Obs and Gynae Flashcards
What is the antibiotic of choice for GBS prophylaxis?
Benzylpenicillin (IV intra-partum)
What is the first line investigation for suspected preterm prelabour ROM?
Speculum examination
A 32-year-old woman has come into your GP surgery requesting contraception. She is paralysed from the waist down from birth, but apart from that she has no other medical history of note and is fit and well with no symptoms. Which form of contraception would be contraindicated due to her paralysis?
COCP - UKMEC 3 due to immobility increasing risk of DVT/PE
A 35-year-old female G1 P0 presents to her local hospital at 36 weeks pregnancy. She is carrying a singleton fetus. She is in the early stages of labour (cervical dilation = 2cm). The amniotic sac has not yet ruptured. An abdominal exam reveals the fetus is presenting in transverse lie. There have been no complications in the pregnancy to date. There is no evidence of abnormal bleeding.
What is the most suitable next step?
External cephalic version
You can attempt external cephalic version for a transverse lie if the amniotic sac has not ruptured
What is the most effective form of contraception?
Contraceptive implant (failure rate of 0.05%)
What is the most common cause of puritus vulvae?
Contact dermatitis
When should serum progesterone level be taken to confirm ovulation?
7 days prior to expected next period
What form of contraception can be started any time post-partum?
Progesterone-only pill
What is the most common cause of post-menopausal bleeding?
Vaginal atrophy
A 20-year-old woman presents to her GP complaining of painful periods. She currently uses an implant (Nexplanon) for contraception which she is very happy with.
What is the most suitable initial treatment?
Mefenamic acid - NSAIDs are first line treatment for primary dysmenorrhoea
What Bishop’s score indicates that labour is unlikely to start without induction?
5 or less
What Bishop’s score indicates a high chance of spontaneous labour, or response to interventions made to induce labour?
≥ 8
What is the preferred method of IOL if the Bishop score is ≤ 6?
Vaginal PGE2 (prostaglandin gel) or oral misoprostol
What is the preferred method of IOL if the Bishop score is > 6?
Amniotomy and an intravenous oxytocin infusion
Describe the clinical presentations of uterine fibroids
Menorrhagia, anaemia, bulk-related symptoms e.g. bloating/urinary frequency
How would you manage hirstutism and acne in PCOS?
- COCP
- Topical eflornithine
- Spironolactone, flutamide and finasteride may be used under specialist supervision
When should a pregnancy test be taken post TOP?
4 weeks
What pharmacological treatment is an option for patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention?
Duloxetine
What are the risk factors for endometrial cancer?
- Increased age
- Nulliparity
- Unopposed oestrogen therapy
- Early onset of menarche and late onset of menopause
- Obesity
What are the diagnostic criteria for menopause?
Clinical diagnosis:
- < 50 years of age AND amenorrhoeic for at least 2 years
OR
- > 50 years of age AND amenorrhoeic for at least 1 year
What are the indications for surgical management of an ectopic pregnancy?
- Size > 35mm
- Visible fetal heartbeat
- hCG >5,000IU/L
What is the first line surgical treatment for an ectopic pregnancy for women with no other risk factors for infertility?
Salpingectomy
When would salpingotomy be considered for surgical management of an ectopic pregnancy?
Should be considered for women with risk factors for infertility such as contralateral tube damage
How many women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)?
1/5
Describe the expectant management of an ectopic pregnancy
Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed
What is the hCG cut off for expectant management of an ectopic pregnancy?
hCG <1,000IU/L
What is the first-line non-hormonal treatment for menorrhagia?
Tranexamic acid
When would you suspect a vesicovaginal fistulae?
Should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services
What investigation is indicated in suspected vasicovaginal fistulae?
Urinary dye studies
When are urodynamic studies indicated in incontinence?
Diagnostic uncertainty (e.g. bladder diary inconclusive) or if there are plans for surgery
An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates a voiding detrusor pressure of 90 cm H20 (normal value < 70 cm H2O) and peak flow rate of 5 mL/second (normal value > 15 mL/second). What is the most likely diagnosis?
Overflow incontinence
A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction
What definition is used to classify menstrual bleeding as ‘abnormally heavy’?
An amount that a woman considers to be excessive
What diagnosis should be considered in a patient with primary amenorrhoea and raised FSH/LH?
