OBS

Question 1

ECTOPIC PREGNANCY

What is an ectopic pregnancy?

Answer 1

• When a fertilised ovum implants outside of the uterine cavity, 98% tubal

Question 2

ECTOPIC PREGNANCY
Where is the most common site for an ectopic?
What is the most common site for a ruptured ectopic?

Answer 2

• Ampulla

- Isthmus

Question 3

ECTOPIC PREGNANCY
What is the epidemiology of ectopics?
What are some risk factors for ectopics?

Answer 3

• 1 in 100 incidence

- Previous ectopic (10% recurrence rate), PID, endometriosis, tubal surgery, IUCD, IVF + POP

Question 4

ECTOPIC PREGNANCY

What are some symptoms of ectopics?

Answer 4

• Amenorrhoea for 6-8w, PV bleeding (small amount, brown)
• Constant lower abdo (iliac fossa) pain
• D+V, dizziness + fainting

Question 5

ECTOPIC PREGNANCY

What are some signs of ectopics?

Answer 5

• Referred shoulder pain due to haemoperitoneum irritating diaphragm
• Abdo or rebound tenderness
• Cervical excitation/motion tenderness
• Peritonism or collapse if rupture

Question 6

ECTOPIC PREGNANCY

What are some crucial investigations for ectopics?

Answer 6

• Beta-hCG to confirm pregnant – should double every 48h in normal
• TVS = empty uterus, may show adnexal mass or free fluid

Question 7

ECTOPIC PREGNANCY

What are some other investigations for ectopics?

Answer 7

• FBC, group + save, serum progesterone <20nmol/L suggests failing pregnancy
• Laparoscopy gold standard but only used as necessary

Question 8

ECTOPIC PREGNANCY

What are the 3 management techniques for ectopic pregnancies?

Answer 8

• Expectant
• Medical
• Surgical

Question 9

ECTOPIC PREGNANCY
What is expectant management?
What are the indications?
What indicates that it has worked?

Answer 9

• Effectively do nothing
• Clinically stable (no Sx), ectopic <35mm, no heartbeat, serum hCG <1000IU/L (consider up to 1500) + able to return for follow up
• Serum hCG days 2, 4 + 7 (drop ≥15% then repeat weekly until negative)

Question 10

ECTOPIC PREGNANCY
What is medical management?
What are the indications?
What indicates that it has worked?

Answer 10

• Single dose IM 50mg/m^2 methotrexate
• No significant pain, unruptured ectopic <35mm, no heartbeat, serum hCG <1500 (consider up to 5000IU/L) + able to return for follow up
• hCG levels at days 4 + 7 then weekly, <15% fall = ?another dose

Question 11

ECTOPIC PREGNANCY
What are the requirements for methotrexate management?
What are some side effects?

Answer 11

• Satisfactory liver + renal functions
• Teratogenic so effective contraception for 3m
• Conjunctivitis, diarrhoea, abdo pain + stomatitis

Question 12

ECTOPIC PREGNANCY
What surgical management is offered?
What are indications?
What else should be given?

Answer 12

• Salpingectomy or salpingotomy
• Does not meet expectant or medical criteria (>35mm, visible heartbeat, ruptured)
• Anti-D for rhesus -ve in surgical management

Question 13

ECTOPIC PREGNANCY

How do you choose which type of surgical management to give?

Answer 13

• Salpingectomy if contralateral tube + ovary healthy to reduce recurrence
• Salpingotomy if contralateral tube defected
• Laparoscopy preferred to laparotomy unless haemodynamically unstable

Question 14

MISCARRIAGE

What is a miscarriage?

Answer 14

• Spontaneous termination of a pregnancy before 24w gestation

Question 15

MISCARRIAGE

What is the epidemiology of miscarriage?

Answer 15

• 15–20% of pregnancies with 85% in first trimester

- No increased risk of having another miscarriage after 1 but is after 2

Question 16

MISCARRIAGE

What are the most common causes of miscarriage in first trimester?

Answer 16

Chromosome abnormality –

• Autosomal trisomy most common (trisomy 16)
• Most common single chromosomal anomaly is 45X
• Increasing maternal age biggest risk

Question 17

MISCARRIAGE
What is the most common cause of miscarriage in the second trimester?
What are some risk factors?

Answer 17

• Incompetent cervix

- Previous cervical surgery, BV in 2nd trimester

Question 18

MISCARRIAGE

What are some other causes of miscarriage?

Answer 18

• PCOS
• TORCH infections
• Iatrogenic (amniocentesis, CVS)
• Smoking, substance abuse

Question 19

MISCARRIAGE

What are the 6 types of miscarriage?

Answer 19

• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Septic

Question 20

MISCARRIAGE

What is a threatened miscarriage?

Answer 20

• Foetus alive but miscarriage may occur (majority don’t)
• Painless vaginal bleeding with closed cervical os
• TVS = viable intrauterine pregnancy

Question 21

MISCARRIAGE

What is an inevitable miscarriage?

Answer 21

• Miscarriage will occur
• Heavy PV bleed with clots + crampy abdo pain with open cervical os (1 finger)
• POC not passed
• TVS = intrauterine gestation sac, foetus may be alive but miscarriage imminent

Question 22

MISCARRIAGE

What is an incomplete miscarriage?

Answer 22

• Not all POC been passed
• PV bleed, abdo pain + open cervical os with POC in canal
• Medical or surgical mx as infection risk

Question 23

MISCARRIAGE

What is a complete miscarriage?

Answer 23

• Full miscarriage occurred with all foetal tissue passing
• Bleeding + pain cease, uterus no longer enlarged, cervical os closed
• TVS = empty uterus, endometrial thickening <15mm, exclude ectopic

Question 24

MISCARRIAGE

What is a missed miscarriage?

Answer 24

• Foetus not developed or died in utero but this is not recognised until bleeding occurs or TVS
• TVS - non-viable intrauterine pregnancy (smaller than expected) e.g. 12w scan shows 9w foetus with no heartbeat

Question 25

MISCARRIAGE | What is a blighted ovum?

Answer 25

- In missed miscarriage, a gestational sac >25mm but no embryonic/foetal pole

Question 26

MISCARRIAGE | What is a septic miscarriage?

Answer 26

- Contents of uterus infected causing endometritis

Question 27

MISCARRIAGE What is a... i) pregnancy of uncertain viability? ii) pregnancy of unknown location?

Answer 27

i) Small sac with no visible heartbeat, rescan 10–14d | ii) No sign of intrauterine, ectopic or retained POC but positive beta-hCG

Question 28

MISCARRIAGE | What is the management of pregnancy of unknown location?

Answer 28

- Beta-hCG >1500IU/L ?ectopic - Significant distress = laparoscopy - Stable = repeat beta-hCG after 48h - If no Dx after 3 samples = expectant or methotrexate Mx

Question 29

MISCARRIAGE | What are the generalised investigations and management of miscarriage?

Answer 29

- Refer to EPAU for Ix - Speculum exam = cervical os open/closed, remove POC if in cervical os - Serum beta-hCG levels - TVS = location + viability - Histological exam of any tissue passed vaginally

Question 30

MISCARRIAGE | What would serum beta-hCG levels show in miscarriage?

Answer 30

- Serial testing as should double every 48h for first few weeks of pregnancy - Levels may be less than expected for dates - Falling indicates failing pregnancy

Question 31

MISCARRIAGE What is the first line management of miscarriage? What are the indications? What is the follow up?

Answer 31

- Expectant (wait 7–14d) - <6w, not bleeding heavily, no signs of infection - Urinary beta-hCG after 3w or repeat TVS if persistent or worse bleeding (or not started)

Question 32

MISCARRIAGE What is the medical management of a miscarriage? What is the follow up?

Answer 32

- PV/PO synthetic prostaglandin misoprostol - Contact HCP if no bleeding in 24h - Urinary beta-hCG 3w after to exclude ectopic or molar

Question 33

MISCARRIAGE | What are the risks of expectant and medical management?

Answer 33

- Bleeding continuing - Increased pain - Infected POC - Failure

Question 34

MISCARRIAGE | What are some indications for surgical management?

Answer 34

- Heavy bleeding - Infection - Failed other methods

Question 35

MISCARRIAGE | What are the options for surgical management?

Answer 35

- Vacuum aspiration (suction curettage) under local as OP | - Surgical Mx (evacuation of retained products of conception) under general

Question 36

MISCARRIAGE | What else may be given in the management of miscarriage?

Answer 36

- Anti-D to rhesus -ve women if >12w, heavily bleeding or surgical Mx

Question 37

MISCARRIAGE | What is a recurrent miscarriage?

Answer 37

- ≥3 consecutive miscarriages in the first trimester with the same biological father

Question 38

MISCARRIAGE | What are some causes of recurrent miscarriage?

Answer 38

- Antiphospholipid syndrome - Hereditary thrombophilias (Factor V leiden deficiency, factor II prothrombin gene mutation, protein C/S deficiency) - Uterine abnormalities (uterine septate, fibroids) - Poor controlled chronic conditions (DM, thyroid, SLE)

Question 39

MISCARRIAGE What is antiphospholipid syndrome? What is the management?

Answer 39

- Hypercoaguable state presenting with thrombosis + pregnancy issues (recurrent miscarriage) - Associated with antiphospholipid antibodies - Can occur on own or secondary to SLE - Low dose aspirin + LMWH

Question 40

MISCARRIAGE | What are the investigations for recurrent miscarriage?

Answer 40

≥3 1st trimester, ≥1 in 2nd – - Lupus anticoagulant, anti-cardiolipin + phospholipid antibodies - Thrombophilia screen - Pelvic USS for structural issues - Cytogenic analysis of POC after 3rd miscarriage - Parental blood for karyotyping

Question 41

TERMINATING PREGNANCY | What is the legal framework for terminating pregnancies?

Answer 41

- 1967 Abortion Act (+ 1990 amendment which reduced gestation from 28 to 24w)

Question 42

TERMINATING PREGNANCY | What are the requirements for an abortion?

Answer 42

- <24w - Continuing pregnancy = great risk to physical or mental health of woman or existing children in family (clinical judgement)

Question 43

TERMINATING PREGNANCY | When may an abortion be performed after 24w?

Answer 43

- Continuing is likely to risk mother's life - Prevents grave injury to physical or MH of woman - Substantial risk of serious handicap for baby

Question 44

TERMINATING PREGNANCY | What are the legal requirements for an abortion?

Answer 44

- 2 registered medical practitioners must sign to agree indication - Must be registered medical practitioner in an approved premise

Question 45

TERMINATING PREGNANCY | What is some pre-abortion care?

Answer 45

- Marie Stopes UK charity that provides abortion services (remote service if <10w gestation, phone consultation, meds issued remotely to take at home) - Women should be offered counselling

Question 46

TERMINATING PREGNANCY | What is the medical management of abortion?

Answer 46

- More appropriate in earlier pregnancy, <24w, <10w can be done at home - Mifepristone (anti-progesterone) to halt pregnancy + relax cervix - Misoprostol (prostaglandin analogue) 24-48h after for contractions

Question 47

TERMINATING PREGNANCY | What is done before surgical management of abortion?

Answer 47

- Cervical priming with mifepristone, misoprostol or osmotic dilators (>14w insert into cervix + gradually expand as absorb fluid to open cervical canal)

Question 48

TERMINATING PREGNANCY | What is the surgical management of abortion?

Answer 48

- Cervical dilatation + vacuum aspiration of uterus contents <14w - Cervical dilatation + evacuation using forceps >14w - Rh -ve >10w = anti-D

Question 49

TERMINATING PREGNANCY | What is post-abortion care?

Answer 49

- Pregnancy test at 3w - Contraception advice - Complications = infection (#1), bleeding, pain, failure or damage to genital tract

Question 50

HYPEREMESIS | How common is nausea and vomiting in pregnancy?

Answer 50

- Very, particularly early on starts in early first trimester, peaks 8–12w + resolves 16–20w

Question 51

HYPEREMESIS What is believed to be responsible for N+V in pregnancy? When is N+V worse? What are some associations of hyperemesis gravidarum?

Answer 51

- Placental beta-hCG as N+V is more severe in molar + multiple pregnancies where beta-hCG high - Assoc = nulliparity, hyperthyroid, obesity, decreased in smokers

Question 52

HYPEREMESIS What is the clinical presentation of hyperemesis gravidarum? Complications?

Answer 52

- Severe + excessive N+V - Associated with dehydration, ketosis + weight loss - May lead to complications like Mallory-Weiss tear

Question 53

HYPEREMESIS What is the diagnostic triad for hyperemesis gravidarum? How is severity assessed?

Answer 53

Triad – - >5% weight loss compared to before pregnancy - Dehydration - Electrolyte imbalance Pregnancy-Unique Quantification of Emesis (PUQE) – - <7 mild, 7-12 mod, >12 severe

Question 54

HYPEREMESIS | What are some investigations for hyperemesis gravidarum?

Answer 54

- Urine dipstick for ketones, MSU to exclude UTI - FBC (raised haematocrit) - U+Es (electrolyte imbalances + dehydration) - May have hypochloraemic metabolic alkalosis - Higher beta-hCG levels - USS to reassure + exclude multiple/molar

Question 55

HYPEREMESIS | What would warrant hospital or EPAU admission?

Answer 55

- Unable to tolerate PO antiemetics or fluids - >5% weight loss compared to before pregnancy - Ketones present in dipstick (++ significant)

Question 56

HYPEREMESIS | What is the inpatient management of hyperemesis gravidarum?

Answer 56

- Monitor U+Es - NBM until tolerate PO = IV fluids + anti-emetics - Vitamin supplements (incl. thiamine), may need artificial nutrition to prevent Wenicke-Korsakoff - Thromboprophylaxis with TED stockings + LMWH - Small + frequent meals when eating allowed

Question 57

HYPEREMESIS What is the community management of hyperemesis gravidarum? What alternative management can be used?

Answer 57

- 1st line antiemetic = promethazine or cyclizine (anti-histamines) - 2nd line = ondansetron (5-HT3 antagonist) or metoclopramide (dopamine antagonist) - Complementary therapies like ginger or wrist acupressure

Question 58

HYDATIDIFORM MOLE | What is a hydatidiform mole?

Answer 58

- Part of group of rare tumours known as gestational trophoblastic disease - Growing mass of tissue that implants into uterus that will not come to term (non-viable fertilised egg, result of abnormal conception)

Question 59

HYDATIDIFORM MOLE | What are the 3 types of hydatidiform mole?

Answer 59

- Complete - Partial - Invasive

Question 60

HYDATIDIFORM MOLE | What is a complete mole?

Answer 60

- Diploid trophoblast cells - Empty egg + sperm that duplicates DNA (all genetic material comes from father) - No foetal tissue

Question 61

HYDATIDIFORM MOLE | What is a partial mole?

Answer 61

- Triploid (69XXX, 69XXY) trophoblast cells - 2 sperm fertilise 1 egg - Some recognisable foetal tissue

Question 62

HYDATIDIFORM MOLE What is an invasive mole? What is the significance of this?

Answer 62

- When a complete mole invades the myometrium | - Metaplastic potential to evolve into a choriocarcinoma

Question 63

HYDATIDIFORM MOLE | What are some risk factors for hydatidiform mole?

Answer 63

- Extremes of reproductive age - Previous molar pregnancy - Multiple pregnancies - Asian women - OCP

Question 64

HYDATIDIFORM MOLE | What is the clinical presentation of hydatidiform mole?

Answer 64

- PV bleed in first or early second trimester - Uterus bigger than expected for gestation - Severe hyperemesis - Early pre-eclampsia + clinical hyperthyroidism (hCG can mimic TSH)

Question 65

HYDATIDIFORM MOLE | What are some investigations for hydatidiform mole?

Answer 65

- Serum beta-hCG abnormally high (trophoblastic tissue producing excessive amounts > hyperemesis + thyrotoxicosis) - USS shows snowstorm appearance - Dx confirmed with histology after evacuation

Question 66

HYDATIDIFORM MOLE | What is the main complication of hydatidiform mole?

Answer 66

- 2-3% complete moles transition to highly malignant choriocarcinoma which can metastasise to the lungs - These are placental site trophoblastic tumours

Question 67

HYDATIDIFORM MOLE | What is the management for hydatidiform mole?

Answer 67

- Urgent referral to specialist centre - Complete moles = suction dilation + curettage - Partial moles = suction or medical evacuation - Invasive = suction D+C but not all removed, some resolve

Question 68

HYDATIDIFORM MOLE | What is the management of hydatidiform mole after evacuation?

Answer 68

- Check urinary pregnancy test in 3w – if high or mets may need chemo (cisplatin) - Effective contraception as advised to avoid pregnancy for 12m

Question 69

ANTENATAL APPTS In terms of antenatal care... i) who is in charge of low risk pregnancies? ii) high risk pregnancies? iii) how many visits? iv) what would you do if reduced foetal movements?

