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Medicine Finals > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Which antihypertensive is used in pregnancy? What if the first line is CI?

A

Labetalol

If BB is contraindicated (e.g. Asthma) -> Nifedipine / Methyldopa

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2
Q

Which anti-epileptics are safe for use in pregnancy?

A

Lamotrigine

Carbamazepine

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3
Q

Which rheumatoid drugs are safe for use in pregnancy?

A

Hydroxychloroquine

Sulfasalazine

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4
Q

What are the antenatal combined test results for Down Syndrome? How does this differ for Edwards and Patau’s?

A

Raised HCG

Low PAPP-A

Thickened nuchal translucency

Edwards and Patau’s = lower PAPP-A

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5
Q

When should fetal movements be felt by?

A

24 weeks

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6
Q

Which anticoagulants are safe for use in pregnancy?

A

Low molecular weight heparin

Aspirin (Antiplatelet)

(DOAC + Warfarin = CI)

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7
Q

What is the normal dose and higher dose of folic acid?

A

Normal dose = 400 micrograms

High dose = 5mg

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8
Q

Who needs the higher dose of folic acid?

A

MORE

Metabolic disease (diabetes, coeliac)

Obesity

Relative/personal history of neural tube defects

Epilepsy

Also- sickle cell, thalassaemia

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9
Q

When should a woman be induced with intrahepatic cholestasis?

A

37-38 weeks

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10
Q

When should a woman with gestational diabetes be induced?

A

37-38 week

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11
Q

How is long-standing hypothyroidism treated in a woman who has become pregnant?

A

Increase levothyroxine by 25mcg

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12
Q

Are ACEi and ARBs safe in pregnancy?

A

No

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13
Q

Are calcium channel blockers safe in pregnancy?

A

Yes

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14
Q

How long does methotrexate need to be stopped prior to trying for a baby?

A

6 months in both men and women

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15
Q

Which diabetic drugs are safe for use in pregnancy?

A

Only insulin and Metformin

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16
Q

How does congenital rubella syndrome present?

A

Congenital sensorineural deafness

Congenital heart disease

Congenital cataracts

Blueberry muffin rash

Congenital hydrocephalus

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17
Q

How do you treat a pregnant woman who has been in contact with chickenpox who has not had chickenpox before?

A

If less than 20 weeks - give varicella zoster immunoglobulins (up to 10 days post exposure)

If more than 20 weeks - oral Aciclovir within 24 hours, or give VZIG or Aciclovir between day 7 and day 14

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18
Q

How do you treat a pregnant woman who has been diagnosed with chicken pox?

A

Oral Aciclovir

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19
Q

What can happen if a woman has chickenpox during pregnancy?

A

Can cause fetal varicella syndrome - skin scarring, eye defects, limb hypoplasia, microcephaly

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20
Q

Which infection during pregnancy can cause hydrops fetalis (severe fetal heart failure)?

A

Parvovirus B19

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21
Q

What intrapartum prophylaxis is given for Group B strep and which women need it?

A

IV Benzylpenicillin

  1. Women who have had GBS in a previous pregnancy
  2. Women with a previous baby with GBS
  3. Women with pyrexia in labour
  4. Women in preterm labour
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22
Q

When do Anti-D injections need to be given?

A

28 weeks

34 weeks

Birth if baby is confirmed +ve

Any sensitisation events (within 72 hrs)

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23
Q

What are sensitisation events?

A

Antepartum haemorrhage

Amniocentesis

Abdominal trauma

Ectopic pregnancy

Miscarriage after 12 weeks

Any bleeding after 12 weeks

Any heavy or painful bleeding before 12 weeks

Termination

Any abdominal trauma (even if no apparent bleeding)

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24
Q

How soon after a sensitisation event does Anti-D need to be given?

A

Within 72 hours

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25
Q

What additional test needs conducting if a sensitisation event occurs after 20 weeks of pregnancy?

A

Kleihauer test

To check if any more anti-D is needed

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26
Q

What is a small for gestational age baby?

A

Below 10th centile for gestational age

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27
Q

What are causes of a baby being small for gestational age?