Gonadal dysgenesis (e.g. Turner’s syndrome)
Name the cyst: sometimes referred to as chocolate cysts due to the external appearance
Endometriotic cyst
Name the cyst: the most common ovarian cancer
Serous carcinoma
Name the cyst: An ultrasound done on a 23-year-old female for recurrent urinary tract infections incidentally shows a 3 cm ‘simple cyst’ on the left ovary. She is asymptomatic
Follicular cyst
Name the cyst: if ruptures may cause pseudomyxoma peritonei
Mucinous cystadenoma
Name the cyst: the most common type of epithelial cell tumour
Serous cystadenoma
Name the cyst: may contain skin appendages, hair and teeth
Dermoid cyst
A 22-year-old pregnant lady of Sudanese origin attends the GP anxious about her impending vaginal delivery. She is currently 30 weeks pregnant and has type 3 female genital mutilation. She advises that she would prefer for her vagina to be reinfibulated (to be sewn back up to infibulated status) post-delivery as this is what she is used to. What would be the recommended management?
Advise her that reinfibulation is illegal and cannot be done under any circumstances
What are the diagnostic criteria for PCOS?
Needs 2/3:
- Oligomenorrhoea
- Clinical and/or biochemical signs of hyperandrogenism
- Polycystic ovaries on ultrasound or increased ovarian volume
Describe the clinical presentation of a ruptured ovarian cyst
- Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity
- Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender
- Ultrasound shows free fluid in the pelvic cavity
What is the typical presentation for endometrial cancer?
A 60-year-old obese, nulliparous woman presents with vaginal bleeding
What are the three components of the RMI?
US findings, menopausal status and CA125 levels
What malignancy does combined HRT increase your risk of?
Breast cancer
What is androgen insensitivity syndrome?
X-linked recessive condition characterised by end-organ resistance to testosterone, causing genetically male children (46XY) to have a female phenotype
What are the clinical features of androgen insensitivity syndrome?
- ‘Primary amenorrhoea’
- Little or no axillary and pubic hair
- Undescended testes causing groin swellings
- Breast development may occur as a result of the conversion of testosterone to oestradiol
What is the most common risk following TOP?
Infection
How is premature ovarian failure defined?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
Can thrush be diagnosed clinically?
Yes - if symptoms highly suggestive (thickened white discharge and itching with normal vaginal pH)
Which form of HRT carries the least increased risk of VTE?
Transdermal
What is the preferred treatment for urge incontinence in an elderly patient?
Mirabegron - anticholingergics are associated with confusion in elderly patients
When can a fibroid be treated medically?
Less than 3cm in size
What complication are women with PCOS at particular risk of when undergoing IVF?
Ovarian hyperstimulation syndrome
What is the investigation of choice for an ectopic pregnancy?
Transvaginal ultrasound
Name that cyst: most common type of ovarian pathology associated with Meigs’ syndrome
Fibroma
What is Meigs’ syndrome?
Benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
Name that cyst: most common benign ovarian tumour in women under the age of 25 years
Dermoid cyst (teratoma)
Name that cyst: most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
When is surgical management indicated in ectopic pregnancy?
> 35 mm in size or with a serum B-hCG >5,000IU/L
What is the management of endometriosis?
- NSAIDs and/or paracetamol
- COCP or progesterones
- GnRH analogues
- Surgery
When should you repeat a smear if the smear is inadequate?
3 months
What are the risk factors for HG?
- Increased levels of beta-hCG e.g. multiple pregnancies, trophoblastic disease
- Nulliparity
- Obesity
- Family or personal history of NVP
Name a factor associated with a decreased incidence of HG
Smoking
What investigations should be performed in patients with suspected PCOS?
Pelvic ultrasound, FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis?
Imperforate hymen
A 25-year-old woman at 15 weeks gestation of her first pregnancy returns to her general practitioner with tremor after starting a medication during pregnancy for hyperemesis gravidarum. On examination, the patient has a resting tremor in their left hand and increased upper limb tone.
What medication was the patient most likely prescribed?
Metoclopramide - it is an option for nausea and vomiting in pregnancy, but it should not be used for more than 5 days due to the risk of extrapyramidal effects
What tumour marker is associated with ovarian cancer?
CA 125
Why should GnRH agonists only be used for short periods in patients with uterine fibroids?
Minimise side effects:
Loss of bone mineral density
Hot flushes and vaginal dryness
Describe the presentation of endometrial hyperplasia
May present with intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding
Being overweight is a risk factor
Describe the clinical presentation of vulval carcinoma
Older woman with labial lump and inguinal lymphadenopathy
What is stage 1 ovarian cancer?
Tumour confined to ovary
What is stage 2 ovarian cancer?
