Obs + Gynae - Obstetrics Flashcards
1
Q
What is the first-line treatment for ovulation induction in patients with polycystic ovarian syndrome?
A
Exercise and weight loss
2
Q
Name a medication used for ovulation induction
A
Letrozole, Clomiphene citrate
3
Q
Which of the following is the most likely cause of oligohydramnios?
Anencephaly / Multiple pregnancy / Diabetes Mellitus / Pre-eclampsia / Oesophageal atresia
A
Pre-eclampsia - High maternal BP causes reduced fetal perfusion
4
Q
Name some contraindications for the COCP
A
Examples of UKMEC 3 conditions (disadvantages outweigh advantages):
- 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
Examples of UKMEC 4 conditions (unacceptable health risk):
- 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
5
Q
Gestational diabetes can be diagnosed by
fasting glucose of what value? OR
2-hour glucose level of what value?
A
fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L
(5678!)
6
Q
3 examination findings of an ectopic pregnancy
A
- abdominal tenderness
- cervical excitation (also known as cervical motion tenderness)
- adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
7
Q
In the case of pregnancy of unknown location, serum bHCG levels above what value points toward a diagnosis of an ectopic pregnancy?
A
> 1,500
8
Q
The cervical screening program involves performing a smear for women (and transgender men that still have a cervix) how often and for what ages?
A
Every three years aged 25 – 49
Every five years aged 50 – 64
9
Q
Urine pregnancy test often remains positive for how long following termination?
A
up to 4 weeks
10
Q
Which hormone level is raised significantly in menopausal patients?
A
FSH
11
Q
What is the medication of choice in suppressing lactation when breastfeeding cessation is indicated?
A
Cabergoline (Dopamine agonist)
12
Q
Cessation of menstruation is called
A
Menopause
13
Q
What is the risk of using SSRIs (eg Fluoxetine) during first vs third trimester
A
First trimester = small increased risk of congenital heart defects
Third trimester can result in persistent pulmonary hypertension of the newborn
14
Q
What is the antibiotic of choice for Acute Pyelonephritis in a pregnant woman who does not require hospital admission?
A
Cefalexin 500mg BD
or Co-Amoxiclav or Trimethoprim
15
Q
Use of what type of medication during pregnancy can cause orofacial clefts?
A
Maternal anti-epileptics / BDPs
16
Q
Name a type of intrapartum fetal monitoring
A
CTG / Intermittent auscultation (doppler or pinard stethoscope) / Scalp ECG
17
Q
CTG interpretation mnemonic - what does Dr C BraVADO stand for?
A
Dr = Define Risk (high or low) (maternal illness?) C = Contractions (duration/intensity) Bra = Baseline Rate (tachy/brady?) V = Variability (reassuring/non-reassuring/abnormal) A = Accelerations D = Decelerations (early/late/prolonged) O = Overall Assessment (reassuring/non-reassuring/abnormal)
18
Q
How is Placenta Accreta/Increta/Percreta diagnosed?
A
Ultrasound/MRI
19
Q
Where does the placenta attach to in Placenta Accreta, Increta and Percreta respectively
A
Accreta = attaches too deeply to uterus Increta = attaches into muscle wall of uterus Percreta = attaches + grows through uterus
20
Q
Bleeding from anywhere in the genital tract (uterus/cervix/vagina/vulva) after the 24th week of pregnancy
A
Antepartum Haemorrhage
21
Q
Name a maternal complication and a neonatal complication of shoulder dystocia
A
maternal - PPH, vaginal tear, psychological
neonatal - hypoxia, cerebral palsy, brachial plexus injury, seizure
22
Q
Name a risk factor for shoulder dystocia
A
- Macrosomia
- Maternal DM
- Disproportion between mum + foetus
- Obesity
- Prolonged labour
- Instrumental delivery
23
Q
a birth injury (also called birth trauma) that happens when one or both of a baby’s shoulders get stuck inside the mother’s pelvis during labor and birth
A
Shoulder Dystocia
24
Q
Condition in which the membranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie or are within 2 cm of the internal cervical os
A
Vasa Praevia
25
Premature separation of placenta from uterine wall
Placental abruption
26
Name a pharmacological therapy and a non-pharmacological therapy for pain in labour
Pharmacological: Entonox, oral analgesia, PCA opioids
| Non-pharmacological: Acupuncture, hypnotherapy, Massage, TENS, Hydrotherapy
27
Involution of the uterus and genital tract leads to Decidua being shed as Lochia. Name these three postpartum bleeding stages.
Lochia rubra (day 0-4), Lochia serosa (day 4-10), Lochia Alba (day 10-28)
28
serious condition where high blood pressure results in seizures after pregnancy
Eclampsia (Pre-eclampsia = within first 72 hours after birth)
29
How long postnatally is abnormal or excessive bleeding from birth canal considered secondary postpartum haemorrhage?
