Obstetrics Flashcards
1
Q
What is the source of progesterone?
A
Corpus luteum
Placenta
Adrenal cortex
2
Q
What is the function of progesterone?
A
Maintainence of endometrium and pregnancy
Thickens cervical mucus
Decreases myometrial excitability
Increases body temperature
Responsible for spiral artery development
3
Q
What is the function of Oestrogen?
A
Proliferation of endometrium
Promotes development of genitalia
Promotes growth of follicle
Causes LH surge
Responsible for female fat distribution
Increases TBG levels
Upregulates oestrogen, progesterone, LH receptors
4
Q
Causes of infertility?
A
Sperm problems- 30%
Ovulation problems- 25%
Tubal problems- 15%
Uterine problems- 10%
Unexplained- 20%
5
Q
General advice offered to couples struggling to concieve?
A
400mcg of folic acid daily
Aim for healthy BMI
Avoid smoking/ drinking
Reduce stress
Aim for unprotected sexual intercourse every 2-3 days
Avoid timed intercourse
6
Q
Why are couples trying to conceive not advised for timed intercourse?
A
Puts strain on relationship
Increases stress
7
Q
Investigations to help diagnose infertility in primary care?
A
BMI
Chlamydia screen
Semen analysis
Female hormone testing
Rubella immunity in mother
8
Q
What hormones are checked when investigating infertility ?
A
LH and FSH; day 2-5 of cycle
Serum progesterone; day 21, or 7 days before end of cycle
Anti-mullerian hormone
Thyroid function test
Prolactin
9
Q
What does high FSH suggest?
A
Poor ovarian reserve, pituitary gland is producing extra FSH to stimulate follicular development
10
Q
What does high LH indicate?
A
PCOS
11
Q
What is the most accurate marker of ovarian reserve?
A
AMH- high level indicates good reserve
12
Q
What investigations can be performed in secondary care to diagnose cause of infertility?
A
Pelvic ultrasound
Hysterosalpingogram
Laparoscopy and dye test
13
Q
What is a hysterosalpingogram?
A
Scan to assess shape of uterus and patency of fallopian tubes where a tube is inserted into cervix and a dye is injected into cavity while X-ray images are taken
14
Q
Management of anovulation?
A
Weightloss; for those with PCOS can restore ovulation
Clomifene can stimulate ovulation
Letrozole is an alternative with anti-oestrogen effects
Gonadotropins can be used in clomifene resistant women
Ovarian drilling
Metformin
15
Q
Management Of infertility caused by tubual factors?
A
Tubual cannulation during hysterosalpingogram
Laparoscopy to remove endometriosis/ adhesions
IVF
16
Q
Mechanism of action of clomifene?
A
Oestrogen receptor modulator taken between day 2 to 6 of menstrual cycle, resulting in reduced negative feedback and increased FSH and LH
17
Q
Management of infertility caused by uterine factors?
A
surgical correction of polyp, adhesion and structural abnormalities
18
Q
What is assessed in semen analysis?
A
Quantity
Quality
19
Q
Advice given to men before providing sample for semen analysis?
A
Abstain from ejaculation for atleast 3 days and 7 days at most
Avoid hot baths, sauna, tight underwear
Attempt to catch full sample
Deliver sample within 1 hour of collection
keep sample warm
20
Q
Factors affecting semen analysis?
A
Hot baths
Tight underwear
Smoking/ alcohol
Caffeine
Rained BMI
21
Q
When is a repeat semen sample indicated?
A
After 3 months in a borderline sample
2-4 weeks in a very abnormal sample
22
Q
What are the normal results of semen analysis?
A
Semen volume; >1.5mls
Semen pH; > 7:2
Concentration; >15million / ml
Total number; >39 million per sample
motility; >40% are motile
Vitality ; >58% are active
Percentage of normal sperm
23
Q
Causes of poor sperm quality?
A
Pre-testicular
Testicular
Post testicular
24
Q
Pre-testicular causes of poor sperm?
A
Pituitary /hypothalamic dysfunction
Stress, chronic illness, hyperprolactinanemia
Kallman syndrome
25
Testicular causes of poor semen quality?
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic/congenital; Klinefelter syndrome, Y chromosome deletion, Sertoli cell only syndrome, Anorchia
26
Post testicular causes of poor semen quality ?
Obstruction preventing ejaculate leaving;
Damage to testicle, vas deferens
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis
Absence of vas deferens (CF)
Young's syndrome
27
Investigations performed after abnormal semen analysis?
Hormonal analysis
Genetic testing
Imaging; transrectal USS, MRI
Vasography
Testicular biopsy
28
Management of male factor fertility?
Surgical sperm retrieval
Surigcal correction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination
29
What is IVF?
Process of fertilising egg in lab with sperm and then implanting fertilised embryo into uterus
30
When is IUI preferred?
Donor for same sex couples
HIV
Practical issues with vaginal intercourse
31
Steps involved with IVF?
Suppressing natural menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination or intracytoplasmic sperm injection
Embryo culture
Embryo transfer
32
How is menstrual cycle surpressed in IVF?
GnRH agonists or GnRH antagonists
Results in suppression of gonadotropins preventing maturation of follicles and hence ovulation
33
Example of GnRH agonist?
goserelin
34
Example of GnRH antagonist?
Cetrorelix
35
What are the steps of ovarian stimulation?
FSH injections for 10-14 days and once enough follicles have matured hCG is given as a trigger injection 36 hours before collection to promote final stages of maturation
36
During IVF at what day is a pregnancy test performed?
16 days after egg collection
37
When is progesterone used in IVF?
from oocyte collection to 8-10 weeks gestation to compensate for corpus luteum
38
Complications of IVF?
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
Egg collection procedure; pain, bleeding, pelvic infection, damage to bladder/bowel
39
What is ovarian hyperstimulation syndrome?
Complication of ovarian stimulation during IVF treatment associated with use of hCG to mature the follicles in final step of ovarian stimulation
40
Pathophysiology of OHSS?
