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YEAR 5: Specialties (Laz) > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What are the risks of asymptomatic bacteriuria in pregnancy?

A

Increased risk of preterm delivery

Increased risk of pyelonephritis during pregnancy

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2
Q

How should asymptomatic bacteriuria be treated?

A

Immediate antibiotic prescription (nitrofurantoin, amoxicillin or cefalexin)

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3
Q

Which tests are done at the booking visit?

A

FBC
MSU
Blood group and antibody screen
Infection screen (Hep B, HIV, Syphilis)

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4
Q

When does gestational thrombocytopaenia tend to occur?

A

> 28 weeks

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5
Q

What should women with a history of GDM be offered in their pregnancy?

A

OGTT or random blood glucose in the 1st trimester

NOTE: helps identify pre-existing diabetes that has developed in the meantime

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6
Q

post natal hepatitis B management

A

Hepatitis B vaccine (at birth, 1 month and 12 months)
Hepatitis B immunoglobulin (within 24 hours of delivery

confirm or deny hepatitis b in the neonate with blood test for serology

encourage breastfeeding (carries no risk of transmission)

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7
Q

Which parameters are used to date the pregnancy on ultrasound scan?

A

10-14 weeks = CRL

14-20 weeks = Head Circumference

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8
Q

What are the components of the combined test for Down syndrome?

A

Nuchal translucency
b-hCG
PAPP-A

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9
Q

What are the components of the quadruple test for Down syndrome?

A 
b-hCG 
AFP
Unconjugated oestriol  
Inhibin A 
NOTE: the triple test is a similar test that doesn't use inhibin A
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10
Q

What should be offered to women with a high risk of Down syndrome according to initial screening tests?

A

CVS (10-14 weeks)
Amniocentesis (15+ weeks)
cffDNA (only available privately)

NOTE: results take 48 hours

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11
Q

How often should SFH be measured?

A

Every antenatal appointment after 24 weeks

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12
Q

What should happen if there are concerns about foetal growth according to SFH measurements?

A

Organise an ultrasound

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13
Q

What is the NICE recommendation regarding vitamin D during pregnancy?

A

All pregnant and breastfeeding women should receive 10 µg vitamin D daily

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14
Q

When should an OGTT be performed in women with a high risk of GDM?

A

24-28 weeks

If previous history of GDM, this should be done at 16-18 weeks and a repeat at 24-28 weeks

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15
Q

What should be offered to women with a history of late pregnancy loss and a short cervix?

A

Prophylactic vaginal progesterone

Prophylactic cervical cerclage

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16
Q

How should PPROM be investigated?

A

Sterile speculum - pooling observed –> diagnose PPROM
No pooling –> test for IGF-like binding protein-1 and alpha-microglobulin-1 test

IMPORTANT: diagnostic tests should NOT be performed if the patient goes into labour

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17
Q

What antibiotic prophylaxis should be given to patients with PPROM?

A

Oral erythromycin 250 mg QDS for 10 days or until the woman is in established labour

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18
Q

Which women should be offered rescue cervical cerclage?

A

16-27 weeks with a dilated cervix and unruptured membranes

Do NOT perform if signs of infection, active vaginal bleeding or uterine contractions

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19
Q

Which investigations should be used to confirm a diagnosis of preterm labour?

A

If suspected preterm labour > 30 weeks

  • Consider TVUSS to determine likelihood of birth within 48 hours (cervical length > 15 mm means it is unlikely)
  • Consider fetal fibronectin (low concentration suggests it is unlikely)

IMPORTANT: if < 30 weeks and clinical assessment suggests preterm labour, treatment is necessary without further investigation

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20
Q

Which agent is most commonly used for tocolysis?

A

Nifedipine

If contraindicated: atosiban (oxytocin receptor antagonist)

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21
Q

Up to what gestation should maternal corticosteroids be considered in preterm labour?

A

36 weeks

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22
Q

Which agent is used for neuroprotection in preterm delivery?

A

IV magnesium sulphate 4 g over 15 mins (loading) and 1 g/hour until birth or for 24 hours

NOTE: this is used in women who are delivering at 24-34 weeks (most important for 24-30 weeks)

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23
Q

How is magnesium sulphate poisoning treated?

A

Calcium gluconate

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24
Q

Which parameters are measured in ultrasound biometry used to monitor foetal growth?

A

Biparietal diameter
Head circumference
Abdominal circumference
Femur length

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25
Q

How should IUGR babies be monitored?

A

Serial growth scans every 2 weeks
Doppler can be done 2 times per week (looks out for placental dysfunction leading to absent/reversal of blood flow in umbilical artery)
Advise monitoring foetal movements

ADMIT if reduced foetal movements

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26
Q

Which antihypertensives are associated with congenital abnormalities?

A

ACE inhibitors
ARBs

NOTE: these are not safe when breastfeeding (neither is amlodipine)

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27
Q

What level of urinary protein: creatinine ratio is considered significant?

A

> 30 mg/mmol

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28
Q

Which agent is used to treat gestational hypertension?

A

Oral labetalol

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29
Q

What should the target blood pressure be in gestational hypertension?

A

Systolic: < 150
Diastolic: 80-100

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30
Q

When should blood pressure be measured in a woman with gestational hypertension who has just given birth?

A

Daily for the first 2 days
Once on day 3 and 5

Continue the use of antihypertensives but consider reducing the dose as the BP falls < 130/80 (same applies for PET)

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31
Q

How often should blood pressure be measured in women who have been admitted for pre-eclampsia?

A

At least 4 times per day

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32
Q

Which other tests should you perform in a woman with pre-eclampsia?

A

FBC
U&E
LFTs
Foetal: USS, Doppler US, CTG

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33
Q

After how many weeks would you consider delivery for a woman with pre-eclampsia?

A

Within 24-48 hours for women with pre-eclampsia > 37 weeks

NOTE: this can be even earlier depending on the severity and response to treatment

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34
Q

How often should blood pressure be measured postnatally in a woman who has had pre-eclampsia? And was taking meds

A

Keep under observation for at least 24 hours
Monitor Bp at least 4/day whilst an inpatient
Every 1-2 days for up to two weeks after discharge from hospital until the woman is off treatment and has no hypertension
 Continue antenatal hypertensive treatment
 Consider reducing treatment if BP < 140/90
 Reduce treatment if BP < 130/80

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35
Q

When should methyldopa be stopped after birth?

A

Within 2 days after birth

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36
Q

When should further scans to assess the foetus be carried out in women with hypertensive disease in pregnancy?

A

28-30 weeks
Repeat at 32-34 weeks if severe pre-eclampsia

NOTE: CTG should be performed for any reported reduced foetal movements

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37
Q

What does magnesium sulphate toxicity cause and how is it treated?

A

Respiratory depression

Treatment: calcium gluconate

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38
Q

How long should magnesium sulphate be continued for in a woman with pre-eclampsia?

A

For 24 hours after the last seizure or until 24 hours after delivery

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39
Q

List some clinical features of severe pre-eclampsia?

A 
Severe headache 
Visual disturbance 
Papilloedema 
Severe pain just below the ribs 
Liver tenderness
Signs of clonus 
HELLP syndrome (platelet count falling below 100 x 109/L, abnormal liver enzymes)
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40
Q

What should be monitored whilst giving magnesium sulphate treatment?

A

every 4 hours - RR, HR, BP, deep tendon reflexes
Oxygen saturation
Urine output

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41
Q

What is the recurrence rate of gestational hypertension?

A

16-47%

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42
Q

What is the recurrent rate of pre-eclampsia?

A

15%

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43
Q

What are the blood glucose targets for a patient with diabetes mellitus in pregnancy?

A

Fasting < 5.3 mmol/L
1-hour post-prandial < 7.8 mmol/L
2-hour post-prandial < 6.4 mmol/L

NOTE: if on insulin or glibenclamide, recommend maintaining BM > 4

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44
Q

How often should pregnant women with diabetes mellitus check their blood glucose?

A

7 times per day

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45
Q

How do insulin requirements change throughout pregnancy?

A

Insulin resistance changes through pregnancy so patients are likely to require an increase in the dose of metformin or insulin in the second half of pregnancy

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46
Q

Which extra screening tests/monitoring would be recommended for women with diabetes during pregnancy?

A

renal and retinal screening - if abn at booking repeat at 16-20 weeks, if normal at booking repeat at 28 weeks
Serial ultrasound for foetal growth and amniotic fluid volume (every 4 weeks from 28-36 weeks)
specialist foetal cardiac scan = Assessment of cardiac outflow tracts

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47
Q

How should blood glucose be managed in a patient with T1DM or T2DM on insulin during labour?