24 hours - 12 weeks
30
how much blood loss (ml) to be considered postpartum haemorrhage
- Minor PPH – under 1000ml blood loss
- Major PPH – over 1000ml blood loss
Major PPH can be further sub-classified as:
- Moderate PPH – 1000 – 2000ml blood loss
- Severe PPH – over 2000ml blood loss
31
The period of about six weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition
Puerperium
32
When is newborn blood spot performed?
5-9 days old
33
Name 2 conditions that the newborn blood spot tests for
Sickle cell/CF/Hypothyroid/PKU/MCADD/MSUD/IVA/GA1/HCU
34
Name some conditions screened for in the newborn/antenatal screening programme
Sickle cell/Thalassaemia/Patau's/Down's/Edward's/Infectious diseases/Fetal anomalies/Diabetic eye/NIPE/Newborn hearing/Blood spot
35
Name 2 factors affecting the success of IVF
Age/Cause of infertility/Duration of infertility/Previous pregnancies/Medical conditions/Environmental
36
Name a risk of IVF
miscarriage/multiple pregnancy/ectopic/fetal abnormality/ovarian hyperstimulation syndrome
37
Name a surgical treatment for male infertility and a form of assisted conception
a. ) correction of epidermal block/varisectomy reversal
| b. ) intrauterine insemination/IVF/Intracytoplasmic sperm injection/ovulation induction
38
Name 2 investigations of infertility (male or female)
Ovarian reserve testing (FSH/AFC/AMH); Imaging of tubal patency (USS/HSG);Semen analysis; Endocrine; Testicular biopsy
39
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is?
Admit and administer IV corticosteroids
40
What is the antibiotic of choice for Group B Streptococcus infection prophylaxis
Benzylpenicillin
41
Which is a contraindication for injectable progesterone contraceptives?
- Concurrent use of enzyme-inducing drugs
- A BMI of 40+
- Previous PE
- Dysmenorrhoea
- Current breast ca.
Current breast cancer
42
How should placental abruption when the fetus is alive, <36 weeks and not showing signs of distress be managed?
Admit and administer steroids
43
A woman presents asking for the 'morning after pill'. Up to what period following intercourse is levonorgestrel licensed to be used?
72 hours
44
Important signs and symptoms to think about when suspecting placental abruption are:
- sudden onset severe continuous abdominal pain
- Vaginal bleeding (APH)
- shock disproportionate to the amount of blood loss (20% of placental abruptions are 'concealed' - the blood is trapped behind the placenta and does not drain)
- Abnormal CTG
- the uterus may be in spasm and feel firm or 'woody'
- the fetus may be hard to feel
- the fetal heart may be hard to auscultate
45
First line treatment for Eclampsia
Magnesium sulfate
46
baby must be assessed by the neonatal team if respiratory rate is above how many breaths per minute
RR>60 per minute
47
Cocaine abuse increases risk of which placental condition?
Placental abruption / Placenta previa
48
What manoeuvre is used in childbirth in case of shoulder dystocia and what does the manoeuvre involve?
McRobert's manoeuvre - flexion and abduction of maternal hips, bringing thighs towards abdomen.
49
What is Clomifene used to treat?
Infertility
50
At what gestation is further investigation required if there are not foetal movements felt by this time?
24 weeks
51
Urine culture to detect asymptomatic bacteriuria should occur at which week gestation?
8-12 weeks
52
Second screen for anaemia and atypical red cell alloantibodies should occur at which week gestation?
Second = 28 weeks
53
A nuchal scan should occur at which week gestation?
11-13+6 week
54
Name a feature of acute fatty liver in pregnancy
abdominal pain; nausea & vomiting; headache; jaundice; hypoglycaemia; severe disease may result in pre-eclampsia
55
What is used for symptomatic relief in Intrahepatic cholestasis of pregnancy
Ursodeoxycholic acid
56
First line antibiotic for mastitis
Flucloxacillin
57
What is the first line treatment for primary dysmenorrhoea
NSAIDs such as mefenamic acid
58
A 36-year-old woman has delivered her second child at 38 weeks gestation. Five minutes after delivery she has a sudden gush of approximately 750 mL of blood. What drug should be administered?
Syntometrine
59
What is the first line drug given for termination of pregnancy?
Misoprostol pessary PV
60
What prophylaxis should be given to all rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy
Anti-D rhesus prophylaxis
61
name 2 investigations for ectopic pregnancy
Transvaginal ultrasound, hCG levels
62
Name a risk factor for ectopic pregnancy
IVF, Hx of pelvic infection, previous tubal surgery, IUCD use
63
97% of ectopic pregnancies occur where?
Fallopian tube (ampullary or isthmus portions)
64
Name 2 investigations for miscarriage
Transvaginal Ultrasound, Serum hCG, Progesterone
65
What percentage of women who have a threatened miscarriage will go on to have a compete miscarriage?