Tumour outside ovary but within pelvis
What is stage 3 ovarian cancer?
Tumour outside pelvis but within abdomen
What is stage 4 ovarian cancer?
Distant metastasis
A 48-year-old woman presents with perimenopausal symptoms. Apart from suffering from migraines with aura, she does not have any relevant medical history. She has a family history of deep vein thrombosis (DVT). The patient’s last menstrual periods are irregular, the last one being 3 months ago. She is not currently on any contraception.
What is the most suitable treatment?
Topical cyclical combined HRT
A 55-year-old woman presents with mood swings and night sweats for the last few years which she has managed herself. She reports her last period was over 1 year ago but reports some vaginal bleeding a few days ago. She is not on any contraception.
What is the most suitable treatment?
HRT contraindicated
Undiagnosed vaginal bleeding is a contraindication
A 49-year-old patient presents with hot flushes and mood swings. She has no previous medical history or family history. She has been amenorrheic since her Mirena (levonorgestrel) coil was placed 2 years ago. She would like to consider HRT with the least side effects.
What is the most suitable treatment?
Oestrogen patch
Which type of ovarian tumour is associated with the development of endometrial hyperplasia?
Granulosa cell tumours
What is the most suitable treatment for symptoms of mild-moderate PMS?
New-generation COCP
What is the management of a ruptured ectopic pregnancy?
Emergency laparotomy
A 24-year-old woman presents to the GP with vaginal bleeding. She is 5-weeks pregnant. She reports no abdominal pain, no dizziness, no shoulder tip pain. There are no clots and she has passed less than a teaspoon amount of blood. She has no history of ectopic pregnancy. On examination, her heart rate is 85 beats per minute, blood pressure is 130/80 mmHg and her abdomen is soft, non-tender.
According to current NICE CKS guidance, what is the next most appropriate management step?
Monitor expectantly and advise to repeated pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continuing/worsening symptoms, refer to early pregnancy assessment unit
What is the most common complication of an open myomectomy?
Adhesions
What diagnosis is associated with a Whirlpool sign on USS?
Ovarian torsion
What are the classic symptoms of endometriosis?
Pelvic pain, dysmenorrhoea, dyspareunia and subfertility
What are the classic symptoms of adenomyositis?
Typically seen in multiparous women towards the end of their reproductive years
Dysmenorrhoea, menorrhagia, dyspareunia
What is the next step in management following abnormal cytology of the cervix?
Large loop excision of transformation zone (LLETZ)
Discuss fibroids in pregnancy
In early pregnancy, they grow primarily in response to oestrogen and can cause pelvic pain and pressure symptoms
They may undergo ‘red degeneration’ if they grow rapidly and outstrip their blood supply
What USS findings are associated with a miscarriage?
A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity
What is goserelin?
GnRH agonist which can be used for short term management of fibroids to reduce size
A 48-year-old female smoker attends the GP for information regarding contraception. Her last menstrual period was 9 months ago and she is convinced that she has ‘gone through the menopause’.
What is the most suitable form of contraception?
Intrauterine system
How do you manage thrush in pregnancy?
Clotrimazole pessary
Who should be referred under the two week suspected cancer pathway for endometrial cancer?
A woman >= 55 years of age presenting with postmenopausal bleeding (i.e. more than 12 months after menstruation has stopped)
A 48-year-old woman visits her general practitioner with a 6-week history of unbearable hot flushes and vaginal dryness. She suspects that she is going through menopause. Her past medical history includes hypothyroidism and psoriasis. She takes regular levothyroxine and has the Mirena intrauterine system in situ.
What is the most appropriate additional treatment to initiate for this patient?
Estradiol
Mirina = progesterone component, add estradiol for oestrogen component
What is the treatment for vaginal vault prolapse?
Sacrocolpopexy
What is the most appropriate investigation to diagnose premature ovarian failure?
FSH level
At menopause (and in premature ovarian failure), ovarian function ceases, leading to high levels of FSH due to the removal of the negative feedback mechanisms
What is the genotype for androgen insensitivity syndrome?
46XY
Give 3 examples of muscarinic antagonists (used to treat urge incontinence)
- Oxybutynin
- Solifenacin
- Tolterodine
When can an IUD be placed after a surgical TOP?
Immediately after evacuation of the uterine cavity
What pharmacological treatment can be given to patients with severe PMS?
SSRI
What is the drug of choice for medical management of ectopic pregnancy?
