Obstetrics Flashcards
How many chromosomes does the primary oocyte have?
46
How many chromosomes does the mature ovum have?
23
Which hormone suppresses the mother’s immune reaction to foetal antigens?
Progesterone
When does the corpus luteum stop producing progesterone?
10 weeks gestation, then placenta produces it.
G4 P3
A pregnant woman with 3 previous deliveries.
G1 P0+1
A non-pregnant woman with a previous miscarriage.
A non-pregnant woman with a previous birth of healthy twins
G1 P1
A non-pregnant woman with a previous stillbirth
G1 P1
What age do foetal movements start?
18-20 weeks
What is the main complication of induction of labour?
Uterine hyperstimulation
What is the normal frequency of contractions?
4 or less in 10 mins
Is there a safe level of alcohol in pregnancy?
No!
Describe the features of foetal alcohol syndrome
- Microcephaly (small head)
- Thin upper lip
- Smooth flat philtrum (the groove between the nose and upper lip)
- Short palpebral fissure (short horizontal distance from one side of the eye to the other)
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
- Cardiac malformations
Which high risk groups should be given 5mg folic acid?
- Women taking anti-epileptic drugs
- Previous baby with neural tube defects or FHx of NTD
- Obesity with BMI over 30
- Diabetes
- Sickle cell disease
- Thalassemia
- Malabsorption disorders (e.g. Crohn’s disease, coeliac)
- Those taking folate antagonist drugs (HIV anti-retroviral drugs, methotrexate, sulphonamides)
Describe some common problems in pregnancy
- Reduced foetal movements.
- N+V.
- Heartburn.
- Constipation.
Low birth weight is defined as…
< 2.5kg (5.5lb)
What is the average birth weight?
3.5kg (7.7lb)
Macrosomia is a birth weight of…
> 4.5kg (9.9lb)
Why might there be an issue measuring SFH?
Large fibroids, multiple pregnancy or BMI > 35.
Which trimester are miscarriages most common?
T1
Which drugs are contraindicated in breastfeeding?
LAMBAST + 6C’s
L - Lithium
A - Aspirin
M - Methotrexate
B - Benzodiazepines
A - Amiodarone
S - Sulphonylureas
T - Tetracycline
6’Cs - Carbimazole, Ciprofloxacin, Chloramphenicol, Cytotoxics, Clozapine, Codeine
Why are tetracyclines contraindicated in breastfeeding?
Tooth discolouration in infants.
Why is chloramphenicol contraindicated in breastfeeding?
Grey baby syndrome.
Why is ciprofloxacin contraindicated in breastfeeding?
Arthropathy in infants.
Does placenta praevia usually present with pain?
No
What is the investigation of choice for placenta praevia?
Transvaginal US.
Define puerperal psychosis
Acute onset of a manic or psychotic episode shortly after childbirth.
What are the indications for 5mg folic acid?
Take MORE Folic acid (5mg) if:
M - Metabolic disease (diabetes or Coeliac)
O - Obesity
R - Relative or personal Hx of NTDs
E- Epilepsy (taking antiepileptic medications)
+ Sickle Cell and Thalassaemia
What prophylactic antibiotics should be given for PPROM?
10 days erythromycin
In males and females how long should methotrexate be stopped for before conception?
6 months
Which SSRIs are safe to use in breastfeeding women?
Sertraline or paroxetine
Management of perineal tears
- First degree: conservative management, no repair required.
- Second degree: suturing on the ward.
- Third/fourth degree: repair in theatre.
In the combined test, how is Down’s syndrome differentiated from Edward and Patau syndrome?
- Down’s - high β-hCG
- Edward/Patau - lower β-hCG
If a pregnant women is not immune to rubella, when should the MMR vaccine be offered?
In the postnatal period.
If the Bishop score is ≤ 6, what is the preferred method of induction?
Vaginal prostaglandins or oral misoprostol.