About 50%
66
In a threatened miscarriage, is there bleeding and is the cervical os open?
Mild bleeding and cervical os is closed
67
Name 3 risk factors for miscarriage
Age (more frequent >30 y.o.), Smoking, Alcohol, Drug use, fertility problems, Uterine surgery, Connective tissue disorders, DM, Stress, obesity
68
Miscarriage is defined as loss of pregnancy before which week of gestation?
before 24 weeks
69
Name a maternal and a fetal complication of shoulder dystocia
Maternal - Postpartum haemorrhage, perineal tears, Vaginal lacerations, Cervical tear, Bladder rupture, Uterine rupture, Symphyseal separation, Sacroiliac joint dislocation, Lateral femoral nerve neuropathy
Fetal -Perinatal morbidity and mortality from hypoxia and acidosis, Fractured humerus or fractured clavicle, Brachial Plexus Injury, Pneumothorax
70
Name a risk factor for shoulder dystocia
Maternal diabetes mellitus, maternal obesity, Fetal macrosomia, Induction of labour, Prolonged labour, Oxytocin, Assisted vaginal delivery - forceps or ventouse, Previous shoulder dystocia
71
Name 3 risk factors for Cord Prolapse
Prematurity, Fetal congenital abnormality, Multiparity, Low birth weight (<2.5 kg), Breech, Oblique/transverse/unstable lie, Cephalopelvic disproportion, Pelvic tumours, Low-lying placenta, Polyhydramnios, Macrosomia, High fetal station, Long umbilical cord
72
Name a short-term and a long-term complication of Intrauterine Growth Restriction
Short-term: meconium aspiration, perinatal asphyxia, hypothermia, hypoglycaemia, hypocalcaemia, polycythaemia, jaundice, feed intolerance
Long-term: Learning difficulties, behavioural problems, cerebral palsy
73
What are the three types of Intrauterine Growth Restriction?
Symmetrical, Asymmetrical, Mixed
74
A condition where a baby's growth slows or ceases when it is in the uterus
Intrauterine Growth Restriction
75
Name a treatment for Rhesus Disease of a newborn after delivery
Phototherapy, Blood transfusion, IV immunoglobulins
76
Name an investigation for Rhesus Disease (aka Haemolytic Disease of Fetus and Newborn (HDFN))
Indirect Coombs' test, Kleihauer test, Ultrasound, Fetal blood sampling, FBC, non-invasive rhesus genotyping of the fetus
77
What would you look for on an indirect Coombs' test if you suspected Rhesus Disease?
Anti-D Antibodies
78
Name a risk factor for Rhesus Disease (aka Haemolytic Disease of Fetus and Newborn (HDFN))
Alloimmunisation during first pregnancy, Alloimmunisation during subsequent pregnancy, Failed prophylaxis.
79
A condition where antibodies in a pregnant woman's blood destroy her baby's blood cells
Rhesus disease (aka Haemolytic Disease of Fetus and Newborn (HDFN))
80
A condition in which large amounts of fluid build up in a baby's tissues and organs, causing extensive swelling
Hydrops Fetalis
81
Name an investigation for Hydrops Fetalis
Genetic testing, obstetric ultrasound, fetal echocardiography
82
Name a cause of Hydrops Fetalis
Haematological (G6PD, haemolytic disease of newborn, fetal haemorrhage)
Cardiac (aortic stenosis, pulmonary atresia, Ebstein's anomaly, vena cava occlusion)
Infective (CMV, Syphilis, Hep B, Herpes Simplex)
Metabolic (Hypo- / Hyperthyroidism, Turner's, Down's)
83
What is Tocolysis and name a tocolytic drug
Tocolysis is the delaying of delivery of a fetus in women presenting with preterm contractions. (between 24 and 33 + 6 weeks)
First choice = Nifedipine; Second choice = Atosiban (Oxytocin receptor antagonist)
84
How might premature labour be investigated?
History, Examination, Transvaginal ultrasound, Fetal fibronectin, Vaginal swab
85
Which type of contraction vary in length and strength/happen infrequently/are unpredictable and non-rhythmic/are more uncomfortable than painful
and do not increase in frequency, duration or intensity
Braxton Hick's contractions
86
What is defined as the presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix before 37 weeks of gestation
Premature labour
87
name 2 possible complications of breech presentation
- Premature rupture of membranes and premature labour
- Cord prolapse
- Fetal head entrapment
- Overly rapid descent of after-coming head, leading to rapid compression/decompression causing intracranial haemorrhage
- Cervical spine injuries associated with hyperextension
- Delay in delivery
- Asphyxia due to cord compression
- Placental separation
- Traumatic injuries (eg. fractures of the humerus, femur or clavicle, brachial plexus injury)
88
What procedure involves the lifting of the fetal bottom with one hand whilst the fetal head is pushed down with the other, moving the fetus in the direction that allows the head to be the presenting part
External cephalic version (ECV)
89
Name 2 clinical findings on examination suggestive of breech presentation
Subcostal tenderness.
