small broad nose, long upper lip, shallow philtrum & micro/retrognathia Cleft lip Neural tube defects: commoner with valproate and carbamazepine

Answer 88

RA - usually alleviated but may be exacerbated in the puerperium - Methotrexate CI , Sulphasalazine may be used AZT - may cause IUGR - NSAIDs can be used in1 st/2nd trimester, but not recommended in 3rd as they can cause premature closure of PDA SLA - exacerbatins common - pre-eclampsia, olgohydramnios and IUGR - -> Anti-Ro/Anti- La antibodies can irreversibly dmg foetal heart condution system causing congenital heart block

Answer 89

Anti-Ro Anti-La ===> both can irreversibly dmg foetal heart conduction system causing congenital heart block

Answer 90

Preconception: ACE inhibitors, A2A blockers and chlorothiazide risk congenital abnormality so change these to Labetalol (first line) or nifedipine (second line), methyldopa , hydralazine Antenatal: Ensure suitable antihypertensive is being used Aim for BP 80 Give aspirin 75mg PO OD from 12 weeks until baby is born USS to assess foetal growth, amniotic fluid and volume and umbilical artery velocity at 28-30 weeks and 32-34 weeks CTG if foetal activity is abnormal Monitor BP during labour If severe hypertension does not respond to treatment advise operative delivery Do not give methyldopa post-delivery as there is a risk of postnatal depression Avoid diuretics if breastfeeding

Answer 91

Needs assessment in secondary care Urine testing for proteinuria Check urine and BP weekly if mild If BP >150/90 start antihypertensive treatment e.g. labetalol If BP >160/110 admit to hospital, measure BP 4 times daily and check urine daily Aim for delivery after 37 weeks unless pre-eclampsia supervenes If BP outside target range (>160/110) advise operative delivery Continue antenatal antihypertensives postnatally