If the Bishop score is > 6, what is the preferred method of induction?
Amniotomy and an intravenous oxytocin infusion.
Describe the interpretation of the Bishop score
- < 5 indicates that labour is unlikely to start without induction.
- ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour.
Name an absolute contraindication for induction of labour
Previous classical Caesarean section.
How can you distinguish between a mass representing a tubal ectopic pregnancy vs the CL, on US?
- Ectopic moves separately to the ovary.
- CL moves with the ovary.
In an intrauterine pregnancy, how much will hCG rise by in 48 hours?
Doubled
What level of hCG should a pregnancy be visible on US scan?
> 1500 IU/L
Symptoms of a miscarriage
Vaginal bleeding and abdominal/pelvic pain.
When can foetal heart beat be detected on transvaginal US?
5.5-6 weeks gestation OR CRL 7mm or more.
What is a key complication of ERPC?
Endometritis (infection of endometrium).
Define recurrent miscarriage
3 or more consecutive miscarriages.
List the causes of recurrent miscarriage
- Idiopathic
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities e.g. fibroids, Asherman’s syndrome, septate uterus.
- Genetics
- Chronic histiocytic intervillositis
- Diabetes, untreated thyroid disease, PCOS and SLE
How would you reduce the risk of miscarriage in patients with antiphospholipid syndrome?
- Low dose aspirin
- LMWH
How long should magnesium sulphate be continued for in high risk severe pre-eclampsia or eclampsia?
24 hours after delivery or 24 hours after last seizure.
Describe the normal laboratory findings in pregnancy
- Reduced urea
- Reduced creatinine
- Increased urinary protein loss
- Reduced Hb
- Normal/reduced platelets
Is weight loss in babies after the first few days after birth normal?
Yes, weight loss between 7-10% in the first few days is normal and most babies return to their birth weight within 2 weeks of life.
What should be done if a breastfed baby loses > 10% of birth weight in the first week of life?
Referral to a midwife-led breastfeeding clinic.
Diagnosis of preterm prelabour rupture of membranes (PPROM)?
- Pooling of amniotic fluid in vagina on sterile speculum examination.
- If amniotic fluid not seen, IGF binding protein-1 or placental alpha-microglobin-1 (e.g. AmniSure) testing indicated.
When should corticosteroids be offered?
To women between 24 and 34 weeks gestation in whom imminent preterm birth is anticipated. In order to mature foetal lungs and reduce respiratory distress syndrome. Example: 2 doses of IM betamethasone or dexamethasone, 24 hrs apart.
What is the first-line medication for pregnancy-induced hypertension?
Labetalol
Define pregnancy-induced hypertension (gestational hypertension)
New-onset hypertension after 20 weeks gestation in a previously normotensive women without evidence of significant proteinuria (< 30mg/mmol).
What is the first-line surgical intervention in postpartum haemorrhage if mechanical and medical measures fail?
Intrauterine balloon tamponade (Bakri catheter).
A 36-year-old multiparous women is in advanced labour at 37 weeks gestation. An ultrasound confirms a breech presentation. She is fully dilated and has been pushing for one and a half hours, however the buttocks are still not visible. How should this situation be managed?
Caesarean section
Is aspirin safe to use whilst breastfeeding?
No, aspirin is contraindicated in breastfeeding due to its association with Reye’s syndrome.
Treatment for pregnant women <= 20 weeks gestation that are not immune to varicella, who get exposed to chickenpox?
Varicella-zoster immunoglobulin.
Treatment for pregnant women > 20 weeks gestation that are not immune to varicella, but have been exposed or present within 24hrs of rash onset?
Antivirals e.g. aciclovir.
Treatment for babies born to mothers who are infected with Hep B?
Vaccination and Hep B immunoglobulin.
Which placenta abnormality is associated with IVF?
Placenta praevia.
What investigations should be performed when there are late decelerations on CTG?
