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Women’s Health > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Risk factors for ectopic pregnancy?

A
  • fallopian tube damage - e.g. salpingitis, previous surgery
  • previous ectopic
  • IVF
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2
Q

Referred pain in an ectopic pregnancy?

A

Shoulder tip pain due to peritoneal bleeding.

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3
Q

What is a threatened miscarriage?

A
  • painless vaginal bleeding occurring before 24 weeks
  • cervical os is closed
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4
Q

When does a threatened miscarriage usually occur?

A

6 - 9 weeks

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5
Q

How common is a threatened miscarriage?

A

Complicates up to 25% of pregnancies.

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6
Q

What is a missed miscarriage?

A

Gestational sac containing a dead fetus before 20 weeks, without symptoms of expulsion.

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7
Q

What is an inevitable miscarriage?

A
  • heavy bleeding with clots and pain
  • cervical os is open
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8
Q

What is placental abruption?

A

Separation of the placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space.

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9
Q

Clinical features of placental abruption?

A
  • shock (doesn’t match visible blood loss)
  • constant abdominal pain
  • tender, tense uterus
  • absent / distressed fetal heartbeat
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10
Q

Risk factors for placental abruption?

A
  • proteinuric hypertension
  • cocaine use
  • multiparity
  • maternal trauma
  • increasing maternal age
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11
Q

Complication of placental abruption?

A

Disseminated intravascular coagulation

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12
Q

Presentation of symphysis pubis dysfunction?

A
  • pain over the pubic symphysis
  • radiation to groins and medial thighs
  • waddling gait
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13
Q

Where does pre-eclampsia abdominal pain occur?

A
  • epigastric
  • RUQ
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14
Q

How does uterine rupture present?

A
  • maternal shock
  • abdominal pain
  • vaginal bleeding
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15
Q

When does uterine rupture typically occur?

A

During labour, but sometimes in the third trimester.

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16
Q

Risk factors for uterine rupture?

A

Previous C section

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17
Q

How does appendicitis present during pregnancy?

A

First trimester - RLQ pain.
Second trimester - umbilical pain.
Third trimester - RUQ pain.

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18
Q

What are the risks of UTI in pregnancy?

A
  • pre-term delivery
  • IUGR
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19
Q

What does increased alpha feto-protein suggest in pregnancy?

A
  • neural tube defects
  • adominal wall defects
  • multiple pregnancy
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20
Q

What does decreased alpha feto-protein suggest in pregnancy?

A
  • Dpwn’s syndrome
  • trisomy 18 (Edward’s syndrome)
  • maternal diabetes
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21
Q

What is an amniotic fluid embolism?

A

Amniotic fluid / fetal cells enter the mother’s bloodstream. Rare complication with a high mortality rate.

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22
Q

When does amniotic fluid embolism typically occur?

A
  • majority of cases during labour
  • during C section
  • immediate post-partum
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23
Q

Clinical presentation of amniotic fluid embolism?

A
  • chills & shivering
  • sweating
  • anxiety
  • coughing
  • cyanosis
  • hypotension
  • tachycardia
  • arrhythmia
  • MI
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24
Q

How is amniotic fluid embolism managed?

A

Critical care unit, mainly supportive care.

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25
Q

What supplements should women take antenatally?

A
  • folic acid
  • vitamin D
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26
Q

Which vitamin should not be supplemented in pregnancy?

A

Vitamin A - high intake may be teratogenic.

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27
Q

Standard dose of folic acid in pregnancy?

A

400mcg

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28
Q

When should folic acid be taken in pregnancy?

A

From before conception until 12 weeks.

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29
Q

Risks of smoking in pregnancy?

A
  • low birthweight
  • preterm birth
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30
Q

Which food-acquired infection are pregnant women at risk of?

A
  • listeriosis
  • salmonella
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31
Q

How can listeriosis be avoided in pregnancy?

A

Avoid:
- unpasteurised milk
- ripened soft cheese (Camembert, Brie, blue cheese)
- pate
- undercooked meat

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32
Q

How can salmonella be avoided in pregnancy?

A

Avoid raw or partially cooked eggs and meat - particularly poultry.

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33
Q

How should nausea and vomiting in pregnancy be managed?

A
  • natural remedies: ginger, acupuncture on wrist point
  • anti-histamines (promethazine) are first-line
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34
Q

When should the booking appointment take place in pregnancy?

A

8-12 weeks (ideally before 10 weeks).

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35
Q

What takes place at the booking appointment?

A
  • general information and advice (diet, alcohol, smoking, supplements, etc)
  • BP
  • urine dipstick & culture
  • BMI
  • bloods
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36
Q

What bloods are done at the booking appointment?

A
  • FBC
  • blood group, rhesus status, red cell alloantibodies
  • haemoglobinopathies
  • hep B, syphilis, HIV
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37
Q

When is the dating scan performed?

A

10 - 13+6 weeks

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38
Q

When does Down’s syndrome screening take place?

A

11 - 13+6 weeks

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39
Q

What takes place at the 16 week appointment?

A
  • blood results discussed
  • consider iron if Hb < 110
  • BP & urine dipstick
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40
Q

When does the anomaly scan take place?

A

18 - 20+6 weeks

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41
Q

What is routine care at antenatal appointments?

A
  • BP
  • urine dipstick
  • symphysis-fundal height
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42
Q

What takes place at the 28 week appointment?

A
  • second screen for anaemia and red cell alloantibodies
  • consider iron if Hb < 105
  • first dose anti-D to rhesus -ve women
  • routine care
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43
Q

What takes place at the 34 week appointment?