A

Constitutionally small

Placenta-mediated -> pre-eclampsia, maternal smoking/alcohol, anaemia, malnutrition

Non-placenta mediated -> genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism

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28
Q

What are maternal risk factors for a baby being small for gestational age?

A

Previous SGA baby

Obesity

Diabetes

HTN

Pre-Eclampsia

Mother > 35

Multiple pregnancy

Antiphospholipid syndrome

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29
Q

What is large for gestational age?

A

Above the 90th percentile or born more than 4.5 kg

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30
Q

What are causes of a baby being born for large for gestational age?

A

Constitutional

Maternal diabetes

Maternal obesity

Overdue

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31
Q

What are complications of a baby being born large for gestational age?

A

Shoulder dystopia

Failure to progress

Perineal tears

Postpartum haemorrhage

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32
Q

What are causes of polyhydramnios?

A

Impaired swallowing (oesophageal atresia)

Fetal anaemia, maternal diabetes (increased urination)

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33
Q

What are causes of oligohydramnios?

A

Decreased urination (renal agenesis)

Pre-eclampsia

HTN

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34
Q

Where should the fundus be palpable?

A

From 20 weeks - at the umbilicus

From 36 weeks - at the xiphisternum

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35
Q

What causes raised alpha-fetoprotein in pregnancy?

A

Meningocele

Omphacele

Multiple pregnancy

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36
Q

What causes low alpha-fetoprotein in pregnancy?

A

Down syndrome

Edwards syndrome

Maternal diabetes

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37
Q

What is the management of choice for UTI in pregnancy?

A

Nitrofurantoin (not in 3rd trimester)

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38
Q

How is VTE risk treated in pregnancy?

A

Low molecular weight heparin

If 3 risk factors - from 28 weeks to 6 weeks postpartum

If 4 or more risk factors - from 1st trimester to 6 weeks postpartum

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39
Q

What are risk factors for VTE in pregnancy?

A

Smoking

Parity of 3 or more

Age over 35

BMI over 30

Reduced mobility

Multiple pregnancy

Pre-eclampsia

Varicose veins

Family history

Thrombophilia

IVF

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40
Q

How can you differ between gestational hypertension and pre-existing hypertension

A

Gestational = occurs after 20 weeks of pregnancy

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41
Q

What is pre-eclampsia? How does it present?

A

New hypertension in pregnancy

Proteinuria

Oedema

End organ dysfunction (e.g. raised creatinine)

Headache

Nausea

Abdominal pain

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42
Q

What is eclampsia?

A

Pre-eclampsia with the addition of seizures

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43
Q

How is eclampsia managed?

A

IV Magnesium sulphate

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44
Q

How is pre-eclampsia risk managed?

A

Aspirin daily from 12 weeks

If 1 high risk factor or 2 moderate factors

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45
Q

How is diagnose pre-eclampsia treated?

A

Oral Labetalol

Planned induction

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46
Q

What are high risk factors for pre-eclampsia?

A

Pre-eclampsia in a prior pregnancy

Pre-existing hypertension

Diabetes

Renal disease

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47
Q

What are moderate risk factors for pre-eclampsia?

A

Nulliparity

Obesity

Mother or sister who had pre-eclampsia

Mother aged 40 years or older

Multiple pregnancy

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48
Q

What is HELLP syndrome?

A

Haemolysis (high LDH)

Elevated liver enzymes

Low platelet count

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49
Q

How does HELLP syndrome present?

A

Nausea and vomiting

Right upper quadrant pain

Lethargy

Headache

Bleeding

Changes in vision

Oedema

SOB

Chest pain

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50
Q

How is HELLP syndrome managed?

A

Delivery

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51
Q

What is gestational diabetes?

A

Diabetes triggered by reduced insulin sensitivity in pregnancy

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52
Q

What are the main complications of gestational diabetes?

A

Large for gestational age neonate

Macrosomia

Polyhydramnios

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53
Q

How is gestational diabetes diagnosed?

A

Oral glucose tolerance test

Fasting glucose >5.6

2 hour glucose >7.8

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54
Q

How is gestational diabetes treated?