Increased VEGF released by granulosa cells of the follicles increases vascular permeability causing fluid to leak from capillaries into extravascular space
Also activation of RAAS
41
Risk factors for OHSS?
Younger age
Lower BMI
Raised AMH
Higher antral follicles count
PCOS
Raised oestrogen levels during ovarian stimulation
42
How can OHSS be prevented?
Each women is assessed for risk of developing disease
During stimulation with gonadotropins serum oestrogen is monitored and ultrasound scans are used to monitor number of follicles
43
Strategies to reduce risk of OHSS?
Use GnRH antagonist protocol
Lower dose of gonadotropin
Lower dose of hCG injection
Alternatives to hCG such as GnRH agonists or LH
44
Features of OHSS?
Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension, hypovolaemia
Ascites
Pleural effusion
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state
45
when does OHSS present?
Within 7 days of hCG injection
Late OHSS is 10 days post injection
46
Management of OHSS?
Oral fluids
Monitor urine output
LMWH
Ascitic fluid removal
IV colloid
47
What is an Ectopic pregnancy?
When a pregnancy implantation outside the uterus
48
Ectopic sites of implantation of pregnancy?
Fallopian tube
Ovary
Cervix
Abdomen
49
Risk factors for Ectopic pregnancy?
Previous Ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to fallopian tubes
Intrauterine devices
Older age
Smoking
50
Presentation of Ectopic pregnancy?
Pr3sents around 6-8 weeks gestation
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness
Dizziness/ syncope
Shoulder tip pain
51
What is seen on ultrasound scan in Ectopic pregnancy?
Gestational sac containing a yolk sac or foetal pole may be seen
Non specific sign in tube may be seen; blob sign, bagel sign or tubule ring sign
52
What is a pregnancy of unknown location?
Woman has a positive pregnancy test with no evidence of pregnancy on ultrasound scan
53
Hos is a pregnancy of unknown location monitoried?
hCG level measured 48 hours apart
Rise in more than 63% indicates intrauterine pregnancy; repeat USS in 1-2 weeks and hCG should be over 1500 IU/ l
Rise less than 63% can indicate ectopic pregnancy so patient should be admitted for review
Fall more than 50% indicates miscarriage
54
Management options for Ectopic pregnancy/ miscarriage?
Expectant management
Medical management
Surgical management
55
Expectant management for Ectopic pregnancy?
Ensure adequate follow up is in place to ensure successful termination
Ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No visible pain
hCG level <1500 IU/ l
56
Criteria for medical management of Ectopic pregnancy with methotrexate?
Ensure adequate follow up is in place to ensure successful termination
Ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No visible pain
hCG level <5000 IU/ l
Confirmed absence of intrauterine pregnancy
57
How is methotrexate administered to manage ectopic pregnancy?
IM injection in buttock
58
Advice given to women who are managed with methotrexate?
Do not get pregnant within 3 months following treatment
59
Common side effects of methotrexate?
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis
60
What is the criteria for surgical management of ectopic pregnancy?
Adnexal mass >35mm
Visible heartbeat
hCG levels > 5000 IU/ l
61
Surgical options for management for ectopic pregnancy?
Laparoscopic salpingectomy- first line treatment with removal of affected fallopian tube
Laparoscopic salpingotomy- an incision is made in fallopian tube and ectopic pregnancy is removed
62
What is the risk of not removing the ectopic pregnancy with salpingotomy?
1 in 5 women, may require further treatment with methotrexate
63
What is a miscarriage?
Spontaneous termination of pregnancy before 24 weeks gestation
If before 12 weeks it is called an early miscarriage
64
What is a missed miscarriage?
The foetus is no longer alive but no symptoms have occurred
65
What is a threatened miscarriage?
Vaginal bleeding with a closed cervix and foetus that is alive
66
What is an inevitable miscarriage?
Vaginal bleeding with open cervix
67
What is an incomplete miscarriage?
Retained products of conception after the miscarriage
68
What is a complete miscarriage?
a full miscarriage with no products of conception left in the uterus
69
What is an anembryonic pregnancy?
Presence of gestational sac with no embryo
70
What investigation is used to diagnose ectopic pregnancy/ miscarriage?
Transvaginal ultrasound
hCG levels
71
What features are assessed on ultrasound scan in early pregnancy?
Mean gestational sac diameter
Foetal pole and crown- rump length
72
When is the pregnancy considered viable?
When foetal heart beat is visible
73
Usually when is the foetal heart beat expected to be visible?
Crown- rump length is 7mm or more
74
When is the foetal pole expected to be visible
Mean gestational sac diameter is 25mm or more
75
When is expectant management appropriate in the context of miscarriage?
Less than 6 weeks gestation
No pain
No other risk factors or complications
76
What investigation is performed in expectant management of miscarriage?
Repeat urine pregnancy test 7-10 days later
If positive may indicate incomplete miscarriage and further management may be required
77
Medical management of miscarriage?
Missed miscarriage;
Oral mifepristone
48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed.
if bleeding has not started within 48 hours after misoprostol treatment, they should contact their healthcare professional
Incomplete miscarriage;
A single dose of misoprostol (vaginal, oral or sublingual)
Women should be offered antiemetics and pain relief
78
Mechanism of action of Mifepristone?
Mifepristone is a progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
79
Mechanism of action of Misoprostol?
Misoprostol is a prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
80
Complications of miscarriage?
Incomplete miscarriage
Haemorrhagic shock
Infection - endometritis
3% of women
Psychological complications; Depression/anxiety
Haemolytic disease of the newborn
Increased risk of having another miscarriage
81
Surgical management of miscarriage?
Manual vacuum aspiration; under local anaesthetic
Electric vacuum aspiration; under general anaesthetic
82
What is recurrent miscarriage?
Three or more consecutive miscarriages
83
When is investigation for recurrent miscarriage initiated?
Three or more first trimester miscarriages
One or more second trimester miscarriage
84
Causes of recurrent miscarriage?
Idiopathic
Antiphospholipid syndrome
Hereditary thrombophilia
Uterine abnormalities
Genetic factors
Chronic histiocytic intervillositis
Other chronic disease such as diabetes, thyroid disease, SLE
85
What hereditary thrombophilia can result in recurrent miscarriage?
