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Passmed Year 4 GOSH > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

NICE recommend giving rhesus negative woman anti-D when?

A

NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks

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2
Q

Risk factors of ectopic pregnancy

A

anything slowing the ovum’s passage to the uterus
* damage to tubes (pelvic inflammatory disease, surgery)
* previous ectopic
* endometriosis
* IUCD
* Smoking
* progesterone only pill
* IVF (3% of pregnancies are ectopic)
* Older age (less important)

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3
Q

Definition of olygohydramniosis

A

less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.

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4
Q

causes of olygohydramnios

A
  • premature rupture of membranes
  • fetal renal problems e.g. renal agenesis
  • intrauterine growth restriction
  • post-term gestation
  • pre-eclampsia
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5
Q

Antepartum haemorrhage is defined as bleeding after …. weeks

A

Antepartum haemorrhage is defined as bleeding after 24 weeks

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6
Q

major causes of bleeding during pregnancy.

A

1st trimester
* Spontaneous abortion
* Ectopic pregnancy
* Hydatidiform mole

2nd trimster
* Spontaneous abortion
* Hydatidiform mole
* Placental abruption

3rd trimester
* Bloody show
* Placental abruption
* Placenta praevia
* Vasa praevia

Alongside the pregnancy related causes, conditions such as sexually transmitted infections and cervical polyps should be excluded.

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7
Q

which examination should be avoided if suspected antepartum haemorrhage

A

vaginal examination should not be performed in primary care for suspected antepartum haemorrhage
- women with placenta praevia may haemorrhage

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8
Q

What are the different types of miscarriage and how does vaginal bleeding present in each

A
  • Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
  • Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
  • Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.
  • Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.
  • Complete miscarriage - little bleeding
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9
Q

key features of ectopic pregnancy

A
  • Typically history of 6-8 weeks amenorrhoea
  • with lower abdominal pain (usually unilateral) initially and vaginal bleeding later.
  • Shoulder tip pain and cervical excitation may be present
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10
Q

key features of hydatidiform mole

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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11
Q

key features of placental abruption

A
  • Sudden onset severe abdominal pain (lower) that is continuous
  • Vaginal bleeding (antepartum haemorrhage)
  • Shock (hypotension and tachycardia)
  • Abnormalities on the CTG indicating fetal heart distress
  • Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
  • Tense, tender uterus with normal lie and presentation
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12
Q

key features of placental praevia

A

Vaginal bleeding, no pain.
Non-tender uterus but lie and presentation may be abnormal

  • bleeding ussually presents later in pregnancy around or after 36 weeks
  • women usually asympomatic and diagnosed at 20 week anomaly scan used to assess position of placenta
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13
Q

key features of vasa praevia

A
  • Rupture of membranes followed immediately by vaginal bleeding.
  • Fetal bradycardia is classically seen, high fetal mortality
  • second to third trimester of pregnancy
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14
Q

Women who have a ‘higher chance’ combined or quadruple tests result are offered either … or ….

A

Women who have a ‘higher chance’ combined or quadruple tests result are offered either further screening (NIPT) or diagnostic tests (amniocentesis, CVS)

Given the non-invasive nature of NIPT and extremely high sensitivity and specificity, it is likely this will be the preferred choice for the vast majority of women.

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15
Q

when should a combined test be performed

A

between 11 - 13+6 weeks

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16
Q

what tests are included inlcuded in Down’s antenatal screening / combined test

A

nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)

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17
Q

what combined test results suggest down syndrome?

A

Down’s syndrome is suggested by
↑ HCG, ↓ PAPP-A, thickened nuchal translucency

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18
Q

if women book later in pregnancy for down syndorme antenatal screening whihc test should they be offered and when?

