Obstetric: Corrections Flashcards
Give some risk factors for miscarriages
1) Age
2) Previous miscarriage (2 or more consecutive)
3) Chronic conditions e.g. uncontrolled diabetes
4) Uterine or cervical problems e.g. large cervical cone biopsies
5) Smoking, alcohol and illicit drugs
6) Underweight/overweight
7) Invasive prenatal tests e.g. chorionic villus sampling and amniocentesis
Give the criteria for expectant management of an ectopic
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
Describe US appearance of a molar pregnancy
‘Snowstorm’ appearance - the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes.
What is an omphalocele?
Omphalocele is a fetal abdominal wall defect which is associated with a raised maternal serum AFP.
How does an omphalocele affect maternal AFP?
Raised
How does maternal obesity affect maternal AFP?
Low levels
How does maternal diabetes affect maternal AFP?
Low levels
What blood test can be used to monitor treatment with LMWH?
Anti-Xa activity
1st line drug for gestational HTN?
oral labetalol
2nd line drug for gestational HTN?
oral nifedipine (e.g. if asthmatic)
Contraindication of labetalol?
asthma
Give some causes of Dupuytren’s contracture
1) manual labour
2) trauma to hand
3) alcoholic liver disease
4) diabetes mellitus
5) phenytoin treatment
AFP levels in neural tube defects?
Raised
Name 2 infections that can cause erythema nodosum
1) TB
2) Streptococci
Why can ALP be raised in pregnancy?
As placenta produces ALP
What BMI indicates the need for higher dose folic acid during pregnancy?
Pregnant women with a BMI >= 30 kg/m² should receive 5 mg folic acid daily until the 13th week of pregnancy
What is Sheehan’s syndrome?
This is post-partum pituitary gland ischemic necrosis due to blood loss and resultant hypovolemic shock in the immediate post-partum period.
What are the features of Sheehan’s syndrome?
Features of hypopituitarism:
1) Hypothyroidism: fatigue, cold intolerance, constipation, weight gain, hair loss
2) Hypoadrenalism: fatigue, weight loss, hypoglycemia, hyponatremia, confusion
3) Hypogonadism: amenorrhea, hot flashes, loss of libido
4) GH deficiency: fatigue and reduced muscle mass
5) Failure of lactation
At what gestational age do pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) occur?
After 20 weeks gestation
what is the drug of choice for treating the patent ductus arteriosus in a newborn?
Indomethacin - acts by inhibiting prostaglandin E2.
What is the Hb cut off to determine if iron supplementation should be taken in the 1st trimester?
110 g/L
What is the biggest risk factor for cord prolapse?
Artificial amniotomy (artificial rupture of membranes)
What infection should you consider with severe transaminitis (i.e. elevated ALT & AST) in pregnancy?
Hepatitis E infection
How is Hep E often contracted?
Undercooked pork
What is seen on FBC in hep E infection?
Thrombocytopenia
What is the Hb cut off to determine if iron supplementation should be taken in the:
a) 1st trimester
b) 2nd/3rd trimester
c) postpartum
a) <100 g/L
b) <105 g/L
c) <100 g/L
How long following a termination of pregnancy can a urine pregnancy remain positive for?
Up to 4 weeks
What does a positive pregnancy test beyond 4 weeks after a termination of pregnancy indicate?
Incomplete abortion or persistent trophoblast
What specific monitoring is recommended when considering starting hydroxychloroquine?
Visual acuity and fundoscopy - risk of severe and permanent retinopathy
What are the gonads in androgen insensitivity syndrome?
Gonads in these patients are testes rather than ovaries.
Up to 90% develop inguinal hernias containing the immature testes.
What is the target for fasting blood glucose in gestational diabetes?
<5.3 mmol/L
What is the target for blood glucose 2 hours after an oral glucose tolerance test in gestational diabetes?
<6.4 mmol/L
How long should magnesium sulphate be given for in eclampsia?
Magnesium treatment should continue for 24 hours after delivery or after last seizure
For patients with with a monochorionic multiple pregnancy, they are asked specifically to report any sudden increases in the size of their abdomen and/or any breathlessness.
Why?
Symptoms of twin-to-twin transfusion syndrome - these symptoms may be the result of polyhydramnios affecting the recipient twin.
Is metformin safe during breastfeeding?
Yes
What is fetal fibronectin (fFN)?
A protein that is released from the gestational sac.
What is a high level of fetal fibronectin (fFN) associated with?
Early labour.
Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN.
What is the key feature seen in obstetric cholestasis?
Pruritus (typically affecting palms & soles) WITHOUT a rash.
What is required following a medical TOP?