Factor V leiden
Factor II gene mutation
Protein S deficiency
86
What uterine abnormalities can lead to recurrent miscarriage?
Uterine septum
Unicornuate uterus
Bicornuate uterus
Didelphic uterus
Cervical insufficiency
Fibroids
87
Investigations to find cause of recurrent miscarriage?
Antiphospholipid antibodies
Testing for heereditary thrombophilias
Pelvic ultrasound
Genetic testing on products of conception and parents
88
What is chronic histiocytic intervillositis?
Build up of histiocytes and macrophages in the placenta causing inflammation and adverse obstetric outcome
Common cause for second and third trimester miscarriage
89
What is termination of pregnancy?
Abortion; elective procedure to end pregnancy
90
When can an abortion be performed?
Continuation of pregnancy will lead to adverse mental and physical health outcomes to the mother or existing children of the family
91
Legal requirements for abortion?
Two medical practioners must sign and agree abortion is indicated
Must be carried out by an approved medical practioner in an NHS hospital or approved premise
92
What are the options for abortion?
Medical abortion
Surgical abortion
93
How is a medical abortion performed?
Mifepristone and misoprostol taken 48 hours apart
94
What are the methods of surgical abortion?
Cervical dilation and suction; upto 14 weeks gestation
Cervical dilation and evacuation using forceps; usually between 14 and 24 weeks
95
Complications of abortion?
Bleeding
Pain
Infection - most commonly endometritis
Failure of abortion
Damage to cervix, uterus or other stuctures
96
Post abortion care?
Urine pregnancy test 3 weeks following abortion
97
What is hyperemesis gravidarum?
Form of nausea and vomiting of pregnancy with protracted including;
More than 5% weight loss compared with before pregnancy weight
Dehydration
Electrolyte balance
98
Triad of hyperemesis gravidarum?
More than 5% weight loss compared with before pregnancy weight
Dehydration
Electrolyte balance
99
How is severity of nausea and vomiting in pregnancy assessed?
Pregnancy Unique Quantification of Emesis (PUQE) scored out of 15
Less than 7; mild
7-12; Moderate
More than 12; Severe
100
Management of Nausea and vomiting in pregnancy?
Antiemetics; Prochlorperazine, Cyclizine, Ondansetron, Metoclopramide
Ranitidine/ omeprazole if acid reflux is a problem
101
What is a hydatiform mole?
Type of tumour that grows like a pregnancy inside the uterus
102
Classification of molar pregnancy?
Complete mole; when two sperm fertilise an egg with no genetic material the cells divide and grow into a tumour
Partial mole; when two sperm cells fertilise a normal ovum and these cells grow and divide
103
Presentation of molar pregnancy?
Compared to a normal pregnancy there will be
More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis
104
Investigations to diagnose molar pregnancy?
Ultrasound showing sandstorm appearance
Definitive diagnosis made with histology following evacuation of mole
105
Management of molar pregnancy?
Evacuation of mole and histology
Referal to gestational trophoblastic disease centre
Sometimes can metastasise and require systemic chemotherapy
106
From which week gestation is each trimester?
First trimester; start till 12 weeks
Second trimesrer; 13 weeks will 26+6
Third trimester; 27 weeks until birth
107
When does the booking appointment take place?
Before 10 weeks
108
When does the dating scan take place?
Between 10 and 13+6 weeks
109
How is an accurate estimate for gestational age calculated?
Crown to rump length measurement
110
What is measured at dating scan?
Presence of heart beat
Gestational age and EDD
Multiple pregnancy
111
When is the anomaly scan?
Between 18 and 20+6 weeks
112
What is routinely assessed at antenatal appointments?
Discuss plans for the rest of the pregnancy and delivery
Symphysis- Fundal height measurement- 24 weeks onwards
Foetal presentation- 36 weeks onward
Urine dipstick and blood pressure
Urine microscopy and culture
113
Which SSRI's are safe to use in breastfeeding?
Sertraline or paroxetine
114
Which vaccinations are offered to all pregnant women?
Whooping cough; after 16 weeks
Influenza in autumn and winter
115
Which vaccines should be avoided by pregnant women?
Live vaccines such as MMR
116
What is the general advice given to pregnant women?
Take 400mcg folid acid daily
Take vit D supplementation
Avoid vitamin A
Don't drink alcohol and smoking
Avoid unpasteurised dairy
Avoid raw or undercooked poultry
Continue moderate exercise but avoid contact sport
Flying increases risk of VTE
Place seatbelt above and below bump
117
Complications of drinking alcohol in pregnancy?
Miscarriage
Small for dates baby
Pre-term delivery
FAS
118
Features of FAS?
Microcephaly
Thin upper lip
Smooth flat philtrum (groove between nose and upper lip)
Short palpebral fissure
Learning disability
Behavioural difficulties
Hearing and vision problems
Cerebral palsy
119
What are the risks of smoking in pregnancy?
Foetal growth restriction
Miscarriage
Stillbirth
Preterm labour and delivery
Placental abruption
Pre-eclampsia
Cleft lip or palate
Sudden infant death syndrome
120
Guidelines surrounding flying during pregnancy?
Fine to fly in uncomplicated pregnancies upto 37 weeks in singleton and 32 weeks in multiple pregnancy
After 28 weeks most doctors require a medical certificate
121
What is the booking clinic appointment?
Initial appointment to discuss and arrange plans for the pregnancy occurring ideally before 10 weeks
Also assess risk for other conditions, check biophysical measurements and ensure wellbeing of mother
122
What blood tests are taken at the booking appointment?
Blood group, antibodies and rheusus D status
FBC- anaemia
Screening for thalassaemia and sickle cell disease (higher risk women)
Also offered screening for infectious diseases like HIV, hepatitis B and syphillis
123
What is the purpose of Down's syndrome screening?
Decide which women should receive more invasive tests to establish diagnosis
124
What is the combined test?