Ballottable head in the fundal area.
Softer irregular mass in the pelvis.
Fetal heartbeat loudest above the umbilicus.
On VE in labour, the sacrum, anus or foot can be palpated through the fornix.
90
Name 3 risk factors for breech presentation
Lax uterus, Uterine anomalies (eg, bicornuate or septate uterus) or tumour, Placenta praevia, Abnormal pelvic brim, Maternal smoking, Maternal diabetes, Fetal malformation (eg, hydrocephalus), Multiple pregnancy, Polyhydramnios or oligohydramnios, Low birth weight (preterm delivery or intrauterine growth restriction), Previous breech delivery
91
What is an operative vaginal delivery?
Delivery that involves application of forceps or vacuum extractor to the fetal head to assist during the 2nd stage of labour to facilitate delivery.
92
Name 3 maternal complications and 3 risks to the fetus of a multiple pregnancy
Maternal: Miscarriage, Anaemia, Pre-eclampsia. (Risk for mothers of twins is three times that of singleton pregnancies), Haemorrhage, both antepartum and postpartum, Operative delivery, Hyperemesis gravidarum. Polyhydramnios, Postnatal illness, Death
Risks to fetus: Stillbirth, preterm birth, feto-fetal transfusion syndrome, umbilical cord entanglement, intrauterine growth restriction, congenital abnormalities, intrauterine fetal death
93
Define chorionicity
Chorionicity is the number of placentae of a pregnancy.
94
Name 2 risk factors for multiple pregnancy
Previous multiple pregnancy, family history, Increasing maternal age, Racial origin (West Africa), Assisted conception
95
Name a possible cause of APH
Placenta praevia, placental abruption, trauma (partner violence), vasa praevia, uterine rupture,
96
What volume of bleeding separates a minor, major and massive APH bleed
Minor haemorrhage = blood loss <50 ml and has stopped.
Major haemorrhage = blood loss 50-1000 ml with no signs of shock.
Massive haemorrhage = blood loss >1000 ml and/or signs of shock
97
Name 3 risk factors for GDM
- Age
- Certain ethnic groups (Asian, African Americans, Hispanic/Latino Americans and Pima Indians)
- High BMI before pregnancy
- Smoking
- Change in weight between pregnancies
- Short interval between pregnancies
- Previous unexplained stillbirth
- Previous macrosomia
- Family history of type 2 diabetes or GDM
98
NICE recommends that GDM should be diagnosed if the pregnant woman has a plasma glucose of what value?
Fasting plasma glucose level of 5.6 mmol/L or above; or
Two-hour plasma glucose level of 7.8 mmol/L or above
(5678!)
99
What condition affecting the liver during pregnancy causes unexplained itching and jaundice
Obstetric Cholestasis
100
Name an anti-emetic medication used for Hyperemesis Gravidarum
Cyclizine + Promethazine first line
| Metocloperamide, Ondansetron, Prochlorperazine second
101
At how many weeks gestation might someone present with Hyperemesis Gravidarum?
Usually before 12 weeks
102
Who might be more at risk of nausea and vomiting in pregnancy?
Younger, obese, Primigravidae, multiple pregnancy, previous hyperemesis, molar pregnancy, female foetus, sero-positive for H.Pylori
103
persistent and severe vomiting leading to fluid and electrolyte disturbance, marked ketonuria, nutritional deficiency and weight loss in pregnancy is called...
Hyperemesis Gravidarum
104
What does HELLP stand for in HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelet count
105
Name the gold standard for treating/preventing seizures in severe pre-eclampsia
Magnesium Sulfate IV (4g then 1g/hour over 24 hours)
106
Name 3 possible investigations for pre-eclampsia
Urinalysis (MC+S), bloods (FBC,LFT,U+E),clotting,USS fetus, MRI/CT head
107
Diagnostic criteria for pre-eclampsia in second half of pregnancy? (BP range + urinalysis)
>140mmHg systolic, >90mmHg diastolic, ≥1+ proteinuria on dipstick
108
Name a risk factor for developing pre-eclampsia
- 10 years or more since last pregnancy
- First pregnancy
- Age 40 years+
- BMI 35+
- FHx of pre-eclampsia
- Multiple pregnancy
- Pre-existing hypertension
- Pre-existing chronic kidney disease
- Pre-existing diabetes mellitus (type 1 and type 2)
- autoimmune disease (eg, systemic lupus erythematosus (SLE) or antiphospholipid syndrome)
- Pre-eclampsia, eclampsia or hypertension in any previous pregnancy
109
Incidence of eclampsia in the UK (to the nearest 5 out of 10,000 pregnancies)
5/10,000 pregnancies
110
What's the name for pregnancy-induced hypertension in association with proteinuria (>0.3 g in 24 hours) with or without oedema
Pre-eclampsia
111
Why should the COCP not be used in the first 21 days postpartum?
due to the increased venous thromboembolism risk post-partum
112
What are the 4 T's of PPH?