Methotrexate
What is the only treatment for large fibroids causing problems with fertility if the woman wishes to conceive in the future?
Myomectomy
What are the criteria for considering admission in a woman with nausea and vomiting in pregnancy?
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
What is the first line drug for infertility in PCOS?
Clomifene
What endocrine markers are associated with PCOS?
- Raised LH:FSH ratio
- Testosterone may be normal or mildly elevated
- SHBG is normal to low
Which component of HRT increases breast cancer risk?
Progestogen
What should you do if a patient has two ‘inadequate’ cervical smears?
Refer for colposcopy
What is the treatment of choice for stage I and II endometrial carcinoma?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy
If a colposcopy identifies CIN, when should the patient be followed up?
Smear at 6 months (to check that the lesion has been adequately treated)
A 27-year-old female presents to her GP as she missed her desogestrel contraceptive pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1430. What advice should be given?
Take missed pill now and advise condom use until pill taking re-established for 48 hours
What advice should you give a woman who vomits within 3 hours of taking levonorgestrel or ulipristal acetate?
She should take a second dose of emergency hormonal contraception ASAP
What are the common examples of UKMEC 3 conditions for the COCP?
- More than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- Family history of thromboembolic disease in first degree relatives < 45 years
- Controlled hypertension
- Immobility e.g. wheel chair use
carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2) - Current gallbladder disease
- Diabetes mellitus diagnosed > 20 years ago is UKMEC 3 or 4 depending on severity
What are the common examples of UKMEC 4 conditions for the COCP?
- More than 35 years old and smoking more than 15 cigarettes/day
- Migraine with aura
- History of thromboembolic disease or thrombogenic mutation
- History of stroke or ischaemic heart disease
- Breast feeding < 6 weeks post-partum
uncontrolled hypertension - Current breast cancer
- Major surgery with prolonged immobilisation
- Positive antiphospholipid antibodies (e.g. in SLE)
- Diabetes mellitus diagnosed > 20 years ago is UKMEC 3 or 4 depending on severity
What is the most common adverse effect of the progestogen-only pill?
Irregular bleeding
When do post-partum women require contraception?
21 days from giving birth
A 13 year old girl presents to GP and wants the pill. She understands the risks. Her boyfriend is 14. What do you do?
Give her a prescription for the pill but encourage her to discuss with a parent
Immediate social services referral if 12 or under, otherwise use Frazer guidelines
What methods of contraception are suitable for a trans man?
Progesterone-only or non-hormonal
Oestrogen is contarindicated in patients on testosterone therapy as it may antagonise its effects
What advice would you give to a women who has missed 1 COCP?
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
No additional contraceptive protection needed
What advise should you give a women who has missed 2 or more COCP?
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
The women should use condoms or abstain from sex until she has taken pills for 7 days in a row
Take emergency contraception if the pills are missed in week 1 if she had sex in the pill-free interval or week 1
Miss the pill-free interval if the pills missed are in week 3
A 25-year-old woman on the COCP is to have an elective laparoscopic cholecystectomy in 8 weeks time. What should be done with regards to her pill and her upcoming surgery?
Stop the pill 4 weeks before surgery and restart 2 weeks after
When can the IUS/IUD be inserted following childbirth?
48 hours of childbirth or after 4 weeks
Can patients restart hormonal contraception immediately after levonorgestrel?
Yes
Can patients restart hormonal contraception immediately after ulipristal acetate?
No - wait 5 days
What options are there for contraception for an obese woman who has had bariatric surgery?
- Implantable contraceptive
- Injectable contraceptives
- IUS/IUD
Oral options are contraindicated due to decreased efficacy
Patch is UKMEC 2 if BMI 30-35 and history of bariatric surgery
What is the best contraception for a patient with heavy bleeding who takes anti-epilepsy medication?
IUS
Yes/no: ellaOne (ulipristal acetate) can be taken more than once in the same menstrual cycle
Yes
What is the time limit for ellaOne (ulipristal acetate) after unprotected sex?
120 hours
What is the time limit for Levonelle (levonorgestrel) after unprotected sex?
96 hours (most effective within 72 hours)
What is the time limit for the IUD after unprotected sex?
5 days
When can a contraceptive implant be inserted following childbirth?
Immediately
What form of contraception is effective immediately?
IUD
What form of contraception is effective after 2 days?
POP
What forms of contraception are effective after 7 days?
COC, injection, implant, IUS
Can a trans female on hormones get a cis female partner pregnant?
Yes - advise condoms
A 36-year-old woman attends her GP surgery seeking contraception. She smokes 20 cigarettes a day and has a body mass index of 25 kg/m².