Answer 92

``` TORCHHH Toxo Other: Syphilis, Listeria, VZV, Chlamydia, gonorrhoea, TB Rubella CMV HSV HBV HIV ```

Answer 93

Childhood vaccination prevents susceptibility Asymptomatic reinfection can occur Foetus is most at risk in the 1st 16 weeks gestation

Answer 94

Causes more congenital retardation than rubella in the UK Maternal infection is mild Vertical transmission to foetus occurs in 40% 5% develop early multiple handicaps and have cytomegalic inclusion disease Sx: IUGR, pneumonia, thrombocytopaenia; neurological sequeulae: hearing, visual and mental impairment or death Amniocentesis at >20 weeks and shell viral culture can detect foetal transmission Reactivation of old CMV can occur in pregnancy – rarely affects the baby

Answer 95

40% of foetuses are affected if the mother has the illness Earlier in pregnancy -> more damage Sx: fever, rash, eosinophilia If symptomatic CNS prognosis is poor Diagnose affected babies by serology Can cause intracranial calcification, hydrocephalus, choroidoretinitis in severely affected babies; encephalitis, epilepsy, mental and physical retardation, jaundice, hepatosplenomegaly, thrombocytopenia, and skin rashes occur

Answer 96

Maternal screening Carriers have persistent HBsAg for >6months Anti-HBe antibodies are negative Without immunisation 95% of babies born to these mothers might develop hepatitis B; 93% would be chronic carriers at 6 months Give immunoglobulin and vaccinate babies of carriers & infected mothers at birth Do serology of vaccinated baby at 12-15 months; if HBsAg negative and anti-HBs is present, the child is protected

Answer 97

Neonatal infection can cause blindness, low IQ, epilepsy, jaundice, respiratory distress DIC and death Past infection recurrence is not usually a problem due to maternal antibodies If the mother develops primary HSV infection in pregnancy give oral acyclovir ± elective c-section if infection within 6 weeks of due date If a mother with primary lesions delivers vaginally give mother and newborn high-dose acyclovir

Answer 98

If chickenpox in last 7 days, of preg, aim for delivery after 7 days + give neonate VZIG at birth + monitor for 28/7 + treat with acyclovir if Sx Babies of non-immune mothers if contact in 1st 7 days of life: VZIG Mother with no history of chicken pox + contact - check varicella Abd, if -ve, give VZIG and mx as infectious. Notify doctor if rash develops Women developing chickenpox in pregnancy: : acyclovir 800mg 5 times daily for 7 days PO if >20wks and presenting within 24hrs of rash Hospitalise if chest, CNS, haemorrhagic rash or immunocomp Fetal varicella syndrome complicates 1% of mothers infected at 3-28 wksof pregnancy by reactivation in utero: Skin scarring, eye defects and neurological abnormalities

Answer 99

Fetal varicella syndrome complicates 1% of mothers infected at 3-28 wksof pregnancy by reactivation in utero: Skin scarring, eye defects and neurological abnormalities

Answer 100

Virus suppresses foetal erythropoiesis causing anaemia and thrombocytopenia Foetal death occurs in 10% Ix: Maternal IgM, US

Answer 101

Chlamydia: - 30% of infected mothers have affected babies - Conjunctivitis develops 5-14 days after birth and may show minimal inflammation or purulent D/C Complications: chlamydia pneumonitis, pharyngitis or otitis media Gonococcal conjunctivitis: - Occurs within 4 days of birth - Purulent d/c + lid swelling , corneal hazing/rupture

Answer 102

Streptococcus agalactiae is carried (without symptoms) by 25% of women Foetus can be infected during labour after membranes have ruptured Common with preterm labour, prolonged labour or if there is maternal fever Give all women IV antibiotics (penicillin) at start of labour or on rupture of membranes if: Positive GBS swab from vagina and anus at 35-37 weeks Any baby previously infected with GBS Documented GBS bacteriuria Recent swab result unknown and gestation

Answer 103

GAS Sx: chorioamnionitis, abdo pain, diarrhoea + severe sepsis mx: Early recognition, culture, high dose Abx and ITU

Answer 104

Gynecological: - Abruption (tender woody uterus) - Uterine rupture - Uterine Fibroids - Uterine torsion - Ovarian tumours - Pre-eclampsia (liver congestion) ``` Abdominal: Pylonephritis Appendicitis Cholecystitis Pancreatitis ```

Answer 105

PIH + Proteinuria + oedema - Failure of trophoblastic invasion of spiral arteries leaving them vasoactive Develops after 20 wks and usually resolves within 10 days post delivery Flu like: chest pain, headache, epigastric pain, vomiting, tachycardia - Visual disturbance - Shaking - Hyper-reflexia - irritability O/E: HTN, Oedema, epigastric tenderness, Urine dipstick Liver involvement: HELLP Syndrome Late: HTN/Renal failure Eclampsia Foetal: - Asphyxia - Abruption - IUGR - Hydrops

Answer 106

High risk: - Chronic HTN/ HTN in previous pregnancy - CKD - DM - AI disease Moderate: - 1st pregnancy - Age >40 - Pregnancy interval >10 yrs - BMI >35 - FH - Multiple pregnancy If 1 high risk, or 2 moderate, take aspirin 75mg OD PO from 12th week until delivery

Answer 107

Liver involvement in pre-eclampsia: Haemolysis Elevated liver enzymes Low platelets

Answer 108

Admit if: - BP rises >30/20mmHg over booking BP - BP > 160/100 - BP > 140/90 + proteinuria - Growth restriction ``` Measure BP 2-4hrly Weigh daily Test urine for protein Monitor fluid balance Bloods: U&E, LFT, platelets CTG on admission USS to check growth, amniotic fluid volume and umbilical artery velicometry ``` If mild HTN & No complications, delivery by 37 weeks If severe: - Prophylactic MgS04 - Prophylactic steroids - Deliver foetus ASAP ``` HTN: BP> 160/110, Labetalol 20mg IV, increasing after 10 min intervals to 40mg then 80mg until 200mg total is given; aim for 150/80 - Alternative = hydralazine - Prophylactic H2 blockers - restrict fluid to 80ml/hr ```

Answer 109

First seizure – 4g magnesium sulphate (beware decreased respiration) Recurrent seizure – 2g magnesium sulphate IVI over 5 minutes Check tendon reflexes and respiratory rate every 15 minutes Stop magnesium sulfate IVI if respiratory rate

Answer 110

Anti-D is given to all rhesus D negative mothers at 28 weeks Anti-D is also given within 72h of any sensitising event e.g. miscarriage or threatened miscarriage after 12 weeks, ERPC, termination of pregnancy, ectopic pregnancy, amniocentesis, after ECV, foetal death or antepartum haemorrhage

Answer 111