Trauma, Tone, Tissue, Thrombin
113
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)
- if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
- if the pregnant woman ≤ 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
(RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure)
- if the pregnant woman > 20 weeks gestationand she presents within 24 hours of onset of the rash and is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
114
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered when?
at 37-38 weeks gestation
115
Prematurity is defined as birth before what gestation?
37 weeks
116
What may be given as prophylaxis for preterm labour?
Progesterone pessary / Cervical cerclage ( putting a stitch in the cervix to add support and keep it closed)
117
What 2 blood tests could be done if you suspect preterm prelabour rupture of membranes?
(+ what antibiotics to prevent what infection?)
- Insulin-like growth factor-binding protein-1 (IGFBP-1)
- Placental alpha-microglobin-1 (PAMG-1)
(+ erythromycin 250mg four times daily to prevent chorioamnionitis)
118
When and why might antenatal steroids be given?
used in women with suspected preterm labour of babies less than 36 weeks gestation to develop the fetal lungs and reduce respiratory distress syndrome after delivery
119
When and why might antenatal IV magensium sulfate be given?
within 24 hours of delivery of preterm babies of less than 34 weeks gestation to help protect the fetal brain
120
Name a cause of placenta mediated and non-placenta mediated growth restriction
Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta:
- Idiopathic
- Pre-eclampsia
- Maternal smoking
- Maternal alcohol
- Anaemia
- Malnutrition
- Infection
- Maternal health conditions
Non-placenta medicated growth restriction refers to pathology of the fetus, such as:
- Genetic abnormalities
- Structural abnormalities
- Fetal infection
- Errors of metabolism
121
When is early and late miscarriage?
Early miscarriage is before 12 weeks gestation.
| Late miscarriage is between 12 and 24 weeks gestation.
122
What is the investigation of choice for diagnosing a miscarriage?
(+ what 3 things to assess viability of pregnancy?)
TVUS
(Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat)
123
Which drug is a prostaglandin analogue and what do prostaglandins do in pregnancy?
Misoprostol + Prostaglandins soften the cervix and stimulate uterine contractions.
124
What are two options for surgical management of a miscarriage?
- Manual vacuum aspiration under local anaesthetic as an outpatient
- Electric vacuum aspiration under general anaesthetic
125
```
What is the difference between:
Threatened miscarriage
Missed (delayed) miscarriage
Inevitable miscarriage
Incomplete miscarriage
```
Threatened miscarriage
- painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
- the bleeding is often less than menstruation
- cervical os is closed
- complicates up to 25% of all pregnancies
Missed (delayed) miscarriage
- a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- cervical os is closed
- when the gestational sac is > 25 mm and no
embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'
Inevitable miscarriage
- heavy bleeding with clots and pain
- cervical os is open
Incomplete miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
126
How many to be classified as recurrent miscarriage and causes?
Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Causes
- antiphospholipid syndrome
- endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
- uterine abnormality: e.g. uterine septum
- parental chromosomal abnormalities
- smoking
127
What is the most significant immediate complication of gestational diabetes?
Macrosomia / Large for dates (increased risk of shoulder dystocia)
(ALSO remember neonatal hypoglycaemia! => IV dextrose)
128
When should OGTT be offered if at risk of GDM?
24 – 28 weeks gestation
129
Management of pregnant women with pre-existing diabetes
- 5mg folic acid from preconception until 12 weeks gestation.
- Type 2 diabetes - metformin and insulin
- Retinopathy screening at booking and at 28 weeks gestation to check for diabetic retinopathy
- planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).
- Type 1 diabetes - sliding-scale insulin regime is considered during labour. A dextrose and insulin infusion is titrated to blood sugar levels (also for poorly controlled blood sugars with gestational or type 2 diabetes)
TIP: It is worth remembering the importance of retinopathy screening during pregnancy for women with existing diabetes
130
What is used to manage seizures associated with pre-eclampsia?
IV Magnesium Sulfate
131
Pre-eclampsia usually occurs after how many weeks gestation?
20
132
Pre-eclampsia triad?
Hypertension, Proteinuria, Oedema
133
Pre-eclampsia pathophysiology??
When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.
Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.
When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
134
What blood pressure qualified as Pre-eclampsia?
Systolic blood pressure above 140 mmHg
| Diastolic blood pressure above 90 mmHg
135
Low-lying placenta vs placenta praevia (4 grades)?
- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia is used only when the placenta is over the internal cervical os
(Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os)
(Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os)
(Partial praevia, or grade III – the placenta is partially covering the internal cervical os)
(Complete praevia, or grade IV – the placenta is completely covering the internal cervical os)
136
What are the three most notable common causes of APH?