A

if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks

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19
Q

which tests are included in the quadruple test

A

quadruple test:
alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A

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20
Q

Results of quadruple test in down syndrom, edward’s syndrome and neural tube defects

A

Down’s syndrome: ↓Alpha-fetoprotein ↓Unconjugated oestriol ↑Human chorionic gonadotrophin ↑Inhibin A

Edward’s syndrome: ↓Alpha-fetoprotein ↓Unconjugated oestriol ↓Human chorionic gonadotrophin ↔Inhibin A

Neural rube defects: ↑Alpha-fetoprotein ↔Unconjugated oestriol ↔Human chorionic gonadotrophin ↔Inhibin A

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21
Q

Both the combined and quadruple tests return either a… or… result

A

Both the combined and quadruple tests return either a ‘lower chance’ or ‘higher chance’ result

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22
Q

what is considered lower chance in terms of results of quadruple or combined testing

A

‘lower chance’: 1 in 150 chance or more e.g. 1 in 300

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23
Q

what is considered higher chance in terms of results of quadruple or combined testing

A

‘higher chance’: 1 in 150 chance or less e.g. 1 in 100

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24
Q

What is NIPT? how does it work? what is its purpose?

A
  • analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
  • cffDNA derives from placental cells and is usually identical to fetal DNA
  • analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
  • sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
  • private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation
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25
Q

Conditions which all pregnant women should be offered screening

A
  • Anaemia
  • Bacteriuria
  • Blood group, Rhesus status and anti-red cell antibodies
  • Down’s syndrome
  • Fetal anomalies
  • Hepatitis B
  • HIV
  • Neural tube defects
  • Risk factors for pre-eclampsia
  • Syphilis

The following should be offered depending on the history:

  • Placenta praevia
  • Psychiatric illness
  • Sickle cell disease
  • Tay-Sachs disease
  • Thalassaemia
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26
Q

Conditions for which screening should not be offered in pregnancy

A

Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis

27
Q

When should you treat mastitis according to the BNF

A

if
* systemically unwell,
* if nipple fissure present,
* if symptoms do not improve after 12-24 hours of effective milk removal of
* if culture indicates infection’.

28
Q

first line antibiotic when you need treatment for mastitis

A

The first-line antibiotic is flucloxacillin for 10-14 days.

29
Q

what is the breastfeeding advise when receiving treatemnt for mastitis such as antibiotics?

A

Breastfeeding or expressing should continue during treatment.

30
Q

If left untreated, mastitis can lead to..

A

If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.

31
Q

presentation of breast engorgement

A
  • Breast engorgement is one of the causes of breast pain in breastfeeding women.
  • It usually occurs in the first few days after the infant is born and
  • almost always affects both breasts.
  • The pain or discomfort is typically worse just before a feed.
  • Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle.
  • Fever may be present but usually settles within 24 hours.
  • The breasts may appear red
32
Q

Complications of breast engorgement

A
  • blocked milk ducts,
  • mastitis and difficulties with breastfeeding
  • and, subsequently, milk supply.
33
Q

what can help relieve the discomfort of engorgement

A

Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.

34
Q

Raynaud’s disease of the nipple presentation

A
  • pain is often intermittent and present during and immediately after feeding.
  • Blanching of the nipple may be followed by cyanosis and/or erythema.
  • Nipple pain resolves when nipples return to normal colour.
35
Q

Options of treatment for Raynaud’s disease of the nipple include

A
  • advice on minimising exposure to cold,
  • use of heat packs following a breastfeed,
  • avoiding caffeine and stopping smoking.
  • If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
36
Q

concerns about poor infant weight gain: definition and how to deal with it

A
  • Around 1 in 10 breastfed babies lose more than the ‘cut-off’ 10% threshold in the first week of life.
  • This should prompt consideration of the breastfeeding problems.
  • The infant should also be examined to look for any underlying problems.
  • NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
37
Q

what are “minor” breastfeeding problems? their presentation and solution

A
  • frequent feeding in a breastfed infant is not alone a sign of low milk supply
  • nipple pain: may be caused by a poor latch
  • Blocked milk duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
  • nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby
38
Q

treatment for nipple candidiasis whilst breastfeeding should involve

A

treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby

39
Q

most likely cause of nipple pain during breastfeeding

A

nipple pain: may be caused by a poor latch

40
Q

Presentation of a blocked milk duct (“milk bleb”)
and advice

A
  • blocked duct (‘milk bleb’): causes nipple pain when breastfeeding.
  • Breastfeeding should continue.
  • Advice should be sought regarding the positioning of the baby.
  • Breast massage may also be tried
41
Q

