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Year 4 (Jesus Bless These Notes) > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Shoulder dystocia management includes:

A
  1. Apply downward suprapubic pressure

2. McRobert’s manoeuvre, woman is supine and the legs are hyperflexed towards the abdomen

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2
Q

Following artificial rupture of the membranes, fetal bradycardia is noted on the cardiotocograph (CTG). This prompts the midwife to perform a vaginal examination, during which the umbilical cord is found to be palpable just below the presenting part.

Umbilical cord prolapse noticed management:

A
  1. Call for senior help
  2. Push the presenting part into the uterus during contractions to prevent compression of the umbilical cord (if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm)
  3. ‘all fours’ (i.e. on the floor on hands and knees) and adopt the knee-to-chest position (bringing the knees towards the chest and raising the bottom in the air so that it is higher than the head).
  4. Catheterization of the bladder is performed during umbilical cord prolapse, the purpose of this is to fill the bladder with 500-750mL of saline by attaching the catheter to an intravenous giving set. This helps to elevate the presenting part, preventing compression of the cord.
  5. Consider delivery of the baby (caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low).
  6. tocolytics may be used to reduce uterine contractions
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3
Q

Risk factors for cord prolapse include:

A
  1. prematurity
  2. multiparity
  3. polyhydramnios
  4. twin pregnancy
  5. cephalopelvic disproportion
  6. abnormal presentations e.g. Breech, transverse lie
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4
Q

If after 28/40 weeks, if a woman reports (Physical examination is unremarkable, and observations are stable) reduced fetal movements and kicking has reduced with no complications throughout the pregnancy and no fetal heart is detected with handheld Doppler then what the next step in management:

A

An immediate ultrasound should be offered

Note if a heartbeat was detected, then a CTG should be used for at least 20 mins to monitor the heart rate

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5
Q

Reduced fetal movements can represent:

A

fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero.

This is concerning, as it reflects risk of stillbirth and fetal growth restriction.

It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

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6
Q

What is the first onset of recognised fetal movement which occurs between 18-20 weeks gestation is known as

A

quickening

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7
Q

Fetal movements start and increase till what weeks:

A

18-20 weeks gestation and increase until 32 weeks gestation at which point the frequency of movement tends to plateau

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8
Q

Multiparous women will usually experience fetal movements sooner, true or false:

A

True, they experience it at 16-18 weeks gestation (towards the end of pregnancy, fetal movements should not reduce)

Normally it occurs between 18-20 weeks and increase between until 32 weeks gestation at which point the frequency of movement tends to plateau

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9
Q

According to the RCOG what is considered for fetal movements indication for further assessment:

A

Considers less than 10 movements within 2 hours ((in pregnancies past 28 weeks gestation) an indication for further assessment).

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10
Q

If the mother is past 28 weeks gestation, and there’s a heart rate present confirmed via a handheld doppler and then a CTG is used for at least 20 mins which can assist in excluding fetal compromise, but concerns remain, what should be done next:

A

ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement

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11
Q

Gravida number refers to what:

A

the TOTAL number of pregnancies, including the present one (twin pregnancy counts as one pregnancy) but since two children past 24 wks then para 2

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12
Q

Parity refers to:

A

the number of children delivered whether alive or dead after 24 weeks, twins count as Para 2 but grava 1 (cos one pregnancy)

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13
Q

What are the stages of labour:

A

Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

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14
Q

primigravida woman have stage 1 labour lasting typically:

A

10-16 hrs

stage 1 has the latent phase = 0-3 cm dilation, normally takes 6 hours

active phase = 3-10 cm dilation, normally 1cm/hr

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15
Q

When you give birth, your baby usually comes out headfirst with 90% of this, this is also called:

A

vertex position

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16
Q

Stage 1 refers to the onset of what….