Answer 69

i) Midwife-led with GP input ii) Doctor/consultant led with midwives alongside iii) 10 if nulliparous, subsequent 7 iv) Handheld doppler for heartbeat – USS if not heard, CTG if present

Question 70

ANTENATAL APPTS Define... i) gestational age ii) estimated date of delivery iii) gravidity iv) parity

Answer 70

i) duration of pregnancy starting from date of LMP ii) 40w gestation iii) Total # of pregnancies iv) number of births ≥24w regardless of outcome

Question 71

ANTENATAL APPTS When is the first visit? What is done?

Answer 71

Booking 8–12w – - General info (diet, alcohol, smoking, folic acid + vitamin D advice, antenatal classes, family origin questionnaire - FBC, blood group, rhesus status, haemoglobinopathies - HIV, hep B + syphilis screening offered - Urine MC&S for asymptomatic bacteriuria

Question 72

ANTENATAL APPTS | What is the recommended amount of folic acid?

Answer 72

- ALL 400mcg | - 5mg if – AEDs, coeliac, DM, >30kg/m^2, NTD risk

Question 73

ANTENATAL APPTS When is the dating scan done? What happens?

Answer 73

11–13+6w – - Confirm viability - Singleton/multiple - Estimate gestational age with crown rump length (top of head > bottom of buttocks) - Detect major structural abnormalities like anencephaly - Offer combined test

Question 74

ANTENATAL APPTS When is the anomaly scan? What happens?

Answer 74

18–20+6w – - Detect major abnormalities (NTD, CHD, CNS abnormality, renal agenesis) - Around 20w foetal movements start + continue (refer if none by 24w)

Question 75

ANTENATAL APPTS | After the anomaly scan, routine care is given but at what times?

Answer 75

- 25w (primis) - 28w (all) - 31w (primis) - 34w (all) - 36w (all) - 38w (all) - 40w (primis) - 41w (all)

Question 76

ANTENATAL APPTS | What routine care is given at 25w for primis?

Answer 76

- BP, urine dipstick, symphysis-fundal height (after 20w should correlate to gestational age ± 2cm)

Question 77

ANTENATAL APPTS | What routine care is given at 28w?

Answer 77

- BP, urine dipstick, SFH - OGTT if risk factors for GDM - Second screen for anaemia (FBC), blood group + rhesus status - First dose of anti-D prophylaxis if Rh-ve

Question 78

ANTENATAL APPTS What routine care is given at... i) 31w (primis)? ii) 34w? iii) 36w?

Answer 78

i) BP, urine dipstick, SFH ii) BP, urine dipstick, SFH + second dose of anti-D if Rh-ve iii) BP, urine dipstick, SFH, check presentation (?ECV), info about breastfeeding, vitamin K + baby blues

Question 79

ANTENATAL APPTS What routine care is given at... i) 38w? ii) 40w (primis)? iii) 41w?

Answer 79

i) BP, urine dipstick, SFH ii) BP, urine dipstick, SFH, discuss options for prolonged pregnancy iii) BP, urine dipstick, sFH, discuss induction

Question 80

ANTENATAL SCREENING | What pre-test information should be provided before antenatal screening?

Answer 80

- Conditions screened for - When + how test carried out - How reliable test is - What results mean + options - False +ve/-ve + detection rates

Question 81

ANTENATAL SCREENING | What are the 3 main syndromes screened for in pregnancy?

Answer 81

- Patau's (trisomy 13) - Edward's (trisomy 18) - Down's (trisomy 21)

Question 82

ANTENATAL SCREENING | What screening is offered in early pregnancy and when?

Answer 82

Combined test (11–13+6w) – - Nuchal translucency (thickness of back of foetus' neck on USS) - Beta-hCG - Pregnancy associated plasma protein-A (PAPP-A)

Question 83

ANTENATAL SCREENING What results indicate higher risk for... i) nuchal translucency? ii) beta-hCG? iii) PAPP-A? What else is taken into account?

Answer 83

i) >6mm ii) Higher result iii) Lower result - Maternal age, USS crown rump length, detection rate 85%

Question 84

ANTENATAL SCREENING | What screening is offered if the mother is too late for the combined test and when?

Answer 84

Triple or quadruple test 15–20w but only tests for Down's syndrome – - Beta-hCG - Alpha-fetoprotein - Oestriol - Inhibin (quadruple)