Foetal blood sampling - to assess for foetal hypoxia and acidosis.
What range is the normal foetal HR?
110-160 bpm
What does late decelerations on CTG indicate?
Foetal distress e.g. asphyxia or placental insufficiency.
What does variable decelerations on CTG indicate?
May indicate cord compression.
Define lochia
Passing vaginal discharge containing blood, mucous and uterine tissue, which can continue for 6 weeks following childbirth.
Reduced foetal movements can indicate what?
Foetal distress and hypoxia.
Stillbirth and restricted growth.
At what gestation would referral to the maternal foetal medicine unit be made if a mother hasn’t felt any foetal movements yet?
24 weeks
How would you investigate reduced foetal movements?
- Handheld Doppler to confirm foetal heartbeat, then CTG to monitor to HR.
- US scan if no foetal heartbeat.
First-line treatment for magnesium sulphate induced respiratory depression?
Calcium gluconate.
Should serum ferritin levels be checked when a pregnant patient has a Hb < 110g/L?
No not routinely - NICE guidelines state that Hb < 110g/L in T1 should begin iron supplementation. In T2&3 serum ferritin levels fall independently of iron stores and are therefore unreliable.
Raised levels of maternal serum AFP produced by the developing foetus suggests…
- NTD.
- Abdominal wall defects.
- Multiple pregnancy.
Low levels of maternal serum AFP produced by the developing foetus suggests…
- Down’s syndrome.
- Edwards syndrome.
- Maternal diabetes.
- Maternal obesity.
Is epilepsy medication contra-indicated in breastfeeding?
No all anti-epileptics are safe in breastfeeding, except barbiturates.
What position should the patient be in with an umbilical cord prolapse?
On all fours or the left lateral position.
Name a cause of visual impairment in babies born before 32 weeks gestation
Retinopathy of prematurity.
List some contraindications for a planned vaginal birth after caesarean (VBAC)
- Previous vertical (classical) caesarean scars.
- Previous uterine rupture.
- Placenta praevia.
What is the most frequent cause of severe early-onset (< 7 days) infection in newborn infants?
Group B streptococcus infection.
List the complications of an abortion
- Bleeding.
- Infection.
- Pain.
- Failure.
- Damage to cervix and uterus.
When does nausea and vomiting of pregnancy (NVP) normally start, peak and settle?
- Starts between 4-7 weeks.
- Peaks at week 9.
- Settles by week 16-20.
Which hormone is responsible for NVP?
hCG - it stimulates the chemoreceptor trigger zone in the brain stem, which signals to the vomiting centre in the brain.
When can NVP be more severe?
Molar pregnancies, multiple pregnancy and Down’s syndrome due to high levels of hCG.
Describe the initial investigations for recurrent miscarriage
- Antiphospholipid antibodies.
- Testing for hereditary thrombophilias
- Pelvic ultrasound.
- Genetic testing of the products of conception from the third or future miscarriages.
- Genetic testing on parents.
What is the only definitive management for pre-eclampsia and eclampsia?
Delivery of baby.
Which antibiotic is used as prophylaxis against group B streptococcus?
Benzylpenicillin
Management for pregnant women with BP > = 160/110?
Admitted for observation
When would arranging an emergency secondary care assessment for a pregnant women be indicated?
When pre-eclampsia is suspected.
How many weeks gestation is an amniocentesis usually performed?
15 weeks onwards.
For women with pre-existing diabetes, how many weeks gestation is planned delivery advised?
Between 37 and 38+6 weeks.
A dextrose and insulin infusion tritiated to blood glucose levels used in labour for women with T1D is known as what?
A sliding-scale insulin regime.
What type of screening is important for pregnant women with pre-existing diabetes?
Retinopathy screening.
Why is neonatal hypoglycaemia a complication of gestational diabetes?
During pregnancy foetus produces high levels of insulin due to high maternal blood glucose. After birth the baby still has high insulin levels, but no longer receives high blood glucose form the mother, resulting in neonatal hypoglycaemia.