A

the onset of true labour to when the cervix if fully dilated

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17
Q

Stage 2 of labours refers to:

A

from full dilation to delivery of the fetus

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18
Q

Stage 3 of labour refers to:

A

from delivery of fetus to when the placenta and membranes have been completely delivered

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19
Q

When the head of the baby enters the pelvis in the occipito-lateral position, the head normally delivers:

A

in an occipito-anterior position

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20
Q

In stage 1 labour, the first stage of it, latent phase, the dilation is how many cm and takes how long:

A

0-3 cm dilation, normally takes 6 hrs

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21
Q

In stage 1 labour, the second stage of it, active phase, the dilation is how many cm and at what rate:

A

3-10 cm dilation, normally 1cm/hr

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22
Q

The birth of the foetus refers to which stage of labour:

A

second stage

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23
Q

The delivery of the placenta refers to which stage of labour:

A

3rd stage

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24
Q

Stage 1 labour involves which features:

A
  1. Onset of regular contractions
  2. Gradual dilation of the cervix
  3. It ends once at 10cm cervical dilation when the cervix is considered fully effaced (shortening and thinning of the cervix)
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25
Q

How does cervix effacement happens and what stage:

A

Occurs during stage 1 of labour

Fetus’s head drops into the pelvis, pushing it against the cervix. This process stretches the cervix, causing it to thin and shorten

10 cm dilation

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26
Q

A pregnant woman has pre-eclampsia, but they can’t give the first line treatment oral labetalol cos she is asthmatic, what should be given instead:

A

Nifedipine (e.g. if asthmatic) and hydralazine may also be used

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27
Q

A mother at 37 weeks pregnant with preterm-PROM triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia points to:

A

chorioamnionitis

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28
Q

chorioamnionitis, a medical emergency, has what treatment for mother at 37 weeks for example:

A
  • IV antibiotics

- Immediate cesarean section

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29
Q

A pregnant has preterm premature rupture of membranes, but now presents with a fever, what is most likely?

A

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus

Considered a medical emergency

It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta

The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens

Prompt delivery of the foetus (via c- section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

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30
Q

A pregnant woman is at 37 weeks, but prior 3 weeks ago had urinary incontinence with some discharge after, but now presents with a fever, what does it suggest?

A

chorioamnionitis

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31
Q

What is the triad for a woman with

chorioamnionitis with preterm-PROM?

A
  1. Maternal Pyrexia
  2. Maternal tachycardia
  3. Fetal tachycardia
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32
Q

What is the screening test for gestational diabetes:

A

oral glucose tolerance test (OGTT)

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33
Q

Screening for gestational diabetes for a mother with previous GD, should be screened at how many weeks?

A
  • Offered ASAP after booking
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34
Q

Screening for gestational diabetes for a mother with previous GD, with a normal first test should be screened at how many weeks?

A

At 24-28 weeks

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35
Q

NICE recommend what test as an alternative to oral glucose tolerance test (OGTT):

A

Early self-monitoring of blood glucose is an alternative to the oral glucose tolerance test (OGTT)

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36
Q

According to NICE, what is the diagnostic thresholds values for gestational diabetes:

A

NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

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37
Q

What is the 6 steps management plan of pre-existing diabetes:

A
  1. weight loss for women with BMI of > 27 kg/m^2
  2. stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  3. folic acid 5 mg/day from pre-conception to 12 weeks gestation
  4. detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  5. tight glycaemic control reduces complication rates
  6. treat retinopathy as can worsen during pregnancy
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38
Q

When should glibenclamide be offered in gestational diabetes:

A

For women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

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39
Q

When should Metformin used for gestational diabetes:

A

when the fasting glucose level is below 7mmol/L AND glucose targets are still not being met despite lifestyle changes for 1-2 weeks

If patient’s blood glucose level is well above 7mmol/L, therefore, offering metformin would not be correct (give insulin instead)

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40
Q

If pregnant woman with gestational diabetes declines insulin, what should be given instead:

A

Glibenclamide

Sulfonylureas such as Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

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41
Q

Can Empagliflozin be given in gestational diabetes?