Placenta praevia, placental abruption and vasa praevia
137
Management of Placenta Praevia
- If diagnosed early at 20-week scan, repeat transvaginal ultrasound scan at: 32 weeks or 36 weeks gestation
- Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature fetal lungs, given the risk of preterm delivery.
- Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).
- Emergency caesarean section may be required with premature labour or antenatal bleeding.
138
Management of Placenta Accreta
- MRI to assess the depth and width of the invasion
- management at birth due to risk of bleeding and difficulty separating the placenta (eg. Complex uterine surgery, Blood transfusions, Intensive care)
- Delivery planned between 35 to 36 + 6 weeks to reduce risk of spontaneous labour and delivery.
- Antenatal steroids to mature fetal lungs before delivery.
- Options during caesarean are: Hysterectomy with the placenta remaining in the uterus (recommended); Uterus preserving surgery, with resection of part of the myometrium along with the placenta; Expectant management, leaving the placenta in place to be reabsorbed over time with risks of bleeding and infection.
139
What test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required?
Kleihauer test
140
2 types of Vasa Praevia
- Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord
- Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe
141
Management of Vasa Praevia
- If asymptomatic with vasa praevia:
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
- If APH: emergency caesarean section is required to deliver the fetus before death occurs.
(After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.)
142
The main risk factor (+ others) for Uterine rupture?
- Previous caesarean section
- Vaginal birth after caesarean (VBAC)
- Previous uterine surgery
- Increased BMI
- High parity
- Increased age
- Induction of labour
- Use of oxytocin to stimulate contractions
143
Presentation + Management of Uterine Rupture
```
- Acutely unwell mother + abnormal CTG.
It may occur with induction or augmentation of labour, with signs and symptoms of:
- Abdominal pain
- Vaginal bleeding
- Ceasing of uterine contractions
- Hypotension
- Tachycardia
- Collapse
```
Management
- Uterine rupture is an obstetric emergency.
- Resuscitation and transfusion may be required.
- Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
144
What conditions might cause an increased or decreased alpha-fetoprotein?
Increased AFP
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
Decreased AFP
- Down's syndrome
- Trisomy 18
- Maternal diabetes mellitus
145
When to give IVIg VZV or Aciclovir during pregnancy?
- if there is doubt about previously having chickenpox maternal blood urgently checked for varicella antibodies
- if <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
- if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
146
Risk factors for VTE in pregnancy
- Smoking
- Parity ≥ 3
- Age > 35 years
- BMI > 30
- Reduced mobility
- Multiple pregnancy
- Pre-eclampsia
- Gross varicose veins
- Immobility
- Family history of VTE
- Thrombophilia
- IVF pregnancy
Prophylaxis is started as soon as possible in very high risk patients and at 28 weeks in those at high risk. It is continued throughout the antenatal period and for six weeks postnatally.
There are additional scenarios where prophylaxis is considered, even in the absence of other risk factors:
- Hospital admission
- Surgical procedures
- Previous VTE
- Medical conditions such as cancer or arthritis
- High-risk thrombophilias
- Ovarian hyperstimulation syndrome
147
Women at increased risk of VTE should receive what prophylaxis?
LMW Heparin (eg. dalteparin)
Prophylaxis is started as soon as possible in very high risk patients and at 28 weeks in those at high risk. It is continued throughout the antenatal period and for six weeks postnatally.
Mechanical prophylaxis includes:
- Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
- Anti-embolic compression stockings
148
Investigation of suspected PE
- Chest xray
- ECG
Two diagnostic tests:
- CT pulmonary angiogram (CTPA)
Chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots. This is usually the first choice for investigating a pulmonary embolism.
- Ventilation-perfusion (VQ) scan.
VQ scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs. First, isotopes are inhaled and a picture is taken to demonstrate ventilation. Contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.
CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)
149
DVT Investigation
- Doppler Ultrasound
- Anti-Xa activity
(Wells is not used for pregnant women!)
(D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer)
150
What is the first-line investigation for preterm prelabour rupture of the membranes?
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault
151
What is the management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress?
admit and administer steroids
152
What are the first-line SSRIs for depression in breastfeeding women?
Sertraline or paroxetine
153
Planned vaginal birth after caesarean (VBAC) is contraindicated in which patients?
- Previous vertical (classical) caesarean scars
- Previous episodes of uterine rupture
- Patients with other contraindications to vaginal birth (e.g. placenta praevia)
154
What dose of Folic Acid given in the first 12 weeks of pregnancy is used to prevent neural tube defects?
(+ what dose should pregnant obese women (BMI >30 kg/m2), be given antenatally?)