What forms of contraception are contraindicated?
All methods of combined hormonal contraception (pill, patch, ring)
Can a women on the POP undergoing surgery stay on the pill?
Yes
What method of contraception is best for patients taking enzyme-inducers?
Injection
A woman is having her IUD removed and starting on the ring. Does she need additional contraception?
If on days 1-5 of cycle - no
From day 6 onwards - 7 days of barrier contraception
A 19 year-old woman attends her GP for a repeat prescription of her combined oral contraceptive pill (COCP). Since starting it, she has been suffering from severe left sided headaches with changes in her vision before the headache begins. Clinical examination is normal. What is the most appropriate step in her management?
Stop COCP and start progesterone-only contraception
What advice should you give a women taking POP and antibiotics?
Usually fine
If an enzyme inducer e.g. rifampicin - use barrier contraception during treatment and for 4 weeks after
How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?
Every 12 weeks
When can a post-partum patient restart COCP?
21 days
What mode of delivery is appropriate for a women with a placenta covering part (grade III) or all (grave IV) of the cervix?
Elective caesarean section at 37-38 weeks
What is a first degree perineal tear?
Superficial damage with no muscle involvement
What is the management of a first degree perineal tear?
Do not require any repair
What is a second degree perineal tear?
Injury to the perineal muscle, but not involving the anal sphincter
What is the management of a second degree perineal tear?
Require suturing on the ward by a suitably experienced midwife or clinician
What is a third degree perineal tear
Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
What is a 3a perineal tear?
Less than 50% of EAS thickness torn
What is a 3b perineal tear?
More than 50% of EAS thickness torn
What is a 3c perineal tear?
IAS torn
What is the management of a 3rd degree perineal tear?
Require repair in theatre by a suitably trained clinician
What is a fourth degree perineal tear?
Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
What is the management of a fourth degree perineal tear?
Require repair in theatre by a suitably trained clinician
What are the causes of oligohydramnios?
- Premature rupture of membranes
- Potter sequence - bilateral renal agenesis + pulmonary hypoplasia
- Intrauterine growth restriction
- Post-term gestation
- Pre-eclampsia
What is HCG?
Hormone secreted by the syncytiotrophoblast into the maternal bloodstream
Acts to maintain the production of progesterone by the corpus luteum in early pregnancy
How would you manage placental abruption when the fetus is alive, <36 weeks and not showing signs of distress?
Admit and administer steroids
When would immediate caesarean section be indicated in placental abruption?
If the fetus was showing signs of distress, demonstrated by the CTG, or if the mother was going into shock from significant blood loss
A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. On examination, the cervix is 7 cm dilated, the head is direct OA, the foetal station is at -1 and the head is 2/5 ths palpable per abdomen. The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes. How should this situation be managed?
Caesarian section
The cardiotocogram is very concerning (the late decelerations which are a worrying sign especially in the context of foetal bradycardia) and indicates that the baby needs to be delivered immediately
What is a normal fetal heart rate?
100-160 bmp
What is an early deceleration? What causes it?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually an innocuous feature and indicates head compression
What is a late deceleration? What causes it?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Indicates fetal distress e.g. asphyxia or placental insufficiency
What are variable decelerations? What causes it?
Decelerations independent of contractions
May indicate cord compression
What is the immediate management of umbilical cord prolapse
Manual elevation of the presenting part of the fetus
If the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out
Tocolytics e.g. terbutaline may be used to reduce uterine contractions
What is the most common explanation for short episodes (< 40 minutes) of decreased variability on CTG?
Baby is sleeping
How often should a pregnant woman with T1DM test BM during pregnancy?
Daily fasting, pre-meal- 1 hour post-meal and bedtime tests
What is the diagnostic criteria for gestational hypertension?
Significant increase in blood pressure (≥140/90 mmHg) after 20 weeks of gestation without any proteinuria or other systemic features
What is the diagnostic criteria for mild pre-eclampsia?
The presence of both hypertension and proteinuria after 20 weeks of gestation
What is the diagnostic criteria for moderate pre-eclampsia?
Hypertension and proteinuria (≥1+ on a dipstick or ≥300 mg/24 hours) along with one or more adverse conditions such as severe headache, visual disturbances, epigastric pain, or abnormal laboratory results
Which drugs are contraindicated in breastfeeding?
- Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Psychiatric drugs: lithium, benzodiazepines
- Aspirin
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
What drug should be given to women with PPROM?