A

No as SGLT-2-inhibitors have no role in the management of gestational diabetes

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42
Q

If a pt has a fasting blood glucose above 7, will advising to maintain a healthy diet and exercise be enough to avoid the complications?

A

Nope, a fasting glucose above 7 requires medication (insulin)

Whilst the patient can be advised to maintain a healthy diet and exercise regularly, this must be done in conjunction with medication.

Simply eating healthy and exercising will not be enough to prevent the complications of gestational diabetes.

Metformin is given if the fasting blood glucose is below 7mmol/L

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43
Q

Gestational diabetes, what should be started if the fasting plasma glucose level is < 7 mmol/l and a trial of diet and exercise is offered
but the glucose targets are not met within 1-2 weeks of altering diet/exercise?

A

metformin

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44
Q

If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, what should be started?

A

insulin

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45
Q

What’s the first line in gestational diabetes, if the fasting plasma glucose level is < 7 mmol/l? Should a medication first be started?

A

No, a trial of diet and exercise should be offered for 1-2 weeks first

If not glucose targets not met, then start on metformin

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46
Q

The diet for gestational diabetes should include one with a:

A

low glycaemic index

Remember exercise should be included

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47
Q

Gestational diabetes is treated with what sort of sub-cut insulin: long or short?

A

SHORT acting

Not long acting SC insulin

Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia.

Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman

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48
Q

If glucose targets not met after, diet, exercise and metformin, what should be started:

A

Insulin

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49
Q

Fetal bradycardia is classically seen in what of the causes of antepartum haemorrhage:

A

Vasa praevia

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50
Q

Tender, tense uterus but with normal lie and presentation, and constant abdo pain is what of the causes of APH?

A

Placental abruption

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51
Q

Which examination should NOT be performed in primary care for APH before doing a ultrasound?

A

vaginal examination, women with placenta praevia may haemorrhage

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52
Q

Hydatidiform mole has what features:

A

Typically bleeding in first or early second trimester

associated with exaggerated symptoms of pregnancy e.g. hyperemesis

The uterus may be large for dates and serum hCG is very high

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53
Q

A pregnant woman has ruptured her membrane, but following this, there is vaginal bleeding immediately, fetal bradycardiac, what is the cause of the APH?

A

Vasa praevia

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54
Q

What is the cause of APH, there is painless vaginal bleeding?

A 
Placental praevia (no pain)
Placental abruption has constant abdo pain
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55
Q

A tender tense uterus with normal lie and presentation in APH is:

A

Placental abruption

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56
Q

A woman presents in the first and another woman in the second, both present with bleeding and exaggerated symptoms of pregancy such as hyperemesis.

The scan the uterus is large for date and serum hCG is very high, what is the APH diagnosis?

A

Hydatidiform mole

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57
Q

What should be ruled out if bleeding during pregnancy?

A

STIs and cervical polys should be excluded

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58
Q

Potential Gestational diabetes: if the fasting plasma glucose is < 7 mmol/l a trial of diet and exercise should be offered for 1-2 weeks….what diet should be offered?

A

advised to eat a high fibre diet with minimal foods containing refined sugars

balanced diet, high in fruit, vegetables, and unrefined foods

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59
Q

Gestational diabetes is caused by:

A

insulin insensitivity which affects women across the BMI spectrum

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60
Q

What are the four signs of labour?

A
  • regular and painful uterine contractions
  • a show (shedding of mucous plug)
  • rupture of the membranes (not always)
  • shortening and dilation of the cervix
61
Q

What drug should NOT be given in the presence of hypertension?

A

Ergometrine (should not be given in the presence of hypertension)

62
Q

Between Ergometrine and Oxytocin, which one casues less nausea and vomitting?

A

Oxytocin

63
Q

3rd stage of labour, active management of this stage is recommended in order to reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery.

What does the guidelines suggest to use?

A

10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder

64
Q

10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of what?

A

anterior shoulder

65
Q

Pregnant obese women (BMI >30 kg/m2) in the 1st trimester, should be given

A

high dose 5mg folic acid

66
Q

Most pregnant patients, how much of folic acid and over how long?