A

Sliding scale or insulin and glucose

Aim for blood glucose 4-7 mmol/L

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48
Q

What are the risks that pregnancy carries in a woman with diabetes?

A

Blood glucose control is more important
Increased insulin requirements
Increased risk of hypoglycaemia
Risk of deterioration of pre-existing retinopathy and nephropathy

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49
Q

What are the risks of diabetes for a pregnancy?

A 
Miscarriage
Stillbirth 
Congenital malformation 
Macrosomia
Pre-eclampsia
Infection 
Operative delivery
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50
Q

Aside from blood glucose control, which other medications should be recommended for women with diabetes during pregnancy?

A

5 mg folate preconception until 12 weeks

75 mg aspirin from 12 weeks until delivery

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51
Q

Who should review a woman with a new diagnosis of GDM and when should this happen?

A

Joint diabetes and antenatal clinic within 1 week of diagnosis

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52
Q

Outline the management options for gestational diabetes mellitus.

A

1) diet and exercise (provided fasting BM < 7)
2) metformin (if step 1 ineffective after 1-2 weeks)
3) add insulin

If fasting BM > 7 –> insulin
If fasting BM 6-6.9 and evidence of complications (e.g. macrosomia) –> insulin

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53
Q

When should women with GDM check their blood glucose on a daily basis?

A

Fasting
Pre-meal
1-hour post-meal
Bedtime

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54
Q

When might HbA1c be used in pregnancy?

A

In all women with pre-existing diabetes at booking

At the time of diagnosis of GDM to identify undiagnosed T2DM

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55
Q

When should women with diabetes in pregnancy ideally deliver?

A

Offer elective birth between 37-39 weeks

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56
Q

How should a woman with GDM be followed-up postnatally?

A

Stop blood glucose lowering treatment immediately after delivery
Monitoring:
- fasting blood glucose at 6-13 weeks postnatal (or HbA1c if after 13 weeks) to exclude new diagnosis of diabetes
- if <6mmol/L = moderate risk of developing T2DM, offer annual HbA1c and diet and lifestyle advice
- if 6-6.9mmol/L = high risk of developing T2DM, offer annual HbA1c and diet and lifestyle advice
- if 7mmol/L = likely to have T2DM at present, offer diagnostic test to confirm

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57
Q

What is an alternative agent that can be used in diabetes in pregnancy is metformin is not tolerated?

A

Glibenclamide (sulphonylurea)

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58
Q

What are the steps in the management of a patient with hyperemesis gravidarum?

A

1st line: antihistamines (promethazine or cyclizine)
2nd line: ondansetron or metoclopramide
Alternative: P6 acupressure, ginger

If severe dehydration: admit for IV rehydration, thiamine supplementation and thromboprophylaxis

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59
Q

What antibiotic regime is recommended for UTI in pregnancy?

A

Nitrofurantoin 50 mg QDS for 7 days - avoid in fullterm women

2nd line (if no improvement after 48 hours): amoxicillin or cephalexin

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60
Q

What TSH level should pregnant women with hypothyroidism aim for?

A

< 4 mmol/L

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61
Q

What are the risks of suboptimal thyroid hormone replacement?

A

Developmental delay

Pregnancy loss

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62
Q

How should hyperthyroidism in pregnancy be treated?

A

Only in 1st trimeste: Propylthiouracil (it crosses the placenta and in high doses may causes foetal goitre and hypothyroidism)

For the rest of the pregnancy: carbimazole
Continue at the lowest possible dose according to TFT –> adjust dose according to TFT ~ women often require lower doses ( and 1/3 are able to stop treatment all together in pregnancy)

Safety net regarding risk of agranulocytosis
Radioactive iodine is contraindicated

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63
Q

What are the risks of uncontrolled thyrotoxicosis in pregnancy?

A

Miscarriage
Preterm delivery
IUGR

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64
Q

What are the three criteria required to diagnose postpartum thyroiditis?

A

< 12 months of giving birth
Clinical manifestations of hypothyroidism
TFTs to support

NOTE: TPO antibodies present in 90%

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65
Q

How is post-partum thyroiditis managed?

A

Thyrotoxic phase: propanolol

Hypothyroid phase: thyroxine

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66
Q

What happens to the pituitary gland during pregnancy?

A

Enlarges by 50%

NOTE: dopamine agonists are usually stopped during pregnancy

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67
Q

heart disease management - intrapartum

A

Aim to wait for spontaneous labour and avoid IOL where possible

advise epidural anaesthesia to reduce pain-related cardiac strain

use prophylactic antibiotics if structural heart defect present –> reduces the risk of bacterial endocarditis

minimise length of 2nd stage of labour (using forceps or ventouse because want to reduce maternal effort and the need for more cardiac output

active management of 3rd stage of labour is with syntocinon alone, but introduce slowly. avoid ergometrine

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68
Q

Which asthma drugs are safe to use in pregnancy?

A

ALL of them

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69
Q

Which medications that are commonly used in labour/delivery should be avoided in asthmatic patients?

A

Ergometrine
Prostaglandin F2a
Labetalol

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70
Q

What congenital abnormalities are associated with anti-epileptic drug use in pregnancy?

A

Neural tube defects
Facial clefts
Cardiac defects

Others: developmental delay, growth restriction

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71
Q

What is the dangerous consequence of a seizure during pregnancy?

A

Maternal and foetal hypoxia

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72
Q

How might the recommendations for delivery be different in a pregnant woman with epilepsy?

A

Recommend epidural analgesia because it reduces stressors that might precipitate an epileptic seizure

NOTE: women should also receive vitamin K in the last month of pregnancy if on phenytoin

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73
Q

Which antiepileptic is considered to carry the lowest risk of congenital malformations?

A

Lamotrigine

NOTE: breastfeeding is considered safe with antiepileptics

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74
Q

How are migraines managed in pregnancy?

A

Simple analgesia
Consider low-dose aspirin and beta-blockers to prevent attacks

NOTE: triptans are contraindicated

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75
Q

Which treatments can be used to increase platelet count in ITP in pregnancy?

A

Steroids
IVIG

NOTE: platelet count > 50 x 10^9/L is required for safe delivery, > 70 x 10^9 is necessary for epidurals

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76
Q

What are the risks associated with untreated coeliac disease in pregnancy?

A

Spontaneous miscarriage

IUGR

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77
Q

List some indications for high dose (5 mg) folic acid preconception to 12 weeks in pregnancy.

A 
Diabetes mellitus 
Obesity
Coeliac disease 
Thalassemia
Sickle cell disease
Epilepsy (i.e. antiepileptic drug use)
Previous child with NTD
HIV positive taking co-trimoxazole
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78
Q

Which investigations should be requested in suspected obstetric cholestasis?

A

LFTs
Bile acid
Coagulation screen (PT may be prolonged due to reduced vitamin K)

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79
Q

What are the main risks of obstetric cholestasis?

A

Prematurity
Stillbirth
Meconium passage

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80
Q

How should obstetric cholestasis be treated?

A

Advise wearing loose cotton clothes
Ursodeoxycholic acid
Vitamin K supplementation (if PT prolonged)
Topical emollients
Offer induction at 37 weeks
Offer weekly LFTs and twice weekly CTG (and close monitoring of foetal movements)

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81
Q

How long before getting pregnant should methotrexate be stopped?

A

Both men and women should be off methotrexate for 6 months before attempting to conceive

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82
Q

Until what point in pregnancy can NSAIDs be used?

A

32 weeks

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83
Q

Outline the reassuring features of a CTG.

A 
FHR/BRA: 110-160 bpm
BV: 5-25 bpm
Decelerations: absent or early 
Accelerations: 2 within 20 mins 	
IMPORTANT: a CTG with each of these features is described as having ‘met criteria’
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84
Q

Outline the non-reassuring features of a CTG.

A

100-110 bpm or 161-180 bpm

BV: < 5 for 30-50 mins or > 25 for 15-25 mins

Variable decelerations with no concerning characteristics for > 90 mins
Variable decelerations with any concerning features in < 50% of contractions for > 30 mins

Variable decelerations with > 50% of contractions for < 30 mins

Late decelerations for < 30 mins

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85
Q

Outline the pathological features of a CTG.

A

< 100 bpm or > 180 bpm
BV: < 5 for > 50 mins, > 25 for > 25 mins, sinusoidal
Variable decelerations with any concerning characteristics in > 50% of contractions for < 30 mins
Late decelerations for 30 mins
Acute bradycardia or a single prolonged deceleration lasting > 3 mins (terminal deceleration)

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86
Q

What is the difference between a suspicious and a pathological trace?

A

Suspicious: 1 non reassuring feature
Pathological: 2 non reassuring features OR 1 pathological feature

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87
Q

Which investigation can help confirm fetal distress after a suspicious CTG?