If mild – neonatal jaundice Severe disease – in utero anaemia leading to cardiac failure, ascites, and oedema (hydrops) followed by foetal death Ix: assess severity by doing Doppler of foetal middle cerebral artery Mx: blood transfusion in utero or delivery if >36 weeks Postnatal Mx: check FBC, bilirubin and rhesus group

Answer 112

Cervical stitch to strengthen the cervix and keep it closed: At 12-14 weeks for women with a history of preterm delivery If cervix is regularly scanned and there is significant shortening Rescue suture to prevent delivery when the “incompetent” cervix is dilated Progesterone supplementation: suppositories from early pregnancy reduce risk of preterm labour in women at high risk Foetal reduction – for multiple pregnancies Needle aspiration of polyhydramnios

Answer 113

Painful contractions Painless cervical dilatation Increased D/C Antepartum haemorrhage and fluid loss (ruptured membranes)

Answer 114

Ix; CTG, foetal fibronectin assay, TVUS of cervical length, vaginal swabs (for infection) In 50% contractions cease spontaneously Treating the cause may make it cease 1) corticosteroids 2) Tocolysis (suppression of contractions) - unlikely to succeed if membranes are ruptured or cervix is >4cm dilated – nifedipine or atosiban

Answer 115

Fetal fibronectin "leaks" into the vagina if a preterm delivery is likely to occur and can be measured in a screening test. When the fFN test is positive, it is an inconclusive result. A positive result can indicate that a woman will go into preterm labor soon, but she may not go into labor for weeks. When the fFN test is negative, the result is a better predictor. A negative result means that there is little possibility of preterm labour within the next 7 to 10 days, and the test can be repeated weekly for women who remain at high risk. A negative fetal fibronectin test gives a more than 95% likelihood of remaining undelivered for the next 2 week

Answer 116

Admit Assess for causes eg. infection If liquor not obvious, use nitrazine stick (turns black if present) Give corticosteroids (betamethasone 12mg IM with a 2nd dose 12-24 hrs later) In 80%, PROM initiates labour - In remaining, balance advantages of remaining in utero against threat of infection - If chorioamnionitis suspected give erythromycin Nb. MgSO4 can be neuroprotective if given antenatally for babies

Answer 117

NVD reduces incidence of RDS C-section if breech Do not rupture membranes Slow delivery allows more time for steroids to act Babies delivered at 28 weeks gestation should be delivered in a room with temperature of 26°C, wrapped in food grade plastic wrap without drying after birth and placed under heat; cord should not be clamped for 45s

Answer 118

Neonate - NICU admission - Death - Cerebral palsy - CLD - Blindness - Minor disabilities Maternal: - Infection - Endometritits

Answer 119

Exceeding 42 weeks of pregnancy ``` Problems: Possible placental insufficiency Larger foetuses Foetal skull more ossified Increased meconium passage in labour Increased foetal distress in labour Increased C-section rates for labour ``` Mx: Membrane sweep Induction with prostaglandin followed by syntocinon If induction declined, arrange twice weekly CTGs and US estimation of amniotic fluid depth to try to detect fetuses that may be becoming hypoxic

Answer 120

Signifies hypoxia Prolonged/repeated hypoxia causes foetal acidosis Early signs may be the passage of meconium in labour, foetal tachycardia, loss of variability, irregularity of the heart rate, CTG changes Hypoxia may be confirmed by the use of foetal blood sampling (severe hypoxia -> foetal scalp blood pH proceed to: Level 2: continuous CTG; if sustained bradycardia -> deliver; if other abnormalities, treat cause; if they fail -> proceed to: Level 3: FBS – if abnormal proceed to: Level 4: delivery by quickest route

Answer 121

Pituitary necrosis caused by post-partum haemorrhage. Leads to lack of pituiatry insufficiency: Lack of TSH, ACTH and GnRH leads to hypothyroidism, addisonian symptoms and genital atrophy

Answer 122

Dangerous: Abruption Praevia vasa praevia Other uterine causes: - Circumvallate placenta - Placental sinuses - Fibroids Lower genital track sources: - Cervical polyps - Erosions and carcinoma - Cervicitis - Vaginitis - Vulval varicosities

Answer 123

Mx: Admit if bleeding Elective C-section at 39 weeks Complications: Intraoperative haemorrhage and postpartum haemorrhage are common – may require hysterectomy If placenta implants deep in a previous C-section scar it may prevent placental separation – placenta accreta or may penetrate through the uterine wall into a surrounding structure (e.g. bladder) – placenta percreta

Answer 124

Occurs in 1% of pregnancies Posterior abruption may present with backache May be uterine hypercontractility May recur in subsequent pregnancies Consequences: Placental insufficiency -> foetal anoxia/death Compression of uterine muscles by blood -> tenderness and prevention of good contractions -> can precipitate PPH Concealed loss may cause maternal shock after which beware DIC, renal failure and Sheehan’s syndrome (pituitary necrosis)

Answer 125

Sx: painful bleeding (degree of vaginal bleeding does not reflect severity of obstruction) OE: tachycardia, hypotension (if massive blood loss), tender uterus,; if severe uterus will be woody hard; foetal heart tones are abnormal or absent Ix: CTG, FBC, coagulation screen, cross match, catheter, U&Es, CVP Mx: Admit Give O2 at 15L/min If mild bleeding – get IV access, bloods (Hb, crossmatch, coagulation studies, U&Es), BP, pulse, monitor blood loss; ultrasound, speculum; give steroids if 37 weeks -> induce labour with amniotomy If bleeding is severe or there is foetal distress -> deliver by C-section

Answer 126

Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment Epidemiology 5% will have low-lying placenta when scanned at 16-20 weeks gestation incidence at delivery is only 0.5%, therefore most placentas rise away from cervix Associated factors multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section ``` Clinical features 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 ``` Classical grading I - placenta reaches lower segment but not the internal os II - placenta reaches internal os but doesn't cover it III - placenta covers the internal os before dilation but not when dilated IV - placenta completely covers the internal os

Answer 127