A

0.4mg (400mcg) daily in the first 12 weeks of pregnancy is sufficient

67
Q

folic acid should also be prescribed at a 5mg daily dose, for what?

A
  • diabetes
  • sickle cell disease (SCD)
  • thalassaemia trait
  • coeliac disease
  • on anti-epileptic medication
  • personal or family history of NTD
  • who have previously given birth to a baby with an NTD
68
Q

all pregnant patients take what vitamin?

A

vitamin D 10mcg (400 units) daily. This should be continued throughout the duration of their entire pregnancy

69
Q

Causes of folic acid deficiency:

A
  • phenytoin
  • methotrexate
  • pregnancy
  • alcohol excess
70
Q

There’s a number of anaesthetic techniques during labour which can be broadly classified as:

A

regional and non-regional (with non-regional being the most widely used)

71
Q

Non-regional anaesthetics for labour include:

A

inhaled nitrous oxide, and systemic analgesics such as pethidine

72
Q

Regional anaesthetics for labour include:

A

epidural anaesthesia, which has been shown to be extremely effective in pain management

73
Q

Regional techniques include epidural anaesthesia, shows there’s an association:

A

prolongation of labour and increased operative vaginal delivery

No association between epidural analgesia and an increased risk of Caesarean delivery or post-partum backache has been found

74
Q

Performing an episiotomy can form the management for what?

A

shoulder dystocia as it can make more space for manoeuvres

75
Q

terbutaline, nifedipine are examples of what in terms of uterus and contractions?

A

tocolytics (e.g. terbutaline, nifedipine) can be used to relax the uterus and stop contractions to delay delivery while transferring a patient to theatre for a caesarian section

76
Q

For cord prolapse, pushing the cord back inside the vagina does what?

A

touching the cord can precipitate vasospasm and result in foetal hypoxia

77
Q

Apply suprapubic pressure forms the management for what?

A

shoulder dystocia

Whereby pressure is placed behind the anterior shoulder of the foetus to disimpact it from underneath the maternal pubic symphysis

78
Q

Suprapubic pressure for shoulder dystocia, helps with:

A

Pressure is placed behind the anterior shoulder of the foetus to disimpact it from underneath the maternal pubic symphysis

79
Q

Is IV oxytocin appropriate to give for cord prolapse?

A

NO! This would induce contractions,

Instead tocolytics e.g. terbutaline, nifedipine can be used to relax the uterus and stop contractions to delay delivery while transferring a patient to theatre for a caesarian section

80
Q

Can a instrumental vaginal delivery be used for a cord prolapse?

A

an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low

although caesarian section is the usual first-line method of delivery

81
Q

what does a first-degree tears involve the perineal muscle, and do require repair?

A

They involve the skin and the subcutaneous tissue between the vagina and the anus

It does not involve the perineal muscle (like the second degree one)

They do not require repair

82
Q

second degree tear involve involves the

A

perineal muscle but does not involve the anal sphincter

It can be sutured on the ward by an experienced midwife or doctor.

83
Q

Third-degree tears involve:

A

anal sphincter and require repair in theatre

They are commonly caused by instrumental delivery

84
Q

A fourth-degree tear involves:

A

the rectal mucosa

This requires repair in theatre.

85
Q

Risk factors for perineal tears:

A
  • primigravida
  • large babies
  • precipitant labour
  • shoulder dystocia
  • forceps delivery
86
Q

What is the most common cause of early-onset severe infection in the neonatal period?

A

Group B Streptococcus (GBS)

87
Q

Risk factors for Group B Streptococcus (GBS) infection:

A
  • prematurity
  • prolonged rupture of the membranes
  • previous sibling GBS infection
  • maternal pyrexia e.g. secondary to chorioamnionitis
88
Q

GBS prophylaxis antibiotic choice:

A

benzylpenicillin

89
Q

Women with a pyrexia during labour (>38ºC) should be given:

A

benzylpenicillin as a intrapartum antibiotic GBS prophylaxis

90
Q

Group B Streptococcus (GBS) screening done for all:

A

universal screening for GBS should not be offered to all women

91
Q

If women are to have swabs for GBS this should be offered at what weeks?

