Obstetrics 1

Question 1

Pregnancy lifestyle advice

1. What advice is given regarding flying for
   a) uncomplicated pregnancy
   b) uncomplicated multiple pregnancy
2. What sports should be avoided?

Answer 1

1. a) do not fly after 37 weeks
   b) do not fly after 32 weeks
2. • high impact sports
   • scuba diving

Question 2

What is the anti-emetic of choice in pregnancy?

Answer 2

anti-histamine e.g. cyclizine, promethazine

Question 3

What is offered as part of antenatal care at the following gestations:

1. 8-12 weeks
2. 10-14
3. 11-14
4. 16
5. 18-21
6. 25
7. 28
8. 31
9. 34
10. 36
11. 38
12. 40
13. 41

Answer 3

1. • BP
   • urine dipstick
   • check BMI
   • bloods: FBC, blood group, red cell antibodies, rhesus status, haemoglobinopathies and check for syphillis, HIV and Hep B
   • urine culture to rule out asymptomatic bacteriuria
2. scan to confirm dates and exclude multiple pregnancy
3. Down’s screening (incl. nuchal scan)
4. • routine: BP + dipstick
   • review blood results: if Hb low offer iron
5. only if prim.: anomaly scan
6. routine: BP, dipstick, SFH
7. • routine: BP + dipstick
   • bloods again
   • first dose of anti-D to rhesus neg
8. only if prim.: - routine: BP + dipstick
9. • routine: BP + dipstick
     +/- second anti-D if rhesus neg
     (evidence one dose enough, whether given varies across trusts)
10. • routine: BP + dipstick
    • check presentation: external cephalic version if indicated
11. • routine: BP + dipstick
12. • only if prim.: - routine: BP + dipstick
13. • routine: BP + dipstick
      +/- discuss possibility of induction

Question 4

Which drugs under the following categories should be avoided in breastfeeding

1. ABx
2. psychiatry
3. cardio
4. diabetes
5. hyperthyroidism

and then common sense don’t give methotrexate or cytotoxics

Answer 4

1. • ciprofloxacin
   • tetracycline
   • chloramphenicol
   • sulphonamides (will start sulf, but trimethoprim ok)
2. • clozapine
   • lithium
   • benzos
3. • aspirin
   • amiodarone (digoxin is ok)
4. sulphonylureas
5. carbimazole

Question 5

What is the medication of choice for suppressing lactation?

Answer 5

cabergoline

Question 6

Chicken pox exposure in pregnancy

1. What are the features of fetal varicella syndrome
2. What should be done if pregnant woman not immune to varicella is exposed to chicken pox
   a) before 20 weeks
   b) 20-28 weeks

(not immune means IgG for varicella negative)

(no cases after 28 weeks have been seen)

Answer 6

1. skin scarring
   eye defects (microphthalmia)
   limb hypoplasia
   microcephaly and learning disabilities

mnemonic: everything is small (skin scarring because skin is small so stretched)

2. a) varicella zoster immunoglobulin immediately (effective up to 10 days post exposure)

b) either varicella zoster immunoglobulin immediately
OR
antiviral 7-14 days after exposure

Question 7

Chorioamnionitis

1. What is it?
2. How is it treated?

Answer 7

1. ascending bacterial infection of the amniotic fluid / membranes / placenta

2.

• immediate delivery
• IV ABx

Question 8

Galactocele

1. What is it?
2. How is it differentiated from abscess?

Answer 8

1. occlusion in lactiferous duct in woman who has recently stopped breast feeding causing cystic like lesion
2. no pain or signs of infection (local or systemic)

Question 9

HIV in pregnancy

1. What is done to reduce vertical transmission?
2. What should be given prior to C-section?
3. How does management change if viral load <50

Answer 9

1. • maternal and neonatal (for 4-6 weeks) antiretroviral therapy
   • caesarean section
   • bottle feeding
2. zidovudine infusion started 4 hrs before
3. • vaginal delivery
   • zidovudine instead of antiretroviral therapy to neonate

Question 10

1. What is the most common cause of early-onset neonatal infection?
2. What is the management in women with a history of a positive test for this bacteria in previous pregnancy?
3. When else is antibiotic prophylaxis offered?

Answer 10

1. group B strep from commensal of maternal bowel
2. • intrapartum IV benzylpenicillin prophylaxis
     OR
   • testing 3-5 weeks before delivery and IV benzylpenicillin given if positive

NOTE: this management is intrapartum ABx even if diagnosed very early in pregnancy

3. • previous baby with group B strep infection
   • preterm birth
   • pyrexia during labour

Question 11

Induction of Labour

1. Bishop score
   How likely is labour in the following scores
   a) <5
   b) 8 or more
2. What should be offered prior to induction of labour?
3. What is the preferred method of induction of labour?
4. What complication can be seen and how is it managed?

Answer 11

1. a) labour unlikely to start
   b) high chance of spontaneous labour
2. membrane sweep (can be done in antenatal clinic)
3. vaginal prostaglandins
4. prolonged + frequent uterine contractions
   - do not continue method of induction
   - terbutaline for tocolysis

Question 12

Intrahepatic cholestasis of pregnancy

1. What clinical features are seen?
2. What does it increase the risk of?

Answer 12

1. • pruritus: typically worse on palms, soles + abdomen
   • raised bilirubin
     +/- jaundice (20%) of cases
2. preterm birth and stillbirth (hence often IOL offered 37/38 weeks)

Question 13

Perineal tears

What is meant by

1. first degree
2. 2nd
3. 3rd
4. 4th

Answer 13

1. superficial with no muscle involvement
   - no repair required
2. injury to perineal muscle with no involvement of anal sphincter
   - require suturing on ward
3. injury to perineum and anal sphincter
   - requires repair in theatre
4. injury to perineum, anal sphincter and rectal mucosa
   - requires repair in theatre

Question 14

Placenta Accreta

1. What is meant by
   a) accreta
   b) increta
   c) percreta
2. What are the risk factors?
3. What is the definitive management?

Answer 14

1. a) villi attach to myometrium rather than being restricted to decide basalis

b) villi invade myometrium
c) villi invade perimetrium
2. previous C/S or praevia
3. hysterectomy

Question 15

Post-partum thyroiditis

1. What are the stages?
2. How is it managed?

Answer 15

1. 1) thyrotoxicosis
   2) hypothyroid
   3) normal thyroid
   (High rate of recurrence in future pregnancies)
2. thyrotoxicosis: propanolol for symptom control
   hypothyroid: levothyroxine

Question 16

Primary Post partum haemorrhage
(occurs within 24 hrs of birth of baby [not placenta])

1. What can cause it?
2. What are the RFs?
3. How is it managed?

Answer 16

1. 4Ts
   - Tone: uterine atony (90%) - Trauma: laceration, hematoma, inversion, rupture
   - Tissue: retained tissue or invasive placenta
   - Thrombin: coagulopathy

2.
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

3. IV syntocin or IV ergometrine and IM carboprost
   + uterine massage if atony only cause

if medical options fail then surgery required
- intrauterine balloon tamponade 1st line if atony only cause

hysterectomy may need to be performed as life-saving procedure (think about gran)

Question 17

Secondary PPH

1. When does it occur?
2. What can cause it?

Answer 17

1. 24hrs - 12 weeks
2. • retained placental tissue
   • endometritis

Question 18

At what haemoglobin level is a woman offered iron in

1. first trimester
2. second + third trimester
3. post partum

Answer 18

1. <110
2. <105
3. <100