A ‘multi-level pregnancy test’ is required 2 weeks following a medical TOP.
\ This test assesses for β-hCG levels and can confirm the successful termination of a pregnancy if these levels are low.
When is anti-D immunoglobulin offered to rhesus-negative women in TOP?
Offered to those who are having an abortion AFTER 10+0 weeks’ gestation.
Do NOT offer to women who are having a MEDICAL abortion up to and including 10+0 weeks’ gestation.
Consider for women who are rhesus D negative and are having a SURGICAL abortion up to and including 10+0 weeks’ gestation.
What is the 1st line management of syphilis?
IM benzathine penicillin G (safe in pregnancy)
What is the diagnostic triad for hyperemesis gravidarum?
1) 5% pre-pregnancy weight loss
2) dehydration
3) elecytolyte imbalance
Definitive management of obstetric cholestasis?
Induction of labour at 37 weeks
How long after receiving the MMR vaccination should women avoid becoming pregnant?
28 days
What is the commonest cause of respiratory distress in the newborn period?
Transient tachypnoea of the newborn (TTN)
What is transient tachypnoea of the newborn (TTN) caused by?
Caused by delayed resorption of fluid in the lungs.
What is transient tachypnoea of the newborn (TTN) more common after?
C-sections: possibly due to the lung fluid not being ‘squeezed out’ during the passage through the birth canal
What may a CXR show in transient tachypnoea of the newborn (TTN)?
Hyperinflation of lungs & fluid in the horizontal fissure.
What is Bishop’s score?
Bishop score, also Bishop’s score or cervix score, is a pre-labor scoring system to assist in predicting whether induction of labor will be required.
What is the classic triad seen in vasa praevia?
1) rupture of membranes
followed by:
2) painless vaginal bleeding
3) foetal bradycardia
1st line investigation in reduced foetal movements?
Handheld Doppler to confirm foetal heartbeat
Stepwise investigations in reduced foetal movements?
1st line –> Handheld doppler to detect heartbeat
If not detectable –> US
If detectable –> CTG for 20 mins to monitor heart rate
Late decelerations on CTG are a pathological finding.
What is the next step?
Urgent foetal blood sampling to assess for foetal hypoxia and acidosis.
What foetal pH is normal in labour?
pH >7.2 in labour is considered normal
<7.2 (acidosis) indicates consideration of urgent delivery.
What should the symphysis-fundal height match?
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm.
What is the gold standard investigation to diagnose placenta praevia and determine the position of the placenta?
TV US
What is the 1st line investigation for PPROM?
Sterile speculum examination
What 2 vitamins should be taken during pregnancy?
Vitamin D & folic acid
What is daily dose of vitamin D that should be taken during pregnancy?
10micrograms
In gestational diabetes, what is management if fasting plasma glucose is <7 mmol/L?
2 week trial of diet & exercise
If targets not me, metformin should be added, then insulin.
In gestational diabetes, what is management if fasting plasma glucose is >7 mmol/L?
Insulin
Which antiepileptics are safe in breastfeeding?
Breast feeding is acceptable with nearly all anti-epileptic drugs
Is aspirin safe in breast feeding?
No - risk of metabolic acidosis and Reye’s syndrome to infants.
Management of pre-eclampsia with mild or moderate hypertension after 37 weeks gestation?
Delivery recommended within 24-48 hours.
Management of pre-eclampsia with severe hypertension after 37 weeks gestation?
IV magnesium sulphate (if concerns that a woman may develop eclampsia) and planned delivery.
How does BP change in pregnancy?
Systolic BP is unaltered.
Diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term.
What is the management of a pregnant woman that has had a previous baby affected by GBS?
Prescribe intrapartum Abx prophylaxis –> either benzylpenicillin or ampicillin.
What is the Abx of choice for GBS prophylaxis?
benzylpenicillin
What should be monitored during treatment with IV magnesium sulphate?
- reflexes
- RR
- urine output
- O2 sats
What is the 1st line treatment for magnesium sulphate induced respiratory depression?
Calcium gluconate
How long should magnesium sulphate treatment continue for?
24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
What is normal effect on urea in pregnancy?
Reduced serum urea –> due to increased perfusion to kidneys in pregnancy (due to physiological changes to circulation).
What is normal effect on creatinine in pregnancy?
Reduced
What is normal effect on urinary protein loss in pregnancy?
usually increased urine protein
1st line analgesic in breastfeeding?
paracetamol
Why is aspirin contraindicated in breastfeeding?
This is due to its association with Reye’s syndrome, which can cause liver and brain damage.
Is rubella immunity routinely checked in pregnancy?