A

If fasting glucose >7 = insulin (short acting only)

Or if there are any complications such as macrosomia or polyhydramnios = insulin

If fasting glucose <7 and no complications = Metformin

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55
Q

How is pre-existing diabetes treated in pregnancy?

A

Stop all medication other than Metformin and insulin

Start daily folic acid 5mg

Retinopathy screening at booking and at 28 weeks

Delivery between 37 and 39 weeks

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56
Q

What are the treatment targets in gestational diabetes?

A

Fasting = 5.3

2 hour = 6.4

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57
Q

What is obstetric cholestasis and how does it present?

A

Pruritus particularly in hands and feet

Due to reduced outflow of bile from liver

Also may be fatigue, dark urine, pale stools, jaundice

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58
Q

What are complications of obstetric cholestasis?

A

Increased risk of stillbirth and preterm birth

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59
Q

Which liver marker is normal to rise in pregnancy?

A

Alkaline phosphatase

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60
Q

How is obstetric cholestasis managed?

A

Ursodeoxycholic acid

Induction at 37-38 weeks due to increased risk of stillbirth

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61
Q

Rash in pregnancy: rash on the abdomen which spares the umbilicus?

A

Polymorphic eruption of pregnancy

Managed with emollients and topical steroids

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62
Q

Rash in pregnancy: red lump often on fingers, can be on gum?

A

Pyogenic granuloma

Resolves after delivery

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63
Q

Rash in pregnancy: fluid filled blisters around the umbilicus?

A

Pemphigoid gestatationitis

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64
Q

What is placenta praevia?

A

When the placenta is lying too low in the uterus and covering the internal cervical os

Can cause antepartum haemorrhage

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65
Q

What are the two main causes of antepartum haemorrhage?

A

Placenta praevia

Placental abruption

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66
Q

How does placenta praevia present?

A

Usually asymptomatic until bleeding occurs

No pain, uterus is soft and non-tender

67
Q

How is placenta praevia diagnosed?

A

TVUSS

Do not perform a bimanual examination (can trigger bleeding)

68
Q

How is a bleeding placenta praevia managed?

A

Less than 34 weeks -> admit for antenatal corticosteroids

More than 34 weeks -> C section

69
Q

How is an asymptomatic placenta praevia diagnosed on scan managed?

A

Planned CS at 37-38 weeks

70
Q

What is a vasa praevia?

A

Exposure of the fetal vessels outside of the umbilical cord placenta, these then pass through the internal cervical os

These vessels are prone to bleeding during labour

71
Q

How is vasa praevia managed?

A

Elective CS at 34-36 weeks

72
Q

What is placental abruption?

A

The placenta separates from the wall of the uterus during pregnancy

Causes antepartum haemorrhage

73
Q

How does placental abruption present?

A

Sudden onset severe abdominal pain

Vaginal bleeding

Woody, hard, tender abdomen

Patient may be in shock - hypotension, tachycardia

May be concealed - cervical os remains closed and blood remains in the uterine cavity

74
Q

How is a placental abruption managed?

A

ABCDE

Gain access

Fluid and blood resus

CTG - If fetal distress, immediate CS

If no feral distress - induce vaginal labour if >36w, admit for antenatal corticosteroids if <36 weeks

75
Q

What are risk factors for placental abruption?

A

Cocaine use

Multi parity

Maternal trauma

Increasing maternal age

Previous abruption

Polyhydramnios

Infection (chorioamnionitis)

HTN, pre-eclampsia

76
Q

What is placenta accreta?

A

When the placenta attached to the myometrium instead of the endometrium

Placenta cannot fully separate after delivery

Leads to postpartum haemorrhage

77
Q

How is placenta accreta managed?

A

Elective CS at 35-37 weeks, hysterectomy

78
Q

What are the four different types of breech presentation?

A

Complete = knees and hips fully flexed

Incomplete = one leg extended at knee

Frank = both legs extended at knee

Footling = foot through cervix

79
Q

When should external cephalic version be tried?

A

If woman is nulliparous - by 36 weeks

If not nulliparous - at 37 weeks

80
Q

What are contraindications to external cephalic version?

A

Antepartum haemorrhage in last 7 days

Abnormal CTG

Major uterine abnormality

Ruptured membranes

Multiple pregnancy

81
Q

What are causes of reduced fetal movement?