``` Pre-eclampsia Smoking IUGR PROM Multiple pregnancy polyhydramnios Increased maternal age Thrombophilia Abdominal trauma Assisted reproduction Cocaine/amphetamine use Infection non-vertex presentation ```

Answer 128

Abruption: shock out of proportion with visible loss Abruption: Constant pain with tender tense uterus, vs painless, non-tender uterus in praevia Abruption - normal lie & presentation Praevia: both may be abnormal Abruption - fetal heart absent/distressed Paevia - fetal heart usually normal Abruption - coagulation problems Paevia - coagulation problems rare Abruption: Beware Pre-eclampsia, DIC, anuria Paevia - small bleeds before large

Answer 129

Foetal vessels run in membranes in front of presenting part Typically occurs when cord is attached to membranes rather than the placenta Vessels may rupture when membranes rupture Sx: painless moderate vaginal bleeding at amniotomy or SROM with severe foetal distress

Answer 130

The powers (Degree of force expelling the foetus) The passage (dimensions of pelvis and resistance of soft tissues) The passenger (diameters of the foetal head)

Answer 131

In established labour the uterus contracts for 45-60 seconds every 2-3 minutes Pulls the cervix up (effacement) and causes dilatation Aided by pressure of head as uterus pushes the head down into the pelvis Poor uterine activity is common in nulliparous women and induced labour

Answer 132

Inlet: transverse diameter is 13cm; AP diameter is 11cm Midcavity: almost round – transverse and AP diameters are similar Outlet: AP diameter (12.5cm) is greater than the transverse diameter (11cm) Descent measured in relation to the ischial spines (in the mid pelvis) which can be palpated vaginally: -2 = 2cm above spines 0 = at level of spines +2 = 2cm below spines Soft tissues of vagina and perineum need to be overcome in the second stage; perineum often tears or is cut (episiotomy) to allow the head to deliver

Answer 133

Presenting part: cephalic (vertex, brow or face) or breech Head is oblong in transverse section Attitude: degree of flexion of head on the neck; ideal is maximal flexion (vertex presentation) with diameter of 9.5cm; extension cases an increase in diameter Position: degree of rotation of head on neck; at inlet sagittal suture is transverse and at outlet it is vertical (occipito-anterior) – head must rotate 90° during labour Head can be compressed in pelvis because of sutures; reduces the diameters of the head (moulding); pressure of the scalp on the cervix or pelvic inlet can cause localised swelling (caput)

Answer 134

Involuntary contractions of uterine smooth muscle occur throughout the 3rd trimester (often felt as Braxton-Hicks contractions) Prostaglandin production reduces cervical resistance Increasing release of oxytocin from the posterior pituitary Labour is diagnosed when painful regular contractions lead to effacement and dilatation of the cervix Effacement is accompanied by a “show” (pink/white mucus plug from the cervix) and/or rupture of membranes

Answer 135

First stage - Latent phase Painful contractions Cervix effaces – becomes softer and shorter Cervix dilates to 4cm - Established phase Contractions with dilatation from 4cm to 10cm Satisfactory rate of dilatation is 0.5cm/h Membranes usually rupture in this stage 1st stage usually takes 8-18h in a primip and 5-12h in a multip

Answer 136

1st stage usually takes 8-18h in a primip and 5-12h in a multip

Answer 137

Allow mother to drink & eat; give freedom to move Assess contractions every 30 mins (strength & frequency – ideally 3-4/10mins) Check maternal pulse every hour Check maternal BP and temperature 4 hourly Offer VE every 4h to assess cervical dilatation, position and station of head and degree of moulding Note the state of the liquor Auscultate FHR for 1 minute every 15 minutes

Answer 138

Passive stage Complete cervical dilatation but no desire to push Head reaches the pelvic floor and mother experiences need to push Active stage Baby can be seen Full dilatation with expulsive contractions and maternal effort Pressure of head on cervix produces desire to push Foetus is delivered in 40 minutes (nulliparous) or 20 minutes (multiparous)

Answer 139

Discourage supine maternal position Monitoring: Record urination Auscultate for 1 minute after a contraction every 5 minutes Assess contractions every 30 minutes Offer VE hourly Check BP and pulse hourly Check temperature 4 hourly If contractions wane, oxytocin augmentation may be needed Birth should be expected within 3 hours for primips and 2 hours for multips 1 minute delay in cord clamping is recommended for term babies 3 minute delay in cord clamping for premature babies

Answer 140

Delivery of the placenta Takes about 15 minutes Normal blood loss is 500ml Uterus contracts to a

Answer 141

Indications: - HTN/ Pre-eclampsia - prolonged pregnancy - Rhesus disease - DM/GDM - Still birth - Abruption - Foetal death in utero/ placental insuffiency CI: - Cephalopelvic disproportion - Malpresentations (other than breech or face) - Foetal distress - Placenta praevia - Cord presentation - Vasa praevia - PElvic tumour - previous repair to cervix

Answer 142

Modified bishops score: - Cervical dilation - Length of cervix - Station of head - Cervical consistancy - Position of cervix 5 = ripe - An unripe cervix may be ripened using prostaglandin vaginal gel - If this fails, may be repeated 6-8hrs later

Answer 143

An unripe cervix may be ripened using prostaglandin vaginal gel If this fails it may be repeated 6-8h later Once the cervix is ripe rupture the membranes (amniotomy) and monitor FHR Given oxytocin in 5% dextrose; increase dose until 3-4 contractions occur every 10 minutes Monitor FHR and stop oxytocin if signs of foetal distress or uterine hyperstimulation Problems of induction: Failed induction Uterine hyperstimulation Iatrogenic prematurity Infection Bleeding (vasa praevia) Cord prolapse (e.g. with high head at amniotomy) C-section and instrumental delivery rates are higher Uterine rupture (rare)

Answer 144

Delay in 1st stage of labour

Answer 145

Delay in 2nd stage of labour Delivery not imminent within 1 hour (multips) or 2 hours (primips) after onset of active 2nd stage Call senior obstetrician Offer amniotomy If prolonged or foetal compromise consider instrumental delivery or c-section

Answer 146

Meconium in liquor at amniotomy suggests placental insufficiency Do foetal blood sample and scalp clip monitoring If low foetal blood pH or very thick meconium -> c-section