An Edinburgh Postnatal Depression Score of what indicates moderate-severe depression?
> 13
Describe McRoberts position for shoulder dystocia
Hyperflex mother’s legs onto her abdomen and apply suprapubic pressure.
Describe Rubin manoeuvre for shoulder dystocia
Press on posterior shoulder to allow an the anterior shoulder extra room.
Describe Wood’s screw manoeuvre for shoulder dystocia
Put hand in the vagina and rotate foetus 180 degrees to attempt to dislodge the anterior shoulder from the pubic symphysis.
List the factors which reduce vertical transmission of HIV from mother to baby
- Maternal antiretroviral therapy.
- C-section.
- Neonatal antiretroviral therapy.
- Bottle feeding - avoid breastfeeding.
When is vaginal delivery of baby with HIV+ mother indicated?
If viral lode is < 50 copies/ml at 36 weeks.
When should anti-D be given to Rh- mothers?
- Delivery of a Rh +ve infant, whether live or stillborn.
- Termination of pregnancy.
- Miscarriage if gestation is > 12 weeks.
- Ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required).
- External cephalic version.
- Antepartum haemorrhage.
- Amniocentesis, chorionic villus sampling, foetal blood sampling.
- Abdominal trauma.
When should an elective c-section should be planned for placenta praevia?
At 36-37 weeks.
Describe the aims of Prevent (valproate pregnancy prevention programme)
Valproate medicine must not be used in women of childbearing age unless there are no suitable alternatives and a strict criteria are met ensure they don’t get pregnant.
Define antepartum haemhorrhage
Any vaginal bleeding from 24 weeks gestation until delivery.
Name 3 causes of antepartum haemorrhage
- Placenta praevia.
- Placental abruption.
- Vasa praevia.
List causes of spotting or minor bleeding in later pregnancy
- Cervical ectropion.
- Infection.
- Vaginal abrasions from intercourse or procedures.
Define the severity of antepartum haemorrhage
- Spotting: spots of blood noticed on underwear.
- Minor haemorrhage: < 50ml blood loss.
- Major haemorrhage: 50-1000ml blood loss.
- Massive haemorrhage: > 1000 ml blood loss, or signs of shock.
What sign on US might indicate a placental abruption?
Retroplacental haematoma.
What is the recurrence rate of postpartum psychosis?
25-50%
Name a tocolytic drug
Terbutaline
An umbilical cord prolapse is linked with what type of labour induction?
Artificial rupture of membranes.
Can Hep B be transmitted to baby via breastfeeding?
No
Where is hCG secreted?
By the syncytiotrophoblasts.
What is the role of hCG?
To maintain production of progesterone by the CL in early pregnancy.
How many days after conception can hCG be detected in maternal blood?
8 days.
What levels of hCG, TSH and thyroxine (T4) would you expect in a molar pregnancy?
High hCG, low TSH, high T4.
In pregnant women, which leg is most commonly affected for DVTs?
Left leg due to compression of left iliac vein by uterus.
V/Q in pregnant women is associated with an increased risk of what?
Childhood cancer for the foetus (minimal absolute risk).
CTPA in pregnant women carries a higher risk of what?
Breast cancer for the mother (minimal absolute risk).
Why can’t warfarin be used in pregnancy?
It can cross the placenta and cause foetal haemorrhage and death.
What are the 3 stages of postpartum thyroiditis and describe the management
- Thyrotoxicosis - propranolol for symptom control.
- Hypothyroidism - thyroxine.
- Normal thyroid function.
What is the first line treatment for moderate to severe postnatal depression for women with no previous history of severe depression?
CBT
Management of women with postpartum psychosis?
Hospitalisation in Mother & Baby unit
A history of sudden collapse occurring soon after rupture of membranes is suggestive of…
Amniotic fluid embolism
A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation. On examination, the cervix is 7 cm dilated, the head is direct Occipito-Anterior, the foetal station is at -1 and the head is 2/5 ths palpable per abdomen. The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes. How should this situation be managed?