First line and most accurate screening test for Down's syndrome combining results from ultrasound scan and maternal blood tests
125
When is the combined test performed?
11 to 14 weeks gestation
126
What components are measured in combined test?
And what results would indicate higher risk of Down's?
Nuchal translucency- >6mm
hCG- high level
PAPP-A- lower level
127
When is the triple/ quadruple screening test for downs syndrome used?
14 to 20 weeks
128
What is measured in the triple test?
hCG- higher level
Alpha fetoprotein - lower result
Serum oestriol - lower result
129
What is measured in the quadruple test?
hCG- higher level
Alpha fetoprotein - lower result
Serum oestriol - lower result
Inhibin-A; higher
130
When is further testing for Down's syndrome indicated?
When screening test reveals chance higher than 1 in 150
Occurs in around 5% of tested women
131
What are the options for invasive testing?
Amniocentesis
Chorionic villus sampling
Karyotyping is performed on foetal tissue for definitive answer
132
What is non invasive prenatal testing?
Using fragments of foetal DNA/ placental fragments in maternal blood to act as a method of screening
Not a definitive test
133
How should dose of levothyroxine be adjusted in pregnancy?
Increase dose by atleast 25-50mcg
Treatment is uptitrated based on TSH levels
134
Which antihypertensive medications are not safe to use in pregnancy?
ACE inhibitors
Angiotensin receptor blockers
Thiazide and thiazide like diuretics
135
How does pre-existing epilepsy change during pregnancy?
Take 5mg folic acid
Seizure control may worsen due to hormonal changes, lack of sleep, stress and altered medication regime
Ideally epilepsy should be controlled by a signle anti-epileptic drug
136
Which anti-epileptic medications are safe to use in pregnancy?
Levetiracetam, lamotrigine, carbamazepine
137
Which anti-epileptic medications are avoided in pregnancy and why?
Sodium valproate; neural tube defects and developmental delay
Phenytoin; cleft lip and palate
138
At which stage in pregnancy should NSAIDs be avoided and why?
third trimester premature closure of the ductus in the foetus and delay labour
139
What effects can beta blockers have on the foetus?
Foetal growth restriction
Hypoglycaemia in neonate
Bradycardia in neonate
140
What adverse outcomes can occur is ACE inhibitors are taken during pregnancy?
Oligohydramnios
Miscarriage or foetal death
Hypocalvaria
Renal failure in neonate
Hypotension in neonate
141
What effect can use of opiates have on neonate?
Withdrawal symptoms between 3-72 hours post birth known as neonatal abstinence syndrome
Presents as irritability, tachypnoea, high temperatures and poor feeding
142
What cardiac defect is lithium associated with?
Ebstein's anomaly
143
What can use of warfarin in pregnancy lead to?
Foetal loss
Congenital malformations- particularly craniofacial malformations
Bleeding during pregnancy
PPH
Foetal haemorrhage
Intracranial bleeding
144
If lithium is used during pregnancy what precautions are taken?
Check lithium levels every 4 weeks then every week from 36 weeks
Avoid breast feeding
145
Risks of using SSRI in pregnancy?
First trimester; congenital heart defects, especially paroxetine
Third trimester; persistent pulmonary hypertension in neonate
Neonates can experience withdrawal symptoms
146
What causes congenital rubella syndrome
Maternal rubella infection before the 20th week of pregnancy
147
Features of congenital rubella syndrome?
Congenital cataracts
Congenital deafness
Congenital heart disease
Learning disability
148
What can chickenpox during pregnancy lead to ?
More severe case in woman with varicella pneumonitis, hepatitis or encephalitis
Foetal varicella syndrome
Severe neonatal varicella syndrome
149
How can varicella during pregnancy be treated?
If presenting within 24 hours of symptoms oral aciclovir if she is over 20 weeks
150
Features of congenital varicella syndrome?
Foetal growth restricition
Microcephaly
Hydrocephalus
Learning difficulty
Scars and significant skin changes
Limb hypoplasia
Cataracts and Inflammation in the eye
151
What is listeria?
Gram positive bacteria infection causing flu like symptoms which is more common in pregnant women and typically transmitted
152
What are the adverse effects of listeriosis in pregnancy?
High rate of foetal death and miscarriage
153
Features of congenital CMV?
Foetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
154
How is CMV spread?
Saliva of asymptomatic children
155
What is congenital toxoplasmosis?
Infection with parasite toxoplasma gondii contracted through infected faeces from cat
can lead to congenital toxoplasmosis and is higher risk in later pregnancy
156
Features of congenital toxoplasmosis?
Intracranial calcification
Hydrocephalus
Chorioretinitis
157
Complications of parovirus B19 infection in pregnancy?
Miscarriage/ foetal death
Severe foetal anaemia
Hydrops fetalis
Maternal pre-eclampsia like syndrome
158
What is mirror syndrome?
Pre-eclampsia like syndrome as a result of parovirus B19 infection presenting with Hydrops fetalis, placental oedema and oedema in mother with hypertension and proteinuria
159
What is the cause of mirror syndrome?
Hydrops fetalis as a result of parovirus B19 infection
160
Investigations for women with suspected parovirus B19 infection?
IgM for parovirus; acute infection in past 4 weeks
IgG for parovirus; long term immunity after infection
Rubella antibodies as a differential
161
How is Zika virus transmitted?
Aedes mosquito and sexual contact
162
Symptoms of congenital zika syndrome?
Microcephaly
Growth restriction
Intracranial abnormalities such as ventriculomegaly and cerebellar atrophy
163
Women with which rhesus status need intervention?
negative
164
Pathophysiology of rhesus incompatibility in pregnancy?
When a rh negative mother becomes pregnant there is a possibility that the baby is positive
If this is true the babys red cells express the Rh antigen and themothers immune syndrome produces Rh antibodies and is said to be sensitised to the antigen
This then causes problems in subsequent pregnancies and can lead to haemolytic disease of the newborn
165
Management of rhesus incompatibility?
Prevent sensitisation; IM anti-D injections
Given with 72 hours of sensitisation event
166
When are anti-D injections given routinely?