400 micrograms
| Pregnant obese antenatal => high dose 5mg folic acid
155
RFs for placental abruption
| ABRUPTION mnemonic
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)
156
If a pregnant woman reports reduced fetal movements then what should be used to confirm fetal heartbeat as a first step?
handheld Doppler
157
Which of these drugs is safe to use while breastfeeding?
| Doxycycline / Tetracycline / Ciprofloxacin / Chloramphenicol / Ceftriaxone
Ceftriaxone - Cephalosporins in breastfeeding is considered safe to use
158
A 33-year-old lady has developed a massive obstetric haemorrhage. A diagnosis of uterine atony is made. After initial stabilisation and general measures, what is the first-line medical management?
Misoprostol / Syntocinon / Ergometrine
Uterine atony is the most common cause of primary postpartum haemorrhage (PPH)
The RCOG has provided guidance of management of primary PPH due to uterine atony (Green-top Guideline No.52). This states that first-line management should be 5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.
159
Primary vs Secondary PPH
Primary PPH: bleeding within 24 hours of birth
| Secondary PPH: from 24 hours to 12 weeks after birth
160
What are the 4 Ts of PPH?
Tone (uterine atony – the most common cause)
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder)
161
PPH preventative measures
- Treating anaemia during the antenatal period
- Giving birth with an empty bladder (a full bladder reduces uterine contraction)
- Active management of the third stage (with intramuscular oxytocin in the third stage)
- Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
162
PPH management - Mechanical, Medical, Surgical
| + Secondary PPH Ix + Mx
Mechanical treatment options involve:
- Rubbing the uterus through the abdomen to stimulates a uterine contraction
- Catheterisation (bladder distention prevents uterus contractions)
Medical treatment options involve:
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
- TIP: The oxytocin is given as 40 units in 500 mls
Surgical treatment options involve:
- Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
- B-Lynch suture – putting a suture around the uterus to compress it
- Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
(Secondary Postpartum Haemorrhage
Investigations:
- Ultrasound for retained products of conception
- Endocervical and high vaginal swabs for infection
Management depends on the cause:
- Surgical evaluation of retained products of conception
- Antibiotics for infection)
163
Postpartum Endometritis Sx, Ix, Mx
Presentation
- shortly after birth to several weeks postpartum
- Foul-smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
Diagnosis
- Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
- Urine culture and sensitivities
( - Ultrasound may be considered to rule out retained products of conception)
Management
- Sepsis 6 => blood cultures and broad-spectrum IV antibiotics (according to local guidelines). A combination of clindamycin and gentamicin is often recommended.
- Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics (eg. Co-amoxiclav)
164
When are women screened for anaemia?
- Booking clinic
| - 28 weeks gestation
165
Pernicious anaemia treatment
- Intramuscular hydroxocobalamin injections
| - Oral cyanocobalamin tablets
166
What antibiotics might be used for maternal sepsis?
piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
167
Most common cause of neonatal sepsis
Group B streptococcus (GBS)
```
Also:
Escherichia coli (e. coli)
Listeria
Klebsiella
Staphylococcus aureus
```
168
Antibiotic choice for neonatal sepsis
- NICE guidelines (2012) recommend benzylpenicillin and gentamycin as first line antibiotics.
(Alternatively a third generation cephalosporin (e.g. cefotaxime) may be given as an alternative in lower risk babies)
169
Risk factors for Neonatal Sepsis
| + red flags?
Risk Factors
- Vaginal GBS colonisation
- GBS sepsis in a previous baby
- Maternal sepsis, chorioamnionitis or fever > 38ºC
- Prematurity (less than 37 weeks)
- Early (premature) rupture of membrane
- Prolonged rupture of membranes (PROM)
Red Flags
- Confirmed or suspected sepsis in the mother
- Signs of shock
- Seizures
- Term baby needing mechanical ventilation
- Respiratory distress starting more than 4 hours after birth
- Presumed sepsis in another baby in a multiple pregnancy
170
Neonatal sepsis signs
- Fever
- Reduced tone and activity
- Poor feeding
- Respiratory distress or apnoea
- Vomiting
- Tachycardia or bradycardia
- Hypoxia
- Jaundice within 24 hours
- Seizures
- Hypoglycaemia
171
When are anti-D injections given?
- 28 weeks gestation
- Birth (if the baby’s blood group is found to be rhesus-positive)
Also, any time when sensitisation may occur:
- Antepartum haemorrhage
- Amniocentesis procedures
- Abdominal trauma
Anti-D is given within 72 hours of a sensitisation event.
After 20 weeks gestation, the Kleinhauer test is performed to see how much fetal blood has passed into the mother’s blood, to determine whether further doses of anti-D are required
172
What is Kleinhauer test a test for?
how much fetal blood has passed into the mother’s blood during a sensitisation event
This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
173
3 options for treating uterine inversion
- Johnson manoeuvre (using a hand to push the fundus back up into the abdomen and the correct position)
- Hydrostatic methods
- Surgery
174
What is the most significant risk factor for cord prolapse?
