Obstetrics Flashcards
7w pregnant G1P0 with severe nausea and vomiting. Dry as. Uterus @ 2cm above the pubic symphysis. Which investigation would most likely affect your management of her N&V?
Pelvic USS
bHCG
Urine & serum osmolarity
Pelvic USS
uterus large, ~14 weeks, USS confirms twin/molar… antiemetic drugs
- Abortion at 7 weeks, small amount of tissue taken (?decidua) but then a week later she presents with a ghost baby and is still pregnant. What investigation?
TVUS
Abdominal US
bHCG
TVUS - better to visualise the uterus
- PPH post delivery 15min, (forceps delivery). Cause?
Uterine hypotonia
Cervical tear
Perineal haematoma
Most common cause of PPH is tone
Trauma ?forceps
- Tetanus in pregnancy: chica wrecked herself on dirty metal gardening tool, third trimester of pregnancy, hasn’t had tetanus booster since age 26 (now 33). Presents and wants vaccine:
No vaccination
Wait till after birth, then just tetanus
Just tetanus now
Tdap/Boostrix now
Tdap/Boostrix at age 36
Tdap/Boostrix now +4 (gets pertussis too - bonus!)
We give this anyway in 3rd trimester for pertussis benefit
- 2 Twins at 24 weeks, 1 with polyhydramnios and the other with oligohydramnios?
TTTS
- PID in pregnancy (third trimester) caused by chlamydia - tx (no triple therapy option)
Azithromycin +6
Ceftriaxone +2 this is for gonorrhea more isn’t it? - I put cef as it is IV (figured she needs IV abx for PID) and thought it covers chlamydia but in hindsight I don’t think it does :(
Metronidazole +1 (NZF agrees with me. Dosing option for PID but azithromycin no dosing regime for PID)
Amoxicillin
The actual answer is:
Azithromycin 1 g orally, and repeat dose 1 week later
PLUS
Metronidazole 400 mg orally, twice daily for 14 days
So think best answer is azithromycin
- Woman with painless vaginal bleeding of 50ml, baby has weird position (not engaged) - oblique, diagnosis?
Placenta previa
Placenta accreta
Vasa previa
Rupture of vaginal varicosities
Bloody show
Placenta previa
- VBAC, contractions stopped, presenting part of baby no longer felt and FHR dropping. And blood on vaginal exam.
Uterine rupture
Cord prolapse
Obstructed transverse lie
Obstructed breech
Uterine rupture (scar from previous CS)
- Vaginal bleeding and cramping, LMP 4/52 ago. Raised B-HCG. Empty uterus and 20mm ovarian mass on pelvic ultrasound. Most appropriate next step?
Reassure and discharge
Pelvic ultrasound
Repeat hcg 48 hrs
Methotrexate
Tumour markers including CA-125
Repeat hcg 48 hours, should have come down - complete miscarriage?
- Reduced foetal movements at 38 wks. What to do:
- CTG
- Urgent CS
- Induce labour
CTG
16 week pregnant lady with first trimester screening 1:100 of it having down syndrome. What do you recommend?
- CVS
- Amniocentesis
- Termination
- Continue normal management
Amniocentesis, after 14 weeks we can do this it is much better than CVS (which only pro is that it can be done from 10 weeks)
Lady with RLQ pain. Regular 28-30 day cycle, last period 2 weeks ago. Had small amount of fluid in Pouch of Douglas, cyst seen in left ovary. Beta HCG negative.
- Endometriosis
- Ectopic pregnancy
- Dermoid cyst
- Haemorrhagic corpus luteum
Haemorrhagic corpus luteum
Timing, fluid, cyst seen
16 week pregnant lady, just had second trimester screening. AFP was elevated - possible neural tube defect. What do you recommend doing next?
- Morphology scan
- Offer termination of preg
- Repeat AFP
- NIPT
- Amniocentesis
- CVS
USS morphology scan for neural tube defects - >90% detection rate
- Cocaine baby, gestation was 28 weeks but on palpation it was 32 weeks, tender uterus. Reduced fetal movements. FHR 60. What is the cause of the reduced fetal movements?
- Drug effect
- Placental abruption
- Polyhydramnios
- IUGR
- Paranoid mum
This is ??placental abruption - which presents with contracted uterus + bleeding
In some cases, bleeding may occur but the blood may clot between the placenta and the wall of the uterus, so vaginal bleeding may be scanty or even non-existent. This is known as a ‘retroplacental clot’.
+ cocaine increases risk of PA
Woman in labour with ?proteinuria (didn’t she have “severe preeclampsia” with proteinuria?), needs an epidural. What test do you need to do beforehand?