A

Foetal blood sampling

This is only done if the patient is at 8-9 cm and you want reassurance that you can continue

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88
Q

What are the features of congenital rubella syndrome?

A 
o	Sensorineural deafness 
o	Congenital cataracts 
o	Blindness 
o	Encephalitis 
o	Endocrine problems
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89
Q

Describe the relationship between the gestation at which a pregnant woman develops rubella and the risk to the foetus.

A

< 11 weeks = nearly 100% risk
> 20 weeks = no risk

< 16 weeks = offer termination of pregnancy

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90
Q

What advice would you give to Rubella IgG negative pregnant women?

A

Keep away from anyone that might have rubella

Offer MMR vaccine in the postnatal period

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91
Q

What are the consequences of syphilis in pregnancy?

A 
o	FGR
o	Foetal hydrops 
o	Congenital syphilis (may cause long-term disability)
o	Stillbirth 
o	Preterm birth 
o	Neonatal death
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92
Q

How should syphilis in pregnancy be treated?

A 
refer to gum clinic (for appropriate contact tracing 
Benzathine penicillin (parenteral)

NOTE: if the woman is not treated during pregnancy, treat the child after delivery

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93
Q

What is the difference between non-treponemal and treponemal tests for syphilis?

A

Non-treponemal tests are non-specific screening tests that detect non-treponemal antibodies
Treponemal tests detect specific treponemal antibodies and are more specific

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94
Q

Name two non-treponemal tests.

A

Rapid plasma reagin (RPR)

Venereal disease research laboratory (VDRL)

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95
Q

Name two treponemal tests.

A

EIA
Treponema pallidum haemagglutination assay (TPHA)

NOTE: these are used in pregnancy

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96
Q

What is a Jarish-Herxheimer reaction?

A

Treatment results in the release of proinflammatory cytokines in response to dying organisms
Presents with symptoms and fever that develops 12-24 hours after treatment

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97
Q

What advice can you give a pregnant woman about avoiding toxoplasmosis?

A

Avoid eating raw/rare meat

Avoid handling cats and cat litter

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98
Q

How is a diagnosis of toxoplasmosis made?

A

Sabin Feldman dye test

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99
Q

Which test should be performed if an ultrasound suggests that there is a risk of congenital toxoplasmosis?

A

Amniocentesis and PCR of amniotic fluid for T. gondii
If toxoplasmosis is found to be the cause of the abnormal ultrasound, TOP should be offered

NOTE: treated with spiramycin

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100
Q

What are the clinical features of congenital toxoplasmosis?

A 
Ventriculomegaly
Microcephaly
Chorioretinitis 
Cerebral calcification 
NOTE: most infants are asymptomatic at birth
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101
Q

Describe the relationships between the gestation at which the mother is exposed to toxoplasmosis and the risk of foetal damage.

A

1st trimester - most likely to cause severe foetal damage but the risk of transmission is low
3rd trimester - low risk of foetal damage but much higher transmission rates

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102
Q

Why is the detection of IgM antibodies not very useful for toxoplasmosis and CMV?

A

They persist for a long time so you don’t know when the patient was infected

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103
Q

How can IgM antibodies be used to confirm a diagnosis of CMV in a pregnant woman?

A

A new finding of anti-CMV IgM in a previously IgM-negative woman is suggestive of primary CMV infection

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104
Q

How can a diagnosis of CMV infection in pregnancy be confirmed?

A

Amniocentesis and PCR

If congenital CMV is detected, offer TOP

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105
Q

How can VZV immunity be confirmed?

A

Detection of VZV IgG

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106
Q

How should you treat non-immune pregnant women who have been exposed to chickenpox?

A

Before 20 weeks:
VZIG as soon as possible given up to 10 days after contact
Seek advice if rash develops

After 20 weeks:
Either VZIG OR acyclovir given 7-14 days after exposure

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107
Q

What are the maternal risks of VZV in pregnancy?

A

Increased risk of pneumonia, hepatitis and encephalitis

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108
Q

How is chickenpox in pregnancy managed?

A

Avoid contact with other pregnant women and infants
Oral aciclovir for 7 days should be prescribed if presenting within 24 hours of rash onset and > 20 weeks gestation (consider in patients < 20 weeks)
If hospitalised, keep in isolation

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109
Q

How should maternal chickenpox around the time of delivery be managed?

A

Significant risk to the newborn if within 4 weeks of delivery
Elective delivery should be avoided until 7 days after the onset of the rash (allow for the passive transfer of antibodies to the foetus)

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110
Q

What are the main features of congenital varicella syndrome?

A

Skin scarring in a dermatomal distribution
Eye defects (microphthalmia, chorioretinitis, cataracts)
Hypoplasia of the limbs
Neurological abnormalities

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111
Q

What prenatal diagnosis techniques can be offered to a woman with chickenpox in pregnancy?

A

Refer to foetal medicine specialist at 16-20 weeks or 5 weeks after infection
Amniocentesis and VZV DNA PCR has a high NPV but low PPV

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112
Q

What is the main risk of parvovirus B19 infection in pregnancy?

A

Aplastic anaemia leading to hydrops fetalis and intrauterine death

May resolve spontaneously or may need intrauterine blood transfusion

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113
Q

At what point in pregnancy does parvovirus B19 infection pose the greatest risk to the foetus?

A

< 20 weeks

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114
Q

What are the risks of listeria in pregnancy?

A

Stillbirth
Late miscarriage
Early-onset sepsis

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115
Q

How is listeria treated?

A

IV antibiotics (ampicillin 2 g every 6 hours and erythromycin)

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116
Q

How should first-episode genital herpes in pregnancy be diagnosed and treated?

A

Refer to GUM
Viral culture and PCR
Aciclovir 400 mg TDS

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117
Q

How should women with primary herpes infection in the 3rd trimester be managed?

A

C-section should be recommended (especially if within 6 weeks of onset)
Give intrapartum IV aciclovir

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118
Q

How should recurrent episodes of herpes simplex infection in pregnancy be managed?

A

NOT an indication for C-section
Consider 400mg TDS oral aciclovir from 36 weeks until delivery
offer vaginal delivery
Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions

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119
Q

How would you manage a woman who is found to have GBS in her genital tract?

A

Intrapartum antibiotics (IV benzylpenicillin) as soon as possible after the onset of labour

Penicillin allergy: clindamycin

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120
Q

List some indications for GBS prophylaxis.

A

Intrapartum fever
PROM
Prematurity
Previous infant with GBS
Incidental detection of GBS in pregnancy
GBS bacteriuria
NOTE: women colonised with GBS who are having an elective C-section do NOT need GBS-specific antibiotic cover

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121
Q

Outline the management of the newborn with risk factors for early-onset GBS disease.

A

1 minor risk factor = remain in hospital for observation for 24 hours
2 or more minor risk factors = full septic screen AND IV penicillin + gentamicin

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122
Q

How should HIV be monitored in pregnancy? - antenatally

A

arrange contact with joint HIV physician and obstetric clinic every 1-2 weeks

monitor CD4 counts at baseline and at delivery
HIV viral load every 2-4 weeks, at 36 weeks and after delivery

all women should be offered antiretroviral therapy throughout pregnancy

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123
Q

What interventions can be used to reduce the risk of transmission of HIV to the baby?

A

ART (antenatally and intrapartum in the mother, in the baby for 4-6 weeks)
Delivery by C-section if the viral load is high
Avoidance of breastfeeding

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124
Q

When would C-section be recommended for women with HIV in pregnancy?

A

Hepatitis C coinfection

High viral load > 50

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125
Q

What antiretroviral cover is recommended for pregnant women undergoing a planned C-section or presenting with SROM?

A

IV zidovudine (4 hours before C-section)

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126
Q

How are neonates born to mothers with HIV treated?

A

Clamp the cord ASAP
Bath the baby
Avoid breastfeeding
AZT aka zidovudine (oral or IV) for 4-6 weeks

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127
Q

How can HIV infection in the newborn be confirmed?

A

Direct viral amplification by PCR

Usually carried out at birth, on discharge, 6 weeks and 6 months

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128
Q

How often should vaginal examination be performed in the first stage of labour?

A

Every 4 hours

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129
Q

When does the active phase of the 1st stage start?

A

When the cervix is 4 cm dilated and fully effaced

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130
Q

What counts as a prolonged second stage of labour?

A

Nulliparous > 2 hours since onset of active 2nd stage
Multiparous > 1 hour since onset of active 2nd stage

Allow an extra hour if they have epidural analgesia

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131
Q

What are some causes of obstructed labour?

A

Shoulder dystocia
Cephalopelvic disproportion
FGM

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132
Q

How should a prolonged second stage of labour be managed?