Caesarean section
The cardiotocogram is very concerning (the late decelerations which are a worrying sign especially in the context of foetal bradycardia) and indicates that the baby needs to be delivered immediately. Instrumental delivery is not possible because the cervix is not fully dilated and the head of the baby is high. Oxytocin and vaginal prostaglandin are contraindicated due to foetal distress. Therefore the safest approach in this case is an emergency caesarean section.
Is it normal for ALP to increase in pregnancy?
Yes - because the placenta produces ALP. Therefore a rise in ALP without other abnormal LFTs is usually due to placental production of ALP, rather than a liver pathology.
Why might clotting be degraded in obstetric cholestasis?
Lack of bile acids secreted in intestine causes reduced fat absorption, therefore fat-soluble vitamins, such as vitamin K, can’t be absorbed. Vitamin K deficiency can lead to impaired clotting.
Apart from pregnancy, when else can melasma occur?
Combined contraceptive pill and HRT.
What are the 2 main differentials for a breech presentation?
- Oblique lie.
- Transverse lie.
Name a contraindication of a vaginal breech delivery
Footling breech
What are the 3 key symptoms to always ask about during pregnancy?
- Reduced fetal movements.
- Abdominal pain.
- Vaginal bleeding.
Define prolonged pregnancy
Pregnancy which persist up to and behind 42 weeks gestation.
What is the primary concern for any prolonged pregnancy?
Increased risk of stillbirth.
What is the most common malpresentation?
Breech
List the main causes of oligohydramnios
- PPROM.
- Placental insufficiency – causes poor urine output.
- Renal agenesis (Potter’s syndrome).
- Non-functioning foetal kidneys, e.g. bilateral multicystic dysplastic kidneys.
- Obstructive uropathy.
- Genetic/chromosomal anomalies.
- Viral infections.
List the main causes of polyhydramnios
- Idiopathic.
- Abnormal swallowing e.g. oesophageal atresia, CNS abnormalities, muscular dystrophies, congenital diaphragmatic hernia obstructing the oesophagus.
- Duodenal atresia – ‘double bubble’ sign on US.
- Anaemia.
- Foetal hydrops.
- Twin-to-twin transfusion syndrome.
- Increased lung secretions – cystic adenomatoid malformation of lung.
- Genetic or chromosomal abnormalities.
- Maternal diabetes.
- Maternal ingestion of lithium – leads to foetal diabetes insipidus.
- Macrosomia – larger babies produce more urine.
Describe the function of prostaglandins in labour
Stimulates contraction of uterus and ripens cervix.
What are Braxton-Hicks contractions?
Occasional irregular contractions of the uterus. They’re usually felt during T2&3. They don’t indicate the onset of labour and don’t progress or become regular.
What is used as a graphic record of observations and events during labour?
Partogram
Differential diagnosis for PROM or PPROM?
Urinary incontinence.
Which anti-emetic has a small increased risk of cleft lip/palate in the newborn if used in T1?
Ondansetron
What is the drug of choice for the medical management of ectopic pregnancy?
Methotrexate
First line investigation for ectopic pregnancy?
Transvaginal US
Describe the management of a pregnant women who is < 6 weeks gestation and presents with vaginal bleeding and no pain
Expectant management:
- Return if bleeding continues or pain develops.
- Repeat a urine pregnancy test after 7–10 days and to return if it is positive.
- Negative pregnancy test means that the pregnancy has miscarried.
What are the current guidelines for a pregnant women > 6 weeks gestation that presents with bleeding?
- Referred to EPAU.
- Transvaginal US.
List the risk factors for an ectopic pregnancy
- Pelvic inflammatory disease.
- Pelvic surgery.
- Previous ectopic.
- Endometriosis.
- ICUD.