- Liver tests
- Platelets
- Serum calcium
- glucose
- Uric acid
Platelets
HELLP
ELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening pregnancy complication usually considered to be a variant of preeclampsia
- Lady who just delivered a baby in 3rd stage of labour, what you give as part of active management
- Oxytocin IM
- Oxytocin in a drip
- Ergometrine
- Prostaglandins
Oxytocin IM (in stem did not already have a drip in)
- Different lady at 32wks on the way to hosp with a breech baby (fully effaced cervix and 3cm dilated) tocolytic been given already. What is your next thing to do?
Check baby’s station via fanny exam
Nil by mouth
Bloods for group and hold
Caesarian right this minute
Check baby’s station via fanny exam
- Lady has premature rupture of membranes at ?31wks; on the way to hospital what should you give her?
Betamethasone and terbutaline (tocolytic)
erythromycin + nifedipine,
betamethasone + erythromycin , erythromycin only,
betamethasone + erythromycin
Steroid for baby, abx for PPROM
- Vegan pregnant lady at 10 weeks. Which test is important to prevent developmental abnormalities in the baby?
a) Vitamin A
b) Vitamin B12
c) Vitamin C
d) Vitamin D
e) Thiamine test
b) Vitamin B12
- Small 2.2kg for gestational age is born at term. What is the baby at greatest risk of?
a) Hyperbilirubinaemia
b) Neonatal sepsis
c) Respiratory distress syndrome
d) Hypoglycaemia
d) Hypoglycaemia
- Pregnant lady ?9wks. What screening do you offer ?
a. First trimester combined screening
b. Amniocentesis
c. CVS
d. Second trimester combined screening
e. Screening no indicated
f. Ultrasound
a. First trimester combined screening
Primagravida contractions every ?, cervix effaced 1cm dilated, membranes intact, FHR 130. 4 hours later 3cm dilated, membranes intact, FHR 140. Management?
a) Amniotomy
b) Re-examine in 4 hours
c) Oxytocin
d) Epi-dural
b) Re-examine in 4 hours
1cm/hour but she is prim
- Baby stuck- patient has a BMI of 38. Head looking dusky. What do you do?
McRoberts maneuver
Downward traction on the head
Syntocinon infusion
Tocolytic
McRoberts maneuver
=hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher when combined with ‘suprapubic pressure’,
- What combination of vaccinations are ok to use in pregnancy - it said which combination of vaccines are used/recommended
Influenza and pertussis
Varicella and influenza
Measles and pertussis
Influenza and measles/mumps/rubella
All other options had either MMR or Varicella
Influenza and pertussis
Cannot give MMR or varicella
Pregnant woman. Her 5 year old child has varicella and has a fever and lots of lesions etc. Women’s rash only appeared 24h ago. Woman gets tested and is negative for Varicella Ig. What is the most appropriate course of action?
a) Oral acyclovir
b) Zoster Ig
c) MMR + Varricella vaccine
d) Varicella vaccine
Zoster Immunoglobulin (ZIG) is a high titre immunoglobulin extracted from donors. It is used in the passive prevention of varicella infection (chickenpox) in high risk individuals.
- Secondary amenorrhea following miscarriage 6 months ago (at 9 weeks) and further D and C for retained products of conception. Not on contraception. No STIs and normal smear. What is the likely cause?
· Ashermmanns
· PCOS
· PID
· Pregnancy
RPOC
Ashermanns
occurs when scar tissue forms inside the uterus and/or the cervix.
Asymptomatic pregnant lady got UTI at 9/40. Sensitive to trimeth and nitrofurantoin
Give nitro
Give trimethoprim
Treat when she has symptoms
Don’t treat
Repeat urine sample in 1 week if remains asymptomatic
Nitro - T1
Trimeth is folate antagonist so avoid in T1.
Early pregnancy PV bleeding. Lower back and pelvic discomfort. Tender suprapubic. Closed os
Threatened miscarriage
Missed miscarriage
Inevitable miscarriage
Threatened miscarriage
Infection postpartum. non fluctuant breast swelling, febrile woman. Has tried to continue breastfeeding with no improvement thus far. What management would you do next?
Empiric
Aspirate breast milk for culture
Only breastfeed from other breast
Compress
Empiric
Almost always Staph aureus - mastitis
Continuing breast feed = presents abscess formation
One of the most common infecting organisms is Staphylococcus aureus and for that reason, flucloxacillin 500 mg four times daily for seven days is recommended
Pregnant lady who had contact with rubella kid. Unsure of vaccination status.What to do to reassure her?
· Rubella IgG estimation
· Give MMR vaccine
· Assess risk of transmission
Pregnant lady who had contact with rubella kid. What to do to reassure her?
Levels > 15 IU/L of rubella IgG are consistent with immunity.
Woman presents in labour with ROM showing meconium-stained fluid, cervical opening 8cm, station +2, CTG shows borderline HR 170ish with late decels. What is the best course of management?