10 days erythromycin
What antenatal care is given at 8 - 12 weeks?
- General info e.g. diet, alcohol, smoking, folic acid + vit D, antenatal classes
- BP
- Check BMI
- Urine dipstick and culture (asymptomatic bacteriuria)
- Bloods - FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies, hepatitis B, syphilis
What antenatal care is given 10 - 13+6 weeks?
Early scan to confirm dates, exclude multiple pregnancy
What antenatal care is given 11 - 13+6 weeks?
Down’s syndrome screening including nuchal scan
What antenatal care is given at 16 weeks?
- Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
- Routine care: BP and urine dipstick
What antenatal care is given at 18 - 20+6 weeks?
Anomaly scan
What antenatal care is given at 28 weeks?
- Routine care: BP, urine dipstick, SFH
- Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
- First dose of anti-D prophylaxis to rhesus negative women
What antenatal care is given at 34 weeks?
- Routine care: BP, urine dipstick, SFH
- Second dose of anti-D prophylaxis to rhesus negative women
- Information on labour and birth plan
What antenatal care is given at 36 weeks?
- Routine care: BP, urine dipstick, SFH
- Check presentation - offer external cephalic version if indicated
- Information on breast feeding, vitamin K, ‘baby-blues’
What are the risk factors for placental abruption?
- A for Abruption previously
- B for Blood pressure (i.e. hypertension or pre-eclampsia)
- R for Ruptured membranes, either premature or prolonged
- U for Uterine injury (i.e. trauma to the abdomen)
- P for Polyhydramnios
- T for Twins or multiple gestation;
- I for Infection in the uterus, especially chorioamnionitis
- O for Older age (i.e. aged over 35 years old)
- N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
A 32-year-old woman presents to the antenatal clinic at 41-weeks gestation. She is concerned that she has not yet gone into labour. She reports normal foetal movements and denies recent illness. This is her first pregnancy and there is no other past medical history of note.
On examination, her abdomen is soft with a palpable uterus in keeping with a term pregnancy. Her Bishop’s score is calculated as 5.
What is the most initial step in the management of this patient?
Membrane sweep
A 23-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents after fainting and has severe abdominal pain. Blood pressure = 92/58 mmHg and heart rate = 132/min. On examination she is cold and her fundal height is 37 cm; the cervical os is closed and there is no vaginal bleeding. Which is the most appropriate diagnosis?
Placental abruption
Absense of bleeding does not rule out this diagnosis - 20% present without bleeding
Key features are sudden abdominal pain in first trimester, mother cold to touch
What conditions are associated with raised AFP?
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
What conditions are associated with reduced AFP?
- Down’s syndrome
- Trisomy 18
- Maternal diabetes mellitus
Baby who is exclusively breastfed and loses >10% of their birth weight within the first week of life - what should you do?
Referral to a midwife-led breastfeeding clinic
What foods should be avoided in pregnancy?
- Listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
- Salmonella: avoid raw or partially cooked eggs and meat, especially poultry
What anti-hypertensives are contraindicated in pregnancy? What should you replace them with?
ACEi/ARB should be stopped immediately and alternative antihypertensive started (e.g. labetalol) whilst awaiting specialist review
How would you monitor a women with gestational diabetes in a previous pregnancy?
Women with gestational diabetes in a previous pregnancy should be offered an OGTT as soon as possible after booking and subsequently at 24-28 weeks
What are the risk factors for gestational diabetes?
- BMI of > 30 kg/m²
- Previous macrosomic baby weighing 4.5 kg or above
- Previous gestational diabetes
- First-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
When should women with a risk factor for gestational diabetes be offered OGTT?
24-28 weeks
What are the diagnostic thresholds for gestational diabetes?
Fasting glucose is >= 5.6 mmol/L
OR
2-hour glucose is >= 7.8 mmol/L
Name 4 causes of folic acid deficiency
- Phenytoin
- Methotrexate
- Pregnancy
- Alcohol excess
Undiagnosed breech birth, not yet fully dilated is a category ____ caesarean section
2 (within 75 mins)
What laboratory findings are associated with a normal pregnancy?
Reduced urea, reduced creatinine, increased urinary protein loss
What is the management of PPH?
- ABCDE approach
- Palpating the uterine fundus and catheterising the patient
- IV syntocinon
- Ergometrine (contraindicated in hypertension) and then a syntocinon infusion
- Carboprost (contraindicated in asthma) and then misoprostol 1000 micrograms rectally are then recommended
- If pharmacological management fails then surgical haemostasis should be initiated
What patient group should receive anti-D (routinely)? When?