A
  • routine care
  • second dose of anti-D to rhesus -ve women
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44
Q

What takes place at the 36 week appointment?

A
  • routine care
  • check presentation & offer external cephalic version if indicated
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45
Q

Is GBS routinely screened for in pregnancy?

A

No

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46
Q

What is antepartum haemorrhage?

A

Bleeding from the genital tract after 24 weeks of pregnancy (prior to delivery of the fetus).

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47
Q

Should vaginal examination be performed for suspected antepartum haemorrhage?

A

No - risk of haemorrhage in placenta praevia.

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48
Q

Features of placenta praevia?

A
  • shock in proportion to visible blood loss
  • painless
  • uterus not tender
  • fetal heart usually normal
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49
Q

Major causes of bleeding during the first trimester of pregnancy?

A
  • (threatened) miscarriage
  • ectopic pregnancy
  • hydatidiform mole
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50
Q

Major causes of bleeding during the second trimester?

A
  • (threatened) miscarriage
  • hydatidiform mole
  • placental abruption
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51
Q

Major causes of bleeding during the third trimester?

A
  • bloody show
  • placental abruption
  • placenta praevia
  • vasa praevia
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52
Q

Presentation of a hydatidiform mole?

A
  • bleeding in first / early second trimester
  • associated with exaggerated symptoms of pregnancy (e.g. hyperemesis, uterus large for dates)
  • serum hCG very high
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53
Q

Presentation of vasa praevia?

A
  • rupture of membranes
  • immediate vaginal bleeding
  • fetal bradycardia
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54
Q

How is a blocked milk duct managed?

A
  • continue breastfeeding
  • advice on positioning of the baby
  • breast massage
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55
Q

How is nipple candidiasis managed?

A
  • miconazole cream for the mother
  • nystatin suspension for the baby
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56
Q

How common is mastitis?

A

Affects 1 in 10 breastfeeding women.

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57
Q

When should mastitis be treated with antibiotics?

A
  • systemically unwell
  • nipple fissure present
  • symptoms do not improve after 12-24 hours of effective milk removal
  • culture indicates infection
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58
Q

First-line treatment for mastitis?

A

Flucloxacillin for 10-14 days.

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59
Q

Can breastfeeding continue with mastitis?

A

Yes

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60
Q

Complication of mastitis?

A

Breast abscess - requires incision and drainage.

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61
Q

How does breast engorgement present?

A
  • typically occurs in the first few days after delivery
  • usually affects both breasts
  • pain / discomfort worse before a feed
  • poor milk flow
  • infant has difficulties attaching & suckling
  • fever (settles within 24 hours)
  • breasts may appear red
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62
Q

Complications of breast engorgement?

A
  • blocked milk ducts
  • mastitis
  • breastfeeding difficulties
  • reduced milk supply
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63
Q

Management of breast engorgement?

A

Hand expression of milk.

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64
Q

How does Raynaud’s disease of the nipple present?

A
  • intermittent pain present during & immediately after feeding
  • blanching of the nipple followed by cyanosis / erythema
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65
Q

Initial management of Raynaud’s disease of the nipple?

A
  • minimise exposure to cold
  • apply heat packs following breastfeeding
  • avoid caffeine
  • stop smoking
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66
Q

Further management if Raynaud’s disease of the nipple persists?

A

Consider specialist referral for a trial of oral nifedipine.

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67
Q

How much weight is normal for babies to lose in the first week of life?

A

< 10%

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68
Q

How should poor weight gain be managed in breast fed infants?

A
  • expert review of feeding - e.g. midwife-led breastfeeding clinic
  • monitor weight gain until satisfactory
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69
Q

Non-medication related breastfeeding contraindications?

A
  • galactosaemia (in the baby)
  • HIV-positive mother
  • active untreated TB
  • active HSV lesions on breasts
  • maternal substance abuse
  • active chickenpox infection
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70
Q

Can mothers with hep B / C breastfeed?

A

Yes - benefits outweigh the risks.

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71
Q

Can mothers who smoke / drink alcohol breastfeed?

A

Yes - benefits outweigh the risks. Avoid breastfeeding for 2+ hours after alcohol intake.

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72
Q

Which antibiotics can be used when breastfeeding?

A
  • penicillins
  • cephalosporins
  • trimethoprim
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73
Q

Which antibiotics cannot be used when breastfeeding?

A
  • ciprofloxacin
  • tetracycline
  • sulphonamides
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74
Q

Can glucocorticoids be taken when breastfeeding?

A

Yes, but avoid high doses.

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75
Q

Can levothyroxine be taken when breastfeeding?

A

Yes

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76
Q

Is sodium valproate safe to use when breastfeeding?

A

Yes

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77
Q

Is carbamazepine safe to use when breastfeeding?

A

Yes

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78
Q

Is salbutamol safe to use when breastfeeding?

A

Yes

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79
Q

Is theophylline safe to use when breastfeeding?

A

Yes

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80
Q

Are TCAs safe to use when breastfeeding?

A

Yes

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81
Q

Are antipsychotics safe to use when breastfeeding?

A

Yes, apart from clozapine which should be avoided.

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82
Q

Are beta-blockers safe to use when breastfeeding?

A

Yes

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83
Q

Is hydralazine safe to use when breastfeeding?

A

Yes

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84
Q

Is warfarin / heparin safe to use when breastfeeding?

A

Yes

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85
Q

Is digoxin safe to use when breastfeeding?

A

Yes

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86
Q

Is lithium safe to use when breastfeeding?

A

No

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87
Q

Are benzodiazepines safe to use when breastfeeding?

A

No

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88
Q

Is aspirin safe to use when breastfeeding?