Emergency CS
Immediate ventouse delivery
Immediate forceps delivery
Wait and watch
Close monitoring with low threshold for intervention
Emergency CS
Woman 6 weeks post partum. Says baby cries a lot then starts to cry herself. Says she has been struggling, not eating, lost 5kg since birth, can’t sleep even when baby is asleep. Vehemently denies depression because she didn’t have it with her first baby. What is the diagnosis?
Post natal depression
Baby blues
Post partum psychosis
Adjustment disorder
Post natal depression
No signs of psychosis but >>baby blues
30 something year old lady at 12 weeks gestation. Blood pressure is high. No other Sx. What is the cause?
Pre-eclampsia
· Gestational diabetes
· Essential Hypertension
· Pregnancy related hypertension
Chronic/essential HTN if before <20/exists before!
Only gest. HTN if occurs AFTER 20 weeks
Lady with reduced foetal movements at 38 weeks, admitted for observation. Management?
I thought the CTG had late decels and baseline HR was at 160 with reduced variability.
· Emergency C-section
· Send home, do kick test then repeat CTG in one week
· Send home, do kick test and return if have further concern
· Admit and observe
Emergency C-section or something like deliver baby
- Pregnant lady with gestational diabetes which she had been controlling with diet. Had a consistently high poly glucose test? >7. What to do next?
Insulin
Some drug
Stricter diet
Increase exercise
Would be metformin and/or insulin
Someone coming is with contractions with 2cm long cervix, posterior soft tighty closed
Not in labour, Braxton Hicks
18 year old woman who is 41 weeks gestation in late second stage labour. Baby estimates to be 3.6kg. 9cm dilated, same as 2 hours previously. Head 3/5 palpable abdominal. She is exhausted and distressed. Wants more pain relief, has had pethidine 2x, last one 2 hours ago. Management?
epidural
syntocinon
caesar
epidural
1st trimester screening showing 1:100 chance of downs what do you offer they are 16 weeks
Amnio
CVS
NIPT
PCR
Karyotype
FISH
Amnio
Woman with assisted delivery 7 days ago, had prolonged rupture of membranes, now has smelly lochia, temp 39
Endometritis
. Couple with 2 years no pēpi, all tests normal both partners, both aged 32, woman BMI 36 and man BMI 40, what’s your advice?
Weight loss
IVF
Artificial insemination by husband
Weight loss
Fetus at 40 weeks, normal pregnancy, meconium stained fluid, CTG provided: baseline 170bpm Definitely clear late decels, also decreased baseline variability and absent normal accelerations . Effaced, 8cm dilated, station +2
· Monitor as vag delivery is likely
· Monitor with low threshold for intervention
· Discharge
· Deliver with forceps
· Delivery with ventouse
· Immediate C section
Immediate C section
- Woman has a completely closed cervix which is 2cm long. Things are fine and she is having some uncomfortable contractions every 3-5 minutes. Not requiring analgesia. Been going at it 4 hours with no changes to cervix??? What’s up?
Not in labour
Prolonged latent phase of labour
A few other options
Not in labour
Woman in labour baby has descended 2cm over last 1 hr from at the bones to 2cm below bones. Cervix fully dilated. CTG was normal and FHR was 144. Has been pushing for 1 hour. How to manage?
Check back in an hour
Give oxytocin
3 other options
Ventouse delivery
Forceps delivery
C section??
Check back in an hour
No concerns
Given a history and an image of baby CTG.Baseline CTG had foetal HR ~160bpm. With reduced variability and decelerations.
Emergency caesarean
Lady presenting with baby with transverse lie at 39 weeks. She presented with no antenatal care for the last 8 weeks so assuming she had had some initially???. Best management? (i thought she was earlier than 39 but in the late 30s still nah defs 39/40 +2) Didnt actually say whether she was in labour or just a check up
a. External version +9 (isn’t this only an option until 37 weeks?? Yup i think so +3, Just checked up to date, says performed from 36 weeks) RIP
b. C/S+ 13
c. Wait for spontaneous version +1
d. Vaginal exam
e. others
Think USS
?placenta previa
Pregnant lady 32/40 with small vulval warts that were first identified at a booking scan but are now slowly increasing in size & number. What would you do in the current situation? (Repeat q kind of)
a. Oral acyclovir
b. No further treatment
c. Topical Imiquimod
d. Topical podophyllotoxin
e. Surgical excision
No further treatment
/cryotherapy
- Pregnant lady wondering about the flu vaccine. 8 weeks pregnant
a. Vaccinate now
b. Defer until 3rd trimester
- Pregnant lady wondering about the flu vaccine. 8 weeks pregnant
a. Vaccinate now +24
b. Defer until 3rd trimester +3
- Kid who was born via forceps and now not moving left arm
a. Left brachial plexus injury
b. Fractured humerus
c. Normal
d. Right intracerebral haemorrhage
e. Intrauterine encephalopathy?