A

Posture of mother

Placental position

Fetal position

Medication

Maternal obesity

Oligohydramnios/polyhydramnios

SGA fetus

82
Q

How should reduced fetal movements be investigated?

A

Handheld Doppler

If no heartbeat -> immediate ultrasound

If heartbeat -> CTG for 20 mins

83
Q

Which antibiotics should be avoided in pregnancy and breastfeeding?

A

Tetracyclines - doxycycline

Trimethoprim (safe in breastfeeding)

Clarithromycin

Ciprofloxacin

84
Q

What is the definition of stillbirth?

A

Birth of a dead fetus from 24 weeks

85
Q

What are causes of stillbirth?

A

Unexplained

Pre-eclampsia

Placental abruption

Vasa praevia

Cord prolapse

Infection

86
Q

How is stillbirth managed?

A

Vaginal delivery is preferred

Can give oral mifepristone and vaginal misoprostol to induce

If mother is Rh -ve give Anti-D

87
Q

How is preterm premature rupture of membranes managed?

A

Admit for oral erythromycin 10 days

Antenatal corticosteroids

88
Q

What are indications for induction of labour?

A

Prolonged pregnancy

Premature rupture of membranes

Diabetic mother >38 weeks

Pre-eclampsia

Fetal growth restriction

Bishop score <5

89
Q

What is the stepwise approach for induction of labour?

A
  1. Membrane sweep
  2. Vaginal prostaglandins (E2) - gel/pessary
  3. Cervical ripening balloon
90
Q

What is uterine hyper stimulation and how is it managed?

A

Prolonged and frequent contractions caused by induction

Can cause uterine rupture

Remove prostaglandins and administer tocolysis

91
Q

How is the Bishop score calculated?

A

Position - posterior, middle, anterior

Consistency - firm, medium, soft

Effacement

Dilation

Foetal station

92
Q

What two things does a CTG measure?

A

Fetal heart rate

Contractions

93
Q

What are indications for continuous CTG during labour?

A

Sepsis/fever

Maternal tachycardia

Pre-eclampsia / severe HTN

Antepartum haemorrhage that starts in labour

Significant meconium

94
Q

What is the normal baseline rate on a CTG?

A

110-160

95
Q

What is normal variability on a CTG?

A

5-25

96
Q

What do short episodes of decreased variability on a CTG suggest?

A

Fetus is asleep

97
Q

When are variable decelerations ok?

A

If they last less than 2 minutes

If there are brief accelerations before and after

98
Q

What kind of decelerations are normal?

A

Early decelerations (correspond to contractions)

Decelerations that last less than 2 minutes

99
Q

What should you do if there is a prolonged deceleration?

A

If deceleration is more than 2 minutes this is prolonged

3 mins - call for help

6 mins - move to theatre

9 mins - prepare for delivery

12 mins - deliver baby

100
Q

How can you diagnose the cause late decelerations?

A

Do fetal blood sampling

If pH is low then baby is hypoxic

101
Q

What are causes of baseline tachycardia on CTG?

A

Maternal pyrexia

Chorioamnionitis

Hypoxia (cord compression)

Prematurity

102
Q

What are obstetric analgesia options? (During labour)

A

Gas and air (Entonox)

Paracetamol

Oral codeine or IV Diamorohine

Epidural (only once in established labour)

Pudendal nerve block

103
Q

How is failure to progress managed?

A

If due to contraction power - oxytocin

If due to abnormality of baby/passage - instrumental delivery or C section

104
Q

What is an umbilical cord prolapse?

A

Umbilical cord descends below the present in part - into the vagina

105
Q

How is umbilical cord prolapse seen on CTG?

A

Variable or prolonged decelerations

106
Q

How is umbilical cord prolapse managed?

A

Get woman on all fours

Elevate presenting part

Immediate c-section

107
Q

What is shoulder dystocia?

A

Anterior shoulder becomes stuck behind pubic symphysis after head has been delivered

108
Q

What is the main cause of shoulder dystocia?

A

Macrosomia - usually due to gestational diabetes

109
Q

How does shoulder dystocia present?