A

No

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89
Q

Is carbimazole safe to use when breastfeeding?

A

No

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90
Q

Is methotrexate safe to use when breastfeeding?

A

No

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91
Q

Are sulfonylureas safe to use when breastfeeding?

A

No

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92
Q

Is amiodarone safe to use when breastfeeding?

A

No

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93
Q

How can lactation be suppressed?

A
  • stop suckling / expressing
  • well-supported bra
  • cabergoline - first-line medication
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94
Q

How does cabergoline suppress lactation?

A

Dopaminergic - suppresses prolactin.

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95
Q

Percentage of breech pregnancies at 28 weeks?

A

25%

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96
Q

Percentage of breech pregnancies at term?

A

3%

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97
Q

Extended (frank) vs flexed vs footling breech?

A

Extended - hips flexed and knees extended.
Flexed - hips and knees flexed.
Footling - one or both feet are present below the fetal buttocks.

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98
Q

Most common type of breech presentation?

A

Extended (frank) breech.

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99
Q

Risk factors for breech presentation?

A
  • uterine malformation, fibroids
  • placenta praevia
  • poly / oligohydramnios
  • fetal abnormality (e.g. chromosomal disorder)
  • prematurity
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100
Q

Management of breech presentation < 36 weeks?

A

No intervention, monitor fetal lie. Many fetuses will turn spontaneously.

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101
Q

Management of breech presentation at 36 weeks?

A

Offer external cephalic version.

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102
Q

Success rate of external cephalic version?

A

60%

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103
Q

External cephalic version timing in nulliparous vs multiparous women?

A

Nulliparous - from 36 weeks.
Multiparous - from 37 weeks.

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104
Q

Management of breech position if ECV unsuccessful / contraindicated / declined?

A

Counselling on C section vs vaginal delivery.

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105
Q

C section vs vaginal delivery for breech presentation?

A
  • C section carries reduced perinatal mortality & early neonatal morbidity compared to vaginal delivery.
  • No difference for long term health outcomes.
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106
Q

Contraindications for external cephalic version?

A
  • C section is required
  • antepartum haemorrhage within 7 days
  • abnormal CTG
  • major uterine anomaly
  • ruptured membranes
  • multiple pregnancy
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107
Q

When is a cat 1 C section indicated?

A

Immediate threat to the life of the mother or baby - delivery should occur within 30 minutes of making the decision.

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108
Q

Examples of indications for a cat 1 C section?

A
  • suspected uterine rupture
  • major placental abruption
  • cord prolapse
  • fetal hypoxia
  • persistent fetal bradycardia
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109
Q

When is a cat 2 C section indicated?

A

Maternal or fetal compromise which is not immediately life threatening - delivery should occur within 75 minutes of making the decision.

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110
Q

When is a cat 3 C section indicated?

A

Delivery is required, but mother and baby are stable.

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111
Q

What is a cat 4 C section?

A

Elective

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112
Q

Serious maternal risks of C section?

A
  • emergency hysterectomy
  • need for further surgery (e.g. retained placental tissue)
  • ICU admission
  • thromboembolism
  • bladder / ureteric injury
  • death
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113
Q

Frequent maternal risks of C section?

A
  • wound / abdominal discomfort in the first few months after surgery
  • repeat C section when attempting VBAC
  • readmission
  • haemorrhage
  • infection
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114
Q

Frequent fetal risks of C section?

A

Laceration (1-2%)

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115
Q

Risks to future pregnancies after C section?

A
  • uterine rupture
  • antepartum stillbirth
  • placenta praevia
  • placenta accreta
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116
Q

How successful is VBAC?

A

70-75%

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117
Q

Contraindications to VBAC?

A
  • uterine rupture
  • classical C section scar (vertical)
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118
Q

When is VBAC appropriate?

A

37+ weeks gestation with a single previous C section delivery.

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119
Q

Normal fetal heart rate?

A

100-160 bpm

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120
Q

What is considered loss of baseline variability on CTG?

A

< 5 bpm variability.

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121
Q

Causes of loss of baseline variability?

A
  • prematurity
  • hypoxia
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122
Q

Causes of baseline tachycardia on CTG?

A
  • maternal pyrexia
  • chorioamnionitis
  • hypoxia
  • prematurity
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123
Q

What is an early deceleration?

A

HR deceleration which starts at the onset of a contraction and returns to normal when the contraction is completed.

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124
Q

What do early decels indicate?

A

Head compression during contractions.

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125
Q

What are late decelerations?

A

HR deceleration which lags after the onset of a contraction and does not return to normal until 30s after the contraction is completed.

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126
Q

What do late decels indicate?

A

Fetal distress

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127
Q

What are variable decelerations?

A

Deceleration in HR independent of contractions.

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128
Q

What do variable decels indicate?

A

May indicate cord compression.

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129
Q

Maternal risk of varicella exposure in pregnancy?

A

5x greater risk of pneumonitis.

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130
Q

Fetal risk of varicella exposure in pregnancy?

A
  • fetal varicella syndrome risk if exposed at < 20 weeks gestation (rare after 20 weeks)
  • shingles in infancy (if exposed in second / third trimester)
  • severe neonatal varicella if mother develops rash from 5 days before up to 2 days after birth
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131
Q

Features of fetal varicella syndrome?

A
  • skin scarring
  • eye defects (e.g. microphthalmia)
  • limb hypoplasia
  • microcephaly
  • learning disabilities
132
Q

Prognosis for neonatal varicella?

A

20% mortality rate.

133
Q

How is chickenpox exposure in pregnancy managed?