Answer 147

Waterbirth Narcotic injectinos eg. PethidineUsed in first stage of labour Not given in birth is expected within 2-3h as it can cause neonatal respiratory depression Doses frequently produce vomiting but no pain relief SE: disorientation, nausea, vomiting, drowsiness G&A (Entonox) Can be inhaled throughout labour CI: pneumothorax SE: light-headedness and nausea Pudendal block Blocks S2-4 nerve roots using lidocaine Injected 1cm inferior and medial to the ischial spine Used with perineal infiltration for instrumental delivery Spinal anaesthesia LA injected through the dura mater into the CSF Rapidly produces short lasting but effective analgesia for C-section or mid-cavity instrumental vaginal delivery SE: hypotension; total spinal analgesia causing respiratory paralysis Epidural anaesthesia Anaesthesia of pain fibres carried by t11-S5 Started during latent 1st phase and continued until placenta delivered and any perineal tear is repaired SE: postural hypotension, urinary retention, paralysis

Answer 148

Pair of membranes which contain the fetus, composed of: - Inner amnion - encloses the amniotic cavity - Outer chorion - contains the amnion and is part of the placenta

Answer 149

Monozygotic twins: Identical twins - due to fertilisation of a single ovum that then separates into two. The time at which the separation occurs determines the chorionicity and amnionicity of the pregnancy Dizygotic twins: Fraternal twins, resulting from independent fertilisation of two ova. Always dichorionic - diamniotic - AS up to 20% of monozygotic pregnancies are also DCDA - 80% of all twin pregnancies are DCDA Risk factors for dizygotic: - IVF - Advanced maternal Age - Advanced parity - Maternal FH - Ethnicity (eg. Nigerians)

Answer 150

Division at: 1-4 days (morula) results in dichorionic-diamniotic twins (di-di) (DCDA): 20-30% of monozygotic twin pregnancies 76% of all twin pregnancies 4-8 days (blastocyst) results in monochorionic-diamniotic twins (mono-di) (MCDA): 70-75% of monozygotic twin pregnancies 30% of all twin pregnancies 1-2 weeks results in monochorionic-monoamniotic twins (mono-mono) (MCMA): 1-5% of monozygotic twin pregnancies 1.5% of all twin pregnancies > 2 weeks results in conjoined twins:

Answer 151

Early pregnancy: Uterus large for dates, hyperemesis Later: Polyhydramnios Signs: > 2 poles felt, multiplicity of etal parts, 2 FHS Dx: US Nb. Higher foetal loss rate in monochorionic twins

Answer 152

``` PPH Malpresentation Vasa previa rupture Cord prolapse Premature placental separation Cort entaglement Higher risk of GDM/Pre-E Greater mortality/miscarriage rates Preterm labour IUGR Twin-Twin transfusion syndrome if monochorionic ```

Answer 153

In monochorionic pregnancies: Unequal blood distribution in shared placenta leading to discordant blood volumes, liquor and growth Sx; recipient twin is large, polyhydramnios, fluid overload, heart failure; donor twin is smaller, stuck, oligohydramnios Mx: ultrasound surveillance from 12 weeks; laser therapy Complications: late miscarriage, preterm delivery, IUD, neurological damage

Answer 154

``` Ultrasound at 11-13 weeks Iron & folic acid Check FBC at 20-24 weeks Antenatal visits weekly from 30 weeks TVUS to monitor cervical length Delivery: C-section is increasingly used If first foetus is cephalic then vaginal delivery can be attempted First twin is delivered as normal Contractions often diminish after the first twin but usually return; start oxytocin if not ECV may be needed if 2nd twin is not longitudinal C-section may be needed Induction ```

Answer 155

Commonest malpresentation (40% at 20 weeks but only 3% at term) Risk factors: contracted pelvis, bicornuate uterus, fibroid uterus, placenta praevia, oligohydramios, spina bifida, hydrocephalic foetus Extended breech: commonest; flexed at the hips but extended at the knees Flexed breech: hips and knees both flexed; buttocks, external genitalia and feet all present Footling breech: feet are the presenting part; highest risk of cord prolapse Dx: Mother may complain of pain under the ribs On palpation: longitudinal lie, head in fundus which can be balloted

Answer 156

External cephalic version: Turning the breech by manoeuvring it through a forward somersault Turn baby only if vaginal delivery is planned Attempt ECV at 36 weeks in primips or 37 weeks in multips Success rate: 40% primips; 60% multips CI: placenta praevia, multiple pregnancy, APH in last 7 days, ruptured membranes, growth restricted babies, abnormal CTG, uterine scars/abnormalities, foetal abnormality; pre-eclampsia or HTN, unstable lie Complications: foetal damage, placental abruption, uterine rupture Vaginal breech birth Pushing not encouraged until buttocks are visible CTG monitoring advised Slow cervical dilatation in 1st stage and poor descent in 2nd stage – may be better to do a C-section Episiotomy may be needed C-section may provide better outcome vs vaginal delivery