f. Hypoxia? Birth asphyxia
Left brachial plexus injury
from pulling on head
Primigravida lady with twins at 12/40. Separate chorion and amniotic sacs. Normal BMI. What is she most at risk of?
a. Pre-eclampsia
b. Gestational diabetes
c. Hyperemesis gravidarum
d. Twin-twin transfusion syndrome
Pre-eclampsia +19
Something about when does a fertilised egg implant into the endometrium
a. 5days
b. 2days
c. 4-5hrs
d. On the 1st day of next missed period
e. 10d after ovulation
5 days
Women who took home pregnancy test two weeks ago and was positive. Now presenting with R lower abdo pain. bHCG of 3200. USS empty uterus and small cyst in R ovary.
a. Ectopic pregnancy +21
b. Ovarian cancer
c. Hydatidiform mole +7 (isn’t bhcg too high for ectopic, ectopic usually lower than normal hcg compared to gestation - need serial hcg measurements to determine this)
d. Ovarian cyst
The cyst in ovary is theca cyst associated with hydatiform mole
Ectopic (the uterus is empty girl)
Woman with dysmenorrhoea, some spotting before heavier days during period. No dyspareunia. Never had STIs. Partner has had previous kids? Why are they struggling to conceive?
a. Endometriosis
b. PID
c. PCOS
d. Altered cervical mucus
Endometriosis
women is in early labour. has UTI. what to do next-
?Amoxicillin
antepartum vaginal bleeding, uterine tenderness, diagnosis?
Placental abruption
large for date uterus, hyperemesis gravidum,
choriocarcinoma
Infertility due to tubal problems
Tubal surgery
Infertility as oligospermic
intra cytoplasmic inclusion
Low lying placenta at 18/40, Management?
another scan at 3rd trimester
Transverse lie in second trimester
Reassurance as it may correct itself
Infertility due to male azoospermia
donor insemination
donor insemination
Serial bHCG
Pregnant lady @ 34/40, SFH only 29 cm, smoker. Whats going on?
IUGR
Female with infertility, anovulatory cycles. & acne
Clomiphene/Letrozole: medication used to treat infertility in women who don’t ovulate
Question re: endometriosis grading
Mild or Stage I
small patches or surface lesions scattered around the pelvic cavity, no scarring.
Moderate or Stage II - III
Appears as large patches or patches that are more widely spread. They may be attached to the ovaries, fallopian tubes, uterosacral ligaments and the Pouch of Douglas. Cysts may be present and are often associated with significant scarring.
Severe of Stage IV
At Stage IV endometriosis affects most of the organs in the pelvic cavity, often with severe scarring. The uterus, ovaries, fallopian tubes, bowel, bladder, uterosacral ligaments and the Pouch of Douglas are often held down by adhesions.
Female refuses emergency C section, abnormal CTG
Respect her wishes and work around
How does clomiphene work?
triggers the pituitary gland to secrete FSH and LH –> stimulates the growth of the ovarian follicle and initiates ovulation
When to give folate based on evidence for (-) risk of NTD
4 weeks preconception and carry on through 1st trimester (up to 12 weeks)
lady 37/40 pregnant, meconium in amniotic. What investigation?
Fetal Scalp pH
Case of young woman with vaginal bleeding, heaving cramping. Previous breast tenderness. Uterus shows empty uterus
Complete miscarriage
Infertility, male had chlamydia orchitis, not testes are atrophied, (-) sperm count
Donor sperm
Pregnant lady presenting with thrush. What investigation should be done?
Blood sugar –> diabetes predisposes to thrush
Overweight female & anovulatory cycles + polyuria, polydipsia
investigation?
Blood glucose (PCOS)
Female with late period, pelvic pain and peritonism
Ectopic pregnancy
20 weeks gestation, (+) SFH with non-palpable fetal parts. Cause?
Polyhydramnios
10 weeks gestation, (+) hcg, PV bleeding
Molar pregnancy
Baby born from a mother with gestational diabetes. What complication is the neonate
most likely to have?
Hypoglycaemia
Lady at 8 weeks gestation with frank bleeding. Uterus 12 weeks and lumpy.
Brown discharge. Para-urethral nodule. Diagnosis?
Choriocarcinoma
Lady having a miscarriage has very low BP
Cervical shock
Which kind of miscarriage? Bright red bleeding and os is open. No passage of
products of conception?
Inevitable
Woman with fetal demise at roughly 37-38 weeks. Ripe cervix. Management?
Oxytocin/syntocinon augmentation
Lady in labour (cervix effaced, dilated), low anterior placenta, breech
presentation. 31/34 weeks gestation.
Group + hold, C-section
Women with pain and bleeding at 38 weeks or so gestation. Noted to have a
placenta 2cm away from internal OS. Diagnosis?
This is praevia (right on the line)