A
  • check varicella antibodies
  • give VZIG as soon as possible if non-immune and <= 20 weeks
  • give VZIG / aciclovir 7-14 days after exposure if non-immune and > 20 weeks
134
Q

How is chickenpox infection managed in pregnancy?

A
  • seek specialist advice
  • oral aciclovir if 20+ weeks & within 24 hours of rash onset
  • consider oral aciclovir with caution if < 20 weeks
135
Q

Major risk factor for chorioamnionitis?

A

Preterm premature rupture of membranes

136
Q

How should chorioamnionitis be managed?

A
  • prompt delivery of the fetus (by C section if necessary)
  • IV antibiotics
137
Q

What is the standard screening test for Down’s syndrome?

A

Combined test at 11 - 13+6 weeks.

138
Q

Which tests are involved in the combined test?

A
  • nuchal translucency measurement
  • serum β-HCG
  • PAPP-A
139
Q

Combined test results suggesting Down’s syndrome?

A
  • increased HCG
  • decreased PAPP-A
  • thickened nuchal translucency
140
Q

Which other conditions are tested for in the combined test?

A
  • Edward syndrome (trisomy 18)
  • Patau syndrome (trisomy 13)
141
Q

Results of the combined test suggesting Edward / Patau syndrome?

A
  • reduced HCG
  • reduced PAPP-A
  • thickened nuchal translucency
142
Q

When is the quadruple test offered?

A

Between 15-20 weeks for late bookers.

143
Q

Which tests are involved in the quadruple test?

A
  • alpha-fetoprotein
  • unconjugated oestriol
  • HCG
  • inhibin A
144
Q

Results of the quadruple test suggesting Down’s syndrome?

A
  • reduced AFP
  • reduced unconjugated oestriol
  • increased HCG
  • increased inhibin A
145
Q

Results of the quadruple test suggesting Edward syndrome?

A
  • reduced AFP
  • reduced unconjugated oestriol
  • reduced HCG
  • normal inhibin A
146
Q

Results of the quadruple test suggesting neural tube defects?

A
  • increased AFP
  • normal unconjugated oestriol
  • normal HCG
  • normal inhibin A
147
Q

Which conditions does the quadruple test screen for?

A
  • Down’s syndrome
  • Edward’s syndrome
  • neural tube defects
148
Q

What do positive results from the combined / quadruple test indicate?

A

‘Higher chance’ of the condition (more than 1 in 150).

149
Q

Options if a woman has a ‘higher chance’ result from the combined / quadruple test?

A
  • second screening test (non-invasive prenatal screening test)
  • diagnostic test (amniocentesis or chorionic villus sampling)
150
Q

Advantages of non-invasive prenatal screening test?

A
  • high sensitivity and specificity
  • non-invasive
151
Q

How does the non-invasive prenatal screening test work?

A

Analyses cell free fetal DNA (cffDNA) that circulates In maternal blood.

152
Q

What is the sensitivity and specificity of the non-invasive pre-natal screening test for Down’s syndrome?

153
Q

What is eclampsia?

A

Development of seizures in association with pre-eclampsia.

154
Q

Definition of pre-eclampsia?

A
  • pregnancy-induced hypertension
  • proteinuria
  • occurs after 20 weeks
155
Q

First-line treatment for eclampsia?

A

Magnesium sulphate

156
Q

What should be monitored when giving magnesium sulphate?

A
  • urine output
  • reflexes
  • resp rate
  • SpO2
157
Q

Risk when giving magnesium sulphate?

A

Respiratory depression

158
Q

Treatment for magnesium sulphate induced respiratory depression?

A

Calcium gluconate

159
Q

How long should magnesium sulphate treatment continue for eclampsia?

A

24 hours after last seizure / 24 hours after delivery (40% seizures are postpartum).

160
Q

Folic acid dose for epilepsy?

A

5mg (from 3 months prior to conception to 12 weeks).

161
Q

Can sodium valproate be given in pregnancy?

A

No - associated with neural tube defects & neurodevelopmental delay.

162
Q

Risk of phenytoin in pregnancy?

A

Cleft palate

163
Q

How does pregnancy affect seizure control in epileptic women?

A

60% improves / stays the same.
40% gets worse.

164
Q

Should anti epileptic drug levels be monitored in pregnancy?

A

No formal recommendation - often measured at 20+ weeks due to increased blood volume.

165
Q

Is carbamazepine safe in pregnancy?

A

Considered the least teratogenic of the older anti-epileptics. Usually only advised if benefits outweigh the risks.

166
Q

Is lamotrigine safe in pregnancy?

A

Low rate of congenital malformations.

167
Q

Why is folic acid important in pregnancy (physiology)?

A
  • folic acid is converted to tetrahydrofolate
  • THF has a key role in the transfer of 1-carbon units to substrates involved in DNA & RNA synthesis
168
Q

Causes of folic acid deficiency?

A
  • phenytoin
  • methotrexate
  • pregnancy
  • excessive alcohol intake
169
Q

Maternal consequences of folic acid deficiency?

A

Macrocytic, megaloblastic anaemia.

170
Q

Fetal consequences of folic acid deficiency?

A

Neural tube defects

171
Q

How are neural tube defects prevented in pregnancy?

A
  • all women should take 400 mcg folic acid until week 12
  • women at higher risk of having a baby with a neural tube defect should take 5mg folic acid from pre-conception until week 12
172
Q

Which women are considered at higher risk of having a baby with a neural tube defect?

A
  • partner has a neural tube defect
  • previous pregnancy affected by neural tube defect
  • family history of neural tube defect
  • antiepileptic drugs
  • coeliac
  • diabetes
  • thalassaemia
  • BMI > 30
173
Q

Indications for a forceps delivery?