Question 85

``` ANTENATAL SCREENING What results indicate higher risk for... i) beta-HCG? ii) AFP? iii) oestriol? iv) inhibin? ```

Answer 85

i) Higher result ii) Lower result iii) Lower result iv) Higher result

Question 86

ANTENATAL SCREENING What risk score would warrant further invasive tests? What are those tests?

Answer 86

- >1:150 = screen +ve - Amniocentesis - Chorionic villus sampling (CVS)

Question 87

ANTENATAL SCREENING What is amniocentesis? What is CVS? What are the risks?

Answer 87

- USS guided aspiration of some amniotic fluid, performed later in pregnancy when enough fluid to make safer - USS guided biopsy of placental tissue for karyotyping, performed earlier (before 15w) - Miscarriage, infection + failed samples

Question 88

ANTENATAL SCREENING What other testing is available in the private sector? What does it involve?

Answer 88

- Non-invasive prenatal testing - Analyses fragments of foetal DNA in maternal blood - 99% accurate, done from 10w

Question 89

APH | What is an antepartum haemorrhage (APH)?

Answer 89

- Genital tract bleeding after 24w gestation

Question 90

APH | What are the causes of APH?

Answer 90

Majority idiopathic, dangerous causes – - Placental abruption or praevia - Vasa praevia - Morbidly adherent placenta

Question 91

APH | What are some generic investigations for APH?

Answer 91

- Exclude placenta praevia with USS | - Kleihauer test to confirm transplacental blood loss from foetus>mother

Question 92

APH | What are some complications of APH?

Answer 92

- PPH, DIC - Premature labour - ITU admission - Maternal or foetal death - Sheehan's syndrome

Question 93

PLACENTA PRAEVIA | What is placenta praevia?

Answer 93

- When placenta is inserted wholly, or in part, into the lower segment of the uterus (low lying placenta)

Question 94

PLACENTA PRAEVIA | What are the grades of placenta praevia?

Answer 94

Minor (I or II) – - I = reaches lower segment but not internal os - II = reaches internal os but doesn't cover Major (III or IV) – - III = covers internal os before dilation (not when dilated) - IV = completely covers internal os - Cervical effacement + dilation > catastrophic bleeding + potential maternal + foetal death

Question 95

PLACENTA PRAEVIA | What are some risk factors for placenta praevia?

Answer 95

- Embryos more likely to implant on lower segment scar from previous c-section - Multiple pregnancy - Multiparity - Previous praevia - Assisted conception

Question 96

PLACENTA PRAEVIA | What is the clinical presentation of placenta praevia?

Answer 96

- PAINLESS PV bleeding, BRIGHT RED blood, shock IN proportion to visible loss - Foetus may have abnormal lie + presentation (breech + transverse) - Uterus is not tender

Question 97

PLACENTA PRAEVIA | What are the investigations for placenta praevia?

Answer 97

- TV USS safe + more accurate - Can be Dx on routine antenatal USS (20w) - Repeat USS at 36w if minor or 32w if major - If over or close to internal os repeat scans every 2w

Question 98

PLACENTA PRAEVIA | What are some complications of placenta praevia?

Answer 98

- PPH | - Placenta accreta or percreta

Question 99

PLACENTA PRAEVIA | What is the normal management of placenta praevia?

Answer 99

- Asymptomatic can stay at home if access to hospital, aware of risks/Sx, companion (rest + avoid intercourse) - <20mm from os = elective c-section ≥38w or earlier if bleeding does not settle - Anti-D if Rh-ve

Question 100

PLACENTA PRAEVIA | What is the acute management of placenta praevia?

Answer 100

- ABCDE + admission - IV access, fluids (crystalloid), X-match blood, inform senior team + paeds - Foetal monitoring with CTG ± delivery - Steroids if <34w gestation

Question 101

PLACENTAL ABRUPTION | What is placental abruption?

Answer 101

- Placenta prematurely separates (in part or fully) from uterus wall leading to APH from where the placenta was previously attached - Blood can accumulate behind placenta in uterine cavity or exit via cervix

Question 102

PLACENTAL ABRUPTION What are the major risk factors for placental abruption? What are some other risk factors?

Answer 102

- IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption - Cocaine use, multiple pregnancy or high parity, trauma

Question 103

PLACENTAL ABRUPTION | What are the 2 types of abruption?

Answer 103

- Concealed = cervical os closed so haemorrhage remains in uterus – Maternal shock out of proportion with visible loss may > underestimation - Revealed = PV bleeding

Question 104

PLACENTAL ABRUPTION | What is the clinical presentation of placental abruption?

Answer 104

- Sudden onset severe abdo PAIN which is continuous - PV bleeding often DARK red - Maternal shock (hypotension, tachycardia = adverse signs) - Foetal distress common on CTG (absent or abnormal FHR) - Posterior placenta may cause severe backache

Question 105

PLACENTAL ABRUPTION | What are some investigations for placental abruption?

Answer 105

- Tender "woody" uterus on palpation (blood invading myometrium) - FBC, coagulation, X-match (may need catheter for urine output + U+Es for renal function) - USS + CTG for foetal wellbeing + exclude praevia

Question 106

PLACENTAL ABRUPTION | What are the maternal and foetal complications of placental abruption?

Answer 106

- Shock, DIC, renal failure, PPH | - IUGR, hypoxia + death

Question 107

PLACENTAL ABRUPTION | What is the general management of placental abruption?

Answer 107

- Mum + foetus stable at <36w then admit + observe carefully, induce after 36w with amniotomy aiming for vaginal delivery, steroids if <34w - Anti-D if Rh-ve

Question 108

PLACENTAL ABRUPTION | What is the management of acute placental abruption?

Answer 108

- A–E resus - IV access, fluids, ABO Rh compatible or O-ve blood - Mum unstable, foetal distress or heavy bleeding = emergency c-section - Steroids if <34w MUM COMES FIRST

Question 109

ADHERED PLACENTA | What is a morbidly adhered placenta?

Answer 109

- The chorionic villi attach to the myometrium rather than being restricted within the decidua basalis

Question 110

ADHERED PLACENTA | What are the different types of morbidly adhered placenta?

Answer 110

- Accreta = placenta invades into superficial myometrium - Increta = placenta invades deeper through the myometrium - Percreta = placenta invades through myometrium, into nearby organs of abdomen (bladder, bowel)

Question 111

ADHERED PLACENTA | What are some risk factors for a morbidly adhered placenta?

Answer 111

- Previous c-sections (placenta attaches to site) - Myomectomy - Surgical TOP

Question 112

ADHERED PLACENTA | What are some investigations for a morbidly adhered placenta?

Answer 112

- USS may show loss of definition between wall of uterus + abnormal vasculature - MRI scan if degree of adherence uncertain

Question 113

ADHERED PLACENTA | What are some complications of a morbidly adhered placenta?

Answer 113

- Poor placental separation may occur > difficult to deliver placenta after baby delivered > retained products > infection risk - Delivery risks = PPH, transfusion, caesarean hysterectomy, ITU

Question 114

ADHERED PLACENTA | What is the management of a morbidly adhered placenta?

Answer 114

- Elective LSCS at 36–37w - ?Caesarean hysterectomy - ?Leave in situ (expectant) - ?Uterus preserving surgery (resecting part of myometrium + placenta)

Question 115

ADHERED PLACENTA | What is the acute management of a morbidly adhered placenta?

Answer 115

- Blood + blood products available - Local ITU availability - Tamponade with balloon - Hysterectomy last resort

Question 116

VASA PRAEVIA | What is vasa praevia?

Answer 116

- Major foetal vessels run in membranes below the presenting foetal part, so they present before the foetus, unsupported by placental tissue or umbilical cord - Exposed mean prone to rupture + bleed

Question 117

VASA PRAEVIA | What are some risk factors for vasa praevia?

Answer 117

- Placenta praevia - Multiple pregnancy - IVF pregnancy - Bilobed placentas

Question 118

VASA PRAEVIA | What is the clinical presentation of vasa praevia?

Answer 118

- PV bleed straight after rupture of foetal membranes > rapid foetal distress - CTG abnormalities (bradycardia) with high foetal mortality - No major maternal risk just major foetal risk (massive haemorrhage)

Question 119

VASA PRAEVIA | What is the management of vasa praevia?

Answer 119

- A–E approach, manage bleeding | - Deliver c-section (elective if antenatally diagnosed, emergency if present with bleeding)

Question 120

PRE-ECLAMPSIA | What is pre-eclampsia?

Answer 120

- Pregnancy induced HTN + proteinuria at >20w gestation | - Results due to abnormal development of the placenta

Question 121

PRE-ECLAMPSIA | How can pre-eclampsia be classified?

Answer 121

- Mild-mod = pre-eclampsia without severe HTN (<160/110) and NO Sx, biochemical or haematological impairment - Severe = pre-eclampsia w/ severe HTN ± Sx ± biochem ± haem impairment - Early <34w, late >34w

Question 122

PRE-ECLAMPSIA | What is the normal physiology of the placenta?

Answer 122

- Spiral arteries dilate + develop into large utero-placental arteries, supplying lots of blood to the endometrium > placenta + foetus

Question 123

PRE-ECLAMPSIA | What is the pathophysiology of pre-eclampsia?

Answer 123

- Spiral arteries do not remodel + dilate but become fibrous so utero-placental arteries deliver less blood > placental ischaemia

Question 124

PRE-ECLAMPSIA | What is the result of placental ischaemia?

Answer 124

- Pro-inflammatory protein + thromboplastin release leads to endothelial damage > vasoconstriction, clotting dysfunction + increased vascular permeability - Ultimately leads to poor renal perfusion > RAAS activation > HTN, proteinuria ± oedema > pre-eclampsia + eclampsia (if continues)

Question 125

PRE-ECLAMPSIA What are the... i) high risk ii) moderate risk factors for pre-eclampsia?

Answer 125

i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM) ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2

Question 126

PRE-ECLAMPSIA | What are the 2 main causes of symptoms in pre-eclampsia?

Answer 126

- Local areas of vasospasm leading to hypoperfusion | - Oedema due to increased vascular permeability + hypoproteinaemia

Question 127

PRE-ECLAMPSIA | What symptoms are caused by local areas of vasospasm and what area is affected?

Answer 127

Renal = glomerular damage (low GFR) – - Oliguria + proteinuria Retinal – - Visual disturbances (blurred, flashing lights, scotoma) Liver = injury + swelling stretches liver capsule – - RUQ or epigastric pain

Question 128

PRE-ECLAMPSIA | What symptoms are caused by oedema?

Answer 128

- Face, hands + legs (generalised) - SOB + cough (pulmonary) - Headaches, confusion + seizures in eclampsia (cerebral)

Question 129

PRE-ECLAMPSIA | What are the signs of pre-eclampsia?

Answer 129

- Raised BP + proteinuria are hallmarks - Rapid weight gain, RUQ tenderness - Ankle clonus (brisk reflexes normal in pregnancy but not clonus) - Papilloedema if severe

Question 130

PRE-ECLAMPSIA | How can a diagnosis of pre-eclampsia be made?

Answer 130

- BP ≥140/90mmHg | - Proteinuria in a 24h collection (>0.3g) or dipstick with +

Question 131

PRE-ECLAMPSIA | What blood investigations would you do in pre-eclampsia?

Answer 131

- FBC with platelets (thrombocytopenia) - Serum uric acid levels (raised due to renal issues) - LFTs (elevated liver enzymes ALT + AST)

Question 132

PRE-ECLAMPSIA | What other investigations could you perform in pre-eclampsia?

Answer 132

- Proteinuria on dipstick (++ or +++ is severe) - Protein:Creatinine ratio (PCR) ≥30ng/nmol = significant proteinuria - Accurate dating + USS to assess foetal growth

Question 133

PRE-ECLAMPSIA | What are the 2 big complications of pre-eclampsia?

Answer 133

- Eclampsia | - HELLP syndrome

Question 134

PRE-ECLAMPSIA What is eclampsia? What causes it?

Answer 134

- Generalised tonic-clonic seizures in a patient with a Dx of pre-eclampsia - Hypoalbuminaemia > hypovolaemia > cerebral hypoperfusion

Question 135

PRE-ECLAMPSIA | What is the management of eclampsia?

Answer 135

IV magnesium sulfate to prevent + treat seizures – - Reduces DIC risk as reduced platelet aggregation - Continue 24h after last seizure or delivery Treat HTN with labetalol 1st line or nifedipine Stabilise mum and delivery baby

Question 136

PRE-ECLAMPSIA | What needs to be monitored when giving magnesium sulfate?

Answer 136

- Magnesium levels for toxicity - Reduced reflexes, confusion + respiratory depression - Calcium gluconate first line

Question 137

PRE-ECLAMPSIA What is HELLP syndrome? Give a specific marker other than those mentioned

Answer 137

- Haemolysis, Elevated Liver enzymes + Low Platelets - Signs of liver damage + abnormalities of blood clotting - LDH raised in haemolysis

Question 138

PRE-ECLAMPSIA How does HELLP syndrome present? Association? How is it managed?

Answer 138

- RUQ pain, N+V, urine tea coloured due to haemolysis - 10% have antiphospholipid syndrome - Magnesium sulfate, anti-hypertensives + deliver baby!

Question 139

PRE-ECLAMPSIA | What are some other important complications of pre-eclampsia?

Answer 139

- DIC, CVA (haemorrhagic) - Multi-organ failure (renal, hepatic) - Foetus = IUGR (poorly perfused placenta), prematurity, placental abruption

Question 140

PRE-ECLAMPSIA | What should be given to women who are at high or moderate risk of pre-eclampsia and why?

Answer 140

- 75mg aspirin PO OD at 12w until birth | - Spiral arteries form around 12w so thought to help them develop

Question 141

PRE-ECLAMPSIA | What medical treatment can be given for pre-eclampsia?

Answer 141

Treat HTN with – - PO Labetalol first line (can use IV if severe + inpatient) - PO nifedipine (used if asthmatic) - Hydralazine too - ACEi = CONTRAINDICTAED

Question 142

PRE-ECLAMPSIA What is the criteria for outpatient management of pre-eclampsia? What care is given?

Answer 142

- BP <160/110, no or low proteinuria (≤+, <0.3g/24h) + no symptoms - Weekly review of bloods, twice weekly mother + foetal evaluation (HBPM + urine) - Any changes > hospital

Question 143

PRE-ECLAMPSIA What is the definitive cure of pre-eclampsia? What are the indications? What method is preferred?

Answer 143

- Delivery (around 36w) - Mother = liver/renal failure, HELLP, eclampsia, severe Sx - Foetal = severe IUGR, oligohydramnios, abnormal CTG - PV + neuraxial techniques for spinal/epidural preferred

Question 144

PRE-ECLAMPSIA | What is the management of pre-eclampsia during delivery?

Answer 144

- Regular investigations (BP, urinalysis, bloods, CTG, fluid balance chart (restrict if severe) - BP control (IV labetalol first line of nifedipine if asthmatic) - IV magnesium sulfate prophylaxis during labour + 24h after

Question 145

PRE-ECLAMPSIA | What are the 3 other types of HTN in pregnancy conditions?

Answer 145

- Chronic HTN - Gestational/pregnancy induced HTN - Pre-eclampsia superimposed on chronic HTN

Question 146

PRE-ECLAMPSIA | What is chronic HTN?

Answer 146

- HTN diagnosed prior to pregnancy, before 20w gestation or that develops during pregnancy but does not resolve postpartum

Question 147

PRE-ECLAMPSIA | What is gestational or pregnancy induced HTN?

Answer 147

- New HTN >20w gestation with NO proteinuria that resolves after giving birth - 25% will progress to pre-eclampsia

Question 148

PRE-ECLAMPSIA | What is pre-eclampsia superimposed on chronic HTN?

Answer 148

- HTN + no proteinuria <20w with new onset proteinuria after 20w - HTN + proteinuria <20w with sudden rise in proteinuria or BP when HTN was well controlled, or development of thrombocytopenia or abnormal ALT/AST

Question 149

IUGR | What is intrauterine growth restriction (IUGR)?

Answer 149

- Baby has not maintained its growth potential (slows or creases) - I.e. drops below centile line it was following > pathological

Question 150

IUGR | What are the two types of IUGR?

Answer 150

- Symmetrical = entire body is proportionately small, tends to be seen in early onset IUGR, TORCH + chromosomal abnormalities - Asymmetrical = undernourished foetus that is compensating by directing most of its energy to maintain growth of vital organs like brain + heart

Question 151

IUGR | What might be seen in asymmetrical IUGR?

Answer 151

Head-sparing effect – - Normal head size but small abdominal circumference + thin limbs - Mostly secondary to placental insufficiency

Question 152

IUGR | What is small for gestational age (SGA)?

Answer 152

- Estimated foetal weight (EFW) or abdominal circumference (AC) below 10th centile for their gestational age - May be constitutionally small with no pathology identified (parental height)

Question 153

IUGR | What is low birth weight?

Answer 153

- Baby born with a weight <2.5kg (regardless of gestational age)

Question 154

IUGR | What are the 3 broad categories causing IUGR?

Answer 154

- Placental insufficiency (most common cause) - Maternal factors - Foetal factors

Question 155

IUGR | What are some placental causes of IUGR?

Answer 155

- Abnormal trophoblast invasion (pre-eclampsia, placenta accreta) - Infarction, abruption, location (praevia)

Question 156

IUGR | What are some maternal causes of IUGR?

Answer 156

- Chronic disease (HTN, cardiac, CKD) - Substance abuse (cocaine, alcohol) smoking, previous SGA baby - Autoimmune - Low socioeconomic status - >40

Question 157

IUGR | What are some foetal causes of IUGR?

Answer 157

- Genetic abnormalities (trisomies 13/18/21, Turner's) - Congenital infections (TORCH) - Multiple pregnancy

Question 158

IUGR | What are some complications of IUGR?

Answer 158

- Hypoglycaemia - Risk of necrotising enterocolitis - Neonatal jaundice - Hypothermia - Respiratory issues - Long-term sequelae include T2DM, HTN, obesity, behavioural problems, CP

Question 159

IUGR What causes... i) hypoglycaemia? ii) necrotising enterocolitis? iii) neonatal jaundice?

Answer 159

i) Blood directed away from liver>brain so glycogen stores don't develop adequately ii) Reduced blood to bowel iii) Compensatory polycythaemia for reduced oxygen supply from mother if reduced placental perfusion

Question 160

IUGR What causes... i) hypothermia? ii) respiratory problems?

Answer 160

i) No fat stores developed so cannot thermoregulate, large surface area ii) Kidney hypoperfusion > decreased urine output > oligohydramnios > inadequate lung development

Question 161

IUGR | What are the investigations for IUGR?

Answer 161

- BP + urine dipstick (?pre-eclampsia) - Karyotyping (?foetal) - Infection screen, TORCH (?infection)

Question 162

IUGR When would you be concerned about IUGR? What would you do?

Answer 162

- SFH < 10th centile, slow or static growth or crossing centiles - Refer for serial growth scans (USS) every 2w, umbilical artery doppler + amniotic fluid volume - MCA doppler performed after 32w

Question 163

IUGR What is umbilical artery doppler for? What happens if it's abnormal?

Answer 163

- Assesses if baby is getting enough blood | - Abnormal = twice weekly review

Question 164

IUGR | What is the management (and the indications of management) for IUGR?

Answer 164

Consider delivery (corticosteroids if <34w to mature foetal lungs) if – - Static growth on growth charts - Absent end-diastolic flow (AEDF, abnormal doppler) - Abnormal CTG (foetal distress) - MCA doppler PI <5% delivery by 37w (early sign of foetal hypoxia in SGA, shows increased diastolic flow > head-sparing effect)

Question 165

MACROSOMIA What is... i) large for gestational age (LGA)? ii) macrosomia?

Answer 165

i) Estimated foetal weight above the 90th centile for their gestational age ii) Baby with a weight >4kg regardless of gestational age

Question 166

MACROSOMIA | What are the causes of macrosomia?

Answer 166

- Constitutionally large or familial (parental height + weight) - Maternal diabetes, previous macrosomia, obesity or rapid weight gain - Overdue - Male baby

Question 167

MACROSOMIA | What are some complications of macrosomia?

Answer 167

- Maternal = failure to progress, perineal tears, instrumental/c-section, PPH, uterine rupture (rare) - Foetal = shoulder dystocia, neonatal hypoglycaemia, obesity in childhood + later life

Question 168

MACROSOMIA | How do you diagnose and manage macrosomia?

Answer 168

- OGTT to screen for diabetes - SFH + EFW from USS to plot on growth chart + >90th centile = Dx - Regular growth scans to assess progress + check amniotic fluid index levels to exclude polyhydramnios - Most vaginal delivery, consider c-section if v large or signs of distress

Question 169

MULTIPLE PREGNANCY What is meant by... i) monozygotic ii) dizygotic iii) mono/diamniotic iv) mono/dichorionic in terms of multiple pregnancy?

Answer 169

i) identical (come from single zygote) ii) non-identical (come from two different zygotes > diamniotic + dichorionic) iii) share/two separate amniotic sacs iv) share/two separate placentas

Question 170

MULTIPLE PREGNANCY What are some predisposing factors to multiple pregnancies? What is one way of preventing them?

Answer 170

- Previous twins, FHx, increasing parity + maternal age, IVF, race (Afro-Caribbean) - No more than 2 embryos transferred per IVF cycle

Question 171

MULTIPLE PREGNANCY | What is the clinical presentation of multiple pregnancies?

Answer 171

- Uterus larger than expected for dates - May suffer from hyperemesis gravidarum - Multiple foetal poles may be palpable at >24w - Multiple foetal hearts on auscultation - Majority diagnosed on dating scan

Question 172

MULTIPLE PREGNANCY | What are some maternal and foetal complications of multiple pregnancy?

Answer 172

- Anaemia, HTN, APH + PPH, preterm birth, stillbirth | - Twin-twin transfusion syndrome, IUGR, polyhydramnios, malpresentation

Question 173

MULTIPLE PREGNANCY | What is twin-twin transfusion syndrome?

Answer 173

- Associated with monoamniotic monochorionic twins - Recipient gets majority of blood so is larger with polyhydramnios - Donor is starved of blood + can become anaemic, recipient worse off (hydrops) - Severe cases > laser ablation of connecting vessels

Question 174

MULTIPLE PREGNANCY | What is the antenatal care for multiple pregnancies?

Answer 174

- High risk – 5mg folic acid, iron supplements to prevent anaemia - Additional scans for growth restriction + twin-twin transfusion (2w from 16w for monochorionic, 4w from 20w for dichorionic)

Question 175

MULTIPLE PREGNANCY | What is the management of multiple pregnancies?

Answer 175

- Steroids if <34w - Monochorionic/amniotic twins = elective c-section 32-34w - Diamniotic twins = 37–38w, vaginal if presenting twin cephalic but may need c-section for second

Question 176

OLIGOHYDRAMNIOS What is oligohydramnios? What is it defined as?

Answer 176

- Abnormally low levels of amniotic fluid during pregnancy | - Amniotic fluid index <5th centile for gestational age

Question 177

OLIGOHYDRAMNIOS | What are some causes of oligohydramnios?

Answer 177

- PROM or SROM - Renal agenesis (Potter's syndrome) or non-functional kidneys - Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output - Genetic anomalies - Obstructive uropathy

Question 178

OLIGOHYDRAMNIOS | What is the clinical presentation of oligohydramnios?

Answer 178

- May have experienced leaking fluid or feeling damp - Measure SFH - Sterile speculum may show pool of liquor in birth canal

Question 179

OLIGOHYDRAMNIOS | What are some investigations for oligohydramnios?

Answer 179

- USS foetus = AFI or maximum pool depth calculated + doppler - TORCH screen as may be infection - Test fluid for IGFBP-1 or PAMG-1 if concerned about PPROM. - Foetal CTG for signs of distress

Question 180

OLIGOHYDRAMNIOS | What are some complications of oligohydramnios?

Answer 180

- 2nd trimester = poor prognosis due to PPROM leading to premature delivery + pulmonary hypoplasia > resp distress - Muscle contractures as amniotic fluid allows foetal to move limbs in utero

Question 181

OLIGOHYDRAMNIOS | What is the management of oligohydramnios?

Answer 181

- Treat as PROM if present | - Frequent monitoring of growth for IUGR

Question 182

POLYHYDRAMNIOS | What is amniotic fluid (liquor)?

Answer 182

- Fluid between baby + amnion (sac) acts as a cushion around foetus to protect it from trauma - Foetus can swallow amniotic fluid which helps create urine + meconium

Question 183

POLYHYDRAMNIOS | What is polyhydramnios?

Answer 183

- Abnormally large levels of amniotic fluid | - AFI >95th centile for gestational age

Question 184

POLYHYDRAMNIOS | What are the causes of polyhydramnios?

Answer 184

- Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops - Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)

Question 185

POLYHYDRAMNIOS | How may polyhydramnios present?

Answer 185

- Maternal discomfort - LGA - Foetal parts hard to palpate - Taut uterus

Question 186

POLYHYDRAMNIOS | What are the investigations for polyhydramnios?

Answer 186

- Exclude GDM with OGTT - USS foetus to calculate AFI or maximum pool depth - TORCH screen as can be cause by viral infections

Question 187

POLYHYDRAMNIOS | What are some complications of polyhydramnios?

Answer 187

- Preterm delivery - Malpresentation - Maternal discomfort from abdo distension

Question 188

POLYHYDRAMNIOS | What is the management of polyhydramnios?

Answer 188

- If severe = amnioreduction or NSAIDs (indomethacin) | - If preterm assess risk of delivery with cervical scan ± foetal fibronectin assay

Question 189

POLYHYDRAMNIOS | What are the risks of amnioreduction and indomethacin?

Answer 189

- Associated with infection + placental abruption | - Associated with premature closure of ductus arteriosus so not used beyond 32w

Question 190

RHESUS DISEASE | What are rhesus antigens?

Answer 190

- On surface of red blood cells + differs to the ABO groups | - A+ve is blood group A with rhesus D antigens

Question 191

RHESUS DISEASE | What is the pathophysiology of rhesus disease in the first pregnancy?

Answer 191

- Rh-ve woman exposed to Rh+ve foetal blood, her immune system recognises as foreign + produce antibodies against rhesus D (sensitisation) - Usually no issues in 1st pregnancy as IgM produced that cannot cross placenta

Question 192

RHESUS DISEASE | What is the pathophysiology of rhesus disease in subsequent pregnancies?

Answer 192

- Memory cells produce IgG which can cross placenta so if Rh+ve foetus will attack leading to haemolysis (haemolytic disease of newborn) with jaundice + hydrops fetalis (abnormal accumulation of fluid)

Question 193

RHESUS DISEASE | What events are considered potential sensitising events?

Answer 193

- Delivery of Rh+ve infant - APH - Amniocentesis or CVS - Abdo trauma - ECV - Surgical Mx of ectopic + miscarriage - PV bleed >12w

Question 194

RHESUS DISEASE | What are some investigations for rhesus disease?

Answer 194

- Kleihauer test (check how much foetal blood > mother's blood after event) - All babies born to Rh-ve women should have cord blood at delivery for FBC, blood group + Direct Coombs (antiglobulin) test for antibodies on baby's RBC

Question 195

RHESUS DISEASE | What is the Kleihauer test?

Answer 195

- Add acid + foetal Hb more resistant to acid so number of cells that still contain Hb represents remaining foetal cells

Question 196

RHESUS DISEASE | What is the management of rhesus disease?

Answer 196

- Prophylaxis crucial as sensitisation is irreversible - IM anti-D routinely at 28w, 34w + after birth but also potential events - Newborn haemolysis > exchange transfusions (severe) or UV phototherapy

Question 197

RHESUS DISEASE | How does anti-D work?

Answer 197

- Immunoglobulin attaches to Rh D antigens on foetal blood in maternal circulation preventing recognition

Question 198

CHORIOAMNIONITIS What is chorioamnionitis? What is a major factor in the condition?

Answer 198

- Acute inflammation of amnion + chorion membranes due to ascending bacterial infection in setting of membrane rupture - PPROM

Question 199

CHORIOAMNIONITIS | What is the clinical presentation of chorioamnionitis?

Answer 199

- Uterine tenderness - Evidence of foetal distress on CTG - Foul odour, purulent/offensive PV discharge (yellow/brown) - Maternal infection (fever, abdo pain, maternal + foetal tachycardia)

Question 200

CHORIOAMNIONITIS | What are some investigations for chorioamnionitis?

Answer 200

- FBC, CRP (raised WCC + CRP) - Swabs (high + low vaginal swabs), MSU - USS for foetal presentation, EFW + liquor volume

Question 201

CHORIOAMNIONITIS | What is the management of chorioamnionitis?

Answer 201

- Steroids <34w - Deliver foetus (whatever gestation, often c-section) - IV Abx

Question 202

GESTATIONAL DIABETES | What is Gestational Diabetes Mellitus (GDM)?

Answer 202

- Carbohydrate intolerance during pregnancy which often resolves after birth

Question 203

GESTATIONAL DIABETES | What is the pathophysiology of GDM?

Answer 203

- Increased insulin resistance due to placental production of anti-insulin hormones - Allows post-prandial glucose peak to be higher for longer to spare glucose for foetus (main source of nutrients) - If maternal pancreas cannot increase insulin production to combat this > GDM

Question 204

GESTATIONAL DIABETES | What are some anti-insulin hormones produced by the placenta?

Answer 204

- Main one is human placental lactogen (hPL) | - Also glucagon + cortisol

Question 205

GESTATIONAL DIABETES | What are some risk factors for GDM?

Answer 205

- BMI >30kg/m^2 - PMH of GDM - FHx of DM (first-degree) - Asian + Afro-Caribbean ethnicity - Previous macrosomic baby

Question 206

GESTATIONAL DIABETES | What is the clinical presentation of GDM?

Answer 206

- May be asymptomatic or present with polydipsia, polyuria, nocturia + fatigue

Question 207

GESTATIONAL DIABETES What is the diagnostic investigation for GDM? Who is given this?

Answer 207

- OGTT (75g glucose given in morning after a fast) - Anyone with previous GDM at booking + 24–28w - Anyone with risk factors at 24-28w

Question 208

GESTATIONAL DIABETES | What OGTT results are diagnostic for GDM?

Answer 208

5-6-7-8 rule: - Baseline/fasting >5.6mmol/L - At 2h >7.8mmol/L

Question 209

GESTATIONAL DIABETES | What are the foetal risks of GDM?

Answer 209

- Macrosomia - Polyhydramnios - Birth trauma - Stillbirth + miscarriage - Congenital malformations (CHD, NTD, cleft palate) - Neonatal hypoglycaemia - RDS, polycythaemia - Obesity + T2DM later in life

Question 210

GESTATIONAL DIABETES What causes... i) macrosomia? ii) polyhydramnios? iii) birth trauma? iv) neonatal hypoglycaemia?

Answer 210

i) Excess foetal glucose > hyperinsulinaemia + so increased fat deposition ii) Excess foetal glucose > polyuria iii) Cephalopelvic incompatibility, shoulder dystocia iv) Climatization + hyperinsulinaemia

Question 211

GESTATIONAL DIABETES | What are the maternal risks of GDM?

Answer 211

- Pre-eclampsia - DKA or hypos - UTIs - IHD - Nephropathy, retinopathy

Question 212

GESTATIONAL DIABETES | What pre-conceptual advice should be given to women with pre-existing diabetes?

Answer 212

- Contraception until good diabetic control - 5mg folic acid until 12w - Stop any ACEi or statins - Retinopathy screening at booking + 28w - Aspirin 75mg OD at 12w to reduce pre-eclampsia risk - Monitor BMs regularly

Question 213

GESTATIONAL DIABETES What is the management of... i) pre-existing T1DM? ii) pre-existing T2DM?

Answer 213

i) Insulin with dose adjustment for normal changes to glucose metabolism in pregnancy ii) Only metformin is safe, may need upgrading to insulin

Question 214

GESTATIONAL DIABETES | What is the management of GDM?

Answer 214

- Fasting glucose <7 = lifestyle (low GI foods, exercise) > metformin after 1-2w if targets not met - Fasting glucose ≥7 = insulin ± metformin - Fasting glucose ≥6 + macrosomia or other complications = insulin - Glibenclamide if cannot tolerate metformin or decline insulin

Question 215

GESTATIONAL DIABETES When should the foetus be delivered in... i) pre-existing DM? ii) GDM

Answer 215

i) 37–39w | ii) No need before 41w

Question 216

VTE IN PREGNANCY What is VTE? What is the significance?

Answer 216

- DVTs + PEs = large cause of mortality in obstetrics | - High risk during postpartum period, top cause of direct maternal death

Question 217

VTE IN PREGNANCY What are the... i) high ii) intermediate risk factors of VTE?

Answer 217

i) PMH of VTE, antenatal LMWH requirements, high-risk thrombophilia or low risk + FHx ii) Smoking, parity >3, age >35, BMI >30, reduced mobility, multiple pregnancy, pre-eclampsia, gross varicose veins, IVF

Question 218

VTE IN PREGNANCY | What is the clinical presentation of VTE in pregnancy?

Answer 218

- Swollen, warm, tender, red calf, Homan's sign (calf pain on dorsiflexion) > DVT - SOB, sudden CP (pleuritic), haemoptysis, tachycardia > PE

Question 219

VTE IN PREGNANCY | What are the investigations for VTE?

Answer 219

- ECG in PE commonly shows sinus tachycardia, rarely S1Q3T3 - Doppler USS diagnostic for DVT - FBC, U+Es, LFTs, clotting screen, CXR if ?PE - CTPA gold standard for PE, can do V/Q scan

Question 220

VTE IN PREGNANCY | How do you manage VTE risk in pregnancy?

Answer 220

- Risk assessment at booking, antenatal admissions + postnatally - Antenatal: LMWH from 28w if increased risk or ASAP if high risk - Postnatal: LMWH for 10d if increased risk or 6w if high risk - TED stockings - Low risk Mx = mobilise early, hydration

Question 221

VTE IN PREGNANCY What is the management of a VTE event? Any contraindications?

Answer 221

- Embolectomy + anticoagulate ASAP with LMWH | - Do NOT use warfarin (or DOACs) as can cross placenta + may cause foetal abnormalities (CHD) + intracranial bleeding

Question 222

OBSTETRIC CHOLESTASIS What is obstetric cholestasis? What are some associations?

Answer 222

- Intrahepatic cholestasis = reduced outflow of bile acids from liver - Asian women, thought to be due to increased oestrogen + progesterone levels

Question 223

OBSTETRIC CHOLESTASIS | What is the clinical presentation of obstetric cholestasis?

Answer 223

- Typically later in pregnancy (3rd trimester) - Itchy skin (palms of hands + soles of feet) but with NO rash – WORSE at night - Jaundice, pale greasy stools + dark urine less common

Question 224

OBSTETRIC CHOLESTASIS | What are the investigations for obstetric cholestasis?

Answer 224

- Clotting screen (prothrombin time) deranged - Abnormal LFTs + raised bile acids (ALT, AST, GGT + bilirubin raised, ALP too but that is normal in pregnancy), monitor LFTs weekly

Question 225

OBSTETRIC CHOLESTASIS | Why can clotting be deranged in obstetric cholestasis?

Answer 225

- Bile acids important for fat soluble vitamin absorption like vitamin K

Question 226

OBSTETRIC CHOLESTASIS | What are the complications of obstetric cholestasis?

Answer 226

- Maternal = vitamin K deficiency (may lead to PPH) | - Foetal = stillbirth (#1), increased risk of prematurity (often iatrogenic)

Question 227

OBSTETRIC CHOLESTASIS | What is the management of obstetric cholestasis?

Answer 227

- Ursodeoxycolic acid first line to improve LFTs + bile acids - Induce labour at 37–38w to reduce stillbirth risk - Vitamin K supplementation - Emollients (calamine lotion to sooth skin) - Antihistamines to help sleep

Question 228

INFECTIONS + PREGNANCY What is Parvovirus? What are the adverse effects? What is the management?

Answer 228

- Parvovirus B19 can give viral Sx then 'slapped cheeks' (erythema infectiosum) - Worse <20w = suppresses foetal erythropoiesis causing anaemia + foetal hydrops, death, pre-eclampsia-like (mirror) syndrome in women - Maternal IgM + IgG, supportive, refer to foetal medicine to monitor

Question 229

INFECTIONS + PREGNANCY What is Group B strep (GBS) infection? What can it cause? How is it spread?

Answer 229

- Strep agalactiae - Most common cause of early-onset severe infection (Sepsis) in neonates - Commonly found in maternal bowel flora

Question 230

INFECTIONS + PREGNANCY What are the risk factors of GBS? When should you screen?

Answer 230

- Prematurity, prolonged ROM, previous GBS sibling, maternal pyrexia - If previous GBS in pregnancy either intrapartum IV Abx prophylaxis or test in late pregnancy (3-5w before EDD) + IV Abx if +ve

Question 231

INFECTIONS + PREGNANCY When would you give intrapartum IV Abx? What would you give?

Answer 231

- Previous baby with GBS (no screening), preterm labour or pyrexia >38 during labour - Benzylpenicillin

Question 232