- Progesterone only pill.
- IVF.
- Cilia dysfunction.
How should an ectopic pregnancy >35 mm in size or with a serum B-hCG >5,000IU/L be managed?
Surgically
What type of seizures are seen in eclampsia?
Tonic clonic seizures.
List the key signs of magnesium toxicity
- Reduced RR.
- Reduced BP.
- Absent reflexes.
A ‘multi-level pregnancy test’ is required 2 weeks following a medical termination of pregnancy. What is meant by a ‘multi-level pregnancy test’?
It measures the hCG level quantitively i.e. is not simply a positive/negative pregnancy test. The ‘multi-level pregnancy test’ is used to quantify the serum hCG and monitor that it is declining to a low level as expected.
Describe the process of a membrane sweep
The procedure is performed by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua. The separation helps to release natural prostaglandins in an attempt to kick-start labour and spontaneous delivery.
Define prostaglandin pessary
The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours.
Indication for cervical ripening ballon?
This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).
When would amniotomy +/- oxytocin be used as the primary method of IOL?
ONLY when prostaglandins are contraindicated e.g. high risk of uterine hyperstimulation.
List some contraindications for instrumental delivery
- Unengaged foetal head in singleton pregnancies.
- Incompletely dilated cervix in singleton pregnancies.
- True cephalo-pelvic disproportion (where the fetal head is too large to pass through the maternal pelvis).
- Breech and face presentations, and most brow presentations.
- Preterm gestation (<34 weeks) for ventouse.
- High likelihood of any fetal coagulation disorder for ventouse.
What are the pre-requisites for instrumental delivery?
- Fully dilated.
- Ruptured membranes.
- Cephalic presentation.
- Defined foetal position.
- Foetal head at least at the level of the ischial spines, and no more than 1/5 palpable per abdomen.
- Empty bladder.
- Adequate pain relief.
- Adequate maternal pelvis.
When should the attempt be abandoned with instrumental delivery?
After 3 contractions and pulls with any instrument and there is no reasonable progression.
Which instrument has the lower risk of foetal complications but a higher risk of maternal complications?
Forceps
Risk factors for perineal tears
- First births (nulliparity).
- Large babies (over 4kg).
- Shoulder dystocia.
- Asian ethnicity.
- Occipito-posterior position.
- Instrumental deliveries.
List the short term and long term complications of perineal tears
Short term: pain, bleeding, infection, wound dehiscence.
Long term: urinary and anal incontinence, fistula, sexual dysfunction, dyspareunia.
Other than an episiotomy, what other measures can be taken to reduce the risk of perineal tears?
Perineal massage.
How long after birth should the cord be clamped?
Within 5 mins of birth.
There should be a delay of 1-3 mins between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).
Describe physiological management of third stage
The placenta is delivered by maternal effort without medications or cord traction.
What is the most common cause of PPH?
Uterine atony
In the assessment of a PPH, what should be examined?
The placenta.
What preventative measure routinely reduces the risk of PPH?
Active management of 3rd stage of labour:
- Women delivering vaginally should be administered 5-10 units of IM oxytocin.
- Women delivering via C-section should be administered 5 units of IV oxytocin.
List 2 key causes of sepsis in pregnancy
- Chorioamnionitis (infection of the chorioamniotic membranes and amniotic fluid - leading cause - due to PPROM, causing maternal pyrexia, tachycardia, and foetal tachycardia).
- UTIs.
Investigations for maternal sepsis
BLOODS:
- FBC to assess cell count including white cells and neutrophils.
- U&Es to assess kidney function and for AKI.
- LFTs to assess liver function and as a possible source of infection (e.g. acute cholecystitis).
- CRP to assess inflammation
- Clotting to assess for (DIC).
- Blood cultures to assess for bacteraemia.
- Blood gas to assess lactate, pH and glucose.
OTHERS:
- Urine dipstick and culture.
- High vaginal swab.