A

Failure of resuscitation - baby does not turn sideways

Turtle neck sign - baby’s head retracts back up to vagina

110
Q

How is shoulder dystocia managed?

A

McRoberts manoeuvre - bring knees to abdomen and apply suprapubic pressure

If this fails - episiotomy

111
Q

What is a complication of shoulder dystocia?

A

Brachial plexus palsy (Erb’s palsy)

112
Q

What are the 4 types of perineal tears and how are they managed?

A

1st degree - frenulum of labia minors and superficial skin (no sutures needed)

2nd degree - includes perineal muscles (sutures needed)

3rd degree - includes anal sphincter (repair in theatre)

4th degree - includes rectal mucosa (repair in theatre)

113
Q

What are complications of perineal tears?

A

Urinary incontinence

Faecal incontinence (3rd and 4th degree)

Dyspareunia

114
Q

How much blood loss is needed to count as a postpartum haemorrhage?

A

More than 500ml after vaginal delivery

More than 1000ml after c-section

115
Q

What is the difference between a primary and secondary PPH?

A

Primary - from birth to 24 hours

Secondary - from 24 hours to 12 weeks

116
Q

What are causes of secondary PPH?

A

Retained products of conception (treated with D+C)

Infection (endometritis) - treated with Abx

117
Q

What are the four main causes of primary PPH?

A

Tone (uterine atony - uterus fails to contract after delivery)

Trauma (e.g. perineal tear)

Tissue (retained placenta)

Thrombin (bleeding disorder)

118
Q

How do you treat uterine atony?

A

Uterine massage (Bimanual stimulation)

IV syntocinon

IM Carboprost

119
Q

What are the two main causes of maternal sepsis?

A

Chorioamnionitis

Urinary tract infections

120
Q

What is Chorioamnionitis?

A

Bacterial infection of the amniotic fluid/membranes/placenta

121
Q

How is chorioamnionitis managed?

A

IV Abx

Prompt delivery

122
Q

How do you investigate signs of sepsis in a pregnant woman?

A

Bloods

Urine dipstick

High vaginal swab

123
Q

What is an amniotic fluid embolism and how does it present?

A

When amniotic fluid passes into the mothers blood

Presents around labour/delivery - often with sudden collapse

124
Q

What is the difference between baby blues and postnatal depression?

A

Baby blues - first week of life, usually resolves within 2 weeks of delivery

Postnatal depression - low mood, Anhedonia, low energy, presents around 3 months after birth

125
Q

How is postnatal depression managed?

A

Mild - self-help

Moderate - SSRIs (Sertraline/Paroxetine) / CBT

Severe - psych services

126
Q

What is puerperal psychosis and how is it managed?

A

Psychotic symptoms - delusions, hallucinations, depression, mania, confusion

Presents 2-3 weeks after delivery

Urgent psychiatric assessment - usually admission to Mother & Baby Unit

127
Q

Which medications are safe during breastfeeding (but unsafe during pregnancy)?

A

Trimethoprim

Sodium valproate

Warfarin

128
Q

What is lactational amenorrhoea?

A

Complete amenorrhoea when a woman is fully or nearly breastfeeding

This is an effective contraception for up to 6 months

129
Q

What causes a raised alpha feto-protein in pregnancy?

A

Neural tube defects - meningocele, anencephaly

Abdominal wall defects - omphacele, gastroschisis

Multiple pregnancy

130
Q

How is UTI in pregnancy treated?

A

Nitrofurantoin/Amoxicillin

Avoid Nitrofurantoin in the last trimester

131
Q

How is chlamydia in pregnancy treated?

A

Azithromycin/erythromycin

132
Q

When should folic acid be started and stopped for pregnancy?

A

Started = upon trying to conceive

Stopped = end of first trimester

133
Q

Which conditions are all pregnant woman offered screening for?

A

Anaemia

Bacteriuria

Blood group

Down syndrome

Fetal anomalies

Hepatitis B

HIV

Neural tube defects

Risk factors for pre-eclampsia

Syphilis

134
Q

How is premature rupture of the membranes diagnosed?

A

Speculum examination to look for pooling of amniotic fluid in the posterior vagina vault

Avoid digital examination due to the risk of infection

Consider ultrasound If no fluid seen in vault

135
Q

Which liver enzyme can be raised in pregnancy?