Management of chicken pox in pregnancy

A
  • specialist advice should be sought
  • oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
  • if the woman is < 20 weeks the aciclovir should be ‘considered with caution’

there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy

42
Q

Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP): first step if there is any doubt about the mother previously having chickenpox

A

if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies

43
Q

Management of chickenpox exposure in pregnancy if the pregnant woman <= 20 weeks gestation is not immune to varicella

A
  • if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
  • RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
44
Q

Management of chickenpox exposure in pregnancy if the pregnant woman > 20 weeks gestation is not immune to varicella

A

if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

45
Q

Chickenpox exposure: risks to the mother

A

5 times greater risk of pneumonitis

46
Q

Chickenpox exposure during pregnancy: risks to the fetus

A

Fetal varicella syndrome

  • risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
  • studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks

Other risks to the fetus
* shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
* severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

47
Q

features of FVS include

A
  • skin scarring,
  • eye defects (microphthalmia),
  • limb hypoplasia,
  • microcephaly and
  • learning disabilities
48
Q

For patients assigned female at birth, which contraception is contraindicated if they are undergoing testosterone therapy

A

Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy.

49
Q

Can progestrone only contraceptives be used in patients assigned female at birth using testosterone therapy?

A

Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.

50
Q

Can progestrone only contraceptives be used in patients assigned female at birth using testosterone therapy?

A

Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.

51
Q

What effect do Non-hormonal intrauterine devices have as contraception for female born patients undergoing testosterone therapy?

A

Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.

52
Q

If a female born patient undergoing testosterone therapy needs emergency contraception, what should you prescribe?

A
  • Either of the available oral emergency contraceptive options may be considered as it is believed that neither oral formulation interacts with testosterone therapy.
  • the non-hormonal intrauterine device may be considered, however can exacerbate menstrual bleeding, which may be unacceptable to patients.
53
Q

What type of contraception should be advised in In patients assigned male at birth undergoing oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate therapy

A

Condoms should be recommended in those patients assigned male at birth engaging in vaginal sex wishing to avoid the risk of pregnancy.

In patients assigned male at birth, oestradiol, gonadotrophin-releasing hormone analogs, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception.

54
Q

what advice is given about breast feeding and antiepilectics drugs

A

Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

55
Q

first degree perineal tear description

A

superficial damage with no muscle involvement
do not require any repair

56
Q

second degree perineal tear description

A
  • injury to the perineal muscle, but not involving the anal sphincter
  • require suturing on the ward by a suitably experienced midwife or clinician
57
Q

third degree perineal tear description and subtypes

A
  • injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
  • 3a: less than 50% of EAS thickness torn
  • 3b: more than 50% of EAS thickness torn
  • 3c: IAS torn
  • require repair in theatre by a suitably trained clinician
58
Q

fourth degree perineal tear description

A
  • injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
  • require repair in theatre by a suitably trained clinician
59
Q

Risk factors for perineal tears

A
  • primigravida
  • large babies
  • precipitant labour
  • shoulder dystocia
  • forceps delivery
60
Q

A 25-year-old woman at 15 weeks gestation of her first pregnancy returns to her general practitioner with tremor after starting a medication during pregnancy for hyperemesis gravidarum. On examination, the patient has a resting tremor in their left hand and increased upper limb tone.

A

Metoclopramide is an option for nausea and vomiting in pregnancy, but it should not be used for more than 5 days due to the risk of extrapyramidal effects

61
Q

What are the rules around Methotrexate for conception and pregnancy?

A

Methotrexate: must be stopped at least 6 months before conception in both men and women

62
Q

If low-lying placenta is found at the 20-week scan then rescan at… weeks to assess

A

If low-lying placenta is found at the 20-week scan then rescan at 32 weeks to assess

63
Q

first-line in the management of nausea & vomiting in pregnancy/hyperemesis gravidarum

A

Antihistamines
Promethazine

Passmed Year 4 GOSH (10 decks)

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