Answer 157

Descent of cord through the cervix alongside (occulta) or in front (overt) of the presenting part in the presence of ruptured membranes Emergency – cord compression causes foetal asphyxia Incidence: 0.1-0.6% Increased risk if: twin, footling breech, shoulder presentation, polyhydramnios, unengaged head, transverse/unstable lie, male If cord presentation is noted prior to rupture -> C-section Signs: foetal bradycardia, variable FH decelerations Mx: Displace presenting part by putting a hand in the vagina and pushing the cord back up during contractions Either place the woman head down (left lateral position) or get her into knee-elbow position Tocolysis to reduce contractions and help bradycardia Immediate c-section is best

Answer 158

Impacted shoulders – inability to deliver shoulders after the head has been delivered Incidence: 0.6% Associated with high rate of foetal mortality and morbidity PPH occurs in 11% of mothers 4th degree tears occur in 4% Risk of brachial plexus injury and permanent disability to baby Common cause of litigation: only anterior shoulder can be injured by this Associations: large/postmature foetus, maternal BMI >30, induced labour, prolonged labour or secondary arrest, assisted delivery, previous shoulder dystocia, macrosomia due to diabetes Can squash cord at pelvic inlet and cause death from asphyxia

Answer 159

1) McRoberts (hyperflexed lithotomy position) - successful n 90% - Abduct, rotate outwards and flex maternal femurs so each thigh touches the abdomen (1 assistant to hold each leg) - Straightens sacrum relative to lumbar spine and rotates sypmhasis superiorly, helping the impacted shoulder enter the pelvis without manipulating the fetus. 2) Apply suprapubic pressure for 30s, with flat of hand laterally in the direction baby is facing and towards mother's sacrum - aims to displace anterior shoulder allowing it to enter the pelvis 3) If this fails, check ant shoulder is under symphysis via VE. If not, rotate it to be so and repeat traction 4) If this fails, rotate by 180 deg so post. shoulder now lies anterior. Episiotomy helps rotation/arm delivery 5) if all failed, get mother in all 4, maternal symphisiotomy or replacement of the foetal head by firm pressure of the hand to reverse the movements of labour and return the head to the fleed OA position + caesarean delivery. Baby severely acidotic by this stage - If babies dies prior to delivery, cutting through both clavicles (cleidotomy) with strong scissors assists delivery. - Check baby for dmg eg. Erb's plasy or fractured clavicle

Answer 160

Babies may pass fresh meconium during labour (dark green, sticky & lumpy) May be a response to the stress of normal labour or sign of distress/hypoxia -> commence continuous FHR monitoring Complications: aspiration of meconium can cause pneumonitis

Answer 161

Used only when: Head is deeply engaged and cannot be palpable abdominally Membranes have ruptured Position of head is known and presentation is suitable i.e. vertex or face Cephalo-pelvic disproportion is absent Cervix is fully dilates Uterus is contracting Adequate analgesia has been given Bladder is empty Inidcations: Delay or maternal exhaustion in second stage Dense epidural block with diminished urge to push Rotational instrumental delivery needed for malposition of head Suspected foetal distress

Answer 162

Forceps Designed with a cephalic head (to fit around the foetal head) and a pelvic curve (to fit around the pelvis) Wrigley’s (short-shanked) – for lift out deliveries when head is on perineum Neville Barnes (long shanked) – for higher deliveries when sagittal suture lies in the AP diameter Kielland’s – suitable for rotation Indications: delay in second stage (failure of maternal effort, epidural analgesia, malpositions of foetal head), foetal distress, prolapsed cord, eclampsia, delivery of head in breech deliveries Complications: maternal trauma (vaginal laceration, blood loss or 3rd degree tears), foetal facial brusing, foetal CN VII paralysis or brachial plexus injury Ventouse Cup is placed over posterior fontanelle with a suction force of 0.8kg/cm2 CI: head is above ischial spines, face presentations, babies

Answer 163

``` Failure to progress Foetal distress Breech Previous section Severe pre-eclampsia Placental abruption ```

Answer 164

``` Knwon cephalo-pelvic disproportion Placenta praevia Placenta accreta/percreata Breech Twins where 1st chephalic After vaginal surgery Maternal infections Maternal request ```

Answer 165

Inhalation of gastric acid during general anaesthesia (eg. for C-section) leading to cyanosis, bronchospasm, pulmonary oedema and tachycardia Prevention: pre-operative H2 antagonists, sodium citrate, gastric emptying, cricoid pressure, cuffed ET tubes during anaesthesia and pre-extubation emptying of stomach Mx: Tilt patient head down and to one side Aspirate the pharynx Give 100% oxygen

Answer 166

Babies are born dead after 24 weeks gestation Rate 1:200 births Causes: Antepartum: malformation, congenital infection (TORCH), pre-eclampsia, maternal disease, hyperpyrexia, postmaturity Intrapartum: abruption, maternal & foetal infection, cord prolapse/knots, uterine rupture Dx: absent foetal movements, no heart sounds Mx: Do Kleihauer on all women to diagnose foetomaternal haemorrhage Check maternal temperature, BP, urine for protein, blood clotting screen Deliver away from sound of babies and ensure good pain relief Offer baby to mother to see and to hold if she wishes