28 weeks gestation
At birth if baby's blood group is postive
167
At what other occasions should anti-D be administered?
Antepartum haemorrhage
Amniocentesis procedure
Abdominal trauma
168
What is the Kleinhauer test?
A test performed after 20 weeks gestation
Determined how much foetal blood has passed into mothers blood
169
What is a small for gestation age baby?
Foetus that measures below the 10th centile for their gestational age
170
How is size of foetus measured?
Estimated foetal weight
Foetal abdominal circumference
Both measured on USS
171
What factors are taken into account with customised growth charts?
Ethnic group
Height
Weight
Parity
172
What is the definition of low birth weight?
Birth weight below 2500g
173
Causes of SGA babies?
Constitutionally small
Placenta mediated FGR; idiopathic, pre-eclampsia, maternal smoking, maternal alcohol, anaemia, malnutrition, infection, maternal health conditions
Non placental mediated FGR; Genetic abnormalities, structural abnormalities, foetal infection, errors of metabolism
174
Signs of foetal growth restriction?
Reduced amniotic fluid level
Abnormal doppler studies
Reduced foetal movements
Abnormal CTG
175
Complications of FGR?
Short term;
Foetal death/ still birth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Long term;
Cardiovascular disease
Hypertension
T2DM
Obesity
Mood and behavioural problems
176
Risk factors for SGA?
Previous SGA baby
Obesity
Smoking
Diabetes
Existing HTN
Pre-eclampsia
Older mother
Multiple pregnancy
Lower PAPP-A
Antepartum haemorrhage
Antiphospholipid syndrome
177
Monitoring SGA babies?
Serial ultrasound scans
178
Management of SGA?
Identify those at risk
Start aspirin for high risk women, treat modifable risk factors
Serial growth scans
Delivery when growth is static and ther are other concerns
179
What is Large for gestational age?
Macrosomia when the weight of the baby is more than 4.5kg at birth
During pregnancy estimated foetal weight is over the 90the centile
180
Causes of macrosomia?
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
181
Risks of macrosomia to the mother?
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery/ C-section
PPH
Uterine rupture
182
Risks of macrosomia to the baby?
Birth injury
Neonatal hypoglycaemia
183
What type of multiple pregnancy has the best outcome?
Diamniotic, dichorionic twin pregnancy
184
On USS what is seen in dichorionic diamniotic pregnancy?
Lambda sign, twin peak sign, there is a membrane between the twins
185
On USS what is seen in a monochorionic diamniotic pregnancy?
T sign with a membrane separating the twins
186
Complications experience by mother my multiple pregnancy?
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery/ C-section
PPH
187
Complications experienced by baby in multiple pregnancy?
Miscarriage
Still birth
FGR
Prematurity
Twin twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
188
What is Twin Twin Transfusion Syndrome?
When foetuses share a placenta where one of the foetus gets more of the blood supply from the placenta leading to a discrepancy in size
189
What is the management of TTTS?
Referal to teritary centre and in severe cases can require laser ablation
190
What is Twin Anaemia Polycythaemia Sequence?
Less severe version of TTTS, where one twin becomes anaemic and other becomes polycythaemic
191
In a multiple pregnancy at what time points is FBC for anaemia monitored?
Booking clinic
20 weeks
28 weeks
192
Frequency of USS in multiple pregnancy?
Every 2 weeks for monochorionic twins from 16 weeks
Every 4 weeks for dichorionic twins from 20 weeks
193
When is planned birth offered in multiple pregnancy?
32 and 33+6 for uncomplicated monochorionic monoamniotic twins
36 and 36+6 for monochorionic diamniotic twins
37 to 37+6 for uncomplicated dichorionic diamniotic twins
Before 35+6 for triplets
194
What is the mode of delivery in monoamniotic twins?
Elective C-section
195
Complications associated with UTI in pregnancy?
Preterm delivery
Low birth weight
Pre-eclampsia
196
Presentation of lower UTI in pregnant women?
Dysuria
Suprapubic pain
Increased frequency of urination
Urgency
Incontinence
Haematuria
197
Presentation of pyelonephritis in pregnant women?
Fever
Loin, suprapubic or back pain
Vomiting
Loss of appetite
Haematuria
Renal angle tenderness
198
Investigations for UTI in pregnancy?
Urine dip
MSC
199
Causes of UTI in pregnancy?
Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
Staphylococcus
Candida albicans
200
Management of UTI in pregnancy?
7 days antibiotics
Nitrofurantoin- avoid in third trimester
Amoxicillin- only after sensitivities are known
Cefalexin
201
Why is nitrofurantoin avoided in third trimester?
Risk of neonatal haemolysis
202
When are women routinely screened for anaemia during pregnancy?
Booking clinic
28 week gestation
203
What are the haemoglobin cutoffs at each check point in pregnancy?
Booking bloods; >110
28 weeks gestation; >105
Post partum; >100
204
Risk factors for VTE in pregnancy?
Smoking
Parity over 3
Age over 35
BMI over 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
205
RCOG recommendations for commencing VTE prophylaxis?
First trimester if there are three risk factors
206
What medication is used for VTE prophylaxis in pregnancy?
LMWH
Also consider mechanical intervention such as compression stockings
207
Management of VTE in pregnancy?
LMWH continued for either 3 months or 6 weeks post partum (whichever is longer)
Can switch anticoagulation to warfarin or DOAC post delivery
If more life threatening case can consider unfractionated heparin, thrombolysis, surgical embolectomy
208
What is pre-eclampsia?
High blood pressure during pregnancy occurring after 20th week with evidence of end organ dysfunction
209
Triad of pre-eclampsia?
Hypertension
Proteinuria
Oedema
210
What is the pathophysiology of pre-eclampsia?
Imbalance of angiogenic and antiangiogenic factors which leads to poor invasion of the trophoblast into to the womb and poor spiral artery remodeling which leads to production of a faulty placenta which is unable to provide adequate support to the baby
211
Risk factors for pre-eclampsia?