A 
ARM if membranes are still intact
Augmentation with oxytocin
Ongoing obstetric review every 15-30 mins 
Continuous foetal monitoring (CTG)
C-section
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133
Q

What is prolonged 3rd stage of labour?

A

If the placenta doesn’t come out within 30 mins

NOTE: usually comes out within 5-10 mins

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134
Q

Which management option for the 3rd stage of labour is recommended to all women?

A

Active management - controlled cord traction (reduces risk of PPH)
If parts of the placenta are retained, it will require manual removal under general anaesthetic

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135
Q

What is physiological management of the third stage?

A

The placenta is delivered by maternal effort and no uterotonic drugs
Associated with heavier bleeding
Active management should be considered if the placenta is not delivered after 60 mins or significant bleeding occurs

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136
Q

Outline the order in which interventions take place in the induction of labour.

A

1st line = vaginal prostaglandin e2 –> tablet or gel (prostin) ~ 1 dose followed by a 2nd dose after 6 hours (max 2 doses) or pessary (Propess) ~ 1 dose over 24 hours
- risk of uterine hyperstimulation

2nd line - ARM (perform VE afterwards to check for cord prolapse) only if the cervix has started to dilate and efface. can be used to augment or accelerate labour

3rd line - IV Syntocinon - if 2 hours after membranes have ruptured, labour has not started. risk of uterine hyperstimulation, inc risk of uterine rupture
If fully dilated, instrumental delivery may be considered.

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137
Q

What is the definitive management option for placenta accreta?

A

Hysterectomy

138
Q

What can cause increased nuchal translucency?

A

Down syndrome
Abdominal wall defects
Congenital cardiac defects

139
Q

How is the Bishop score interpreted?

A

< 5 suggests that labour is unlikely to start without induction

140
Q

How long can lochia go on for after birth?

A

6 weeks

141
Q

What are the risks of smoking in pregnancy?

A 
IUGR
Miscarriage 
Preterm 
Stillbirth 
Sudden infant death
142
Q

What are the characteristic features of foetal alcohol syndrome?

A

Learning difficulties
Facies: smooth philtrum, thin vemilion, small palpebral fissures
IUGR
Microcephaly

143
Q

What is the definition of hyperemesis gravidarum?

A

5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance

144
Q

What are the sepsis 6?

A 
Oxygen 
IV fluids 
IV antibiotics 
Take blood cultures 
Take lactate 
Monitor urine output
145
Q

Under what circumstance would you give a septic patient a fluid bolus and how much would you give?

A

If hypotensive and/or serum lactate > 4 mmol/L

Give 20 ml/kg bolus of crystalloid

146
Q

Which investigations should be performed in a patient with an antepartum haemorrhage?

A

FBC
G&S and consider X-match
Kleihauer test (if RhD negative)

147
Q

How should a stable patient with an antepartum haemorrhage be followed up?

A

Growth scan and umbilical artery Doppler every 2 weeks
Consultant-led antenatal care
Final USS at 36-37 weeks to determine mode of delivery

148
Q

Which investigations should be performed in a patient presenting with suspected placenta praevia causing an antepartum haemorrhage?

A

TVUSS
CTG
Bloods - FBC, clotting studies, G&S and crossmatch

Do NOT do a bimanual

149
Q

How long should a stable woman with an antepartum haemorrhage due to placenta praevia stay in hospital for?

A

Admit for 48 hours for observation

150
Q

How should a patient with a low-lying placenta at the 20-week scan be followed-up?

A

advise to avoid sex
Rescan at 32 weeks
If still low –> rescan at 36 weeks
If still low –> recommend elective C section (if < 2 cm from os)

151
Q

What is placenta praevia and how should it be managed?

A

completely covering the os
advise avoid sex
rescan at 32 weeks gesation –> if still low lying rescan at 36 weeks –> if still low lying recommended elective c section at 36-37 weeks gestation

152
Q

Which pharmacological agents can be used to minimise the risk of PPH?

A

IM oxytocin (10 iU) if vaginal
IM oxytocin (5 iU) if C-section
IM syntometrine if no hypertension and increased risk of PPH
Consider tranexamic acid

153
Q

How is a minor PPH managed?

A 
IV access 
Urgent venepuncture for: 
	Group and screen
	FBC 
	Coagulation screen, including fibrinogen 
Pulse, RR and BP every 15 mins
Commence warmed crystalloid infusion
154
Q

Outline the initial non-pharmacological steps in the management of major PPH.

A 
ABC
Lie flat 
10-15 L/min oxygen 
2 large bore cannulae 
Send blood for FBC, G&S and X-match 
Until blood is available infuse up to 3.5 L of warmed clear fluids
Foley catheter 
Pharmacological/surgical management
Transfuse (O negative and K negative blood, fibrinogen should be maintained > 2, FFP if bleeding continues, platelets if < 75)
155
Q

Outline the pharmacological/surgical steps in the management of major PPH.

A

Step 1: IV/IM syntocinon or IM ergometrine or syntometrine
Step 2: IM carboprost (careful in asthmatics)
Step 3: Bakri balloon tamponade
Step 4: other surgical measures (e.g. B-lynch suture, hysterectomy)
EMERGENCY: bimanual compression

156
Q

Outline the management of eclampsia.

A

Call for senior help
ABCDE
Magnesium sulphate - 4 g loading dose followed by infusion of 1 g/hour for 24 hours after delivery/last seizure

157
Q

What are the consequences of magnesium sulphate overdose and what is the antidote?

A

Respiratory depression
Cardiac arrest
Antidote: 10 mL 10% calcium gluconate

158
Q

Outline the management of cord prolapse.

A

Perform VE immediately
Call senior helps and prepare the operating theatre
Elevate the presenting part (or fill the bladder)
Consider tocolysis
Place mother on all fours
Performed CTG
Usually deliver by emergency C-section

159
Q

List some risk factors for shoulder dystocia.

A

Macrosomia
High BMI
Diabetes mellitus
Prolonged labour

160
Q

Outline the management of shoulder dystocia.

A

Call for senior help
McRobert’s manoeuvre
Suprapubic pressure
Consider episiotomy
Deliver posterior arm and shoulder or consider internal rotational manoeuvres (Rubin, Woods’ screw)
Change position to all fours
Consider symphysiotomy, cleidotomy or Zavanelli

161
Q

Which investigation should be performed in a patient with a suspected DVT?

A

Compress duplex ultrasound

162
Q

Which investigations should be performed in a patient with a suspected PE?

A

ECG
CXR
Compression duplex ultrasound (if DVT)
V/Q or CTPA

163
Q

How should a DVT/PE during pregnancy be managed?

A

Therapeutic dose LMWH given daily in two divided doses according to the patient’s weight until 6 weeks postpartum (at least 3 months in total)

164
Q

How should VTE in a collapsed patient be managed?

A

Unfractionated heparin
Thrombolysis
Thoracotomy and surgical embolectomy

165
Q

Outline the management of uterine inversion.

A

ABCDE
Call for senior help, IV fluid resuscitation, insert urinary catheter, pain management
Attempt manual replacement
Attempt hydrostatic replacement (instilling 2-3 L of warm saline into the vagina)
Attempt surgical procedures (e.g. hysterectomy)

166
Q

What causes puerperal pyrexia?

A 
Endometritis (MOST COMMON) 
UTI 
Wound infection 
Mastitis 
VTE
167
Q

Outline the management of puerperal pyrexia.

A

IV antibiotics (clindamycin and gentamicin) until afebrile for > 24 hours

NOTE: gentamicin should be avoided in pregnancy

168
Q

What features of a pregnancy would suggest that it is safe to offer VBAC?

A

SIngleton
Cephalic presentation at 37+ weeks
Only one previous LSCS
Success rate: 70%

Previous vbac
Normal sized baby
Vertex presentation

169
Q

List some contraindications for VBAC.

A

Previous uterine rupture
Classical C-sections scar
Non-C-section contraindication (e.g. placenta praevia)

170
Q

What are the risks of VBAC?

A

Uterine rupture
Instrumental delivery
Emergency C-section

Infant: stillbirth, transient respiratory morbidity

171
Q

What are the benefits of elective repeat of C-section?

A

No risk of rupture

Can plan the recovery

172
Q

What are the risks of elective repeat of C-section?

A 
Longer recovery 	
Risk of bladder/bowel injury (rare) 
Future placenta praevia/accrete 
Likely to need future LSCS 
Infant: transient respiratory morbidity
173
Q

What are some important things to consider regarding the intrapartum management of VBAC?

A

Electronic foetal monitoring throughout
Induced or augmented labour has an increased risk of uterine rupture
Induction with mechanical methods (e.g. ARM) has a lower risk of scar rupture

174
Q

From what gestation would you expect to be able to visualise the foetal heart beat?