A
  • fetal / maternal distress in labour
  • failure to progress in the second stage of labour
  • control of head in breech delivery
174
Q

What is a galactocele?

A

Build up of milk creates a cystic lesion in the breast. Occurs due to duct occlusion in women who have recently stopped breastfeeding.

175
Q

How can a galactocele be differentiated from an abscess?

A

Galactocele is usually painless, with no local or systemic signs of infection.

176
Q

How common is gestational diabetes?

A

4% of pregnancies.

177
Q

Risk factors for gestational diabetes?

A
  • BMI > 30
  • previous macrosomic baby (> 4.5 kg)
  • previous gestational diabetes
  • first-degree relative with diabetes
  • family origin with high prevalence of diabetes
178
Q

Who should be screened for gestational diabetes?

A

Women with any risk factor(s) for gestational diabetes.

179
Q

How are women who have had previous gestational diabetes screened?

A

OGTT as soon as possible after booking, repeat at 24-28 weeks if first test normal.

180
Q

How are women with risk factors for gestational diabetes screened?

A

OGTT at 24-28 weeks.

181
Q

What are the diagnostic thresholds for gestational diabetes?

A

Fasting glucose >= 5.6 mmol/L
2-hour glucose >= 7.8 mmol/L

182
Q

How should gestational diabetes be managed initially?

A
  • fasting glucose < 7 mmol/L - trial diet and exercise
  • fasting glucose > 7 mmol/L - start insulin
183
Q

How is gestational diabetes managed if diet / exercise is not effective?

A
  • add metformin if glucose targets not met within 1-2 weeks
  • add insulin if targets still not met with metformin
184
Q

What type of insulin is used in gestational diabetes?

A

Short-acting

185
Q

Indications to start insulin < 7 mmol/L?

A

Complications - macrosomia / polyhydramnios.

186
Q

Indication for glibenclamide (sulfonylurea) in gestational diabetes?

A
  • cannot tolerate metformin
  • decline insulin (if glucose targets not met with metformin)
187
Q

How should pre-existing diabetes be managed in pregnancy?

A
  • weight loss if BMI > 27
  • stop oral hypoglcaemics (apart from metformin)
  • start insulin
  • folic acid 5mg from pre-conception to 12 weeks
  • glucose monitoring
188
Q

Glucose targets for pregnancy?

A

Fasting - 5.3 mmol/L
1 hour post-meal - 7.8 mmol/L
2 hours post-meal - 6.4 mmol/L

189
Q

What is gestational thrombocytopenia?

A

Relatively common condition in pregnancy - due to dilution, decreased production, increased destruction of platelets.

190
Q

Why is there increased destruction of platelets in pregnancy?

A

Increased work of the maternal spleen leading to mild sequestration.

191
Q

Does gestational thrombocytopenia affect the fetus?

192
Q

What is a complete hydatidiform mole?

A
  • empty egg is fertilised
  • all 46 chromosomes are of paternal origin
193
Q

Clinical presentation of a complete hydatidiform mole?

A
  • bleeding in the first / early second trimester
  • exaggerated symptoms of pregnancy (hyperemesis)
  • uterus large for dates
  • very high hCG
  • hypertension
  • hyperthyroidism
194
Q

Why can a complete molar pregnancy result in hyperthyroidism?

A

hCG can mimic TSH

195
Q

How should a complete hydatidiform mole be managed?

A
  • urgent referral for evacuation of the uterus
  • effective contraception to avoid pregnancy until advised it’s safe (12 months)
196
Q

Complication of a complete molar pregnancy?

A

2-3% go on to develop choriocarcinoma.

197
Q

What is a partial hydatidiform mole?

A
  • normal egg fertilised by 2 sperm OR 1 sperm with chromosome duplication
  • 1x maternal DNA with 2x paternal DNA
  • XXX or XXY
  • fetal parts may be seen but pregnancy is not viable
198
Q

Most common cause of early-onset severe infection in the neonatal period?

199
Q

How common is GBS carriage in pregnant women?

200
Q

Risk factors for neonatal GBS infection?

A
  • prematurity
  • prolonged rupture of membranes
  • previous sibling GBS infection
  • maternal pyrexia
201
Q

What is the risk of GBS carriage in a woman who’s been GBS positive in a previous pregnancy?

202
Q

When should GBS swabs be taken and what is the indication for this?

A
  • 35-37 weeks (3-5 weeks prior to anticipated delivery date)
  • GBS positive in previous pregnancy
203
Q

When should intrapartum antibiotic prophylaxis be offered?

A
  • GBS positive
  • GBS positive in previous pregnancy
  • previous baby with GBS disease
  • preterm labour
  • pyrexia during labour
204
Q

Antibiotic of choice for GBS prophylaxis?

A

Benzylpenicillin

205
Q

What is HELLP syndrome?

A
  • Haemolysis, Elevated Liver enzymes, Low Platelets
  • presents in late stages of pregnancy
  • patient may have pre-eclampsia or no previous history
206
Q

Features of HELLP syndrome?

A
  • nausea & vomiting
  • RUQ pain
  • lethargy
207
Q

Management of HELLP syndrome?

A

Delivery of the baby.

208
Q

How does hepatitis B screening work in pregnancy?

A

Offered to all pregnant women.

209
Q

Management of babies born to mothers with chronic / acute hep B infection?

A
  • complete vaccination course
  • hep B immunoglobulin
210
Q

Can hep B be transmitted via breastfeeding?

211
Q

Does C section reduce vertical transmission of hep B?

212
Q

How can vertical transmission of HIV be reduced?