High risk factors;
Pre-existing hypertension
Previous hypertension in pregnancy
SLE, antiphospholipid syndrome
Diabetes
Chronic kidney disease
Moderate risk factors;
Older than 40 years
BMI > 35
More than 10 years since previous pregnancy
First pregnancy
Family history of pre-eclampsia
212
Which women are given aspirin and for how long to prevent pre-eclampsia?
Those with 1 high risk factor or those with more than 1 moderate risk factor
From 12 weeks until delivery
213
Symptoms of pre-eclampsia?
Headache
Visual disturbance/ blurriness
Nausea and vomiting
Upper abdominal pain
Oedema
Reduced urine output
214
Investigations to diagnose pre-eclampsia?
High blood pressure; over 140/90
Urine dip; proteinuria
Bloods; raised creatinine, elevated liver enzymes, thrombocytopenia
Placental dysfunction; abnormal doppler, FGR
215
How is proteinuria quantified?
Urine albumin creatinine ratio (>30mg/mmol)
Urine protein creatinine ratio (>8mg/ mmol)
216
Management of pre-eclampisa?
Identify high risk women and commence aspirin therapy
Monitor blood pressure, either as outpatient or inpatient- score like fullPIERS or PREP-S can be used to decide who should be admitted
Antihypertensives safe to use;
Labetolol; first line
Nifedipne; second line
Methyldopa; third line
IV hydralazine in very severe cases
MgSO4 is given during labour and 24 hours post partum to prevent seizures
217
What is eclampsia?
Seizures associated with pre-eclampsia
218
How is eclampsia managed?
Magnesium sulphate
Rest of management is same as PET
219
What is HELLP syndrome?
Severe form of pre-eclmapsia presenting with
Haemolysis
Elevated Liver enzymes
Low Platelets
220
What is gestational diabetes?
Diabetes triggered by pregnancy which resolves after birth of baby
221
Complications of gestational diabetes?
Macrosomia and large for dates baby
Shoulder dystocia
Progression to T2DM
222
Risk factors for gestational diabetes?
Previous gestational diabetes
Previous macrosomic baby
BMI >30
Ethnic group; black caribbean, middle eastern, south asian
Family history of diabetes
223
Features that suggest gestational diabetes?
Large for dates baby
Polyhydramnios
Glucose on urine dip
224
What results on OGTT suggest gestational diabetes?
Fasting > 5.6
2 hours > 7.8
225
Management of gestational diabetes?
Fasting glucose <7; diet and exercise for 1-2 weeks followed by metformin and then insulin
Fasting glucose >7; insulin +/- metformin
Fasting glucose over 6 and macrosomia; same as above
226
What are glucose target levels in women with gestational diabetes?
Fasting; 5.3
1 hour post meal; 7.8
2 hours post meal; 6.4
226
What is the alternative to metformin?
Gibenclamide
226
For women with pre-existing diabetes when should delivery be planned?
Between 37 and 38+6
227
When should women women be referred for retinopathy screening?
Soon after booking appointment
Again at 28 weeks
228
What is the management of gestational diabetes after delivery?
Can stop medications immediately
Repeat OGTT after 6 weeks post partum
229
Risks experienced by babies born with gestational diabetes?
Neonatal hypoglycaemia
Polycythaemia
Neonatal jaundice
Congenital heart disease
Cardiomyopathy
230
What is obstetric cholestasis?
Reduced outflow of bile acids during pregnancy which resolves after delivery
231
Epidemiology of obstetric cholestasis?
1% of pregnancies
Usually develops in later pregnancy
232
Pathophysiology of obstetric cholestasis?
Rise in progesterone and oestrogen lead to stasis of bile acids and reduced outflow
233
What is the risk associated with obstetric cholestasis?
Stillbirth
234
Presentation of obstetric cholestasis?
Puritis on the palms of hands and soles of feets
Fatigue
Pale grey stools
Dark urine
Jaundice
NO RASH
235
Differentials for obstetric cholestasis?
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
236
Investigations to diagnose obstetric cholestasis?
LFT
Bile acids
237
Management of obstetric cholestasis?
Ursodeoxycholic acid
Emollients and antihistamines
Water soluable Vit K if prothrombin time is also derranged
Planned delivery at 37 weeks
238
What is acute fatty liver of pregnancy?
Third trimester complications with rapid accumulation of fat in hepatocytes causing acute hepatitis
239
Pathophysiology of acute fatty liver of pregnancy?
Impaired processing of fatty acids in the placenta due to a genetic mutation in foetus impairing fatty acid metabolism which results in fatty acids entering maternal circulation and accumulate in liver leading to acute hepatitis
240
Most common cause of acute fatty liver of pregnancy?
Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency
241
Mode of inheritance of Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency?
Autosomal recessive
242
Presentation of acute fatty liver of pregnancy?
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia
Ascites
243
Investigations to diagnose acute fatty liver of pregnancy?
LFT; raised liver enzymes
Raised bilirubin
Riased WCC
Deranged clotting
Low platelets
244
Management of acute fatty liver of pregnancy?
Obstetric emergency
Admission and delivery of the baby
Consider liver transplant
245
What is polymorphic eruption of prenancy?
Itchy rash that starts in third trimester characterised by utricarial papules (raised itchy lumps), Wheals (raised itchy areas of skin) and plaques.
Usually begins on abdomen as associated with stretch marks
246
Triad of polymorphic eruption of pregnancy?
Utricarial papules
Wheals
Plaques
247
Management of polymorphic eruption of pregnancy?
Topical emollients, steroids
Oral antihistamines
Oral steroids in severe cases
248
What is atopic eruption of pregnancy?
Eczema that flares up during pregnancy presenting during first and second trimester
249
What are the types of atopic eruption of pregnancy?
E-type; eczematous, inflamed, red and itchy skin
P-type; intensely itchy papules affecting abdomen, back and limbs
250
Management of atopic eruption of pregnancy?
Topical emollients
Topical steroids
Phototherapy with UVB
Oral steroids
251
What is melasma?
AKA mask of pregnancy
Increased pigmentation in patches usually symmetrical and affecting sun affected areas
252
What is the cause of melasma?