A

35-37 weeks or 3-5 weeks prior to the anticipated delivery date

92
Q

Instrumentation is necessary for delivery, which equipment associated with successful outcomes?

A

Kielland’s forceps are associated with the most successful outcomes compared to ventouse, however require particular expertise

93
Q

Which position of the baby is gives the mother an earlier urge to push? OP or OA?

A

OP where the baby’s head is facing the back of the mother

(delivery in the OP position, also causes labour to be longer and more painful

94
Q

On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?

A

The fetal head may rotate spontaneously to on OA position

95
Q

Stage 2 of labour is:

A

associated with transient fetal bradycardia

96
Q

In stage 2, what may be necessary following crowning?

A

episiotomy

97
Q

Active second stage refers to what:

A

active process of maternal pushing

98
Q

Normally, stage 2 (from full dilation to delivery of the fetus) takes 1hr, but they were given epidural so it took longer than 1 hr, what should be considered?

A

Consider Ventouse extraction, forceps delivery or caesarean section

99
Q

If a baby’s head on vaginal examination, the occiput can be palpated posteriorly (near the sacrum)! What should be considered?

A

The fetal head may rotate spontaneously to an OA position

100
Q

Management for grade III or IV placenta praevia is a scheduled:

A

elective caesarean section at 37-38 weeks

Spontaneous vaginal delivery carries a significant risk of haemorrhage in grade III and grade IV placenta praevia and the patient should be counselled about the risk of this

101
Q

Why is the management for grade III or IV placenta praevia is a scheduled elective caesarean section at 37-38 weeks?

A

This is to prevent a massive obstetric haemorrhage which may occur if cervical ripening and dilatation occurs with the placenta overlying the cervical os.

102
Q

If low-lying placenta at the 20-week scan, rescan at?

A

34 weeks, if still present at 34 weeks and grade I/II then scan every 2 weeks

103
Q

For low-lying placenta, should activity or intercourse be limited?

A

No need for it to be limited unless they bleed

104
Q

All grades of low lying placenta, should be advised for c-section?

A

False, Grade I can have a trial of vaginal delivery may offered

105
Q

A history of sudden unwell and collapse with hypotension and tachycardia occurring soon after a rupture of membranes is suggestive of

A

amniotic fluid embolism (Amniotic fluid emboli can indirectly lead to myocardial infarcts)

hypovolaemic shock would also typically evolve at a slower pace

106
Q

Amniotic fluid embolism is:

A

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.

Clinical presentation:
- The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum

  • Symptoms include: chills, shivering, sweating, anxiety and coughing
  • Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
107
Q

What is the management of amniotic fluid embolism?

A

Critical care unit by a multidisciplinary team, management is predominantly supportive

108
Q

Both placenta praevia and vasa praevia both present with painless vaginal bleeding, what would help you differentiate both of them?

A

vasa praevia other expected features would include fetal bradycardia and membrane rupture

109
Q

What is the difference between placenta praevia and placenta abruption?

A

Placenta praevia is painless bleeding, bright red

Placenta abruption is painful bleeding, usually dark red

110
Q

Investigation for placenta praevia is picked up on the routine what?

A

20 week abdominal ultrasound

the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

111
Q

What are the classical grading of the placenta praevia?

A

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os

112
Q

For placenta praevia, the uterus is:

A

uterus not tender

113
Q

Remember to see how the back of the head of the baby is positioned, if the back of the head is positioned on the spine it’s occiput posterior whereas if the back of the head is facing the abdo, then it’s occiput anterior, but the occipital bone which is the semi circle is facing where…towards the left or right, then it’s left occiput posterior or right occiput anterior

A
114
Q

Intrahepatic cholestasis of pregnancy is also known as:

A

obstetric cholestasis

115
Q

What are the features of Intrahepatic cholestasis of pregnancy?