``` INFECTIONS + PREGNANCY What is toxoplasmosis? How is it spread? What is the clinical presentation? What is the management ```

Answer 232

- Toxoplasma gondii protozoan - Cat poo, eating infected meat - Glandular fever-like illness (fever, rash, eosinophilia) - TORCH screen (IgM + IgG), proven infection use spiramycin

Question 233

INFECTIONS + PREGNANCY | What are the risks of Varicella zoster?

Answer 233

- Maternal risk = 5x greater risk of pneumonitis | - Foetal varicella syndrome = skin scarring, microphthalmia, limb hypoplasia, microcephaly + learning difficulties

Question 234

INFECTIONS + PREGNANCY | What is the management of chickenpox exposure in pregnancy?

Answer 234

- Any doubt in immunity, check for varicella zoster IgG - ≤20w + not immune = VZIG within 10d - >20w + not immune = VZIG or aciclovir days 7–14 post-exposure

Question 235

INFECTIONS + PREGNANCY | What is the management of chickenpox infection in pregnancy?

Answer 235

- PO aciclovir if ≥20w + presents within 24h of rash onset | - <20w then consider

Question 236

INFECTIONS + PREGNANCY | What is the management of Hep B in pregnancy?

Answer 236

- Babies born to Hep B +ve mothers should be vaccinated within 24h of birth as well as other times recommended on vaccination schedule - No breastfeeding transmission in contrast to HIV

Question 237

INFECTIONS + PREGNANCY What are the risks of rubella in pregnancy? What is the management?

Answer 237

- Congenital rubella syndrome in first 8–10w (sensorineural deafness, CHD like PDA + PS, congenital cataracts, cerebral palsy) - Live vaccines like MMR avoided in pregnancy (offer postnatally if no immunity), avoid contacts

Question 238

INFECTIONS + PREGNANCY | What is the management of HIV in pregnancy?

Answer 238

- Normal vaginal delivery if viral load <50 copies/ml if. not c-section (IV zidovudine 4h before) - Neonatal zidovudine PO if maternal viral load <50 if not triple ART, both for 4–6w - Breastfeeding C/I

Question 239

ANAEMIA + PREGNANCY Why is anaemia common in pregnancy? What are some causes? What are some risk factors?

Answer 239

- Hb normally falls slightly in pregnancy due to increased plasma volume diluting Hb - Physiological, Fe deficiency (increased demand), B12 or folate deficiency - Menorrhagia, malaria, hookworm, twins, poor diet

Question 240

ANAEMIA + PREGNANCY | What are some investigations for anaemia?

Answer 240

- FBC (normal ranges >110g/L at booking, >105g/L at 28w) - Microcytic hypochromic = Fe deficiency - Macrocytic = B12 or folate - Iron studies = TIBC (high), serum iron (low), serum ferritin (low but acute phase) - Haematinics, intrinsic factor Ab if ?pernicious

Question 241

ANAEMIA + PREGNANCY What are the complications of iron deficiency anaemia? How is it managed?

Answer 241

- LBW + preterm delivery - Ferrous sulfate 200mg TDS - If not anaemic but low ferritin indicating iron stores then start them on it - Vitamin C can increase absorption of iron

Question 242

ANAEMIA + PREGNANCY | What is the management of macrocytic anaemias?

Answer 242

- Pernicious = IM hydroxocobalamin - B12 deficiency = B12 tablets (cyanocobalamin) - Folate = increased from 400mcg to 5mg/day to reduce NTD.

Question 243

ASTHMA + PREGNANCY | What are the complications of asthma in pregnancy?

Answer 243

- Foetal growth restriction due to inadequate placental perfusion - Premature delivery (usually due to maternal deterioration)

Question 244

ASTHMA + PREGNANCY | What is the management of asthma in pregnancy?

Answer 244

- Optimise control pre-conception - All drugs for asthma safe - Risk of exacerbation, esp in third trimester as baby grows it can press up on lungs > in asthma attack, prioritise mum

Question 245

ACUTE FATTY LIVER | What is acute fatty liver of pregnancy?

Answer 245

- Rapid accumulation of fat within the hepatocytes that occurs in the third trimester of pregnancy - Rare cause of hepatitis in pregnancy

Question 246

ACUTE FATTY LIVER | What is the clinical presentation of acute fatty liver in pregnancy?

Answer 246

Vague Sx like – - Abdo pain - N+V - Jaundice - Anorexia - Ascites

Question 247

ACUTE FATTY LIVER | What is the management of acute fatty liver?

Answer 247

- LFTs show elevated liver enzymes, esp. ALT | - Stabilise, admit + deliver foetus as high risk of liver failure + mortality (for both)

Question 248

THYROID + PREGNANCY How common is hyperthyroidism in pregnancy? How does hyperthyroidism present? What are some complications?

Answer 248

- Uncommon, often improves after 1st trimester - May present with excessive vomiting - Maternal = thyroid crisis with cardiac failure - Foetal = thyrotoxicosis due to transfer of thyroid stimulating antibodies

Question 249

THYROID + PREGNANCY | What is the management of hyperthyroidism in pregnancy?

Answer 249

- Propylthiouracil is choice in 1st trimester (associated with maternal hepatic injury) - Carbimazole C/I until 2nd trimester as causes foetal abnormalities - If mother has stimulating antibodies, monitor foetal growth with USS

Question 250

THYROID + PREGNANCY Is hypothyroidism in pregnancy common? What is the prognosis of untreated hypothyroidism in pregnancy? What is the management?

Answer 250

- Yes - Early foetal loss + congenital hypothyroidism leading to impaired neurodevelopment - Aim for adequate replacement with levothyroxine (safe), especially in 1st trimester

Question 251

THYROID + PREGNANCY | What is post-partum thyroiditis?

Answer 251

3 stages – - Thyrotoxicosis (3m) - Hypothyroidism (3–6m) - Normal thyroid function Sx control of thyrotoxicosis, treat hypothyroidism with levothyroxine Just need TFTs to Dx if within 12m of giving birth + Sx

Question 252

CARDIAC DISEASE | How does cardiac disease affect pregnancy?

Answer 252

- CV disease is leading cause of indirect maternal death - Older women = IHD - Younger women = CHD that's exacerbated in pregnancy

Question 253

CARDIAC DISEASE | What are some complications with cardiac disease in pregnancy?

Answer 253

- Fixed output heart disease is most risky during pregnancy (AS, coarctation, prosthetic valves [anticoagulation issue], cyanosed pts) - Low risk cardiac conditions include AR, MR, ASD + VSD

Question 254

CARDIAC DISEASE | What is the management of cardiac disease in pregnancy where anticoagulation is needed?

Answer 254

- Pre-conception take off warfarin + switch to LMWH like daltaparin - HASBLED score + predict bleeding risk as higher risk of APH + PPH

Question 255

CARDIAC DISEASE | What is the antenatal + postnatal management of cardiac disease in pregnancy?

Answer 255

- Joint care with cardiologist, ideally with pre-pregnancy Ax - Prediction + prevention of heart failure (ECHO/ECG) - Monitor foetal growth + wellbeing - Timing + mode of delivery - Postpartum complications (cardiac failure)

Question 256

EPILEPSY + PREGNANCY | What are the complications of epilepsy in pregnancy?

Answer 256

- Maternal = increased frequency of seizures, can lead to falls + so trauma, SUDEP (esp. if reluctant to take meds) - Foetal = inheritance, risk of hypoxia with maternal seizures

Question 257

EPILEPSY + PREGNANCY | What pre-conception advice should be given for women with epilepsy?

Answer 257

- 5mg folic acid - Determine if medication required or if it can be rationalised - Aim for monotherapy > carbamazepine + lamotrigine safest - Valproate can cause NTD + phenytoin can cause cleft lip + palate

Question 258

EPILEPSY + PREGNANCY | What is the management of epilepsy in pregnancy?

Answer 258

- Screen for foetal anomalies - Control seizures - Plan for delivery (avoid prolonged labour, post-partum support)

Question 259

RENAL DISEASE | What are the complications of CKD in pregnancy?

Answer 259

- Maternal = severe HTN, worsened renal function or renal failure, pre-eclampsia - Foetal = premature delivery, IUGR, stillbirth, abnormalities (drug therapy)

Question 260

RENAL DISEASE What affects the outcome of pregnancy in renal disease? What is the pre-conceptual advice?

Answer 260

- Degree of renal dysfunction, BP, creatinine level + proteinuria (keep high suspicion for pre-eclampsia) - Aspirin 75mg OD from 12w

Question 261

RENAL DISEASE What is the management of renal disease in pregnancy? What drugs should be used for UTI? What drugs should be avoided in UTI?

Answer 261

- Closely monitor renal function (U+Es, urine dipstick) + BP with regular assessment of foetal growth + wellbeing - Nitrofurantoin or amoxicillin - Trimethoprim unsafe 1st trimester (folate antagonist), nitrofurantoin unsafe in 3rd trimester (haemolytic anaemia of newborn)

Question 262

PROM | What is the physiology of ruptured membranes?

Answer 262

- Foetal membranes = chorion + amnion strengthened by collagen - SROM occurs naturally at any point prior to or during labour due to weakening in chorion/amnion, rarely born en caul - ARM can augment or induce labour

Question 263

PROM What is i) prelabour rupture of membranes? ii) preterm prelabour rupture of membranes? What are the risks?

Answer 263

i) Rupture of amniotic sac at least 1h prior to onset of labour at >37w ii) Rupture of amniotic sac prior to onset of labour pre-term (<37w) - PROM = minimal risk as advanced gestation - PPROM = risk of chorioamnionitis + spontaneous labour

Question 264

PROM | What are some risk factors for (P)PROM?