Increased female sex hormones
253
Management of melasma?
Avoid sun exposure
Use SPF
Use make up to cover up
Resolves following delivery
254
What is pyogenic granuloma?
Benign rapidly growing tumour of capillaries presenting as a discrete lump with a red or dark appearance
255
Causes of pyogenic granuloma?
Pregnancy
Hormonal contraceptive
Minor trauma
Infection
256
Presentation of pyogenic granuloma?
1-2 cm in size
Occur on fingers, upper chest, back, neck, head
Can cause profuse bleeding and ulceration
257
Management of pyogenic granuloma?
Surgical removal and histology
258
What is pemphigoid gestationis?
Autoimmune skin condition in which autoantibodies damage connection between epidermis and dermis
This separates the layers meaning there is potential for fluid to fill the space and form bullae
259
When does pemphigoid gestationis occur?
Second to third trimester
260
Presentation of pemphigoid gestationis?
Itching
Red papular blistering rash
Fluid filled blisters
261
Management of pemphigoid gestationis?
Topical emollients, corticosteroids
Oral steroids
Immunosuppressants
262
Risk to the baby of pemphigoid gestationis?
FGR
Preterm delivery
Blistering rash post delivery
263
What is placenta praevia?
Low lying placenta, lower than the presenting part of the foetus
264
What is a low lying placenta vs placenta praevia?
Low lying placenta is within 20mm of the internal cervical os
Placenta praevia is when the placenta lies over the internal cervical os
265
Epidemiology of placenta praevia?
1% of pregnancies
266
Causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
Vasa praevia
267
What risks are associated with placenta praevia?
Antepartum haemorrhage
Emergency C-section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
268
Risk factors for placental praevia?
Previous C-section
Previous placental praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities
Assisted reproduction
269
When is placenta praevia diagnosed?
20 week anomaly scan
270
Presentation of placenta praevia?
PAINLESS PV bleeding
271
At what gestation is a repeat transvaginal ultrasound required for placenta praevia?
32 weeks
36 weeks to guide decision around delivery
272
Management of placenta praevia?
Planned C-section between 36 and 37 weeks
273
Complication of placenta praevia?
Haemorrhage
274
Management of haemorrhage caused by placenta praevia?
Emergency C-section
Blood transfusion
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
275
What is vasa praevia?
Foetal vessels are within foetal membranes and travel across internal cervical os
276
Pathophysiology of vasa praevia?
In normal pregnancies the umbilical cord contains foetal vessels whereas in vasa praevia the vessels are in the membranes and out of the protection provided by the umbilical cord which makes them more prone to bleeding
277
What are the types of vasa praevia?
Type 1; foetal vessels are exposed as a velamentous umbilical cord
Type 2; foetal vessels are exposed as they travel to an accessory placental lobe
278
Risk factors for vasa praevia?
Low lying placenta
IVF pregnancy
Multiple pregnancy
279
Investigations to diagnose vasa praevia?
Ultrasound scan; however no reliable at picking up
Can see on examination or palpation of cervix you will feel pulsation
280
Management of vasa praevia?
Corticosteroids to mature foetal lungs and deliver between 34 and 36 weeks
If not diagnosed can result in major antepartum haemorrhage and require emergency C-section
281
Complications of vasa praevia?
Still birth
Antepartum haemorrhage
Emergency C-section
282
What is placental abruption?
Placenta separates from wall of the uterus during pregnancy
283
Risk factors for placental abruption?
Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
FGR
Multigravida
Increasing maternal age
Smoking
Cocaine or amphetamine use
284
Presentation of placental abruption?
Sudden onset severe abdominal pain that continues
Vaginal bleeding
Shock
Abnormal CTG
Woody abdomen on palpation
285
How is severity of antepartum haemorrhage quantified?
Spotting
Minor; less than 50mls
Major; 50-100mls
Maasive; more than 100mls
286
What is a concealed abruption?
Cervical os remains closed and any bleeding that occurs is within uterine cavity
287
What is the initial management of a major or massive haemorrhage?
Involve senior members
2 grey cannulas
Bloods; FBC, U+E, LFT and coagulation
Crossmatch 4 units of blood
GTC monitoring
Close monitoring of mother
288
Management of placnetal abruption?
Delivery of baby, usually by C-section
Active management of third stage of labour
289
What is placenta accreta?
Placenta implants deeper through and past the endometrium making delivery of placenta more difficult
290
How is placenta accreta spectrum defined?
Placenta accreta; placenta implants in the surface of the myometrium
Placenta increta; placenta attaches deeply into myometrium
Placenta percreta; placenta invades past the myometrium, perimetrium and potentially to other organ
291
Risk factors for placenta accreta syndrome?
Previous placenta accreta syndrome
Previous endometrial curettage procedures
Multigravida
Increased maternal age
Low lying placenta/ placenta praevia
292
Presentation of placenta accreta syndrome?
Asymptomatic
May be seen on ultrasound
Present at time of birth as PPH
293
Investigations to diagnose placenta accreta syndrome?
Seen on ultrasound scan
MRI is used to assess thickness of adherence
Early detection allows planning of birth
294
When is delivery planned for placenta accreta syndrome?
35 to 36+6
295
What options are available during delivery for patient with placenta accreta syndrome
Hysterectomy- recommended
Uterus preserving surgery
Expectant management; high risk of infection, bleeding
296
What is breech presentation?
Presenting part of the foetus is the legs and bottom as opposed to cephalic presentation
297
Epidemiology of breech presentation?
5% of pregnancies
298
Types of breech presentation?
Complete; legs are fully flexed at hips and knees
Incomplete; flexed at hip and extended at knee
Extended; flexed at hip and extended at knee
Footling breech; foot presents through cervix with leg extended
299
Management of breech presentation?
Breech babies before 36 weeks often turn spontaneously
External cephalic version can be attempted at term
If ECV fails woman is given choice with mode of delivery, vaginal delivery is associated with 40% chance of requiring a CAT1 C-section
If first baby in twin pregnancy is breech a C-section is required
300
What is external cephalic version?