A

ALP due to placental ALP

136
Q

How is lactation mastitis treated?

A

Symptoms less than 12-24 hours - conservative

More than 12-24 hours - Oral flucloxacillin

Continue breastfeeding

137
Q

How is nipple candidiasis treated?

A

Miconazole cream for the mother

Nystatin suspension for the baby

138
Q

What is the cut off of how much weight breastfed babies should lose in the first week of life?

A

No more than 10%

If more than 10% -> refer to midwife led breastfeeding clinic

139
Q

Which foods should be avoided in pregnancy?

A

Unpasteurised milk

Ripen soft cheeses e.g. camembert, brie and blue veined cheeses

Pâté

Liver

140
Q

From what gestation should a travel be avoided in pregnancy?

A

From 37 weeks or from 32 weeks if multiple pregnancy

141
Q

What is the stepwise management for uterine atony?

A

Bimanual uterine compression/uterine massage

IV oxytocin and/or ergometrine

IM carboprost

Intramyometrial carboprost

Rectal misoprostol

Surgical intervention e.g. balloon tamponade

142
Q

Which cardiovascular signs can be normal in pregnancy?

A

Third heart sound

Ejection systolic murmur

Forceful Apex beat

Peripheral oedema

143
Q

What are the requirements for an instrumental delivery?

A

Fully dilated cervix

OA position

Ruptured membranes

Cephalic presentation

Engaged presenting part

Pain relief

Empty bladder

144
Q

Which medications are contraindicated in breastfeeding?

A

Aspirin

Amiodarone

Codeine

Lithium

Naproxen

Ciprofloxacin

Methotrexate

Any diabetic drugs except Metformin

ACEi/ARB

145
Q

 is sodium valproate safe in breastfeeding?

A

Yes nearly all antiepileptic drugs are safe in breastfeeding

146
Q

Is warfarin safe in breastfeeding?

A

Yes

147
Q

Which VTE prophylaxis is used in pregnancy?

A

Low molecular weight heparin

148
Q

What are the SSRIs of choice in breastfeeding women?

A

Sertraline or paroxetine

149
Q

How do you manage a woman with known placenta previa who goes into labour?

A

Emergency Caesarean

150
Q

How is anaemia in pregnancy treated?

A

Oral iron tablets

151
Q

How long should magnesium sulphate treatment for eclampsia continue for?

A

24 hours after the last seizure or delivery

152
Q

What is a complication of magnesium sulphate and how can this be treated?

A

Magnesium sulphate can cause respiratory depression

Calcium gluconate can be used to treat this

153
Q

Can a VBAC occur at home?

A

No - must be on labour ward

154
Q

How long after delivering can an IUD/IUS be inserted?

A

Either in first 48 hours after birth

Or then must wait at least 4 weeks

155
Q

What’s the difference between placenta accreta, increta and percreta?

A

Accreta = placenta attached to superficial myometrium

Increta = placenta invades into the myometrium

Percreta = placenta goes through the myometrium

156
Q

What is the earliest gestation that a pregnant woman can be diagnosed with pre-eclampsia/gestational HTN?

A

20 weeks- any earlier is chronic hypertension

157
Q

How long do you need to take folic acid?

A

Til end of first trimester

158
Q

What medication is routinely given prior to a c section? Why?

A

PPI

Reduces the risk of acid aspiration

159
Q

When can an artificial rupture of membranes be performed as part of induction of labour?

A

If cervix is ripe and head is well engaged

160
Q

Why does maternal diabetes casue polyhydramnios?

A

Hyperglycaemia –> Increased urination

161
Q

What are contraindications to tocolysis?

A 
>34w
Non-reassuring CTG
IUGR
Cervical dilation >4cm
Chorioamnionitis
Pre-eclampsia
APH
Haemodynamic instability
162
Q

After how long does lochia need to persist before ultrasound is warranted?

A

6 weeks

163
Q

How much weight is normal for a breastfed baby to lose in the first week of life?

A

No more than 10% of birthweight

If more than 10% - referral needed

Medicine Finals (32 decks)

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