Answer 264

- Previous PROM/preterm - Smoking - Polyhydramnios - Amniocentesis

Question 265

PROM | What is the clinical presentation of (P)PROM?

Answer 265

- Gush or constant trickle or dampness from vagina | - Clear fluid

Question 266

PROM | What are some investigations for PROM?

Answer 266

- Sterile speculum 1st for pooling of amniotic fluid - USS may show oligohydramnios if speculum normal - Ferning test (cervical secretion on glass slide shows fern-pattern crystals) - Test fluid for IGFBP-1 or PAMG-1 - CTG for foetus (tachycardia is suggestive of infection)

Question 267

PROM | What is IGFBP-1 or PAMG-1?

Answer 267

- Insulin-like growth factor-binding protein-1 - Placental alpha-microglobin-1 - High concentrations of these proteins in amniotic fluid

Question 268

PROM | What are some complications of PPROM?

Answer 268

- Risk of prematurity, chorioamnionitis, pulmonary hypoplasia

Question 269

PROM | What is the management of PPROM?

Answer 269

- 1st line = IM corticosteroids if foetus <34w - Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d or until labour is established if within 10d - Consider induction at 34w (trade off)

Question 270

PREMATURITY | What are the WHO definitions of prematurity?

Answer 270

- Birth before 37w - Extreme preterm = <28w - Very preterm = 28–32w - Mod-late preterm = 32–37w (term >37w)

Question 271

PREMATURITY | When are babies considered non-viable?

Answer 271

- <24w so if no signs of life = no resus | - From 24w chances improve so full resus

Question 272

PREMATURITY | What are the classifications of prematurity?

Answer 272

- Spontaneous (70%) = PPROM, cervical weakness, amnionitis | - Iatrogenic = induced due to some complication

Question 273

PREMATURITY | What are the risk factors of prematurity?

Answer 273

- 50% none - Multiple pregnancy - Complications (IUGR, pre-eclampsia) - APH - Previous cervical surgery - Previous preterm - Polyhydramnios - Infection - Maternal diseases

Question 274

PREMATURITY | What is the clinical presentation of prematurity?

Answer 274

- Persistent uterine activity WITH change in cervical dilatation ± effacement - Preterm labour with intact membranes if no ruptured amniotic sac - Increase or change in PV discharge or bleeding

Question 275

PREMATURITY | What are the investigations for prematurity?

Answer 275

- Speculum (assess cervical dilatation, look for amniotic fluid) can Dx if <30w - TVS if >30w to measure cervical length (<15mm + contractions = Dx) - OR foetal fibronectin (Actim Partus, acts as glue between chorion + uterus + found in vagina during birth) test >50ng/ml = early labour

Question 276

PREMATURITY | What are the complications of prematurity?

Answer 276

- Maternal = infection - Neonatal = necrotising enterocolitis, apneoa of prematurity, RDS, intraventricular haemorrhage, retinopathy of prematurity, jaundice, hearing issues, chronic lung disease

Question 277

PREMATURITY | What is the prophylaxis for prematurity and how do they work?

Answer 277

- Progesterone gel or pessary decreases activity of myometrium + prevents cervix remodelling in preparation for delivery - Cervical cerclage = ≥1 sutures to strengthen + keep cervix closed - 'Rescue' cerclage to halt delivery

Question 278

PREMATURITY What are the indications for... i) progesterone prophylaxis? ii) cervical cerclage? iii) 'rescue' cerclage?

Answer 278

i) Cervical length <25mm on TVS at 16–24w ii) Cervical length <25mm on TVS at 16–24w, previous premature birth or cervical trauma (colposcopy, cone biopsy) iii) Cervical dilatation without ROM at 16–27+6 with no infection, bleeding or contractions

Question 279

PREMATURITY | What is the acute management of prematurity?

Answer 279

- Senior obs + neonate input - Foetal monitoring (CTG) - Tocolytics - Corticosteroids - IV magnesium sulfate - Consider delayed cord clamping or cord milking (increases circulating blood volume + Hb in baby)

Question 280

``` PREMATURITY What are tocolytics? Why are they used? Who for? Examples? ```

Answer 280

- Drugs to delay uterine contractions - Administer 2x steroids or transfer to more specialist unit (with neonatal ICU) - Those 24–33+6w - CCBs like nifedipine or oxytocin receptor antagonist like atosiban if C/I, terbutaline (SABA)

Question 281

PREMATURITY What are corticosteroids used for? Who for? Give examples

Answer 281

- Aids surfactant production so helps develop + protect baby's lungs - Those <34w - Dexamethasone, betamethasone

Question 282

PREMATURITY What is magnesium sulfate used for? What is the regime?

Answer 282

- Neuroprotection + reduced risk of cerebral palsy | - Bolus + infusion for up to 24h or until birth in <34w

Question 283

STAGES OF LABOUR | What is the WHO definition of normal birth?

Answer 283

- Spontaneous in onset, low risk at start + remaining throughout labour + delivery - Infant born spontaneously in the vertex position between 37–42w - After birth, mother + infant are in good condition (aka no interventions)

Question 284

STAGES OF LABOUR | What are 7 important hormones in labour?

Answer 284

- Prostaglandins - Oxytocin - Oestrogen - Beta-endorphins - Adrenaline - Prolactin - Relaxin

Question 285

STAGES OF LABOUR What is the role of these hormones in labour... i) prostaglandins? ii) oxytocin iii) oestrogen iv) beta-endorphins

Answer 285

i) Aids with cervical ripening (effacement) ii) Produced by hypothalamus, secreted by post. pituitary, surge at labour inhibits progesterone to prepare smooth muscle for uterine contractions, milk ejection reflex postpartum iii) Surges at onset of labour to inhibit progesterone to prepare smooth muscle for labour iv) Natural pain relief

Question 286

STAGES OF LABOUR What is the role of these hormones in labour... i) adrenaline? ii) prolactin? iii) relaxin?

Answer 286

i) Released as birth imminent to give energy ii) Produced + secreted by ant. pituitary, allows process of milk production in mammary glands when oestrogen + progesterone decline postpartum iii) Released from placenta to soften ligaments + cartilage of pelvis so it can expand (cervix, vaginal tissues, perineum)

Question 287

STAGES OF LABOUR | What are Braxton-Hicks contractions?

Answer 287

- 'Practice' contractions from 3rd trimester - Irregular + not felt by everyone - Mild cramp, last few minutes then ease

Question 288

STAGES OF LABOUR | What are signs of labour?

Answer 288

- Show (shedding of mucus plug from cervix that prevents ascending bacteria) - Rupture of membranes - Shortening + dilation of cervix - Regular painful contractions

Question 289

STAGES OF LABOUR | What is the physiology of contractions?

Answer 289

- Start in fundus (pacemaker) - Retraction/shortening of muscle fibres with each contraction pulls lower segment of uterus towards fundus - Causes cervical dilation + forces foetus down causing pressure on cervix

Question 290

STAGES OF LABOUR What is the first stage of labour? How is it further divided?

Answer 290

- From onset of labour (true contractions) until the cervix is fully dilated - Latent phase = from 0–3cm dilation - Active phase = from 3–10cm

Question 291

STAGES OF LABOUR What is the difference between latent and active phase of the first stage of labour? How quickly are women expected to dilate during the active phase?

Answer 291

- Latent: cervix begins to efface, irregular contractions, 'show', can last 2–3d (usually 6h) - Active: stronger, more regular contractions (4:10), cervix continues effacing - Primis = 0.5cm/h, multiparous = 1cm/h

Question 292

STAGES OF LABOUR What is the second stage of labour? How is it further divided?

Answer 292

- From full dilation to delivery of the foetus - Passive stage: complete dilation but no pushing (often 1 hour) - Active stage: maternal pushing until delivery

Question 293

STAGES OF LABOUR What is considered a delay in the active second stage of labour? What does success depend on?

Answer 293

- >2h in nulliparous, 1h in multiparous | - 3Ps (power, passenger + passage [?Psyche of mum])

Question 294

STAGES OF LABOUR Once the foetus has been delivered, what should be assessed and when? What does it calculate?

Answer 294

- APGAR score - 1, 5 + 10 minutes - 10–7 = normal - 6–4 = moderately depressed - <4 = severely depressed

Question 295

STAGES OF LABOUR | What are the parts of the APGAR score?

Answer 295

Activity – absent 0, flexed arms + legs 1, active 2 Pulse – absent 0, <100bpm 1, >100bpm 2 Grimace – floppy 0, minimal response to stimulation 1, prompt response to stimulation 2 Appearance – blue 0, blue extremities 1, pink 2 Respiration – absent 0, slow + irregular 1, vigorous cry 2

Question 296

STAGES OF LABOUR What is the third stage of labour? What should it involves?

Answer 296

- From birth of the foetus to expulsion of placenta - Physiological Mx = placenta delivered by maternal effort without medications or cord traction, cord clamped + cut after stops pulsating

Question 297

STAGES OF LABOUR | What should be done after delivery of the placenta?

Answer 297

- Examine placenta + membranes to check complete as RPOC can cause serious PPH or infection

Question 298

STAGES OF LABOUR | What can be used when monitoring labour?

Answer 298

Partogram is graphic record of key maternal + foetal data – - FHR every 15m (low risk = intermittent auscultation) high = continuous CTG - Contractions every 30m (4 in 10 in established labour) - Maternal pulse every 60m - Maternal BP, temp, urine (ketones + protein) + VE to assess progress every 4h - Drugs, IV fluids given + Cervical dilation noted too

Question 299

STAGES OF LABOUR | Why can partograms be useful?

Answer 299

- Have alert + action line - Indicates slow progression so if at action line = take action - Provides clear guidance on when to intervene, alert means be wary - Point at which progression stops is useful to see where problem is

Question 300

STAGES OF LABOUR | What are the 6 cardinal movements of labour?

Answer 300

- Engagement + descent - Flexion - Internal rotation - Extension (crowning) - Restitution/external rotation - Expulsion

Question 301

STAGES OF LABOUR | What is engagement?

Answer 301

- Passage of presenting part into pelvic inlet - Entire head felt = 5/5ths palpable aka not engaged - Unable to feel head = 0/5ths palpable aka fully engaged - Foetus is engaged when >50% of presenting part descended into pelvis

Question 302

STAGES OF LABOUR What is descent? How can descent be described? What is descent encouraged by?

Answer 302

- Downward passage of presenting part through bony pelvis - Position of baby's head (cm) in relation to mother's ischial spines - Increased abdo muscle tone and increased frequency + strength of contractions

Question 303

STAGES OF LABOUR | How can descent of the baby be described?

Answer 303

In relation to ischial spines in cm – - –5 = baby high up at around the pelvic inlet - 0 = head at ischial spines (engaged) - +5 = foetal head descended further out

Question 304

STAGES OF LABOUR | What position is the foetal head during engagement and descent?

Answer 304

- Occiput transverse

Question 305

STAGES OF LABOUR | What is flexion?

Answer 305

- Uterine contractions exert pressure down foetal spine towards occiput + cause neck flexion, allowing circumference of foetal head to reduce

Question 306

STAGES OF LABOUR What is internal rotation? Why does it occur?

Answer 306

- Foetus passively internally rotates from OT to OA/OP to allow shoulders to negotiate pelvic inlet - Pelvic inlet widest diameter is transverse (side-side)

Question 307

STAGES OF LABOUR | What is extension?

Answer 307

- Foetal occiput slips beneath suprapubic arch allowing head to extend + foetal head is born, usually facing maternal back (occiput anterior)

Question 308

STAGES OF LABOUR | What is restitution?

Answer 308

- Shoulders only now negotiating pelvic outlet so head externally rotates to face mother's L/R medial thigh so shoulders can pass - Pelvic outlet widest diameter is A-P (front-back)

Question 309

STAGES OF LABOUR What is expulsion? How may this be assisted?

Answer 309

- Ultimately ends with delivery of foetus - Gentle downwards traction > deliver shoulder below suprapubic arch - Gentle upwards traction > deliver posterior shoulder (caution with excessive force as may cause brachial plexus damage)

Question 310

STAGES OF LABOUR What is caput? What is moulding?

Answer 310

- Diffuse swelling of scalp caused by pressure of scalp against dilating cervix during labour - Caput may lead to moulding of the head (oblong not round shape) but this often disappears after a few days

Question 311

FAILURE TO PROGRESS | What are the 2 types of abnormal progression in labour?

Answer 311

- Slow from beginning (primary dysfunctional labour) – may be insufficient uterine contractions - Sudden slowing of labour (secondary arrest) – may be cephalopelvic disproportion

Question 312

FAILURE TO PROGRESS | How can you assess a woman failing to progress?

Answer 312

- Palpate abdomen for lie, head + contractions (may need USS) - CTG, colour of amniotic fluid, VE

Question 313

FAILURE TO PROGRESS | What factors may influence the mode of delivery of a baby in failure to progress?

Answer 313

- Baby size + presentation - Well-being of baby + mother - How long labour has been going on for - Maternal exhaustion - Pelvic adequacy

Question 314

FAILURE TO PROGRESS What may be calculated when considering inducing labour? What does it calculate?

Answer 314

- Bishop score = used to calculate how likely spontaneous labour is to occur - Score <5 = unripe cervix (less likely for induction success) - Score >9 = favourable cervix ready for labour or induction

Question 315

FAILURE TO PROGRESS | What are the components of the Bishop score?

Answer 315

- Cervical dilation – <1cm (0), 1-2 (1), 3-4 (2), >5cm (3) - Cervical consistency – firm (0), intermediate (1), soft (2) - Cervical effacement – <30% (0), 40-50 (1), 60-70 (2), 80% (3) - Cervical position – posterior (0), intermediate (1), anterior (2) - Foetal station – –3 (0), -2 (1), -1/0 (2), ≥1 (3)

Question 316

FAILURE TO PROGRESS | What are some methods of inducing labour?

Answer 316

- Membrane sweep - Prostaglandin E2 (PGE2) pessary or gel like dinoprostone - Cervical ripening balloon (gently inflates + dilates cervix) - Amniotomy if not ruptured already - Oxytocin analogue (syntocinon) infusion to cause uterine contractions

Question 317

FAILURE TO PROGRESS | What is the process of a membrane sweep?

Answer 317

- Done before meds to try + encourage labour to start on its own (promotes positive feedback of stretch > oxytocin release)

Question 318

``` FAILURE TO PROGRESS What is the process of PGE2? What might it be used for? What is a risk? How to manage that risk? ```

Answer 318

- Stimulates contraction of uterine muscles + ripens cervix - Improve Bishop score by cervical ripening so can induce - Uterine hyperstimulation (>5 in 10 for 20m or contraction >2m) - ?Remove PGE2, ?terbutaline tocolytic

Question 319

FAILURE TO PROGRESS | What are some indications and contraindications for inducing labour?

Answer 319

- PROM, IUGR, pre-eclampsia, obstetric cholestasis | - Severe degree of placenta praevia, transverse foetal lie, severe cephalopelvic disproportion, low Bishop score

Question 320

FAILURE TO PROGRESS | What is the aetiology of failure to progress in labour?

Answer 320

- Power (most common) - Passage - Passenger - Psyche (maternal exhaustion in second stage)

Question 321

FAILURE TO PROGRESS | How can 'power' cause failure to progress?

Answer 321

- Poor uterine contractions - Common in primigravida women - May need instrumental delivery or syntocinon

Question 322

FAILURE TO PROGRESS How can 'passage' cause failure to progress? What can be a consequence of this?

Answer 322

- Inadequate pelvis, cephalopelvic disproportion - Obstructed labour = presenting part of foetus cannot progress into birth canal despite strong uterine contractions - Common in developing countries, risk of infection, fistulas

Question 323

FAILURE TO PROGRESS | How can 'passenger' cause failure to progress?

Answer 323

- Size - Attitude - Lie - Presentation - Position

Question 324

FAILURE TO PROGRESS In terms of 'passenger' in failure to progress, what is important about... i) size? ii) attitude? iii) lie? iv) presentation?

Answer 324

i) Macrosomia, size of head as this is largest part ii) Posture of foetus (how the back is rounded + how the head + limbs are flexed) iii) Longitudinal, transverse, oblique iv) Part of foetus closest to the cervix (cephalic = head first > most optimal)

Question 325

FAILURE TO PROGRESS What is malpresentation? What are the different types?

Answer 325

- Presenting part of foetus is not the vertex of the foetal head - Shoulder = c-section - Breech (leg/bottom) = ECV or c-section - Brow = c-section - Face = c-section likely

Question 326

FAILURE TO PROGRESS | What is the difference between brow and face presentation?

Answer 326

- Brow: head between full flexion + extension, associated with mentovertical diameter (chin to highest point of vertex) - Face: head hyperextended >120, associated with submentobregmatic diameter (junction of neck/lower jaw to anterior fontanelle)

Question 327

FAILURE TO PROGRESS | In terms of 'passenger' in failure to progress, what is important about position?

Answer 327

- Refers to foetal head position on VE - Anterior/posterior fontanelles as landmarks, OA ideal - If OP at delivery means head is at posterior quadrant of pelvis requiring greater rotation which can prolong labour

Question 328

FAILURE TO PROGRESS | How would you manage failure to progress in the first stage of labour?