Answer 167

Primary PPH: >500ml in first 24 hrs after delivery. Major PPH = >1L Causes: Uterine Atony Genital trauma Clotting disorders Risk factors: - Previous PPH - Prolonged labour - Pre eclampsia - Increased maternal age - Polyhydramnios - Emergency C-section - Placenta praevia - Macrosomia - Ritodrine (a b2 agonist used for tocolysis)

Answer 168

ABC IV syntocinon (Oxytocin) 10U or IV ergometrine 500ug IM carboprost (induces contractions and reduces post partum bleeding) Other options: - B lynch suture - Ligation of uterine arteries/ Internal Iliac arteries - Rusch balloon if persistent haemorrhage - If severe, unontrolled haemorrhage, then a hysterectomy is sometimes performed as a life saving procedure

Answer 169

Occurs between 24 hrs - 12 weeks | - Due to retained placental tissue or endometritis

Answer 170

Third stage of labour is delayed if not complete by 30 minutes with active management or by 60 minutes with physiological 3rd stage Danger with retained placenta is haemorrhage Associated with: previous retained placenta or uterine surgery, preterm delivery, maternal age >35y, placental weight 5, induced labour, pethidine used in labour

Answer 171

Avoid excessive cord traction Check that the placenta is not in the vagina Palpate the abdomen: if uterus is well contracted the placenta has probably separated but trapped by the cervix; if uterus is bulky the placenta has probably failed to separate Rub up a contraction, put the baby to the breast to stimulate oxytocin production, give 20IU oxytocin and clamp cord If placenta does not deliver within 30 mins examine (with analgesia or anaesthetic) to see if manual removal is needed Manual removal Place one hand on abdomen to stabilise the uterus Insert other hand through cervix into uterus Follow cord to find the placenta and work round the placenta separating it from the uterus using the ulnar border of the hand When separated remove by cord traction Start Abx: doxycycline and metronidazole

Answer 172

Subperiosteal swelling on fetal head Boundaries LIMITED by individual bone margins/suture lines Spontaenous absorption occurs, but may takes weeks and may cause/contribute to jaundice

Answer 173

Oedematous swelling of the scalp, Superficial to cranial periosteum Forms over vertex and crosses suture lines Resolves within days

Answer 174

Blood lies between aponeurosis and periosteum - not limited by suture lines Haematoma not contained, and collections of blood may be large enough to result in anaemia or jaundice Associated with vacuum extractions

Answer 175

1st degree tears – superficial tears which do not damage muscle; suture unless skin edges well apposed to aid healing 2nd degree – laceration involve perineal muscle; repair is similar to that of episiotomy 3rd degree – damage involves the anal sphincter muscle 3a – external anal sphincter (circular fibres) thickness 50% torn 3c – both external and internal anal sphincters (longitudinal fibres) torn 4th degree – involving external & internal anal sphincters and rectal mucosa; repair in theatre Episiotomy Performed to enlarge the outlet to hasten birth of a distressed baby, for instrumental or breech delivery, to protect a premature head and to try to prevent 3rd degree tears Complications: bleeding, infection, breakdown, haematoma

Answer 176

Two questions should be asked: During the past month, have you often be bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things? If the woman says yes, a third question should be asked: Is there something you feel you need or want help with? May consider using further screening tests e.g. Edinburgh Post Natal Depression Scale (EPDS)

Answer 177

FSH, LH, E2, Testosterone, Prolactin, Thyroid, AMH, Luteal phase progesterone (day 20), TVUS (Ovaries/cysts), tubal patency - HyCosY (Foam squirted up vagina and watch for it to come out of tube) If hx of endometriosis - laparoscopy Men: Semen analysis: - Good number of sperm - Good morphology - Swimming well

Answer 178

Paramesanephric ducts don't form a uterus at all: - Ovaries , no uterus, but bottom 3rd of the vagina. Pc/ No periods

Answer 179

immobile organs (endo), tender uterus (adeno)

Answer 180

30% Anovulatory (PCOS, hypothalamic/hypogonadotrophic hypogonadism, hyperprolactinaemia) 25% Male factor (idiopathic, varicocele, drugs/chemicals, funny syndromes) 25% Tubal factor (infection, endo, surgery)