A
  • maternal antiretroviral therapy
  • C section
  • neonatal antiretroviral therapy
  • bottle feeding rather than breastfeeding
213
Q

How does HIV screening work in pregnancy?

A

Offered to all pregnant women.

214
Q

Can vaginal delivery be recommended in HIV positive mothers?

A

Yes - if viral load is less than 50 copies/ml at 36 weeks.

215
Q

What medication should be given prior to C section delivery for a HIV positive mother?

A

Zidovudine infusion 4 hours prior to C section.

216
Q

What should be given as neonatal antiretroviral therapy?

A
  • oral zidovudine if maternal viral load is < 50 copies/ml
  • triple ART of maternal viral load > 50 copies/ml
  • continue for 4-6 weeks
217
Q

Is breastfeeding with HIV recommended?

A

No - possibility of transmission.

218
Q

What produces hCG?

A
  • initially produced by the embryo
  • later produced by the placental trophoblast
219
Q

What is the role of hCG?

A

Prevents disintegration of the corpus luteum.

220
Q

How do hCG levels change during pregnancy?

A
  • double every 48 hours in the first few weeks
  • levels peak around 8-10 weeks
221
Q

How does blood pressure change in normal pregnancy?

A
  • falls until 20-24 weeks
  • after 20-24 weeks BP increases to pre-pregnancy levels by term
222
Q

Management of women at high risk of pre-eclampsia?

A

Aspirin 75mg OD from 12 weeks until delivery.

223
Q

How is hypertension in pregnancy defined?

A

-systolic > 140 or diastolic > 90
- increase from booking reading of > 30 systolic or > 15 diastolic

224
Q

Which antihypertensives must be stopped in pregnancy?

A
  • ACE inhibitors
  • angiotensin receptor blockers
225
Q

How is pre-existing hypertension defined in pregnancy?

A
  • hx of hypertension before pregnancy
  • BP > 140/90 before 20 weeks
  • no proteinuria / oedema
226
Q

How is pregnancy-induced hypertension defined?

A
  • hypertension occurring in the second half of pregnancy
  • no proteinuria / oedema
  • resolves following birth
227
Q

How is pre-eclampsia defined?

A
  • pregnancy induced hypertension associated with proteinuria (>0.3g in 24 hours)
  • oedema may occur
228
Q

First line medication for hypertension in pregnancy?

A

Oral labetalol

229
Q

Alternative medications for hypertension in pregnancy?

A
  • oral nifedipine
  • oral hydralazine
230
Q

Can labetalol be given for hypertension in pregnancy in an asthmatic woman?

231
Q

How commonly does induction of labour occur?

A

20% of pregnancies

232
Q

Indications for induction of labour?

A
  • 1-2 weeks post-dates
  • premature rupture of membranes (where labour does not start)
  • maternal medical problems (diabetes, pre-eclampsia, obstetric cholestasis)
  • IUFD
233
Q

How to interpret Bishop’s score?

A
  • less than 5 indicates that labour if unlikely to start without induction
  • 8 or higher indicates that there is a high chance of spontaneous labour (cervix is favourable)
234
Q

What intervention may be tried prior to induction of labour?

A

Membrane sweep

235
Q

How is a membrane sweep performed?

A

Finger is passed through the cervix and rotated against the wall of the uterus to separate the chorionic membrane from the decidua.

236
Q

What interventions are involved in induction of labour?

A
  • vaginal prostaglandin E2
  • oral prostaglandin E1 (misoprostol)
  • oxytocin infusion
  • amniotomy
  • cervical ripening ballon
237
Q

How should labour be induced if Bishop score is 6 or less?

A
  • vaginal prostaglandins / oral misoprostol
  • consider cervical balloon (if risk of hyper stimulation or woman has had a previous C section)
238
Q

How should labour be induced if Bishop score is more than 6?

A
  • amniotomy
  • IV oxytocin infusion
239
Q

What is the main complication of induction?

A

Uterine hyperstimulation - prolonged and frequent uterine contractions.

240
Q

Consequences of uterine hyperstimulation?

A
  • fetal hypoxaemia / acidaemia due to intermittent interruption of blood flow
  • uterine rupture
241
Q

Management of uterine hyperstimulation?

A
  • remove vaginal prostaglandins
  • stop oxytocin infusion
  • consider tocolysis
242
Q

What are the risks associated with obstetric cholestasis?

A
  • premature birth
  • stillbirth
243
Q

Clinical presentation of obstetric cholestasis?

A
  • pruritis (worse on palms, soles, abdomen)
  • jaundice
  • raised bilirubin
244
Q

How is obstetric cholestasis managed?

A
  • induction at 37-38 weeks
  • ursodeoxycholic acid
  • vitamin K supplementation
245
Q

How is labour defined?

A

Onset of regular and painful contractions, associated with cervical dilation and descent of the presenting part.

246
Q

What are the stages of labour?

A

Stage 1: onset of true labour until full dilation of the cervix.
Stage 2: from full dilation until delivery of the baby.
Stage 3: from delivery of the baby until delivery of the placenta & membranes.

247
Q

What monitoring should be done in labour?

A
  • fetal HR every 15 minutes (or continuous CTG)
  • contractions assessed every 30 minutes
  • maternal HR every 60 minutes
  • maternal BP & temp every 4 hours
  • offer vaginal examination every 4 hours
  • check maternal urine for ketones and protein every 4 hours
248
Q

What are the two phases in stage 1 of labour?

A

Latent phase - 0-3cm dilation, usually takes 6 hours.
Active phase - 3-10cm dilation, usually 1cm/hr.

249
Q

How long does stage 1 of labour last in a primigravida?