A

Features

  • pruritus - may be intense - typical worse palms, soles and abdomen
  • clinically detectable jaundice occurs in around 20% of patients
  • raised bilirubin is seen in > 90% of cases
116
Q

What is the management of Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis)?

A

Management

  • induction of labour at 37-38 weeks is common practice but may not be evidence based
  • ursodeoxycholic acid - again widely used but evidence base not clear
    vitamin K supplementation
117
Q

Is there a recurrence of intrahepatic cholestasis of pregnancy in subsequent pregnancies?

A

Yes, it’s 45-90% in subsequent pregnancies

118
Q

Obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy, is a condition caused by:

A
  • Impaired flow of bile
  • This, in turn, causes a build-up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta
  • It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors.
  • Although the pruritic symptoms can be distressing for the mother, the build of bile salts can also be detrimental to foetal well-being

The combination of the immature foetal liver’s ability to cope with breaking down the excessive bile salt levels as well as the vasoconstricting effect of bile salts on human placental chorionic veins, has been theorised to be the cause of sudden asphyxial events in the foetus leading to anoxia and death.

119
Q

What is the investigation of choice for gestational diabetes?

A

oral glucose tolerance test

120
Q

What are the risks of gestational diabetes?

A

severe pregnancy complications such as pre-eclampsia, stillbirth, or macrosomia

121
Q

For a cord prolapse, what medication can be used to relax the uterus?

A

Tocolytic, such as terbinafine, to relax the uterus

122
Q

If a pregnant woman is above 28 weeks and she reports reduced fetal movements then what’s the initial management:

A
  • Handheld doppler should be used to confirm fetal heartbeat as a first step
  • If this is not detectable, ultrasound should be offered immediately
  • If a heartbeat was detected, cardiotocography should be used for 20 minutes to monitor the heart rate
123
Q

At how many weeks should there be a referral to fetal medicine unit if no movements had been felt at all by:

A

24 weeks

124
Q

Give a list of reasons for reduced fetal movements including posture, distraction, placental position and fetal position, body habitus, amniotic fluid volume:

A

Risk factors for reduced fetal movements

Posture: There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing

Distraction: Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent

Placental position: Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements

Medication: Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements

Fetal position: Anterior fetal position means movements are less noticeable

Body habitus: Obese patients are less likely to feel prominent fetal movements

Amniotic fluid volume: Both oligohydramnios and polyhydramnios can cause reduction in fetal movements

Fetal size: Up to 29% of women presenting with RFM have a SGA fetus

125
Q

What are the three features of Intrahepatic cholestasis of pregnancy:

A

Features

  • pruritus, often in the palms and soles
  • no rash (although skin changes may be seen due to scratching)
  • raised bilirubin
126
Q

What are the three management features of Intrahepatic cholestasis of pregnancy:

A

Management

  • ursodeoxycholic acid is used for symptomatic relief
  • weekly liver function tests
  • women are typically induced at 37 weeks
127
Q

Is there a rash present in obstetric cholestasis?

A

No skin rash present, diagnosed if there are abnormal liver function tests, with pruritis in the absence of a skin rash

128
Q

What is raised in obstetric cholestasis?

A

It is bile acids that are raised in obstetric cholestasis

129
Q

When does Acute fatty liver of pregnancy occur?

A

Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.

130
Q

Acute fatty liver of pregnancy, what is the Investigation and what level is it elevated?

A

ALT is typically elevated e.g. 500 u/l

131
Q

What is the management of Acute fatty liver of pregnancy?

A

Management

  • support care
  • once stabilised delivery is the definitive management
132
Q

HIV in pregnancy: what is recommended if viral load is less than 50 copies/ml at 36 weeks?

A

vaginal delivery

Caesarean section at 38-39 weeks is recommended by BHIVA if viral load is >50 copies/mL

Intravenous zidovudine infusion is recommended if viral load is >1000

133
Q

When is Zidovudine considered in pregnant woman with HIV?