Answer 181

``` Prevalence 60% • 100 women become infected • 80 clear the virus in 8-18 months • 20 experience persistent infection • 10 women HG CIN • 1 woman will develop cancer ```

Answer 182

Vaccine for a very common infection • Occasionally it causes abnormal smears • Cervical cancer is a rare complication • Vaccine protects fully against the two most dangerous types • Some protection against other types (6,11) • Still need screening • Safe sex • No protection against STDs • 3 injections in the arm (0,2, 6 months) • Immunity lasts at least 8 years

Answer 183

Pelvic/abdo mass Ascite May present like: IBS (Unlikely to present first time in post-menopausal women/ diagnosis of exclusion) - Prolapse/urinary incontinence - Krukenberg tumours - met from GIT - Para-neoplastic syndrome: eg. dermatomyositis

Answer 184

Ca125 ovarian Ca19-9 - Mucinos CEA - Bowel (krukenberg) Ca153 - Breast - may metastasise to ovary AFP - Liver LDH (not specific) Inhibin (ovarian cancer) Beta-HCG + AFP ovarian germcell tumours

Answer 185

USS Pelvis: Endometrial, ovary MRI Pelvis: Endometrial, ovary + cervix CT ACP: Endometrial, ovary, cervix, vulva (Useful to look for distant mets/peritoneal involvement)

Answer 186

Chemo: Ovary/Cervix Radiotherapy: Endometrial,cervical and vulval nb. with cervical, chemotherapy first to sensitise to radiotherapy

Answer 187

1st stage: Latent: Painful contractions + cervical effacement/dilatation up to 4cm Established: Regular painful contractions + progressive cervical dilatation from 4cm 2nd Stage; Full dilatation to explusion of fetus Latent: Cervix fully dilatated, but presenting part hasn't reached outlet yet so no urge to push Active phase: as fetus descends, pressure from presenting part stimulates the nerve receptors in the pelvic floor (Ferguson reflex), producing the urge to push 3rd stage: From delivery of baby to complete explusion of placenta

Answer 188

Primip : 8 (Avg) - 18 | Multip: 5 (avg) - 12

Answer 189

Single document available in labour that should have all information about labour ``` eg. Fetal condition (HR, Liquour) Cervical dilation Descent of head Uterine contractions Maternal condition (T, P, R, BP, Urinalysis) ``` DRAW: Alert line shows 1cm/dilation an hour. 4 hrs to the right of that is action line. If it hits this, you have to do something to promote labour progression ONLY start using when in active labour (>4cm)

Answer 190

``` Transitional behaviour (irrational/erratic) SROM SHow Unctrolled urge to push DIlatation and gaping of anus OFten bowels open with pushing Appearnce of the rhomboid michaelis Women with an epidural may have upper abdominal pressure Perineum bulges and vagina gapes Presenting part becomes visible at vulva ```

Answer 191

nulliparous - birth within 3hrs of start of active 2nd stage Parous: within 2 hrs of start of active 2nd stage

Answer 192

1) Cord lengthening 2) Fresh PV bleeding 3) Fundus rises up and becomes more globular (on palpation feels like a rugby ball)

Answer 193

NICE recommend syntocinon 10U given IM for active management of the 3rd stage of labour (not syntometrine as ergometrine induces a strong sustained non-physiological spasm which can last 2-4hrs)

Answer 194

Prolonged if not completed within 30 mins of birth in active mx or 60 mx in passive mx

Answer 195

Not compatible with vaginal birth, would have to be delivered by C section

Answer 196

``` S O A P S ```

Answer 197

Life-threatening organ dysfunction caused by a dysregulated host response to infection Suspected infection + organ dysfunction qSOFA score of 2 points or more: - Resp rate > 22 - Systolic BP 100 or less - Alternation of mental state (from baseline)

Answer 198

A subset of sepsis: - Profound disturbances of circulatory, cellular and metabolic function - Greater mortality than sepsis alone - Hospital mortality over 40% Clinical findings in the presence of adequete volume resuscitation: - Serum Lactate > 2mmol/L - Requiring vasopressors to maintain BP

Answer 199

Infection of the genital tract at any time from ROM or labour to 6 weeks postpartum Fever + 1+ features: - Pelvic pain - Abnormal vaginal D/C - Abnormal odour of discharge - Delay in involution of uterus

Answer 200

booking: Blood group + Abds, FBC, Sickle / Thalassaemia screen, HBV, HIV, syphilis, rubella immunity 28 wks: FBC, G&S, Glucose (GCT/GTT) 34 weeks: FBC, Group and antibody screen

Answer 201

``` BMI > 30 Previous macrosomic baby (4.5kg or more) Previous GDM FH (1st degree relative) Ethnics Any stage in pregnancy if fetal abdomen or liquour volume > 95th centile ``` Or if there in an abnormal screening test. GDM diagnosed if: - Fasting plasma >5.6 - 2 hour GTT > 7.8

Answer 202

Preterm - oral erythromycin 10/7 , steroids, monitor for infection, deliver at 34 wks Term - IVAB (benpen/clindamycin in pen allergic) from 18-24 hrs PROM until delivery, do something to get labour started by 24 hrs IF signs of chorioamnioitis, expedite delivery by the safest method for both mother and baby, depending on gestation

Answer 203

No routine swabs in UK Swabs indicated if: - PROM (

Answer 204

Pens/cephs are drugs of choice in pregnancy and breastfeeding Clindamycin if pen allergic Avoid quinolones, tetracyclines aminoglycosides unless severe Avoid trimethoprim in 1st trimester: folate antagonist Avoid nitrofurantoin at term: risk of neonatal haemolysis Co-amoxiclav - Link with NEC in preterm, therefore avoid

Answer 205

pregnancy : Aspirin 75mg okay, everything else not Breastfeeding: aspirin not okay (Reye's), ibuprofen Okay

Answer 206

Normal: Continue monitoring (if appropriate indication) Suspicious: - Inform obstetric staff/senior midwife - Assess the woman - Consider position, hydration - Check not hyperstimulating (contraction every min) - Treat maternal pyrexia if present - Reassess in 30 mins Pathological: - Urgent obstetric review - Examine the woman - is sje progressing? Is she fully dilated and deliverable in the room? - Acute fetal compromise? Deliver without delay (eg. bradycardia not recovering) - Not acute compromise? FBS now or delivery within 30 mins

Answer 207

Abnomral: FBS 7.25