Non-sensitised Rh -ve mothers at 28 and 34 weeks
What are the non-routine indications for anti-D?
- Delivery of a Rh +ve infant, whether live or stillborn
- Any termination of pregnancy
- Miscarriage if gestation is > 12 weeks
- Ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
- External cephalic version
- Antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling - Abdominal trauma
What are the risk factors for umbilical cord prolapse?
- Artificial amniotomy - around 50% of cord prolapses occur at artificial rupture of the membranes
- Prematurity
- Multiparity
- Polyhydramnios
- Twin pregnancy
- Cephalopelvic disproportion
- Abnormal presentations e.g. Breech, transverse lie
What is the first stage of labour?
From the onset of true labour to when the cervix is fully dilated
What is the second stage of labour?
From full dilation to delivery of the fetus
What is the third stage of labour?
From delivery of fetus to when the placenta and membranes have been completely delivered
What is the active management of the third stage of labour?
- Uterotonic drugs - 10 IU oxytocin IM
- Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
- Controlled cord traction after signs of placental separation
What is placental accreta?
Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis
Can cause PPH
What is placenta increta?
Chorionic villi invade into the myometrium
What is placenta percreta?
Chorionic villi invade through the perimetrium
What are the SSRIs of choice in breastfeeding women?
Sertraline or paroxetine
What is the definitive management of intrahepatic cholestasis of pregnancy?
IOL at 37-38 weeks
List the indications for continuous CTG monitoring during labour
- Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
- Severe hypertension 160/110 mmHg or above
- Oxytocin use
- The presence of significant meconium
- Fresh vaginal bleeding that develops in labour
What are the ‘high risk’ factors for pre-eclampsia?
- Hypertensive disease in a previous pregnancy
- Chronic kidney disease
- Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- Type 1 or type 2 diabetes
- Chronic hypertension
What are the ‘moderate’ risk factors for pre-eclampsia?
- First pregnancy
- Age 40 years or older
pregnancy interval of more than 10 years - Body mass index (BMI) of 35 kg/m² or more at first visit
- Family history of pre-eclampsia
multiple pregnancy
What are the indications for aspirin (75-150 mg) in pregnancy?
≥ 1 high risk factors OR
≥ 2 moderate factors
How does intrahepatic cholestasis of pregnancy present?
- Common cause of itch in the third trimester of pregnancy
- It will give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT
- Patients may also be jaundiced with right upper quadrant pain and steatorrhoea
How does acute fatty liver of pregnancy present?
- Occurs in the third term of pregnancy
- Hepatic picture would be expected on LFTs, with a rise in ALT/AST greater than that of ALP, a raised white cell count and potential clotting abnormalities
- This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy.
A 24-year-old woman attends her booking scan and finds out that she is pregnant with monochorionic twins. Her general practitioner asks her specifically to report any sudden increases in the size of her abdomen and/or any breathlessness. What complication of monochorionic multiple pregnancy is the GP describing the symptoms of?
Twin-to-twin transfusion syndrome
A 34-year-old woman attends a routine antenatal clinic at 16 weeks gestation. No significant PMH. BP 148/76 mmHg.
What is the most likely diagnosis?
Chronic hypertension
At 16 weeks gestation, this lady is too early into her pregnancy to have developed any of the pregnancy related causes of hypertension
True or false: patients on anti-epileptic medications can’t breast feed
False - all anti-epileptic medications are fine apart from barbiturates
Asymptomatic patient > 20 weeks with raised BP and proteinuria. What do you do?
Urgent obstetrics referral
Although pre-eclampsia may present with symptoms such as headache or swelling, it is often asymptomatic and detected initially through routine monitoring of urine and blood pressure. It is potentially life-threatening and should therefore be referred to secondary care for further investigation and management.
What is the latent phase of 1st stage of labour?
0-3 cm dilated
What is the active phase of 1st stage of labour?
3-10 cm dilated
Can mothers with hep B breastfeed?
Yes
What layers have to be cut through in a lower caesarian section?
- Skin
- Superficial and deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle
- Transversalis fascia
- Extraperitoneal connective tissue
- Peironeum
- Uterus
Which antibiotics are safe in breastfeeding?
Penicillins, cephalosporins, trimethoprim
Describe the management of eclampsia
- Magnesium sulphate - prevent/treat seizures
- Delivery
How long should treatment with magnesium sulphate be continued in eclampsia?