Answer 328

- PGE2 if low bishop score as if not cannot induce - Oxytocin infusion ± amniotomy (if membranes not ruptured) > reassess in 2h - CTG with foetal blood sample if concerns, consider c-section if doesn't help

Question 329

FAILURE TO PROGRESS | How would you manage failure to progress in the second stage of labour?

Answer 329

- Allow to push for 2h if nulliparous or 1h if multiparous | - No imminent delivery obstetric review for ?instrumental or c-section

Question 330

FAILURE TO PROGRESS How would you manage failure to progress in the third stage of labour? What are the indications for management?

Answer 330

- IM oxytocin to cause uterus contraction to expel placenta - Cord clamp + careful cord traction to guide placenta out - Haemorrhage or >60m delay in physiological management (delay in active Mx is >30m)

Question 331

FAILURE TO PROGRESS | What are the consequences of failure to progress?

Answer 331

- Foetal = distress, hypoxia (HIE, cerebral palsy), morbidity + mortality - Maternal = bleeding, tears, amniotic fluid embolism

Question 332

BREECH What is breech presentation? What are the risks?

Answer 332

- When baby's buttocks/legs lies over the maternal pelvis - Longitudinal lie but head at fundus - Risk of hypoxia + trauma

Question 333

BREECH | What are some causes/risk factors for breech presentation?

Answer 333

- Idiopathic - Prematurity as baby may not have turned itself yet - Previous breech - Uterine abnormalities (bicornuate uterus), fibroids - Placenta praevia - Foetal abnormalities (CNS malformation - Multiple pregnancy - Poly/oligohydramnios

Question 334

BREECH | What are the 3 types of breech presentation?

Answer 334

- Extended (Frank) = most common, hips flexed, both legs extended with feet by head, buttocks presenting - Flexed (Complete) = hips + knees flexed so buttocks + feet presenting (Cannonballing) - Footling = one leg flexed, one extended, foot hanging through cervix

Question 335

BREECH | Which breech is most associated with cord prolapse and why?

Answer 335

- Footling | - Nothing to act as plug over cervix if membranes ruptured

Question 336

BREECH | What are the investigations for breech?

Answer 336

- Ideally antenatal Dx with USS, if <36w unimportant unless in labour - Abdo exam = longitudinal lie, head palpated at fundus, presenting part not head, foetal heart best heard high up uterus

Question 337

BREECH | What is the management of breech?

Answer 337

- External cephalic version to move baby to correct position at 37w - C-section if ECV unsuccessful or contraindicated

Question 338

BREECH | What are some contraindications for ECV?

Answer 338

- Absolute = pre-eclampsia, APH, oligohydramnios, foetal compromise - Relative = maternal HTN, foetal abnormality, 1 previous c-section

Question 339

FOETAL LIE What is foetal lie? What are the 4 types of lie?

Answer 339

- Position of the foetus in relation to the mother's body | - Longitudinal, transverse, oblique, unstable

Question 340

FOETAL LIE What is... i) longitudinal lie? ii) transverse lie? iii) oblique lie? iv) unstable lie?

Answer 340

i) Straight up + down ii) Side-side, foetus perpendicular to long axis of uterus iii) Angle iv) Lie is actively changing (may be transverse, longitudinal, cephalic or breech)

Question 341

FOETAL LIE | What are some risk factors for foetal lie?

Answer 341

- Multiparity (>P2) with lax uterus (common) - Polyhydramnios, prematurity - Uterine abnormalities, fibroids - Placenta praevia - Foetal abnormalities

Question 342

FOETAL LIE | What are some investigations for foetal lie?

Answer 342

- Abdo exam = neither head nor buttocks presenting - Transverse = ovoid uterus wider at sides, lower pole empty, head in flank - USS can be used to confirm lie, often antenatally

Question 343

FOETAL LIE | What are some complications of abnormal lie?

Answer 343

- May result in pre-term rupture of membranes - Membrane rupture risks cord prolapse (longitudinal lie prevents descent of cord) so transverse lie = highest risk of prolapse

Question 344

FOETAL LIE | What is the management for foetal lie?

Answer 344

Stable but transverse – - ECV >36w even in early labour if membranes intact - C-section if fails or pt choice Unstable lie – - Admit whilst unstable from 37w so c-section if labour starts

Question 345

FOETAL LIE | What are the contraindications to ECV for transverse lie?

Answer 345

- Maternal rupture in last 7d - Multiple pregnancy (except for 2nd twin) - Major uterine abnormality

Question 346

CTG | What are the indications for a continuous cardiotocography (CTG)?

Answer 346

- During labour for every woman - High risk pregnancies - Pyrexia (?chorioamnionitis) - Severe HTN ≥160/110 - Oxytocin use - Fresh bleeding

Question 347

CTG | How do you interpret a CTG?

Answer 347

Dr C Bravado – - Dr = define risk (high risk = continuous - C = contractions (bottom trace shows frequency) - Bra = baseline rate - V = variability - A = accelerations - D = decelerations - O = overall assessment

Question 348

CTG | What might different foetal baseline rates tell you?

Answer 348

- >160 may be maternal pyrexia, prematurity, chorioamnionitis - <110 may be maternal beta-blockers, increased foetal vagal tone

Question 349

CTG | What does variability tell you?

Answer 349

- Reduced variability may be hypoxia, lactic acidosis, prematurity - 40m reduced variability accepted as baby may be sleeping

Question 350

CTG What are accelerations? What do they show you?

Answer 350

- Rise in baseline HR by 15 for ≥15s | - Reassuring as baby moving

Question 351

CTG What are decelerations? What are the 3 types and their causes?

Answer 351

- Fall in baseline HR by 15 for ≥15s - Early = peak of contraction corresponds with trough of depression (head compression from uterine contraction = normal) - Late = deceleration after contraction (hypoxia = placental insufficiency, asphyxia) - Variable = vary in shape + timing (cord compression)

Question 352

CTG What are the features of a reassuring CTG for... i) baseline? ii) variability? iii) accelerations? iv) decelerations?

Answer 352

i) 110–160bpm ii) >5bpm iii) Present iv) Early

Question 353

CTG What are the features of a non-reassuring CTG for... i) baseline? ii) variability? iii) decelerations?

Answer 353

i) 100–109bpm or 161–180bpm ii) <5bpm for 40–90m iii) Variable

Question 354

CTG What are the features of an abnormal CTG for... i) baseline? ii) variability? iii) decelerations?

Answer 354

i) <100bpm or >180bpm ii) <5bpm for >90m iii) Late

Question 355

CTG What makes a CTG... i) suspicious? ii) pathological?

Answer 355

i) 1 non-reassuring | ii) ≥2 non-reassuring or 1 abnormal

Question 356

CTG | What are the pros of CTGs?

Answer 356

- Allows long-term monitoring - Can pick up on foetal distress - Can be on constantly to identify any slight changes

Question 357

CTG | What are the cons of CTGs?

Answer 357

- No improvement in perinatal outcomes in low-risk pregnancies - Foetal exposure to USS ionisation - Ambulatory monitoring may not be possible - Doesn't give true beat to beat FHR monitoring or morphological Ax of heart

Question 358

FOETAL ECG What is a foetal ECG? What are the pros? What are the cons?

Answer 358

- Obtained via scalp - Gold standard for FHR, true beat to beat information - Invasive, associated with scalp injury + perinatal infection, only during labour when membranes ruptured + >2cm dilated

Question 359

FOETAL ECG | What is an alternative to scalp ECG?

Answer 359

- Abdominal foetal ECG | - Can be used ambulatory at home but only for high risk, morphological analysis possible + non-invasive

Question 360

CORD PROLAPSE What is cord prolapse? What is the danger?

Answer 360

- Umbilical cord descends below the presenting part of the foetus after rupture of the membranes - Presenting part can compress cord or exposure of cord leads to vasospasm > significant risk of foetal morbidity + mortality from hypoxia

Question 361

CORD PROLAPSE | What are some risk factors for cord prolapse?

Answer 361

- Prematurity - Polyhydramnios - Long umbilical cord - Malpresentation (Footling breech + transverse lie) - Multiparity + multiple pregnancy - Placenta praevia

Question 362

CORD PROLAPSE | What are the investigations for cord prolapse?

Answer 362

- Foetal CTG distress (heart decelerations + bradycardia) | - Dx via VE (cord at introitus), speculum confirms

Question 363

CORD PROLAPSE | What is the management of cord prolapse?

Answer 363

- 999/emergency buzzer, neonatal team - Fill bladder with 500ml warmed saline via catheter (elevate presenting foetal part + lift off cord) - Left lateral position with head down or knee-chest position - Presenting part pushed back into uterus to prevent compression - Avoid handling cord > vasospasm - Tocolytics like terbutaline (SABA) to abolish contractions if delivery not imminently available

Question 364

SHOULDER DYSTOCIA | What is shoulder dystocia?

Answer 364

- Failure of anterior shoulder to pass under symphysis pubis after delivery of foetal head

Question 365

SHOULDER DYSTOCIA | What are some risk factors for shoulder dystocia?

Answer 365

- Macrosomia - Maternal DM - High maternal BMI - Cephalopelvic disproportion - Post-maturity - Previous shoulder dystocia

Question 366

SHOULDER DYSTOCIA | What is the clinical presentation of shoulder dystocia?

Answer 366

- Head remaining tightly applied to vulva or retracting (turtle neck sign) - Failure of restitution (head does not turn sideways)

Question 367

SHOULDER DYSTOCIA | What are the maternal and neonatal complications of shoulder dystocia?

Answer 367

- PPH, perineal tears (3rd/4th degree), psychological impact | - Hypoxia, cerebral palsy, injury to brachial plexus, Erb's palsy, fits, # humerus or clavicle

Question 368

SHOULDER DYSTOCIA Explain what is the result of... i) erb's palsy? ii) clavicle fracture?

Answer 368

i) Injury of C5/6 nerves causing paralysis of arm, looks limp, waiters tip position ii) Painful movements, shoulder asymmetry

Question 369

SHOULDER DYSTOCIA | What is the management of shoulder dystocia?

Answer 369

HELPERR[R] – - Help (call with emergency buzzer, obs, neonates) - Evaluate for episiotomy (enlarge opening) - Legs = McRobert's - Pressure = suprapubic - Enter = pelvis for rotation - Remove = posterior arm - Replace = head in vagina + deliver by section (Zavanelli)

Question 370

SHOULDER DYSTOCIA What is McRobert's manoeuvre? Why is it done?

Answer 370

- Hips fully flexed + abducted (knees to abdo) | - Posterior pelvic tilt lifting symphysis pubis up + out of way

Question 371

SHOULDER DYSTOCIA | What are the 3 rotational manoeuvres?

Answer 371

- Rubin II = pressure on post. aspect of ant. shoulder to help deliver under symphysis pubis - Woods' screw = Rubin II + pressure on ant. aspect of post. shoulder - Reverse woods' screw = pressure on ant. aspect of ant. shoulder + post. aspect of post. shoulder in opposite way

Question 372

INSTRUMENTAL DELIVERY | What are some indications for instrumental delivery?

Answer 372

- Failure to progress in second stage. - Foetal or maternal distress + maternal exhaustion in second stage - Control of head in various foetal positions (incl. breech)

Question 373

INSTRUMENTAL DELIVERY | What are the types of instrumental delivery?

Answer 373

- Ventouse = suction cup on a cord on baby's head with traction - Forceps = 2 curved pieces of metal attach either side of baby's head + grip with traction

Question 374

INSTRUMENTAL DELIVERY | What are the main risks of ventouse delivery?

Answer 374

- Cephalohaematoma = collection of blood between periosteum + skull from damaged blood vessels, does not cross suture lines, presents hours after - Caput Succedaneum = Crosses Sutures, diffuse oedema outside periosteum due to pressure to a specific area of scalp, resolve in few days, conehead present at birth

Question 375

INSTRUMENTAL DELIVERY | What are the main risks of forceps delivery?

Answer 375

- Maternal = vaginal tears, anal sphincter trauma - Foetal = facial nerve palsy (main), bruises on baby's face, fat necrosis > hardened lumps of fat on baby's cheek that will resolve spontaneously over time, skull #

Question 376

INSTRUMENTAL DELIVERY | What are some maternal consequences of instrumental delivery?

Answer 376

- Infection (co-amox stat) - PPH - Episiotomy - Tears - Incontinence

Question 377

C-SECTION | What are some indications for c-section?

Answer 377

- Placenta praevia (3/4) - IUGR - Uncontrolled HIV - Active herpes - Cephalopelvic disproportion - Pre-eclampsia - Post-maturity

Question 378

C-SECTION | What are the different categories of c-section?

Answer 378

- 1 = immediate threat to life of mother/baby. Decision>delivery time = 30m - 2 = not imminent threat to life but c-section required urgently due to compromise. Decision>Delivery time = 75m - 3 = c-section required but both stable - 4 = elective section

Question 379

C-SECTION What two types of anaesthesia can be used in c-sections? What else is given in c-sections?

Answer 379

- General - Regional block (spinal) - H2 receptor antagonists or PPIs, prophylactic Abx, oxytocin (PPH), LMWH for VTE prophylaxis

Question 380

C-SECTION What are the indications for general anaesthesia? What are the cons?

Answer 380

- Imminent threat to mother ± foetus, C/I to regional, maternal preference, failed regional technique - Aspiration, failed intubation, awareness, damage to mouth/throat

Question 381

C-SECTION | What are the pros and cons for spinal anaesthesia?

Answer 381

- Safer, see baby immediately, partner present, improved post-op analgesia - Hypotension, headache, discomfort with pressure sensations, failure

Question 382

C-SECTION | What are the complications of c-sections?

Answer 382

- Surgical risk (bleeding, infection/endometritis, VTE) - Damage risk (ureter, bladder, bowel, vessels) - Future pregnancies (increased risk of uterine rupture, placenta praevia, stillbirth + repeat section) - Baby (risk of lacerations, increased incidence in transient tachypnoea)

Question 383

C-SECTION Is vaginal birth after caesarean (VBAC) allowed? What are the contraindciations?

Answer 383

- Yes provided cause of caesarean is unlikely to recur, 75% success rate - Previous uterine rupture, classical caesarean scar

Question 384

PAIN RELIEF | What are some non-pharmacological pain relief for labour?

Answer 384

- Trained support - Relaxation techniques, hypnotherapy - Massage, water births - Comfortable position + environment for birth

Question 385

PAIN RELIEF | What simple analgesia can be used in labour?

Answer 385

- Paracetamol + codeine useful in early labour | - Avoid NSAIDs

Question 386

PAIN RELIEF What is Entonox? What are the pros? What are the cons?

Answer 386

- Gas + air (N2O + O2 50/50 mixed) - Rapid onset analgesia, minimal SEs, self-limiting, available for home delivery - Theoretic risk of bone marrow suppression, greenhouse gas, N+V

Question 387

PAIN RELIEF | What opioids can be used for pain relief?

Answer 387

- Single shot IM opioids (diamorphine, pethidine) | - Patient-controlled analgesia via IV cannula (fentanyl, alfentanil, remifentanil)

Question 388

PAIN RELIEF | What are some important notes about single shot opioids?

Answer 388

- Lipid soluble so crosses placenta rapidly - Diamorphine 2x as potent as morphine so faster onset - Pethidine metabolites can cause seizures so avoid in epileptics

Question 389

PAIN RELIEF | What are some important notes about PCA?

Answer 389

- Fentanyl = very lipid soluble, rapid onset of action, long half-life - Alfentanil + remifentanil = shorter half-lives

Question 390

PAIN RELIEF | What are some side effects from opioids?

Answer 390

- Foetal = resp depression, diminishes breast seeking + feeding behaviour - Maternal = euphoria + dysphoria, N+V, can prolong 1st + 2nd stages, resp depression + pruritus

Question 391

PAIN RELIEF What regional techniques can be used for pain relief? How is this performed?

Answer 391

- Epidural, spinal or combined spinal epidural (CSE) | - Epidural at L3/4 'Tuffiers' line connecting 2 iliac crests bisects L4 vertebral body or USS to avoid cord damage

Question 392

PAIN RELIEF What causes labour pain in... i) first stage? ii) second stage?

Answer 392

i) Uterine contraction at T10-L1 | ii) Perineum + vaginal stretching S2-4 (pudendal)

Question 393

PAIN RELIEF | What 4 regimes can be given for regional techniques?

Answer 393

- Intermittent = high conc LA, labour intensive, periods of inadequate analgesia + haemodynamic instability - Continuous = low dose LA + opioid, less labour intensive, constant analgesia + haemodynamic stability - Continuous + bolus = greater maternal satisfaction - CSE = rapid onset, high satisfaction, reduced LA dose

Question 394

PAIN RELIEF | What medications can be given epidurally?

Answer 394

- LA like bupivacaine | - Opioids like fentanyl, diamoprhine

Question 395

PAIN RELIEF | What sequential effects do regional techniques have?