A

Delivery

Zidovudine is only recommended for vaginal deliveries if a woman presents in labour or with spontaneous rupture of membranes (SROM) and has a viral load of >1000 or an unknown viral load.

Zidovudine can also be considered if viral load 50-1000 and presenting with labour or SROM.

134
Q

Most often hypersegmented neutrophils are associated with which type of anemia and what are the causes?

A

Megaloblastic anemia

Megaloblastic anemia can be caused by folic acid deficiency or vitamin B12 deficiency including pernicious anemia

135
Q

Folic acid is converted to what and what is its role?

What are good sources of folic acid?

A

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid

Functions
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

136
Q

Chickenpox exposure in pregnancy, what is the first step?

A

check varicella antibiotics

137
Q

If a pregnant patient >20 weeks gestation is found to not be immune to varicella-zoster after antibody testing, they should be prescribed what?

A

Prescribed varicella-zoster immunoglobulin or they should be given oral acyclovir 7-14 days post-exposure.

Delaying the administration of oral acyclovir has been shown to reduce the rate of development of chickenpox.

Oral acyclovir is indicated if a pregnant patient >20 weeks gestation develops chickenpox. It can also be used in caution in a patient <20 weeks gestation. As this patient doesn’t have signs and symptoms of chickenpox as of yet, this is not indicated.

138
Q

What is the triad for pre-eclampsia?

A
  • new-onset hypertension (≥ 140/90 mmHg after 20 weeks of pregnancy)
  • proteinuria
  • oedema
139
Q

If a pregnant woman over 20 weeks, has a bp ≥ 160/110 mmHg are likely should she be admitted and observed?

A

Yes

140
Q

Which of the following presentations has the greatest mortality and morbidity?

A

Footling presentation at delivery

There is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency

141
Q

Transverse lie is what part of the baby is presenting?

And when does it occur?

A

Shoulder

Multiparous women due to their uterine muscles being less tight than a nulliparous woman

Extracephalic version may be attempted from 32 weeks and thus is manageable at 30 weeks.

142
Q

For a In occipitoposterior presentation where the the posterior fontanelle is found in the posterior quadrant of the pelvis; greater rotation is required so labour is usually longer, what is the best intervention?

A

22% require forceps and 5% require caesarean section

143
Q

40% of babies are breech at 20 weeks but what is the % at term?

A

only 3% at term- there is still plenty of room for the foetus to turn around and resolve to head down.

144
Q

Pre-eclampsia: Pregnancy-induced hypertension in association with proteinuria what is the level?

A

> 0.3g / 24 hours

145
Q

What is the scale for screening tool for postnatal depression?

A

The Edinburgh Scale

146
Q

Is there a difference between baby blues and postnatal depression?

A

yes, even the management is different.

baby blues seen in 60-70% of pts vs postnatal depression affects 10% of pts

baby blues short term 3-7 days so just needs reassurance and support, the health vistor has a key role vs postanatal depression has reassurance and support PLUS cbt and ssris such as sertraline and paroxetine (cos of low milk/plasma ratio) may be used if symptoms are severe

Fluoxetine is best avoided due to a long half-life

147
Q

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.

What is the most appropriate management for prophylaxis of Rhesus sensitisation?

A

One dose of anti-D immunoglobulin followed by a Kleihauer test

APH is associated with fetomaternal haemorrhage (FMH) and therefore an increased risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies.

This is a question about the prophylaxis of Rhesus sensitisation in a Rhesus negative Mother with antepartum haemorrhage.

148
Q

What does the Kleihauer test determine?

A

The proportion of fetal RBCs present in the maternal blood circulation

A Kleihauer test is a test for fetomaternal haemorrhage (FMH) which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin

According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation

149
Q

At how many weeks, is anti-D immunoglobulin given according to BCSH guidelines?

A

After 20 weeks gestation

Year 4 (Jesus Bless These Notes) (3 decks)

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