A

6 weeks

175
Q

How does hCG change in early pregnancy?

A

Double every 48 hours

176
Q

List some causes of miscarriage.

A 
Chromosomal abnormalities 
Medical/endocrine disorders 
Uterine abnormalities 
Infections 
Drugs/chemicals
177
Q

How often should the following types of multiple pregnancies receive ultrasound scans?
MCDA
DCDA

A

MCDA: 2-weekly growth and Doppler scans from 16 weeks (refer to foetal medicine specialist)
DCDA: 4-weekly growth and Doppler scans from 20-36 weeks

178
Q

List some maternal and foetal complications associated with multiple pregnancy.

A

Maternal: preterm delivery, traumatic birth, hypertension, hyperemesis gravidarum
Foetal: IUGR, TTTS, Down syndrome

179
Q

How is IUGR in twin pregnancy monitored and what result would indicate IUGR?

A

Estimate foetal weight using > 2 biometric parameters at each scan from 20 weeks
Aim to repeat the scan at least every 4 weeks
Difference in size > 20/25% is IUGR

180
Q

In a multiple pregnancy, the presence of which other risk factors would warrant the use of 75 mg aspirin from 12 weeks until term?

A
  • First pregnancy
  • 40+ years
  • Pregnancy interval > 10 years
  • BMI > 35 at first visit
  • Family history of pre-eclampsia
181
Q

At what point should elective delivery be offered to uncomplicated MCDA and DCDA twin pregnancies?

A

MCDA: from 36 weeks
DCDA: from 37 weeks
MCMA: C-section at 32-34 weeks

NOTE: increased risk of foetal death beyond 38 weeks

182
Q

Which type of delivery is possible with twin pregnancy?

A

Vaginal if the 1st twin is in the cephalic position

5% risk of the second twin requiring C-section

183
Q

How is TTTS managed?

A

Fetoscopic laser ablation if < 26 weeks
If > 26 weeks, delivery may be considered
Weekly ultrasound
Aim for delivery at 34-37 weeks

184
Q

How should a breech presentation be managed?

A

< 36 weeks: many foetuses will turn spontaneously
> 36 weeks: ECV (36 weeks for nullip, 37 weeks for multip)
If ECV fails: planned C-section or planned vaginal delivery

185
Q

List some contraindications for ECV.

A 
Ruptured membranes 
Multiple pregnancy
APH within the last 7 days 
Abnormal CTG 
Major uterine anomaly

C-section is required
Avoid inducing labour

186
Q

What are the risks and benefits of planned C-section for breech presentation?

A

Risks: increased risk of immediate maternal complications, increased risk of complications in future pregnancy (e.g. placenta accreta)
Benefits: small reduction in perinatal mortality, planned vaginal delivery is associated with short-term complications in the baby (e.g. low Apgar scores)

187
Q

How is an unstable lie managed?

A

If mechanical cause (e.g. placenta praevia) –> LSCS
Hospital admission is usually recommended from 37 weeks
Consider ECV, ARM or LSCS

188
Q

How is mastitis managed?

A

Encourage continuation of breastfeeding
If systemically unwell, nipple fissures or symptoms not improving 12-24 hours after milk removal –> flucloxacillin 10-14 days

189
Q

What are some causes of baseline tachycardia?

A

Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity

190
Q

List some causes of reduced baseline variability.

A

Prematurity
Hypoxia
Foetal sleep (up to 40 mins)

191
Q

List some causes of late decelerations.

A

Asphyxia or placental insufficiency

192
Q

What typically causes variable decelerations?

A

Cord compression

193
Q

Outline a useful approach to interpreting CTGs.

A 
DR C BRAVADO
DR - define risk 
C - contractions 
BRA - baseline rate 
V - variability 
A - accelerations 
D - decelerations 
O - overall impression
194
Q

What is considered a normal pattern of accelerations?

A

Rise in FHR of > 15 bpm lasting > 15 seconds

Should be 2 accelerations every 20 mins (usually with contractions and should occur with foetal movements)

195
Q

What is a deceleration?

A

Reduction in FHR by at least 15 bpm lasting > 15 seconds

196
Q

What is a terminal bradycardia and terminal deceleration?

A

Terminal Bradycardia: < 100 bpm for > 10 mins
Terminal Deceleration: FHR drops and does not recover for > 3 mins

These are indications for C-section

197
Q

What are some non-reassuring features of a CTG?

A

100-110 bpm or 161-180 bpm
BV: < 5 for 30-50 mins or > 25 for 15-25 mins
Variable decelerations with no concerning characteristics for > 90 mins
Variable decelerations with < 50% of contractions for > 30 mins
Variable decelerations with > 50% of contractions for < 30 mins
Late decelerations in > 50% of contractions for < 30 mins

198
Q

What are some abnormal features of a CTG?

A

< 100 bpm or > 180 bpm
BV: < 5 for > 50 mins, > 25 for > 25 mins, sinusoidal
Variable decelerations with any concerning characteristics in > 50% of contractions for < 30 mins
Late decelerations for 30 mins
Acute bradycardia or a single prolonged deceleration lasting > 3 mins (terminal deceleration)

199
Q

What are the features of a normal intrapartum CTG?

A 
FHR: 110-160 bpm
BV: 5-25 bpm
Decelerations: absent or early 
Accelerations: 2 within 20 mins 	
IMPORTANT: a CTG with each of these features is described as having ‘met criteria’
200
Q

What counts as a normal, suspicious and pathological CTG?

A

Normal: all features are reassuring
Suspicious: 1 non-reassuring + 2 reassuring
Abnormal: 1 abnormal feature OR 2 non-reassuring features

201
Q

What is a combined deceleration and what causes it?

A

This is a deceleration within a deceleration

Usually due to overzealous use of syntocinon but can also be caused by infection and bleeding

202
Q

How is a preterm CTG different from one that is done at term?

A

Higher baseline rate
Lower variability
Decelerations are less helpful
Recovery from decelerations should be rapid

203
Q

Outline the degrees of perineal tears.

A

1st Degree: superficial damage with no muscle involvement
2nd Degree: injury to the perineal muscle, but not involving the anal sphincter
3rd Degree: injury to perineum involving the anal sphincter complex (EAS and IAS)
• 3a: < 50% of EAS
• 3b: > 50% of EAS
• 3c: IAS torn
4th Degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

204
Q

Outline the interpretation of the Edinburgh Postnatal Depression scale.

A

10-item questionnaire exploring how the mother is feeling
Maximum 30 points
> 13 suggests depressive illness

205
Q

List some medications that are contraindicated with breastfeeding?

A 
o	Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
o	Psychiatric drugs: lithium, benzodiazepines
o	Aspirin 
o	Carbimazole 
o	Methotrexate 
o	Sulphonylureas 
o	Cytotoxic drugs 
o	Amiodarone
206
Q

What are some requirements for instrumental delivery?

A

o Fully dilated cervix
o OA position (OP delivery is possibly with Keilland forceps and ventouse)
o Ruptured membranes
o Cephalic presentation
o Engaged presenting part (NOT palpable abdominally)
o Pain relief
o Sphincter (bladder) empty (usually requires catheterisation)

207
Q

Outline what is monitored during labour.

A

FHR monitored every 15 mins (or continuously via CTG)
Contractions every 30 mins
Maternal pulse rate every 1 hour
Maternal BP and temp every 4 hours
Vaginal examination every 4 hours to check progression of labour
Maternal urine for ketones and protein every 4 hours

208
Q

Which women require a partogram?

A

All women in active labour
All women on syntocinon
Threatened premature labour with the use of atosiban

209
Q

What do the alert line and the action line indicate in a partogram?

A

Alert line: when cervical dilatation is < 0.5 cm/hour (may require intervention (e.g. ARM))
Action line: 4 hours to the right of the alert line (requires urgent obstetric review)

210
Q

What can cause slow progress in the 1st stage of labour?

A

Malposition

Epidural analgesia

211
Q

How can a prolonged 1st stage of labour be managed?

A

ARM
Syntocinon (if there are inadequate contractions)
If they achieve full dilatation and enter the 2nd stage, instrumentation can be considered

212
Q

What postnatal care advice would you offer a woman who has had a vaginal delivery?

A

Stitches - bath every day and gently pat dry
Using the toilet - drink lots of water and eat a healthy diet, peeing may be a bit painful and you may not poo for a few days
Haemorrhoids - very common but disappear after a few days
Lochia - quite heavy at first but disappears by about 6 weeks
Breasts - initially produces yellowish colostrum, may feel tight and tender

213
Q

What postnatal care advice would you offer a woman who has had a C-section?