A

10-16 hours.

250
Q

Baby’s head position during labour?

A
  • head enters pelvis in occipito-lateral position
  • head usually delivers in occipito-anterior position
251
Q

How long does stage 2 of labour last?

252
Q

Active vs passive second stage of labour?

A

Passive - full dilation but no pushing.
Active - maternal pushing.

253
Q

Management options if stage 2 of labour is prolonged?

A
  • ventouse
  • forceps
  • C section
254
Q

What is lochia?

A

Vaginal discharge containing blood, mucus, and uterine tissue. May continue for 6 weeks after childbirth.

255
Q

How is oligohydramnios defined?

A

Reduced amniotic fluid - e.g. less than 500ml at 32-36 weeks, amniotic fluid index < 5th percentile.

256
Q

Causes of oligohydramnios?

A
  • premature rupture of membranes
  • bilateral renal agenesis & pulmonary hypoplasia (Potter sequence)
  • IUGR
  • post-term
  • pre-eclampsia
257
Q

What is a first degree perineal tear?

A

Superficial damage to the perineum, no muscle involvement.

258
Q

How should a first-degree tear be managed?

A

Does not require any repair.

259
Q

What is a second degree tear?

A

Injury to the perineal muscle, but not involving the anal sphincter.

260
Q

How should a second degree tear be managed?

A

Suturing on the ward by a suitably experienced midwife / clinician.

261
Q

What is a third degree tear?

A

Injury to the perineum involving the anal sphincter complex (external / internal anal sphincters).

262
Q

How should a third degree tear be managed?

A

Repair in theatre by a suitably trained clinician.

263
Q

What is a fourth degree tear?

A

Injury to the perineum involving the anal sphincter complex and rectal mucosa.

264
Q

How should a fourth degree tear be managed?

A

Repair in theatre by a suitably trained clinician.

265
Q

Risk factors for perineal tears?

A
  • primigravida
  • large baby
  • short & fast labour
  • shoulder dystocia
  • forceps delivery
266
Q

What is placenta accreta?

A

Attachment of the placenta to the myometrium, due to a defective decidua basalis.

267
Q

Risk associated with placenta accreta?

A

Postpartum haemorrhage - placenta does not properly separate during labour.

268
Q

Risk factors for placenta accreta?

A
  • previous C section
  • placenta praevia
269
Q

What are the three types of placenta accreta?

A

Accreta - chorionic villi attach to the myometrium.
Increta - chorionic villi invade the myometrium.
Percreta - chorionic villi invade past the myometrium, into the perimetrium.

270
Q

What is placenta praevia?

A

Placenta lies completely or partially in the lower uterine segment.

271
Q

Risk factors for placenta praevia?

A
  • multiple pregnancy
  • multiparity
  • previous C section
272
Q

How is placenta praevia investigated?

A
  • 20 week abdominal USS
  • transvaginal USS improves accuracy of placental localisation
273
Q

What is the management if low-lying placenta is found at the 20 week scan?

A
  • rescan at 32 weeks
  • no limit on activity unless bleeding occurs
  • scan every 2 weeks if grade 1/2 at 32 weeks (grade 3/4 unlikely to resolve)
  • final scan at 36-37 weeks to determine method of delivery
274
Q

Mode of delivery for placenta praevia?

A
  • elective C section at 37-38 weeks
  • may offer trial of vaginal delivery if grade 1
275
Q

How should placenta praevia with bleeding be managed?

A
  • admission
  • ABCDE approach to stabilise the woman
  • unable to stabilise - emergency C section
  • in labour / at term - emergency C section
  • stable and not in labour or at term - watchful waiting
276
Q

Risk factors for placental abruption?

A
  • proteinuric hypertension
  • cocaine use
  • multiparity
  • maternal trauma
  • increasing maternal age
277
Q

Management of placental abruption before 36 weeks?

A

Fetal distress: immediate C section.

No fetal distress:
- close observation
- steroids
- no tocolysis
- consider delivery depending on gestation

278
Q

Management of placental abruption after 36 weeks?

A

Fetal distress: immediate C section.
No fetal distress: vaginal delivery.

279
Q

Management of placental abruption when the fetus has died?

A

Induce vaginal delivery.

280
Q

Maternal complications of placental abruption?

A
  • shock
  • DIC
  • renal failure
  • PPH
281
Q

Fetal complications of placental abruption?

A
  • IUGR
  • hypoxia
  • death
282
Q

What is the definition of post-term pregnancy?

283
Q

Fetal consequences of post-term pregnancy?

A
  • reduced placental perfusion
  • oligohydramnios
284
Q

Maternal consequences of post-term pregnancy?

A

Increased rates of intervention:
- forceps delivery
- C section
- induction of labour

285
Q

How is post-partum haemorrhage defined?

A

Blood loss of > 500 ml after a vaginal delivery.

286
Q

Primary vs secondary PPH?

A

Primary - occurs within 24 hours of delivery.
Secondary - occurs between 24 hours and 6 weeks after delivery.

287
Q

Causes of (primary) PPH?

A
  • tone (most common)
  • trauma
  • tissue
  • thrombin
288
Q

Risk factors for primary PPH?
(7 P’s and 3 M’s).

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydramnios
  • emergency C section
  • placenta praevia
  • placenta accreta
  • macrosomia
  • nulliparity
289
Q

Initial ABCDE approach for PPH?

A
  • 2x large bore cannulas
  • lie woman flat
  • bloods (including group & save)
  • warmed IV fluids
290
Q

First line interventions for PPH after ABCDE?

A
  • palpate & rub the fundus
  • catheterisation - prevent bladder distension & monitor urine output
291
Q

Management options for PPH after mechanical interventions?