- Throat swab.
- Sputum culture.
- Wound swab after procedures.
- Lumbar puncture for meningitis or encephalitis.
Give examples of antibiotics used for maternal sepsis
- Piperacillin and tazobactam (tazocin) plus gentamicin.
- Amoxicillin, clindamycin and gentamicin.
What is the definitive diagnosis and findings for amniotic fluid embolism?
- Post mortem histology.
- Foetal squamous cells along with debris in the pulmonary vasculature.
What is a normal APGAR score?
7-10
What is the most important investigation for bleeding in the first trimester?
Transvaginal US
Describe the pathophysiology of postpartum thyroiditis
Once delivery has occurred, mother no longer has immunosuppressive effect causing an exaggerated rebound effect, stimulating the production of antibodies, including TPO Abs.
Why does Sheehan’s syndrome only affect anterior pituitary gland?
Due to different blood supplies. The anterior pituitary is supplied by hypothalamo-hypophyseal portal system which is susceptible to rapid drops in BP. Whereas posterior pituitary is supplied by arteries which are not susceptible to ischaemia when there’s a drop in BP.
Which hormones are affected in Sheehan’s syndrome?
- Thyroid-stimulating hormone (TSH)
- Adrenocorticotropic hormone (ACTH)
- Follicle-stimulating hormone (FSH)
- Luteinising hormone (LH)
- Growth hormone (GH)
- Prolactin
Which hormones are spared in Sheehan’s syndrome?
- Oxytocin
- Antidiuretic hormone (ADH)
Describe factors leading to successful lactation
- Effective attachment to nipple.
- Bonding with baby.
- Skin-to-skin contact.
- Fed on demand.
- Good positioning.
Describe some common breastfeeding problems
- Sore or cracked nipples.
- Not enough breast milk.
- Breast engorgement.
- Baby not latching on properly.
- Too much breast milk.
- Nipple thrush.
- Blocked milk duct.
- Mastitis.
- Breast abscess.
Describe the 3 main types of fertility treatment
- Medical treatment e.g. drugs to induce ovulation such as Clomifene.
- Surgical treatment e.g. tubal microsurgery in women with tubal damage.
- Assisted conception e.g. intrauterine insemination, in vitro fertilisation (IVF).
A raised haematocrit can indicate what (with regards to OHSS)?
Dehydration - less fluid in intravascular space, concentrating the blood.
Role of prolactin and oxytocin in lactation?
- Prolactin produces milk
- Oxytocin releases milk via contraction
A 33-year-old primigravida attends an antenatal appointment at 9 weeks gestation. She had a private ultrasound a week ago showing dichorionic, diamniotic twins. She has a past medical history of hypothyroidism for which she takes levothyroxine, and has a BMI of 38 kg/m². Although she admits to smoking during her pregnancy, she cut down from 20 to 5 cigarettes/day and is keen to try nicotine replacement therapy. While her pregnancy has been uncomplicated so far, she is concerned as her mother and sister both developed hyperemesis gravidarum.
What factor in this patient’s history is associated with a decreased incidence of developing the same condition as her relatives?
Smoking
Define foetal position
- Relationship between a denominator of presenting part of foetus (e.g. occiput, sacrum or mentum) and maternal pelvis.
- Position of foetal head as it exits birth canal.
- Usually head engages at occipito-anterior (OA) position, but it can engage in occipito-posterior (OP) or occipito-transverse (OT) positions.
Placenta accreta increases the risk of what complication?
PPH
What is the most common risk following TOP?
Infection
Management steps in PPH?
- Bimanual uterine compression.
- IV oxytocin and/or ergometrine.
- IM carboprost.
- Intramyometrial carboprost.
- Rectal misoprostol.
- Balloon tamponade.
Which location for an ectopic pregnancy has the greatest risk of rupture?
Isthmus of fallopian tubes.
Miscarriage management for a patient with a past medical history of Von Willebrand disease?