A

Average hospital stay: 3-4 days
Offer regular painkillers (avoid codeine) and encourage contact with the baby
Gently clean and dry the wound every day
Get stitches removed at 5-7 days
Caution with driving, exercising, heavy lifting and sex (should be fine after 6 weeks)
Avoid getting pregnant for 12-18 months

214
Q

Which vaccines are recommended in pregnancy?

A

Influenza (at any gestation)

Pertussis (16-32 weeks)

215
Q

How is secondary PPH managed?

A

High vaginal and endocervical swabs (endometritis) followed by appropriate antibiotic treatment (e.g. ceftriaxone and metronidazole)
TVUSS to exclude retained products of conception
Surgical evacuation of retained placental tissue

216
Q

What are some contraindications for digital examination?

A

Placenta praevia

Prelabour rupture of membranes (and not in labour)

217
Q

List some risks of obesity in pregnancy.

A

Antenatal: difficulty accurately assessing foetal growth, GDM, hypertensive disease, VTE
Intrapartum: difficulty with analgesia, difficulty monitoring labour, increased C-section rate
Postnatal: VTE, wound infection, PND

218
Q

What are the WHO recommendations regarding breast feeding?

A

Initiate breastfeeding within 1 hour of birth
Exclusive breastfeeding for 6 months
Continue breastfeeding for at least 2 years

219
Q

List some causes of IUGR.

A 
Placental insufficiency 
Infection 
Hypertensive disease 
Chronic maternal disease 
Maternal drug use (e.g. smoking, alcohol)
220
Q

How are antenatal corticosteroids given?

A

2 x 12 mg IM betamethasone 24 hours apart
Alternative: 4 x 6 mg IM dexamethasone 12 hours apart

NOTE: optimal benefit is seen 24 hours after starting treatment

221
Q

List some causes of polyhydramnios.

A 
Maternal diabetes mellitus 
Oesophageal or duodenal atresia
Chromosomal abnormalities (e.g. Down, Edwards)
Multiple pregnancy
Anencephaly
222
Q

List some causes of oligohydramnios.

A 
PROM 
Potter sequence (renal agenesis) 
IUGR 
Post-term 
Intrauterine infection 
Polycystic kidneys
223
Q

What is the normal range for the CRL at the dating scan?

A

45-84 mm

This will be from 11 - 13+6 weeks

224
Q

List some abnormalities that can be seen on the foetal anomaly scan.

A

Spina bifida
Hydrocephalus
Skeletal abnormalities (e.g. achondroplasia)
Abdominal wall defects (e.g. gastroschisis)
Cleft lip/palate
Congenital cardiac abnormalities

225
Q

What proportion of women have a low-lying placenta at the 20-week scan and how many of them will go on to have placenta praevia?

A

Low-lying placenta = 15-20%

Placenta praevia = 10% of those with a low-lying placenta

226
Q

Which approaches are used to assess amniotic fluid volume by ultrasound?

A

Maximum vertical pool
Amniotic fluid index

NOTE: AFI < 5th centile for gestation is commonly defined as oligohydramnios and > 95th centile is polyhydramnios

227
Q

What should be monitored in women with a history of midtrimester pregnancy loss?

A

TVUSS assessment of cervical length - regularly from 16 weeks

228
Q

Which parameters are measured in a biophysical profile?

A 
Foetal breathing movements (FBMs)
Foetal gross body movement
Foetal tone 
CTG 
Amniotic fluid volume

NOTE: a score of 2 for each is normal (8-10 overall is considered normal)

229
Q

What does increased resistance in the foetal aorta suggest?

A

Foetal acidaemia

230
Q

What does high resistance in the uterine artery suggest?

A

Pre-eclampsia

Placental abruption

231
Q

When would cordocentesis be performed?

A

If foetal blood is needed (e.g. suspected severe foetal anaemia, thrombocytopaenia)

This can be performed from 20 weeks

232
Q

What are the three main congenital uterine anomalies?

A

Subseptate/septate uterus
Bicornuate uterus
Uterus didelphys

233
Q

List some predisposing factors for breech presentation.

A

Maternal: fibroids, congenital uterine anomaly, uterine surgery
Foetal/Placental: multiple pregnancy, prematurity, placenta praevia, oligo/polyhydramnios

234
Q

What is the success rate of ECV?

A

50%

NOTE: ECV may be performed with the use of a tocolytic and FHR should be monitored before and after the procedure

235
Q

What are some risks of ECV?

A

Placental abruption
PROM
Transplacental haemorrhage

236
Q

Which manoeuvres may be used in a vaginal breech delivery?

A

Delivery of the legs: Pinard
Delivery of the shoulders: Loveset
Delivery of the head: Mauriceau-Smellie-Veit

237
Q

What are the risks of post-term pregnancy?

A

Post-term > 42 weeks

Stillbirth
Perinatal death
Prolonged labour
C-section

238
Q

On which chromosome are the Rhesus genes located?

A

Chromosome 1

Main Rhesus antigens = C, D and E (only D and c can caused haemolytic disease)

239
Q

Outline the management of rhesus disease in a sensitised woman.

A

Anti-D wont make a difference
Close monitoring of antibody levels every 2-4 weeks
Regular MCA Doppler US
Treat by delivering or foetal blood transfusion

240
Q

What is ‘shouldering’ on a CTG and what does it suggest?

A

Small rise in FHR before and after a deceleration

Shows that the foetus is coping well with the compression

241
Q

What can cause a sinusoidal pattern?

A

Foetal anaemia/hypoxia
This requires delivery

NOTE: pseudosinusoidal traces are benign and uniform. They are less regular in shape and amplitude than sinusoidal traces. This can be due to thumb sucking

242
Q

What are the different degrees of cranial moulding?

A 
0 = sutures felt 
1+ = bones are opposed 
2+ = bones overlap but can go back into normal position 
3+ = bones overlap and can't reset
243
Q

What is uterine hyperstimulation?

A

Either a series of single contractions lasting 2 minutes or more OR a contraction frequency of five or more in 10 minutes

244
Q

What should be offered to post-term women who decline IOL?

A

Twice-weekly CTG and USS

245
Q

Outline the sequence of movements of the foetal head as it passes through the pelvis.

A

Descent - descent of the head into the pelvis
Engagement - < 2/5 of the head palpable abdominally
Flexion - head flexes to give the smallest diameter
Internal rotation - rotates from OT to OA
Extension - head extends as it reaches the perineum (crowns)
External rotation (restitution) - on delivery, the foetal head reverts to original OT position
Lateral flexion - needed for shoulders/trunk to be delivered

246
Q

State the gestation at which the fertilised egg splits to give rise to MCMA, MCDA and DCDA twins.

A

MCMA: > 8 days
MCDA: 4-7 days
DCDA: <3 days

247
Q

List some sensitising events that would require anti-D immunoglobulin.

A 
Antepartum haemorrhage 
ECV
Abdominal injury 
Invasive prenatal diagnosis (CVS, amniocentesis)
Intrauterine procedures

Ideally should be given within 72 hours by IM injection

NOT needed < 12 weeks unless surgical management of ectopic, surgical TOP or molar pregnancy

248
Q

When is anti-D routinely given to RhD-negative women?

A

28 weeks and 34 weeks (500 iU)

Another 500 iU will be given postpartum if the woman has given birth to an RhD-positive baby

249
Q

What are the components of the Bishop score?

A

Dilation (<1, 1-2, 2-4, >4)
Consistency (firm, average, soft)
Length of cervix (>4, 2-4, 1-2, <1)
Position of cervix (posterior, mid/anterior)
Station of presenting part (-3, -2, -1 or 0, below spines)

250
Q

What are the different grades of placenta praevia?

A 
1 = encroaches on lower segment 
2 = reaches internal os 
3 = covers part of os (partial)
4 = completely covers the os (complete)

1 + 2 = minor
3 + 4 = major

251
Q

Which bacteria cause chorioamnionitis?

A

E. coli
Streptococcus
E. faecalis

252
Q

How should prelabour rupture of membrane be managed?

A

Immediate induction of labour
Expectant management (as 70% will spontaneously go into labour within 24 hours)
Antibiotic prophylaxis
NOTE: expectant management should not exceed 24 hours

253
Q

What is the recurrence rate of HELLP?

A

20%

254
Q

What biochemical change seen in acute fatty liver of pregnancy helps differentiate it from HELLP?

A

Hypoglycaemia

255
Q

How is acute fatty liver of pregnancy managed?

A

Strict fluid balance
Correction of coagulopathy and electrolyte disturbance
Hasty delivery

256
Q

How are the antihypertensives used in pregnancy administered?

A

Labetalol - oral or IV
Nifedipine - oral
Hydralazine - oral, IV or IM

257
Q

When should you exercise caution with the use of antenatal corticosteroids?