Abnormal lie after 37 weeks (breech presentation)
Being in an abnormal lie provides space for the cord to prolapse below the presenting part. In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend
175
Diagnosis and Management of Cord Prolapse
Diagnosis
- Suspected if signs of fetal distress on the CTG.
- Diagnosed by vaginal examination
- Or Speculum examination can be used to confirm the diagnosis.
Management
- Emergency caesarean section is indicated.
(normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby)
(The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm))
If the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position or on all fours to reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.
176
4 types of breech presentation
- Complete breech, where the legs are fully flexed at the hips and knees
- Incomplete breech, with one leg flexed at the hip and extended at the knee
- Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee
- Footling breech, with a foot is presenting through the cervix with the leg extended
177
What do these terms mean and what type of multiple pregnancy has the best outcomes?
Monozygotic / Dizygotic / Monoamniotic / Diamniotic / Monochorionic / Dichorionic
Monozygotic: identical twins (from a single zygote)
Dizygotic: non-identical (from two different zygotes)
Monoamniotic: single amniotic sac
Diamniotic: two separate amniotic sacs
Monochorionic: share a single placenta
Dichorionic: two separate placentas
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
178
What ultrasound sign is characteristic for dichorionic and diamniotic twins?
Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
(triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane)
179
What ultrasound sign is characteristic for monochorionic and diamniotic twins?
Monochorionic diamniotic twins have a membrane between the twins, with a T sign
(where the membrane between the twins abruptly meets the chorion, it gives a T appearance)
180
What treatment for twin-twin transfusion syndrome may be used to destroy the connection between the two blood supplies?
Laser treatment
181
How often are ultrasound scans used to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome?
2 weekly scans from 16 weeks for monochorionic twins
| 4 weekly scans from 20 weeks for dichorionic twins
182
Multiple pregnancy delivery
Planned birth is offered between:
- 32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
- 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
- 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
- Before 35 + 6 weeks for triplets
(Waiting beyond these dates is associated with an increased risk of fetal death. Corticosteroids are given before delivery to help mature the lungs)
(Caesarean section may be required for the second baby after successful birth of the first baby - if not cephalic pres)
183
A single dose of what antibiotic is recommended after instrumental delivery to reduce the risk of maternal infection?
co-amoxiclav
184
Indications for instrumental delivery
- Failure to progress
- Fetal distress
- Maternal exhaustion
- Control of the head in various fetal positions
TIP: There is an increased risk of requiring an instrumental delivery when an epidural is in place for analgesia.
185
Risks of ventouse vs forceps delivery (+ instrumental delivery in general)
- Cephalohaematoma with ventouse
- Facial nerve palsy with forceps
Instrumental delivery:
- Postpartum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of the bladder or bowel
- Nerve injury (obturator or femoral nerve)Rarely there can be serious risks to the baby:
- Subgleal haemorrhage (most dangerous)
- Intracranial haemorrhage
- Skull fracture
- Spinal cord injury
186
Rarely forceps delivery may result in injury of which nerves for the mother?
(+ what are some other maternal nerve injuries during delivery?)
- Femoral nerve may be compressed against the inguinal canal during a forceps delivery. Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.
- Obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.
These usually resolve over 6 – 8 weeks
- Prolonged flexion at the hip while in the lithotomy position can result in Lateral Cutaneous Nerve injury, causing numbness of the anterolateral thigh.
- The Lumbosacral Plexus may be compressed by the fetal head during the second stage of labour, causing foot drop and numbness of the anterolateral thigh, lower leg and foot.
- Common Peroneal Nerve may be compressed on the head of the fibula whilst in the lithotomy position, causing foot drop and numbness in the lateral lower leg.
187
Polyhydramnios complications and management
Complications
- higher incidence of preterm labour and Caesarean section.
- premature rupture of the membranes
- placental abruption
- malpresentation
- postpartum haemorrhage
- cord prolapse
- risk of UTI is increased
- risk of SOB and HT higher
Management
- Cause identified + treated (eg. Fetal hydrops anaemia is treated with intravascular transfusion; If GDM => tight glycaemic control)
- Mild polyhydramnios can be monitored and treated conservatively.
- Serial ultrasound scans should be carried out to monitor the AFI and fetal growth.
- Induction of labour by ARM should be considered if fetal distress develops
- Corticosteroids given to mother antenatally if preterm delivery is imminent
- Prostaglandin synthetase inhibitors, particularly indometacin (fetal ductus arteriosus constriction)
- Amnioreduction (drainage of amniotic fluid under ultrasound guidance) is also used if indometacin is contra-indicated or for twin-to-twin transfusion syndrome
188
How much amniotic fluid at 34-36 weeks gestation?
About 1 litre
189
How long after exposure is varicella-zoster immunoglobulin (VZIG) effective after chickenpox exposure in a non-immune pregnant woman?
up to 10 days post-exposure