Answer 395

- Autonomic (vasodilation = reduced MAP) - Sensory (analgesia) - Motor (motor blockade) + fever

Question 396

PAIN RELIEF | What are the indications for regional techniques?

Answer 396

- Maternal request - HTN/pre-eclampsia - Cardiac disease - Induced labour - Multiple births - Instrumental/op delivery likely

Question 397

PAIN RELIEF | What are some complications of regional techniques?

Answer 397

- Potential for spinal cord damage - Hypotension + bradycardia - Haematoma/abscess at injection site - Anaphylaxis if allergic - Post-dural puncture headache

Question 398

PAIN RELIEF What is a post-dural puncture headache? How does it present? What is the management?

Answer 398

- Leak of CSF + reduced CSF pressure, within 1–2d (up to 7) - Headache, worse when upright, improves when flat - Supportive, pain >72h = epidural blood patch, IV caffeine

Question 399

PAIN RELIEF | What are some contraindications to regional techniques?

Answer 399

- Absolute = maternal refusal, local infection, allergy to LA - Relative = coagulopathy, systemic infection, fixed cardiac output

Question 400

PAIN RELIEF | What are some side effects from regional techniques?

Answer 400

- Foetal = tachycardia (maternal pyrexia), diminishes breast-feeding behaviour - Maternal = increased length of 1st + 2nd stages, need more oxytocin, increased need for instrumental, loss of mobility + bladder control, pyrexia

Question 401

PERINEAL TEARS | What is a perineal tear?

Answer 401

- External vaginal opening is too narrow to accommodate the baby, leading to a ripping of the skin in that area as the baby's head comes through

Question 402

PERINEAL TEARS | What is the classification of perineal tears?

Answer 402

- 1st degree = limited to superficial skin of perineum - 2nd degree = above PLUS perineal muscles (includes episiotomy) - 3rd degree = above PLUS anal sphincter involvement - 4th degree = above PLUS injury to rectal mucosa

Question 403

PERINEAL TEARS | How are third degree tears further classified?

Answer 403

- 3A = <50% of external anal sphincter thickness torn - 3B = >50% of EAS thickness torn - 3C = EAS + internal anal sphincter torn

Question 404

PERINEAL TEARS | What are some risk factors for perineal tears?

Answer 404

- Primigravida - Macrosomia - Shoulder dystocia - Forceps

Question 405

PERINEAL TEARS | What is an episiotomy?

Answer 405

- Diagonal incision (45 degrees) from opening of vagina downwards + laterally (medio-laterally) to avoid anal sphincter damage or midline in anticipation of needing additional room to delivery baby (e.g. prior to forceps) – suture after - Should be done under LA

Question 406

PROLONGED PREGNANCY What is a prolonged pregnancy? What are some investigations?

Answer 406

- Pregnancy exceeding 42w from LMP - USS assessment of growth + amniotic fluid volume - Daily CTGs after 42w + Advised to report any decreased foetal movements

Question 407

PROLONGED PREGNANCY | What are some complications of prolonged pregnancy for the foetus?

Answer 407

- Macrosomia (+ dystocia) - Oligohydramnios - Reduced placental perfusion - May have meconium stained liquor (foetal distress), beware of aspiration as can cause severe pneumonitis

Question 408

PROLONGED PREGNANCY What are the maternal complications of prolonged pregnancy? What is the management?

Answer 408

- Anxiety, more interventions (induction, operative delivery) - Confirm EDD, offer one membrane sweep at 41w + induction at 41–42w to prevent this

Question 409

UTERINE RUPTURE What is a uterine rupture? What are the two types? What is the risk?

Answer 409

- Complication of labour where myometrium bursts - Incomplete = peritoneal lining surrounding uterus intact - Complete = peritoneal lining ruptures so uterine contents released into peritoneal cavity - Significant haemorrhage, high morbidity + mortality for baby + mother

Question 410

UTERINE RUPTURE | What are some risk factors for uterine rupture?

Answer 410

- VBAC - Previous uterine surgery - Increased BMI - High parity - Congenital uterine abnormalities - Oxytocin use

Question 411

UTERINE RUPTURE | What are the clinical features of uterine rupture?

Answer 411

- Tenderness over previous uterine scars - PV bleed, maternal shock - CTG = foetal distress + no or cessation of contractions

Question 412

UTERINE RUPTURE | What is the management of uterine rupture?

Answer 412

- ABCDE resus - Cross match blood - Urgent laparotomy to stop bleeding - Repair or remove uterus - C-section to save baby

Question 413

AMNIOTIC EMBOLISM | What is an amniotic fluid embolism?

Answer 413

- Amniotic fluid/foetal cells enter mother's blood stream causing an immune reaction from the mother's immune system > systemic illness

Question 414

AMNIOTIC EMBOLISM What are some risk factors for amniotic fluid embolism? Presentation?

Answer 414

- Increasing maternal age + ARM - Often around time of labour + delivery but can be postpartum - Sx = SOB, sweating, anxiety, seizures, haemorrhage - Signs = hypoxia, tachycardia + hypotension, may lead to cardiac arrest

Question 415

AMNIOTIC EMBOLISM | What is the management of amniotic fluid embolism?

Answer 415

- Supportive + requires involvement from critical care (maternal A-E resus)

Question 416

PPH What is a postpartum haemorrhage (PPH)? What are the classifications?

Answer 416

Primary = loss of >500ml blood in the first 24h after delivery - Minor = 500–1000ml estimated blood loss - Major = >1000ml, clinically in shock Secondary = excessive blood loss from genital tract between 24h–12w after delivery (can result in Sheehan's syndrome)

Question 417

PPH | What are the causes of PPH?

Answer 417

Primary (4Ts) – - Tone (uterine atony = most common) - Trauma (perineal tear) - Tissue (retained products) - Thrombin (clotting issue e.g. DIC in pre-eclampsia) Secondary most common cause is retained placental tissue, endometritis

Question 418

PPH | What are the risk factors for PPH?

Answer 418

- Before birth = previous PPH, APH, twins/triplets, pre-eclampsia, obesity, polyhydramnios - Labour = prolonged, c-section, perineal tear or episiotomy, macrosomia

Question 419

PPH | How might uterine atony present in PPH?

Answer 419

- Unpalpable uterus on abdo exam (should normally be palpable in period following birth)

Question 420

PPH | What are some preventative measures to reduce risk and consequences of PPH?

Answer 420

- Treat anaemia during antenatal period - Empty bladder (?catheter) as full bladder reduces uterine contractions - Active Mx of third stage (IM oxytocin) - IV TXA during c-section in third stage of labour if high risk

Question 421

PPH | What is the acute management of PPH?

Answer 421

- ABCDE resus - 2x large bore cannulas - Group + X match - Activate major haemorrhage protocol for quick blood access - IV fluids/bloods

Question 422

PPH | What mechanical treatment can be trialled in PPH?

Answer 422

- Rub uterus through abdomen to stimulate contraction

Question 423

PPH What is the role of medical management in PPH? What is the medical management of PPH?

Answer 423

- All stimulate uterine contractions - IV syntocinon - IV/IM ergometrine, C/I in HTN as vasoconstrictor (can combine with syntocinon as syntometrine) - IM carboprost, caution in asthma (prostaglandin analogue) - Sublingual misoprostol (prostaglandin analogue)

Question 424

PPH | After failed medical management, what is the surgical management of PPH?

Answer 424

- Intrauterine balloon tamponade (1st line in uterine atony) - B-lynch sutures (suture around uterus to compress it) - Internal iliac/uterine artery ligation (reduces blood flow to stop bleeding) - Hysterectomy as last resort (may save life)

Question 425

MATERNAL SEPSIS What is sepsis? What is septic shock? What is the importance of sepsis?

Answer 425

- Life-threatening organ dysfunction from dysregulated host response to infection - Persistent tissue hypoperfusion despite adequate fluid replacement - One of top direct causes of maternal death in UK

Question 426

MATERNAL SEPSIS | What are some causes of sepsis?

Answer 426

- Pyelonephritis - Chorioamnionitis - Wound infection (c-section, episiotomy) - GBS - Pneumonia - Cellulitis - Basically any infection

Question 427

MATERNAL SEPSIS | What are some risk factors for sepsis?

Answer 427

- Immunosuppressed - Obesity - DM - Hx of pelvic infection - Amniocentesis + CVS - Cervical stitch - Prolonged ROM (>18h in prems, >24h in term)

Question 428

MATERNAL SEPSIS | What is the clinical presentation of sepsis?

Answer 428

- Pyrexia OR hypothermia, rigors, non-blanching rash - Tachycardia + hypotension (shock) - Oliguria, hypoxia, impaired consciousness - Failure to respond to treatment

Question 429

MATERNAL SEPSIS | What are the investigations for maternal sepsis?

Answer 429

- Monitor Maternal Early Obstetric Warning Score (MEOWS) | - Warning signs of sepsis (3Ts white with sugar)

Question 430

MATERNAL SEPSIS | What are the warning signs of sepsis?

Answer 430

3Ts white with sugar – - Temp <36 or >38 - Tachycardia >90bpm - Tachypnoea >20bpm - WCC >12 or <4 - Hyperglycaemia >7.7mmol/L in absence of diabetes

Question 431

MATERNAL SEPSIS | How can maternal sepsis be prevented?

Answer 431

- All pregnant ladies get seasonal flu vaccine - Broad-spec IV Abx then alter with sensitivities - Involve senior team + experts early - SEPSIS 6 within first hour - Consider delivery + VTE prophylaxis

Question 432

MATERNAL SEPSIS | What are the SEPSIS 6 components?

Answer 432

BUFALO (3 in, 3 out) – - Blood cultures (out) - Urine output by catheter (hourly, out) - Fluids resus (IV, in) - Abx (IV broad-spec, in) - Lactate (ABG, out) - Oxygen (high flow SpO2 >94%, in)

Question 433

MATERNAL SEPSIS What is puerperal pyrexia? What are the causes? What is the management

Answer 433

- Temp >38 in first 14d postpartum - Endometritis #1, UTI, mastitis, wound infections, VTE - Endometritis = hospital for IV Abx (clindamycin/gent) until afebrile >24h

Question 434

MATERNAL SEPSIS What is the clinical presentation of endometritis? What can cause it? How should you investigate it?

Answer 434

- Foul-smelling discharge or lochia, bleeding gets heavier or does not improve with time, lower abdo pain - Commonly after c-section (give prophylactic Abx), can be caused by STIs - Vaginal swabs + urine MC&S

Question 435

NEWBORN SCREENING | What types of newborn screening are there?

Answer 435

- Newborn infant physical examination (NIPE) - Newborn blood spot conditions - Newborn hearing screen

Question 436

NEWBORN SCREENING When is the NIPE done? What for?

Answer 436

- First within 72h of birth + Second by GP at 6–8w | - Screens for problems with hips, eyes, heart + genitalia

Question 437

NEWBORN SCREENING | What is the process of the newborn blood spot conditions screen (Guthrie/heel-prick)?

Answer 437

- Screening on day 5–9 | - Residual blood spots stored for 5 years (part of consent process) for research

Question 438

NEWBORN SCREENING | What conditions does the newborn blood spot screen for?