No
If a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
What is the preferred method of induction of labour if the Bishop score is ≤ 6?
Vaginal or oral prostaglandins
What is the 1st line treatment for magnesium sulphate induced respiratory depression?
Calcium gluconate
At what date is a external cephalic version (ECV) offered if baby is breech?
36 weeks
What is a 1st degree perineal tear? Mx?
Superficial damage with no muscle involvement - does not require any repair.
What is a 2nd degree perineal tear? Mx?
Injury to the perineal muscle, but NOT involving the anal sphincter.
Require suturing on the WARD by a suitably experienced midwife or clinician.
What is a 3rd degree perineal tear? Mx?
Injury to perineum involving the anal sphincter complex:
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
Mx - require repair in THEATRE by a suitably trained clinician
What is a 4th degree perineal tear? Mx?
Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa.
Mx - require repair in THEATRE by a suitably trained clinician
What type of ovarian tumour is associated with the development of endometrial hyperplasia?
Granulosa cell tumour
What Hb cut off should be used in the first trimester to determine if iron supplementation should be taken?
≤110 g/L
When should women with uncomplicated, multiple pregnancies avoid travel by air?
Once >32 weeks
When is a urine culture done in pregnancy to detect asymptomatic bacteriuria?
8 - 12 weeks (booking scan)
Which procedure carries the greatest risk of haemorrhage in the newborn in a mother with immune thrombocytopenic purpura (ITP)?
Prolonged ventouse delivery - the high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate.
What are 4 medical treatment for PPH 2ary to uterine atony?
1) oxytociin
2) ergometrine
3) carboprost
4) misoprostol
What BMI should women take high dose (5mg) folic acid?
> 30
Management of exomphalos (omphalocoele)?
Schedule elective C-section at 37 weeks to reduce risk of sac rupture
What is the 1st line surgical intervention in PPH if other measures fail?
Intrauterine balloon tamponade (AKA intra-uterine Bakri catheter)
What is the most initial step in IoL with a Bishop score <8?
Membrnae sweep
How does an OP position of foetal head affect delivery?
Labour is likely to be longer and more painful.
Generally, women will experience an earlier urge to push in OP than OA.
After how many weeks gestation should the symphysis-fundal height in cm = gestation in weeks?
After 20 weeks
Is the ‘snow storm’ appearance on US seen in a complete or incomplete hydatidiform mole?
Complete hydatidiform mole
What is often the presenting feature of a complete hydatidiform mole?
Vaginal bleeding early in pregnancy
If a semen sample is abnormal in fertility testing, when should it be repeated?
In 3 months time
1st line medication for vomiting in pregnancy?
H1 antagonist antihistamines e.g. promethazine
Is amiodarone safe in breastfeeding?
No - highly lipid-soluble and therefore, extensively stored in body tissues, including breast milk.
This can result in significant exposure to the breastfeeding infant, potentially causing neonatal hypothyroidism or hyperthyroidism.
What can amiodarone cause in the neonate if taken whilst breastfeeding?
neonatal hypothyroidism or hyperthyroidism.
Is methydopa safe in breastfeeding?
Yes
What are the two 1st line options for depression in breastfeeding women?
Sertraline & paroxetine
At what gestational age would you expect the fundal height to increase by 1cm a week?
24 weeks
In what 2 conditions is cervical excitation found?
1) PID
2) Ectopic pregnancy
When is a trans person assigned male at birth eligible for breast cancer screening?
If they have been taking feminising hormones for >2 years
What should be given to all women with PPROM?
10 days erythromycin
What is the preferred method of smoking cessation in pregnant women?
Nicotine replacement therapy (NRT)
What is the 1st line therapy for vulval candidiasis in non pregnant women?
Oral fluconazole
How soon after using levonorgestrel (Levonelle) for emergency contraception can hormonal contraception be started?
Immediately
Give 5 causes of oligohydranios?
1) PROM
2) Potter sequence: bilateral renal agenesis + pulmonary hypoplasia
3) IUGR
4) Post-term gestation
5) Pre-eclampsia
What 2 features are seen in Potter sequence?
Bilateral renal agenesis + pulmonary hypoplasia
Management of all patients with secondary dysmenorrhoea?
Referral to gynaecology (due to possible causes e.g. PID, endometriosis, fibroids, adenomyosis).
At what gestational age should anti-D prophylaxis be given to women who are Rhesus-D negative who are having an abortion?
10+0 weeks gestation
Management of complex (i.e. multi-loculated) ovarian cysts?
Biopsy of cyst for ovarian malignancy
At what gestational age should you refer to an obstetrician for lack of fetal movements?
24 weeks