A

Active septicaemia in the mother

Insulin-dependent diabetics (can lead to ketoacidosis)

258
Q

What is the earliest gestation at which a ventouse can be used?

A

34 weeks

Before this, immaturity of the foetal head is associated with a risk of intracranial haemorrhage

259
Q

Describe the features of congenital syphilis.

A 
Poor feeding 
Runny nose (bloody)
Rash
Keratitis 
Deafness 
Frontal bossing 
Pregnancy: miscarriage, preterm, stillbirth
260
Q

Describe how symphysis fundal height corresponds to gestational age.

A

It is 20 cm at 20 weeks
Then it should increase by 1 cm per week until 36 weeks

Should be measured at each antenatal appointment after 24 weeks

261
Q

Which staging system is used for TTTS?

A

Quintero (goes from stage 1 to 5)

262
Q

What is twin anaemia-polycythaemia sequence?

A

A rarer chronic form of TTTS where there is a large inter-twin difference in haemoglobin (likely due to small unidirectional arteriovenous anastomosis)

263
Q

What are some risk factors for multiple pregnancy?

A

Age
Family history of multiple pregnancy
Assisted reproductive technology

264
Q

Which manoeuvre can be performed to deliver the 2nd twin if they are lying abnormally?

A

External cephalic version
Internal podalic version

NOTE: these are only possible for twin 2
For twin 2, the membranes should be broken as late as possible

265
Q

What is the effect of progesterone on myometrial activity?

A

Maintains uterine quiescence

266
Q

Describe how oxytocin levels change at the onset of labour.

A

There is no change in the oxytocin levels, however, there is an increase in the sensitivity of the myometrium to oxytocin (due to increased expression of oxytocin receptors)

267
Q

What is the main site of prostaglandin synthesis at labour?

A

Amnion

NOTE: myometrium is the main site of prostaglandin action and the chorion has enzymes responsible for prostaglandin metabolism

268
Q

List some causes of preterm labour.

A

Cervical weakness
Infection (chorioamnionitis)
Uterine anomalies
Haemorrhage

269
Q

What major consequence might chorioamnionitis have for the foetus?

A

Foetal brain damage (periventricular leukomalacia)

270
Q

List some types of tocolytics.

A

Nifedipine
Atosiban
Beta-agonists (e.g. terbutaline, ritodrine)
Magnesium sulphate
NSAIDs (risk of premature PDA closure resulting in persistent pulmonary hypertension)

271
Q

In which women should a choice of prophylactic vaginal cerclage or prophylactic vaginal progesterone be offered?

A

History of midtrimester (16-34 weeks) pregnancy loss
AND
TVUSS at 16-24 weeks showed cervical length < 25 mm

272
Q

Which women should be offered prophylactic vaginal progesterone to prevent preterm labour?

A

History of spontaneous preterm birth/miscarriage
and/or
TVUSS at 16-24 weeks shows cervical length < 25 mm

273
Q

Describe the use of nifedipine for tocolysis in preterm labour.

A

Consider nifedipine at 24-26 weeks
Offer nifedipine at 26-34 weeks
Can only be used if membranes are intact
NOTE: if nifedipine is contraindicated, use atosiban

274
Q

When should magnesium sulphate be used in preterm delivery?

A

24-34 weeks

275
Q

What proportion of women with gestational hypertension will go on to develop pre-eclampsia?

A

1/3

276
Q

Define pre-eclampsia.

A

Hypertension of at least 140/90 mm Hg recorded on at least 2 separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24-hr collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the 6th postpartum week

NOTE: or protein-creatinine ratio > 0.3 or > 30 mg/mmol

277
Q

List some moderate risk factors for pre-eclampsia.

Moderate risk factors -> prescribe aspirin if 2 or more are present

A 
First pregnancy 
Multiple pregnancy 
Family history of PET 
Age > 40 yrs 
BMI >35 
> 10 year pregnancy interval
278
Q

What lesion is seen within the kidneys in preeclampsia?

A

Glomeruloendotheliosis

279
Q

Which antihypertensive medication is safe to use in pregnancy?

A

Labetalol (1st line)
Nifedipine
Methyldopa

NOTE: ACEi, ARB and chlorothiazide are associated with an increased risk of congenital abnormalities

280
Q

List some indications for giving 75 mg aspirin OD to reduce the risk of pre-eclampsia from 12 weeks until conception.

(High risk factors - prescribe aspirin if 1 or more are present)

A 
Hypertensive disease in previous pregnancy 
Chronic hypertension
CKD 
Autoimmune disease (e.g. SLE, APLS) 
Diabetes mellitus
281
Q

When should a woman with gestational hypertension ideally deliver?

A

If < 160/110 mm Hg, do NOT offer delivery until > 37 weeks

282
Q

What proportion of Afro-Caribbean people have sickle cell trait?

A

1 in 10

283
Q

Based on the combined test for Down Syndrome, what is considered a high chance result?

A

< 1 in 150

NOTE: a result will be provided for chance of Down syndrome, and another result for the chance of Edwards and Patau combined

284
Q

What are some indications for immediate delivery in a IUGR pregnancy?

A

Abnormal CTG and reduced foetal movements

Reversal of end-diastolic flow

285
Q

By what point postpartum would you expect all hypertensive diseases of pregnancy to have resolved?

A

6 weeks

286
Q

When should growth scans be performed in a woman with chronic hypertension or high-risk of pre-eclampsia?

A

28-30 weeks
32-34 weeks

Perform CTG if abnormal movements are reported

287
Q

Until what gestation should pre-eclampsia without complications be managed conservatively?

A

34 weeks
Conservative management = BP every 2 days, bloods (fbc,lft, u+e) 2x/week, US foetal surveillance (groth, liquor, UA blood flow) every 2 weeks

288
Q

List some indications for urgent delivery in pre-eclampsia.

A

 Uncontrollable BP
 Rapidly worsening biochemistry/haematology
 Eclampsia
 Maternal symptoms
 Foetal distress, severe IUGR, reduced UA EDF

289
Q

What are some considerations for the intrapartum care of a woman with pre-eclampsia?

A

Timing:
- arrange delivery for 37 weeks gestation (or earlier if - inability to control maternal BP, maternal SpO2 < 92%, deterioration in maternal bloods, neurological/eclamptic features, placental abruption, reversed end diastolic flow)

Mode:
- offer choice between elective c section or induction off labour
- Recommend operative birth if the hypertension is failing to respond to treatment
- if induction is preferred:
- advise delivery in labour ward with
continuous CTG monitoring
- Encourage epidural anaesthesia (helps
control BP)
- Avoid ergometrine as increases BP
- Monitor BP

290
Q

What MEWS score is associated with an increased risk of clinical deterioration?

A

5 or more

291
Q

What are some risks of C-section?

A

Common: persistent wound/abdominal discomfort, increased risk of future C-section, infection
Uncommon: hysterectomy, uterine rupture in future pregnancy, placenta praevia/accreta in future pregnancy

292
Q

What are the different categories of C-section?

A

1 - immediate threat to the life of the woman or foetus
2 - maternal or foetal compromise that is NOT immediately life-threatening
3 - no maternal or foetal compromise but needs early delivery
4 - delivery timed to suit woman or staff

293
Q

How is chlamydia in pregnancy treated?

A

Erythromycin

294
Q

Why should an ultrasound scan be performed at the time of diagnosis of GDM?

A

Exclude congenital anomaly
Assess foetal growth
Assess liquor volume

295
Q

Which investigations would you consider in a pregnant women presenting with jaundice and itching?

A 
LFTs 
Bile acids 
Clotting profile 
Liver screen (hepatitis serology and autoimmune antibodies) 
Liver USS 
FBC 
U&E
296
Q

What measures can be taken to see whether a suspicious CTG trace will improve during labour?

A

Switch off syntocinon

Move to the left lateral position

297
Q

What is a normal foetal pH?

A

> 7.25

If it goes < 7.2, immediate delivery would be indicated
7.20-7.25 is borderline so repeat after 30 mins

298
Q

What is primary dysfunctional labour?

A

When the progress of labour is slow from the start

< 2 cm dilatation every 4 hours

299
Q

Which screening tests are used for Down syndrome and when can they be used?

A

Combined Test: 10-14 weeks
Quadruple Test: 14-20 weeks

NOTE: beyond 20 weeks, a mid-pregnancy scan may be offered to look for physical abnormalities

300
Q

When can cffDNA be performed?

A

10+ weeks

NOTE: it costs about £400-900 and has to be done privately

301
Q

How long are tocolytics usually used for in preterm labour?

A

Up to 48 hours to allow time for steroids to work

302
Q

What proportion of births occur after IOL?