Answer 438

``` 3 genetic – - Sickle cell disease - Cystic fibrosis - Congenital hypothyroidism 6 inherited metabolic – - Phenylketonuria - Medium-chain acyl-CoA dehydrogenase deficiency - Maple syrup urine disease - Isovaleric acidaemia - Glutaric aciduria type 1 - Homocystinuria ```

Question 439

NEWBORN SCREENING What is the rough incidence of... i) sickle cell disease? ii) cystic fibrosis? iii) congenital hypothyroidism? iv) phenylketonuria? v) MCADD? vi) MSUD? vii) IVA? viii) GA1? ix) homocystinuria?

Answer 439

i) 1 in 2000 ii) 1 in 2500 iii) 1 in 3000 iv) 1 in 10,000 v) 1 in 10,000 vi) 1 in 150,000 vii) 1 in 150,000 viii) 1 in 300,000 ix) 1 in 300,000

Question 440

NEWBORN SCREENING What specifically is tested for in... i) cystic fibrosis? ii) congenital hypothyroidism? iii) phenylketonuria?

Answer 440

i) Immunoreactive trypsinogen ii) TSH iii) Phenylalanine

Question 441

NEWBORN SCREENING What is phenylketonuria? What are the features of phenylketonuria? What is the management?

Answer 441

- AR defect in phenylalanine hydroxylase (C12) - LDs, seizures, 'musty' odour to urine + sweat, (fair hair, blue eyes) - Phenylalanine restricted diet

Question 442

NEWBORN SCREENING | What is the management of MCADD?

Answer 442

- Avoid long periods with no food | - High sugar drinks when ill

Question 443

NEWBORN SCREENING What does MSUD, IVA and GA1 have in common? What are their differences? What is the management?

Answer 443

- Issues with processing amino acids - MSUD = leucine, isolecine + valine - IVA1 = leucine - GA1 = lysine, hydroxylysine + tryptophan - Limit high protein foods

Question 444

NEWBORN SCREENING What is homocystinuria? How does it present? What is the management?

Answer 444

- Cystathionine synthetase deficiency - Developmental delay, MSK like Marfan, fair complexion, brittle hair, dislocation of lens - Pyridoxine (vitamin B6)

Question 445

NEWBORN SCREENING What is the newborn hearing screening? Why is it done?

Answer 445

- All babies screened within 4w of birth ideally (up to 3m) | - Early identification crucial for developing speech, language + social skills

Question 446

NEWBORN SCREENING What does the newborn hearing screen involve? What is the outcome?

Answer 446

- Automated otoacoustic emission (AOAE) test with some babies needing automated auditory brainstem response (AABR) test - Refer to audiology within 4w if no clear response with one or both ears

Question 447

MENTAL HEALTH | What are some red flags in terms of maternal mental health?

Answer 447

- Recent change in mental state or new Sx - New thoughts or acts of violence/self-harm - New + persistent feelings of incompetency as mother or estrangement from baby

Question 448

MENTAL HEALTH | Why can mental health disorders be difficult to detect in the puerperium?

Answer 448

- Fear of treatment - Fear of children being removed - Cultural lack of recognition - Denial - Stigma

Question 449

MENTAL HEALTH What are baby blues? How common is it? What is the management?

Answer 449

- Brief period of tearfulness, anxiety + emotional lability starting 3–10d after birth - Affects up to 70% of women, classically primiparous - Reassure natural to feel emotional + overwhelmed, health visitor obs

Question 450

MENTAL HEALTH What is postnatal depression? What are some risk factors?

Answer 450

- Depressive episode, temporally related to childbirth, within 6m post-partum - Risk factors = PMH/FHx of MH issues, Hx of abuse, lack of support/relationships, low socioeconomic status, unemployed

Question 451

MENTAL HEALTH What can be used to measure postnatal depression? How does postnatal depression present?

Answer 451

- Edinburgh postnatal depression scale = screening tool, >10 suspect - Typical depression Sx but may include worries about baby's health or ability to cope adequately, feeling detached from the baby

Question 452

MENTAL HEALTH | What is the management of postnatal depression?

Answer 452

- Early identification + close monitoring of those at risk - CBT may help, sertraline + paroxetine if severe as safer in breastfeeding - ?Hospital admission if thoughts of self or baby-harm

Question 453

MENTAL HEALTH What is postpartum/puerperal psychosis? What are some risk factors?

Answer 453

- Acute psychotic episode with peak occurrence at 2w postpartum - FHx/PMH of MH (esp. postpartum psychosis), traumatic birth or pregnancy, primiparous

Question 454

MENTAL HEALTH | What is the clinical presentation of postpartum psychosis?

Answer 454

- Prominent affective Sx (mania or depression with psychotic Sx) - Schizophreniform disorder (lasts <6m) - Emotional lability, delusions, hallucinations, suicidality, infanticide

Question 455

MENTAL HEALTH | What is the management of postpartum psychosis?

Answer 455

- Assess suicide risk + risk to baby - Often inpatient admission (mother + baby unit) - Antipsychotics ± antidepressants or mood stabilisers (carbamazepine), ECT for major affective disorder - Psychoeducation for pt + family, CBT - Children + family social service involvement

Question 456

PUERPERIUM What is the puerperium? What does it involve?

Answer 456

- Delivery of placenta to 6w following birth | - Return to pre-pregnant state, initiation/suppression of lactation + transition to parenthood

Question 457

PUERPERIUM | What is the postnatal period?

Answer 457

- Period under which woman + baby are still under midwife care, usually at least 10d + for as long as midwife feels necessary

Question 458

PUERPERIUM What is... i) maternal death? ii) direct maternal death? iii) indirect maternal death?

Answer 458

i) Death of a woman during or up to 6w after her pregnancy (may or not have been aggravated by pregnancy) ii) Mother dying as a result of an obstetric complication iii) Mother dying as a result of a pre-existing disease or disease that developed during pregnancy, but not as a direct obstetric cause

Question 459

PUERPERIUM | What are some direct and indirect causes of maternal death?

Answer 459

- Direct = VTE (#1), haemorrhage, HTN disorders, suicide | - Indirect = cardiac disease

Question 460

PUERPERIUM | What are some major and minor post-natal problems?

Answer 460

- Major = sepsis, PPH, pre-eclampsia, VTE, uterine prolapse, breast abscess, MH issues - Minor = fatigue, anaemia, mastitis, baby blues

Question 461

PUERPERIUM | What changes happen during the puerperium?

Answer 461

- Big decrease in serum placental hormones (hPL, hCG, oestrogen + progesterone) - Uterus involutes from 1kg > 100g + cervix firm after 3d - Decidua is shed as lochia - Milk replaces colostrum after 3d - Breast engorgement (swollen, red + tender) after 3d

Question 462

PUERPERIUM | What are the different types of lochia?

Answer 462

- Rubra (red) 0–4d (blood cervical discharge, meconium) - Serosa (yellow) 4–10d (mucus, exudate, foetal membrane, WBCs) - Alba (white) 10–28d (cholesterol, fat, leukocytes, mucus)

Question 463

PUERPERIUM | What is the difference between colostrum and breast milk?

Answer 463

- Colostrum at birth = yellow fluid, first form of milk with high proteins (IgA, lactoferrin), low sugar + fat - Milk = lactose, protein, fat + water

Question 464

PUERPERIUM | What is the physiology of breast feeding?

Answer 464

- Baby suckles so sensory impulses from nipple > brain - Prolactin secreted by ant. pit > breasts via blood + lactocytes produce milk - Oxytocin secreted by post. pit > breasts via blood causes myometrial cell contraction to expel milk

Question 465

PUERPERIUM | When else is prolactin secreted and why?

Answer 465

- More at night - Suppresses ovulation - Levels peak after feed to produce more for next feed

Question 466

PUERPERIUM What stimulates oxytocin secretion? What hinders it?

Answer 466

- Sight, sound + smell of baby (conditioned over time) | - Hindered by anxiety, stress + pain

Question 467

PUERPERIUM | What is lactoferrin?

Answer 467

- Multifunctional protein in milk but loads in colostrum - Regulates iron absorption in intestines + delivery of iron to cells - Prevention against infections - Regulation of bone marrow function + boosts immune system

Question 468

PUERPERIUM | What are some drug contraindications in breastfeeding?

Answer 468

- Abx (ciprofloxacin, tetracyclines, chloramphenicol) - Psych drugs (lithium, BDZs) - Amiodarone, aspirin - Carbimazole, methotrexate - Sulfonylureas - Cytotoxic drugs

Question 469

PUERPERIUM | What are the pros + cons of breast feeding?

Answer 469

- Readily available good nutrition, cheaper, contraceptive effect, decrease childhood infections (gastroenteritis), decrease in necrotising enterocolitis - Feed more often, uncomfortable + pain (mastitis)

Question 470

PUERPERIUM | What contraception can be offered to women?

Answer 470

- POP + implant safe in breastfeeding, start any time - COCP UKMEC4 <6w + UKMEC2 >6w, avoid in breastfeeding - IUD/IUS inserted <48h OR >4w but is UKMEC3 between

Question 471

PUERPERIUM What is mastitis? What can cause it?

Answer 471

- Inflammation of breast tissue - Obstruction of ducts + accumulation of milk (prevent by expressing regularly) - Infection enter at nipple>duct (commonly S. aureus)

Question 472

PUERPERIUM How does mastitis present? What can it lead to?

Answer 472

- Breast pain + tenderness, erythema, local inflammation | - Breast abscess if untreated

Question 473

PUERPERIUM How does breast abscess present? What is the management?

Answer 473

- Unilateral erythema, tenderness, fever, palpable mass + tender/enlarged LNs in axilla - Requires surgical incision + drainage

Question 474

PUERPERIUM | What is the management of mastitis?

Answer 474

- Milk MC&S if ?infection - Analgesia - Continue feeding or expressing - Flucloxacillin 10–14d if systemically unwell, nipple fissure, Sx>24h, infection

Question 475

SHEEHAN'S SYNDROME | What is Sheehan's syndrome?

Answer 475

- Drop in circulating blood volume leads to avascular necrosis of the pituitary gland - Ischaemia + infarction of anterior pituitary cells as supplied by hypothalamo-hypophysial portal system which is susceptible to rapid drops in BP after PPH

Question 476

SHEEHAN'S SYNDROME How does Sheehan's syndrome present? What is the management?

Answer 476

- Reduced lactation (lack of prolactin) - Amenorrhoea (lack of LH + FSH > HRT) - Hypothyroidism (lack of TSH > levothyroxine) - Adrenal insufficiency (lack of ACTH > hydrocortisone)

Question 477

PREGNANCY PHYSIOLOGY | What hormones increase in regards to the anterior pituitary gland?

Answer 477

- ACTH = rise in steroid hormones (cortisol, aldosterone) = improves autoimmune conditions (RA) but susceptible to DM + infections - Prolactin = suppresses FSH + LH - Melanocyte stimulating hormone = increased skin pigmentation (linea nigra + melasma = brown pigmentation)

Question 478

PREGNANCY PHYSIOLOGY | What other hormones rise in pregnancy?

Answer 478

- T3/T4 - HCG = doubles every 48h until plateau at 8–12w then gradual fall - Progesterone - Oestrogen

Question 479

PREGNANCY PHYSIOLOGY | What changes occur to the uterus in pregnancy?

Answer 479

- Increase from 100g–1.1kg - Hyperplasia + hypertrophy of myometrium - Decidual spiral arteries remodelled for wide bore low resistance

Question 480

PREGNANCY PHYSIOLOGY | What changes occur to the cervix in pregnancy?

Answer 480

- Increased oestrogen = ?cervical ectropion + increased discharge - Before delivery, prostaglandins break down collagen in cervix = dilate + efface - Chadwick's sign = early pooled deoxygenated blood > blue tinge

Question 481

PREGNANCY PHYSIOLOGY | What changes occur to the vagina in pregnancy?

Answer 481

- Oestrogen > hypertrophy of vaginal muscles + increased PV discharge - Makes bacterial + candida infection more common

Question 482

PREGNANCY PHYSIOLOGY | What changes occur to the breasts?

Answer 482

- Increased size with increased gestation | - Fat deposition around gland tissue

Question 483

PREGNANCY PHYSIOLOGY In terms of the cardiovascular system in pregnancy, what... i) increases? ii) decreases?

Answer 483

i) Blood volume, plasma volume, CO (as increased SV + HR) ii) Peripheral vascular resistance (can cause flushing + hot sweats) + BP in early-mid pregnancy but returns to normal by term

Question 484

PREGNANCY PHYSIOLOGY | What changes can occur to the vascular system?

Answer 484

- Varicose veins due to peripheral vasodilation + obstruction of IVC by uterus

Question 485

PREGNANCY PHYSIOLOGY | What CVS anatomical changes are there?

Answer 485

- Diaphragmatic elevation > heart displaced upwards/left so apex moved laterally - Increased ventricular muscle mass + increased LV/LA size - Altered QRS (LAD), ECG changes (inverted T waves) + flow (ES) murmurs

Question 486

PREGNANCY PHYSIOLOGY | In terms of the respiratory system, what are the mechanical changes?

Answer 486

- Increased subcostal angle, pulmonary blood flow + tidal volume - Decreased vital capacity + functional residual capacity - Progesterone causes trachea-bronchial smooth muscle relaxation

Question 487

PREGNANCY PHYSIOLOGY | In terms of the respiratory system, what are the biochemical changes?

Answer 487

- Increased oxygen consumption (20%) + RR - Compensated resp alkalosis may occur as increased pO2 + reduced pCO2 (facilitates foetal CO2 excretion), renal HCO3- excretion to prevent this - Increased 2,3 DPG to promote maternal Hb to release oxygen

Question 488

PREGNANCY PHYSIOLOGY In terms of the renal system, what... i) increases? ii) decreases?

Answer 488

i) Blood flow to kidneys (so GFR), aldosterone (Na + water reabsorption + Retention), protein excretion ii) Serum creatinine, urate + albumin

Question 489

PREGNANCY PHYSIOLOGY What can happen in terms of the urinary system? What is a consequence of this? What else contributes?

Answer 489

- Dilatation of ureters + collecting system > physiological hydronephrosis (more R) - Increased risk of UTIs - Decreased ureter tone/peristalsis = urinary stasis

Question 490

PREGNANCY PHYSIOLOGY | What 4 forces/pressures govern fluid retention in pregnancy?

Answer 490

- Capillary (hydrostatic) pressure of blood in vessel = draws fluid OUT - Interstitial fluid colloid oncotic pressure of proteins in interstitial fluid = draws fluid OUT - Interstitial fluid pressure of tissues surrounding vessel = draws fluid IN - Plasma colloid oncotic pressure (albumin) = draws fluid IN

Question 491

PREGNANCY PHYSIOLOGY Why does pregnancy cause dilutional anaemia? What is the purpose of this?

Answer 491

- Increased RBC production = higher iron, folate + B12 requirements - Increased ECF + plasma volume MORE than RBC volume leading to lower red cell conc (haematocrit) + lower Hb conc - Facilitates placental perfusion

Question 492

PREGNANCY PHYSIOLOGY | What happens in terms of clotting in pregnancy?

Answer 492

- Clotting factors (fibrinogen, VII, VIII + X) increase - Plasminogen activator inhibitor increases (plasmin usually breaks clots down) - Hypercoaguable state

Question 493

PREGNANCY PHYSIOLOGY In terms of haematology in pregnancy, what... i) increases? ii) decreases?

Answer 493

i) WBCs, ESR, d-dimers, ALP | ii) Platelets, albumin

Question 494

PREGNANCY PHYSIOLOGY | What are the metabolic changes are there in pregnancy?

Answer 494

- Early = post-prandial glucose plasma peak lower due to fat deposition + glycogen storage - Late = higher for longer + maternal insulin resistance (via hPL) for foetal glucose sparing - Maternal insulin rises during most of pregnancy

Question 495

PREGNANCY PHYSIOLOGY | What are the changes to the skin and hair in pregnancy?

Answer 495

- Linea nigra + melasma - Striae gravidarum - General pruritus (?OC) - Spider naevi + palmar erythema - PP hair loss normal, improves within 6m

Question 496

PREGNANCY PHYSIOLOGY | What facilitates blastocyst implantation in pregnancy?

Answer 496

- Increased GFs, proteolytic enzymes + inflammatory mediators - Not rejected as change in self/non-self pattern recognition molecules (HLA + MHC proteins)

Question 497

PREGNANCY PHYSIOLOGY | In pregnancy, what changes to the humoral and cell-mediated immunity?

Answer 497

- Humoral = unchanged, plenty of circulating Th2 cells to fight infections (antibodies) - Cell-mediated = reduced as progesterone down regulates production of Th1 cells (phagocytes, cytotoxic T lymphocytes)

Question 498

PREGNANCY PHYSIOLOGY What is the impact of dampening Th1 production? What are the implications?

Answer 498

- Shift to increased Th2 production (bias) to protect foetus | - Pre-eclampsia, IUGR + miscarriage do not have a Th2 bias

Question 499

REPRODUCTION | What are the different stages in follicular genesis and what stage in the cell cycle are they?

Answer 499

- Primordial follicles = diploid, arrested at prophase I - Primary follicle = diploid, undergoing meiosis I - Secondary follicle = haploid, once meiosis I complete - Antral (Graafian) follicle = haploid, frozen in metaphase II

Question 500

REPRODUCTION What are the structures of... i) primordial follicles? ii) primary follicles?

Answer 500

i) Each contain primary oocyte (germ cells) that eventually form mature ovum ii) Primary oocyte > zona pellucida > cuboidal granulosa cells, zona pellucida secreted from granulosa cells

Question 501

REPRODUCTION | What happens when follicles reach the secondary follicle stage?

Answer 501

- Granulosa cells express FSH receptors = oestrogen production to grow - Theca cells express LH receptors = steroidogenesis

Question 502

REPRODUCTION | How is a dominant follicle chosen?

Answer 502

- Fluid-filled chamber (antrum) starts to develop causing rapid growth - Rising LH leads to rising oestrogen - Dominant follicle with lots of FSH receptors outgrows the others

Question 503

REPRODUCTION | What happens at ovulation?

Answer 503

- LH surge = smooth muscle of theca externa contracts - Follicle bursts + secretes enzymes puncturing hole in ovary - Fimbriae of fallopian tubes sweeps oocyte up, surrounded by zona pellucida - Leftover follicle > corpus luteum

Question 504

REPRODUCTION | How does fertilisation occur?

Answer 504

- Sperm enters fallopian tube + attempts to penetrate through corona radiata + zona pellucida via acrosome reaction - Fusion of sperm + egg = zygote

Question 505

REPRODUCTION | What happens immediately after fertilisation?

Answer 505

- Cell rapidly divides > mass of cells (morula) travels to uterus - Fluid filled cavity (blastocele) expands to form blastocyst (>80 cells) with outer layer (trophoblast) + inner layer (embryoblast)

Question 506

REPRODUCTION When does the blastocyst reach the uterus? What happens?

Answer 506

- 8–10d after ovulation - Trophoblast cells undergo adhesion to stroma of endometrium - Outer layer of trophoblast (syncytiotrophoblast) forms projections into the stroma

Question 507

REPRODUCTION Once the blastocyst has implanted, what happens to the stroma? What signifies blastocyst implantation?

Answer 507

- Cells of stroma convert into decidua to provide nutrients (decidual reaction) - Syncytiotrophoblast produces hCG to maintain corpus luteum

Question 508

REPRODUCTION | What happens to the embryoblast after implantation?

Answer 508

- Divides into yolk sac + amniotic cavity on opposing sides with embryonic disc between - Chorion surrounds this complex with inner cytotrophoblast + outer syncytiotrophoblast which is embedded in endometrium

Question 509

REPRODUCTION | How does the chorion develop over time?

Answer 509

- Chorionic cavity forms around the yolk sac, embryonic disc + amniotic sac + these structures suspended from the chorion by the connecting stalk (eventually umbilical cord)

Question 510

REPRODUCTION When does the embryonic disc develop further? What does it develop into?

Answer 510

- 5w | - Foetal pole with 3 layers = ectoderm (outer), mesoderm (mid), endoderm (inner)

Question 511

REPRODUCTION What tissues does the... i) ectoderm ii) mesoderm iii) endoderm produce?

Answer 511

i) Skin, hair, nails, teeth, CNS ii) Heart, muscle, bone, connective tissue, kidneys, blood iii) GI tract, lungs, liver, pancreas, thyroid, reproductive

Question 512

REPRODUCTION | When do actual organs begin to develop?

Answer 512

- 6w foetal heart forms + starts to beat | - 8w all major organs start development

Question 513

REPRODUCTION | How does the placenta develop?

Answer 513

- Syncytiotrophoblast forms chorionic villi with foetal blood vessels - Those nearest connecting stalk most vascular, cells proliferate + become placenta at about 10w

Question 514

REPRODUCTION | How is nutrient diffusion facilitated in terms of how the placenta develops?

Answer 514

- Spiral arteries reduce their vascular resistance (narrow bore high resistance > wide bore low) - Makes them more fragile so blood flows out causing pools of blood (lacunae) at 20w surrounding chorionic villi for diffusion

Question 515

REPRODUCTION | What role does the placenta play in immunity?

Answer 515

- IgG crosses placenta to give foetus immunity - Primary immune deficiency hypogammaglobulinaemia can occur in babies whose mothers did not have high enough IgG during pregnancy

Question 516

REPRODUCTION | What role does the placenta play in respiration?

Answer 516

- Oxygen source for foetus, foetal Hb has higher affinity for oxygen so extracts it from maternal blood - CO2, H+, HCO3- + lactic acid exchanged to maintain acid-base balance

Question 517

REPRODUCTION | What role does the placenta play in nutrition and excretion?

Answer 517

- Main source = glucose, can transfer vitamins + minerals as well as alcohol + meds - Similar function to kidneys, filters foetal waste (urea + creatinine)

Question 518

REPRODUCTION | What are the main hormones produced by the placenta?

Answer 518

- hCG (maintain corpus luteum) - Oestrogen - Progesterone - Human placenta lactogen

Question 519

REPRODUCTION | What is the role of oestrogen in pregnancy?

Answer 519

- Softening tissue > more flexible, allows muscles + ligaments of uterus and pelvis to expand + cervix become soft - Enlarges + prepares breasts + nipples for breast feeding - E3 declines with foetal distress, E2 increases endometrial progesterone receptors

Question 520

REPRODUCTION | What is the role of progesterone in pregnancy?

Answer 520

- Produced by corpus luteum until 10w - Initially prepares endometrium for implantation by proliferation, vascularisation + decidual reaction - Later, maintains pregnancy by preventing contraction - Relaxation elsewhere > heartburn, constipation, hypotension

Question 521

REPRODUCTION | What is the role of human placental lactogen in pregnancy?

Answer 521

- Diabetogenic as raises blood glucose levels to help increase nutrient supply + helps convert mammary glands into milk secreting tissue