Medical management with vaginal misoprostol (expectant management contraindicated).
Can pregnant women fly?
- Women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel.
- Women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks.
What is the most common cause of puerperal pyrexia?
Endometritis
Management for obstetric cholestasis
- Induction of labour at 37-38 weeks.
- Ursodeoxycholic acid.
- Vitamin K supplementation.
What type of insulin is used in gestational diabetes?
Short-acting insulin
Which anti-emetic is first line in pregnancy?
Anti-histamines e.g. Promethazine or Cyclizine.
Which drug are safe to use whilst breastfeeding?
- Antibiotics: penicillins, cephalosporins, trimethoprim.
- Endocrine: glucocorticoids (avoid high doses), levothyroxine.
- Epilepsy: sodium valproate, carbamazepine.
- Asthma: salbutamol, theophyllines.
- Psychiatric drugs: TCAs, antipsychotics (apart from clozapine).
- Hypertension: beta-blockers, hydralazine.
- Anticoagulants: warfarin, heparin.
- Digoxin.
Which layers of the abdominal wall are cut in a c-section?
- Superficial fascia
- Deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
- Transversalis fascia
- Extraperitoneal connective tissue
- Peritoneum
- Uterus
List the risk factors for placental abruption
ABRUPTION:
- A - Abruption previously.
- B - Blood pressure (i.e. hypertension or pre-eclampsia).
- R - Ruptured membranes, either premature or prolonged.
- U - Uterine injury (i.e. trauma to the abdomen).
- P - Polyhydramnios.
- T - Twins or multiple gestation.
- I - Infection in the uterus, especially chorioamnionitis.
- O - Older age (i.e. aged over 35 years old).
- N - Narcotic use (i.e. cocaine and amphetamines, as well as smoking).
Define reduced foetal movements
< 10 movements within 2 hours (in pregnancies > 28 weeks gestation) - indication for further assessment.
When should foetal movements be established?
By 24 weeks
Name one side effect of misoprostol for the neonate
Respiratory depression
First line medications for N+V in pregnancy?
- Doxylamine and Pyridoxine (vitamin B6) 20/20mg PO at night, increase to additional 10/10 mg in morning and 10/10mg at lunchtime if required.
- Cyclizine 50 mg PO, IM or IV 8 hourly.
- Prochlorperazine 5-10 mg 6-8 hourly PO (or 3 mg buccal); 12.5 mg 8 hourly IM/IV; 25 mg PR daily.
- Promethazine 12.5-25 mg 4-8 hourly PO, IM or IV.
- Chlorpromazine 10-25 mg 4-6 hourly PO, IM or IV.
Are statins safe in pregnancy?
No they should be avoided in pregnancy (discontinued 3 months before attempting to conceive).
Is felodipine safe in pregnancy?
No
Management of UTI in a pregnant women in T3
Amoxicillin or cefalexin
Outline the medical management of a miscarriage
- Missed miscarriage: oral mifepristone (causes weakening of attachment to endometrial wall, cervical softening and dilation, and uterine contractions) + misoprostol 48hrs later if gestational sac hasn’t been passed (causes uterine contractions expelling products of conception).
- Incomplete miscarriage: single dose of misoprostol.
- All women offered antiemetics and analgesia.
- Pregnancy test at 3 weeks.
List the risk factors for GBS infection
- Prematurity
- Prolonged rupture of the membranes
- Previous sibling GBS infection
- Maternal pyrexia e.g. secondary to chorioamnionitis
Management of GBS prophylaxis
- Intrapartum antibiotics (IAP) should be offered to women with a previous baby with early- or late-onset GBS disease.
- IAP should be offered to women in preterm labour regardless of their GBS status.
- Women with a pyrexia during labour (>38ºC) should also be given IAP
Chicken pox exposure in pregnancy
Antivirals or VZIG (if available) should be given at days 7-14 post-exposure, not immediately