A

20%

Success rate: 75-80%

303
Q

What estimated foetal weight would require a C-section?

A

> 5 kg

304
Q

What are some aspects of 3rd/4th degree perineal repair?

A

Repair in theatre
Antibiotic cover
Laxatives

305
Q

What are the BUBBLE that you should check after delivery?

A 
Breasts 
Uterus (and scar) 
Bowel 
Bladder 
Lochia 
Emotional/Episiotomy
306
Q

List some indications for serial ultrasound scan.

A 
Previous small baby 
Abnormal measurement on SFH 
Unable to measure SFH accurately 
Chronic medical condition  
High risk pregnancy

NOTE: growth scans should be at least 2 weeks apart

307
Q

Describe the change in doppler results with placental failure.

A

First change: umbilical artery PI increases

This requires twice weekly Doppler/CTG

308
Q

How should absent EDF be managed?

A

If > 32 weeks, daily monitoring and aim for delivery by 37 weeks

If < 32 weeks, ductus venosus is used to time delivery (if normal, deliver by 32 weeks; if abnormal then deliver immediately)

If CTG is abnormal at ANY POINT: C-section

309
Q

How should reversed EDF be managed?

A

Urgent delivery

310
Q

What are the main classes of haemorrhagic shock.

A

Class I: < 15%, normal HR/BP/RR, slightly anxious
Class II: 15-30%, mild tachycardia, normal BP, mild tachypnoea, anxious
Class III: 30-40%, moderate tachycardia, reduced BP, moderate tachypnoea
Class IV: >40%, severe tachycardia, reduced BP, severe tachypnoea

311
Q

Which birth defects are more common in mothers with diabetes?

A

Cardiac defects
Brain and spine abnormalities (NTD)
Urinary and kidney
GI tract

312
Q

Define ‘engagement’.

A

When the largest part of the foetal head enters the brim of the pelvis (usually in the OT position)

313
Q

Which drugs used during labour can precipitate bronchoconstriction?

A

Ergometrine

Carboprost (prostaglandin F2a)

314
Q

What are the consequences of hepatitis E infection in pregnancy?

A

Fulminant hepatic failure
Preterm delivery
IUGR
Stillbirth

315
Q

Describe the appearance of polymorphic eruption of pregnancy.

A

Self-limiting pruritic disorder in the 3rd trimester
Often begins in the lower abdomen at striae and extends to the thighs and buttocks
Spares the umbilicus
Lesions usually become confluent
No impact on pregnancy

316
Q

Describe the appearance of prurigo of pregnancy.

A

Common
Excoriated papules on extensor surfaces of limbs, abdomen and shoulders
Resolves after delivery

317
Q

Describe the appearance of pruritic folliculitis of pregnancy.

A

Pruritic follicular eruption with papules and pustules mainly on the trunk
Looks like acne
Resolves within weeks of delivery

318
Q

Where does toxoplasmosis come from?

A

Cat litter
Soil
Raw/undercooked meat

319
Q

What are the average dimensions of the pelvic inlet, mid-pelvis and pelvic outlet?

A

Pelvic inlet: 13.5 x 11 (transverse diameter is biggest)
Midpelvis: 12 (reasonably round)
Pelvic outlet: 11 x 13.5 (AP diameter is biggest)

320
Q

Describe the effects of progesterone in labour and describe how progesterone and oestrogen levels change at term.

A

Progesterone promotes uterine relaxation by suppressing prostaglandin production, inhibiting communication between myometrial cells and preventing oxytocin release

Oestrogen opposes the action of progesterone

Prior to labour, there is a decrease in PR and an increase in ER

NOTE: CRH production by the placenta also increases

321
Q

How long does the 1st stage of labour usually last?

A

Latent Phase: 3-8 hours

Active Phase: 2-6 hours

322
Q

How long does the 2nd stage of labour usually last?

A

Passive Phase: 1-2 hours

Active Phase: < 2 hours

323
Q

How often should the FHR be assessed when using intermittent auscultation?

A

1st stage: every 15 mins

2nd stage: every 5 mins

324
Q

How is AFI interpreted?

A

Normal: 8-18
Low (oligohydramnios): < 5-6
High (polyhydramnios): > 24

NOTE: a deepest pool > 8 cm is also considered polyhydramnios

325
Q

mode of delivery hiv

A

depends on the viral load at 36 weeks gestation
<50 copies/mL –> reassure that vaginal delivery is appropriate
>50 copies or co-existent hepatitis C –> recommoned elective csection with intrapartum IV zidovudine infusion at 38 weeks

cord shoud be clamped as soon as possible and the baby should be bathed immediatrly after birth

326
Q

postnatal advise hiv

A

advise women not to breastfeed
treat all newborns with ART within 4 hours of birth
- if low risk of transmission –> zidovudine monotherapy for 2-4 weeks
- if high risk of transmission –> triple ART (zidovudine, lamivudine, nevirapine for 4 weeks)
confirm or deny diagnosis in neonate with direct viral amplification by PCR (done at birth, on discharge, 6 weeks and 6 months

327
Q

hepatitis b antental management

A

refer to hepatologist

offer tenofovir to women with high HBV viral load (HBV DNA >10^7) –> start in 3rd trimester and stop 4-12 weeks after delivery unless the mother meets criteria for long term treatment
- monitor HBV viral load every 2 months and LFTs monthly

328
Q

membrane sweeping

A

offered weekly from 40 weeks gestation in nulli and 41 weeks in multi
insert gloved finger through cervix and rotate it around the inner rim of the cervix
releases physiological prostaglandins

must exclude placenta praevia

329
Q

uterine rupture mx

A

call for senior help
abcde approach - 2 large bore cannulae, urgent bloods for fbc, clotting g+s, cross match, transfuse blood asap
expedite delivery
urgent laparotomy to examine and repair (or remove the uterus)

330
Q

chronic hypertension antenatal mx

A

conservative: reduce salt intake, exercise

monitoring - bp monitoring (weekly if htn poorly controlled, every 2-4 weeks if htn well controlled). serial growth scans every 4 weeks from 28-36 weeks

medical - low dose aspirin 75mg od from 12 weeks gestation until birth

331
Q

chronic hypertension intrapartum mx

A

as long as BP <150/110, induction <37 weeks gestation should not be offered
if > 160/110 - senior input and patient involvement is required

332
Q

post natal chronic hypertension mx

A

bp monitoring - daily for first 2 days after birth, at least once on day 3 and day 5, as clinically indicated if antihypertensive tx has changed after birth

arrange follow up with gp or specialist for antihypertensive review

333
Q

post natal diabetes mellitus mx

A

monitoring:

  • check neonatal blood glucose within 4 hours of birth (to exclude neonatal hypoglycaemia)
  • refer women back to their routine diabetes care arrangements

medical:
- adjust insulin and metformin doses back to those of pre-pregnancy immediately after birth

334
Q

hypothyroidism antenatal monitoring

A

TFTs every 2-4 weeks to ensure biochemical euthyroidism
aim for TSH <4

continue thyroid replacement therapy
adjust dose according to TFT –> women often require higher doses esp in 1st tri

335
Q

post natal thyroid disease monitoring

A

tfts monitored at 6-8 weeks postnatal check with gp

336
Q

asthma management

A

antenatal: reeducate on inhaler technique, smoking cessation
continue pre-existing asthma treatment regimen as normal

intrapartum: avoid ergometrine (bronchoconstriction), aswella s labetaol and prostoglandin f2a
regional anaesthesia is preferred over general anaesthesia in c section

337
Q

heart disease antenatal care

A

joint cardiac and obstetric clinic (every 2-4 weeks until 20 weeks gestation, every 2 weeks until 24 and weekly thereafter)

maternal echocardiogram at booking and repeat at 28 weeks
specialist foetal cardiac scan at 22 weeks

VTE prophylaxis with LMWH

338
Q

heart disease post natal care

A

transfer to high dependency unit for close monitoring for first 12-48 hours
arrange obstetric and cardiac follow up

339
Q

antenatal epilepsy care

A

joint epilepsy and obstrtric clinic
serial growth scans every 4 weeks from 28-36 weeks
no need to monitor aed levels

340
Q

pre conception epilepsy care

A

reduce to monotherapy where possible –> lamotrigine preferred. sodium valproate causes NTD

5mg folic acid preconception til 12 weeks

vit k in last month of pregnancy

341
Q

post natal chicken pox mx

A

Arrange neonatal ophthalmic examination after birth

If birth within 7 days of onset of maternal rash or the mother develops chickenpox within 7 days of delivery, give VZIG to the neonate and monitorfor signs of infection until 28 days after maternal infection onset

Neonatal infection should be treated with aciclovir

YEAR 5: Specialties (Laz) (19 decks)

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