A
  • IV oxytocin
  • IV ergometrine
  • IM carboprost
  • sublingual misoprostol
292
Q

When should ergometrine not be used for PPH management?

A

History of hypertension.

293
Q

When should carboprost not be used in PPH management?

A

History of asthma

294
Q

What should be tried after medical management of PPH?

A
  1. Intrauterine balloon tamponade.
  2. Artery ligation (uterine / internal iliac).
  3. Hysterectomy
295
Q

What is the screening tool for post-natal depression?

A

Edinburgh Postnatal Depression Scale

296
Q

Baby blues vs post-natal depression?

A

Baby blues - seen 3-7 days following birth, mother is anxious / tearful / irritable.

Post-natal depression - usually starts within a month and peaks at 3 months. Symptoms similar to other depressive episodes.

297
Q

Management of puerperal psychosis?

A

Admission to hospital in a mother & baby unit.

298
Q

Medication for post-natal depression?

A
  • sertraline
  • paroxetine
299
Q

What are the 3 stages of postpartum thyroiditis?

A
  1. Thyrotoxicosis
  2. Hypothyroidism
  3. Return to euthyroid.
300
Q

What antibody is commonly found in post partum thyroiditis patients?

A

Thyroid peroxidase antibodies.

301
Q

How is postpartum thyrotoxicosis managed?

A

Symptom control only - propranolol.

302
Q

How is post partum hypothyroidism managed?

303
Q

Classic triad of pre-eclampsia?

A
  • new-onset hypertension
  • proteinuria
  • oedema
304
Q

Definition of pre-eclampsia?

A
  • new onset BP > 140/90 after 20 weeks of pregnancy
    AND 1 or more:
  • proteinuria
  • other organ involvement (renal, liver, neuro)
305
Q

Maternal consequences of pre-eclampsia?

A
  • eclampsia
  • other neuro complications: stroke, blindness, headaches
  • liver involvement
  • haemorrhage
  • cardiac failure
306
Q

Fetal consequences of pre-eclampsia?

A
  • IUGR
  • prematurity
307
Q

What features suggest severe pre-eclampsia?

A
  • BP > 160/110
  • heavy proteinuria
  • headache
  • visual disturbance
  • papilloedema
  • RUQ / epigastric pain
  • hyperreflexia
  • low platelets
  • abnormal liver enzymes
308
Q

What are the high risk factors for pre-eclampsia?

A
  • hypertensive disease in a previous pregnancy
  • CKD
  • SLE / anti-phospholipid syndrome
  • type 1 / type 2 diabetes
  • chronic hypertension
309
Q

What are the moderate risk factors for pre-eclampsia?

A
  • first pregnancy
  • age 40+
  • pregnancy interval of 10+ years
  • BMI > 35
  • family history of pre-eclampsia
  • multiple pregnancy
310
Q

How is the risk of pre-eclampsia reduced?

A

Aspirin 75mg daily from 12 weeks until delivery.

311
Q

How is suspected pre-eclampsia managed?

A

Arrange emergency secondary care assessment. Admit and observe women with BP > 160/110.

312
Q

When are pregnant women screened for anaemia?

A
  • booking visit (8-10 weeks)
  • 28 weeks
313
Q

Cut-offs for oral iron therapy according to gestation?

A

1st trimester: < 110
2nd / 3rd trimester: < 105
Postpartum: < 100

314
Q

What oral iron therapy is given to pregnant / post partum women?

A
  • ferrous sulfate
  • ferrous fumarate
315
Q

When does obstetric cholestasis usually occur?

A

Third trimester

316
Q

Features of obstetric cholestasis?

A
  • pruritus (often affecting palms and soles)
  • no rash
  • mild jaundice
  • raised bilirubin
317
Q

How is obstetric cholestasis managed?

A
  • ursodeoxycholic acid (symptomatic relief)
  • weekly LFTs
  • induction at 37 weeks
318
Q

When does acute fatty liver of pregnancy typically occur?

A

Rare complication - occurs in third trimester or post-delivery.

319
Q

Features of acute fatty liver of pregnancy?

A
  • abdominal pain
  • nausea & vomiting
  • headache
  • jaundice
  • hypoglycaemia
  • pre-eclampsia (severe disease)
320
Q

How is acute fatty liver of pregnancy managed?

A
  • supportive care
  • delivery once stable
321
Q

Maternal risks of obesity in pregnancy?

A
  • miscarriage
  • VTE
  • gestational diabetes
  • pre-eclampsia
  • induction of labour
  • problems during labour
  • PPH
  • wound infection
322
Q

Fetal risks of obesity during pregnancy?

A
  • congenital anomalies
  • prematurity
  • macrosomia
  • stillbirth
  • childhood obesity / metabolic disorders
  • death
323
Q

Should obese patients be advised to lose weight during pregnancy?

A
  • patients should not try to diet while pregnant
  • risk will be managed by the team in charge of their care
324
Q

Management of obesity in pregnancy?

A
  • 5mg folic acid
  • OGTT at 24-28 weeks
  • consultant-led care if BMI > 35
  • BMI > 40 - antenatal consultation with obstetric anaesthetist
325
Q

Which nerves are responsible for pain in the first stage of labour?

A

T10 - L1
Visceral afferent nerves from the uterus / cervix.

326
Q

Which nerves are responsible for pain in the second stage of labour?

A

S2 - S4
Pelvic splanchnic nerves, pudendal nerve.

327
Q

Side effects of entonox?

A
  • spaced out feeling
  • nausea
  • tiring
  • dry mouth

Women’s Health (2 decks)

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