24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
What is the cut off for a hypertensive pregnant woman who needs admission and observation?
≥ 160/110 mmHg
What drug can be used to suppress lactation when breastfeeding cessation is indicated?
Cabergoline
Pregnant lady dipstick shows trace glycosuria. Should you worry?
No - trace glycosuria is common in pregnancy due to the increased GFR and reduction in tubular reabsorption of filtered glucose
What is Erb’s palsy?
- Occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia
- Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm - ‘waiter’s tip’.
What is Klumpke’s palsy?
- Occurs due to damage of the lower brachial plexus
- Commonly affects the nerves innervating the muscles of the hand
When should men and women stop methotrexate before conception?
At least 6 months in both
Name 3 causes of increased nuchal translucency
- Down’s syndrome
- Congenital heart defect
- Abdominal wall defects
What is HELLP syndrome?
- HELLP syndrome is a severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP)
- A typical patient might present with malaise, nausea, vomiting, and headache
- Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.
What findings on the combined antenatal test (11 - 13+6 weeks) indicate Down’s? What other conditions are screened for at this time?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) - give similar results but the hCG tends to be lower
If a women books in after the window for the combined test, what should she be offered?
Quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A
Perfomed 15-20 weeks
If a women has a ‘higher chance’ result of combined/quadruple test, what should she be offered?
Second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)
Given the non-invasive nature of NIPT and extremely high sensitivity and specificity, it is likely this will be the preferred choice for the vast majority of wome
When is anti-Xa activity monitored for a patient on LMWH following acute VTE in pregnancy?
Women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE)
You are performing a routine examination of a woman who is 37 weeks pregnant. She mentions she is short of breath. Which new sign during a cardiac examination would not be considered normal and prompt referral for further evaluation?
Pulmonary oedema
What normally happens to blood pressure during pregnancy?
Falls in first half of pregnancy before rising to pre-pregnancy levels before term
What is the management of gestational diabetes if the fasting plasma glucose is < 7 mmol/l?
Trial of diet and exercise should be offered for 1-2 weeks
Gestational diabetes, trial of diet and exercise hasn’t worked. What do you do?
Start metformin; if that doesn’t work start short-acting insulin
What is the management of gestational diabetes if the fasting plasma glucose is >= 7 mmol/l?
Start insulin immediately
What are the BM targets for diabetes in pregnancy?
- Fasting: 5.3
- 1 hour after meals: 7.8
- 2 hours after meals: 6.4
Quadruple test results:
AFP ↓
Unconjugated oestriol ↓
HCG ↑
Inhibin A ↑
Down’s syndrome
Quadruple test results:
AFP ↓
Unconjugated oestriol ↓
HCG ↓
Inhibin A ↔
Edward’s sydrome
Quadruple test results:
AFP ↑
Unconjugated oestriol ↔
HCG ↔
Inhibin A ↔
Neural tube defects
Quadruple test results:
AFP ↓
Unconjugated oestriol ↓
HCG ↓
Inhibin A ↑
Patau syndrome
What is the first line treatment for pregnancy-induced hypertension?
Oral labetalol
What terminology is used to describe the head in relation to the ischial spine?
Station
What is the current position of the fetal vertex shown in this image?
Left occiput posterior
What is the investigation of choice in placenta praevia?
Transvaginal ultrasound
What anti-hypertensive can you give an asthmatic pregnant woman with pre-eclampsia?
Nifedipine
Which method of assisted delivery carries the greatest risk of haemorrhage in the newborn?
Prolonged ventouse delivery
What is a galactocele?
Typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct
A build up of milk creates a cystic lesion in the breast
What is the main complication of induction of labour?
Uterine hyperstimulation - refers to prolonged and frequent uterine contractions
What is the preferred method of smoking cessation in pregnant women?
Nicotine replacement
What is the McRobert’s manoeuvre?
Simple and effective intervention in shoulder dystocia
Woman supine with both hips fully flexed and abducted
Women on DOAC gets pregnant. What do you do?
Change to LMWH e.g. enoxaparin
What should be monitored when giving magnesium sulphate for eclampsia?
Urine output, reflexes, respiratory rate and oxygen saturations
A hepatitis B serology positive woman gives birth to a healthy baby girl. The mother is surface antigen positive. What treatment should be given to the baby?
- Hepatitis B vaccine soon after birth
- 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth
- The baby should then further receive a second dose of hepatitis B vaccine at 1-2 months and at 6 months.
Name a specific clinical sign for pre-eclampsia
Brisk reflexes