Mechanical technique to turn the foetus from breech to cephalic position using pressure on the abdomen
301
What is the success rate of ECV?
50%
302
When is external cephalic version attempted?
after 36 weeks in nulliparous women
after 37 weeks i n women who have given birth
303
How common is still birth?
1 in 200 pregnancies
304
Causes of intrauterine foetal death?
Unexplained (50%)
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse/ wrapped around foetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections such as rubella, parovirus, listeria
Genetic abnormalities
Congenital abnormalities
305
What is the most common cause of PPH?
Uterine atony
306
Risk factors for still birth?
FGR
Smoking
Alcohol
Increasing maternal age
Maternal obesity
Twins
Sleeping on back
307
What happens following still birth?
With parental consent;
Genetic testing on foetus and placenta
Post mortem investigation
Testing other for disease
308
Causes of cardiac arrest in pregnancy?
Thrombosis
Tension pneumothorax
Toxins
Tamponade
Hypoxia
Hypovolaemia- haemorrhage
Hypothermia
Hyperkalaemia
Hypoglycaemia
Eclampsia
Intracranial haemorrhage
309
Causes of massive obstetric haemorrhage?
Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture
310
Factors making resuscitation more difficult in pregnancy?
Aortocaval compression
Increased oxygen requirement
Splinting of diaphragm
Difficulty with intubation
Increased risk of aspiration
Ongoing obstetric haemorrhage
311
How is risk of aortocaval syndrome managed during resuscitation?
15 degree tilt to left side
312
In context of cardiac arrest when is baby delivered?
No response within 4 minutes of starting CPR
313
Which medications can be given to breast feeding women?
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
314
Which medications should be avoided in pregnancy?
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
315
Haemoglobin cut-offs for staring therapy to treat anaemia?
First trimester; <110
Second/third trimester <105
Post partum; <100
316
What is high foetal fibronectin correlated to?
Early labour
317
How long after giving birth is MMR vaccine contraindicated?
28 days
318
Contraindications to ECV?
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
319
Monitoring requirements for obstetric cholestasis?
Weekly LFT
320
What is used in magnesium sulphate induced respiratory depression?
Calcium gluconate
321
At what gestation would referral to secondary care be made for lack of foetal movements?
24 weeks
322
For gestational diabetes when is insulin first line treatment?
Fasting glucose over 7
323
What are the stages of labour?
First stage; From the onset of labour until cervix is 10cm dilated
Second stage; from complete cervical dilation until delivery of foetus
Third stage; from delivery of baby to delivery of placenta
324
What are the phases of the first stage of labour?
Latent phase; 0-3cm cervical dilation, Progresses at 0.5cm/ hour with irregular contractions
Active phase; 3-7cm cervical dilation, progresses at 1cm/ hour with regular contractions
Transition phase; 7-10cm cervical dilation, progresses at 1cm/ hour and contractions are strong and regular
325
What are Braxton- Hicks contractions?
Occasional irregular contractions of the uterus usually felt during second and third trimester and are not an indicator for labour
326
What are the signs of labour?
Show
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
327
When is first stage of labour established?
Painful regular contractions
Dilation of cervix from 4cm onwards
328
What is rupture of membranes?
Rupture of the amniotic sac
329
What is spontaneous rupture of membranes?
Spontaneous rupture of the amniotic sac
330
What is Pre-labour rupture of membranes?
Rupture of the amniotic sac before the onset of labour
331
What is pre-term prelabour rupture of membranes?
Rupture of the amniotic sac before the onset of labour and before the 37th week of gestation
332
How is rupture of membranes diagnosed?
Speculum examination; see pooling of amniotic fluid in vagina
Insulin like growth factor binding protein-1 or placental alpha microglobin-1 are two compounds found in high concentrations in the amniotic fluid
333
Management of preterm prelabour rupture of membranes?
Prophylactic antibiotics to prevent development of chorioamnionitis- erythromycin 250mg QDS for 10 days
Consider induction of labour at 34 weeks
334
What is preterm labour with intact membranes?
Regular painful contractions and cervical dilation without rupture of amniotic sac
335
What is fetal fibronectin an indicator of?
Impending labour, a result over 50ng/ ml indicates possible labour
336
Management of pre-term labour?
Foetal monitoring
Tocolysis with nifedipine
Maternal corticosteroids
IV magnesium sulphate
Delayed chord clamping or milking
337
What medications can be used for tocolysis?
Nifedipine
Atosiban; oxytocin receptor antagonist
338
Indications for tocolysis?
If between 24 and 33+6 weeks gestation
Buy more time to administer steroids and magnesium sulphate
Should not be used long term to delay labour
339
What do antenatal corticosteroids do?
Develop foetal lungs and reduce respiratory distress syndrome
Common regimen; two doses IM betamethasone 24 hours apart
340
Why is MgSO4 given antenatally?
Protect foetal brain reducing risk of cerebral palsy
341
Signs of maternal magnesium toxicity?
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
342
Indications for induction of labour?
Prelabour rupture of membranes
FGR
Pre eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine foetal death
343
What is the bishop score?
Scoring system used to determine whether to proceed with induction of labour
Foetal station; 0-3
Cervical position; 0-2
Cervical dilatation; 0-3
Cervical effacement; 0-3
Cervical consistency; 0-2
344
How is the bishop score interpreted?
Score more than 8 predicts successful IOL
Score below 8 suggests cervical ripening may be required
345
Options to induce labour?
Membrane sweep
Vaginal prostaglandin E2; dinoprostone
Cervical ripening balloon
Artificial rupture of membranes +/- oxytocin infusion
Mifepristone and misoprostol if IUFD has occured
346
Methods of monitoring IOL?
CTG
Bishop score
347
Options for managing slow/ no progression of labour?
Further vaginal prostaglandins
Cervical ripening balloon
Artifical rupture of membranes and oxytocin infusion
Elective C-section
348
What is uterine hyperstimulation?
Complication of IOL with vaginal prostaglandin where uterine contractions are prolonged and frequent
349
Criteria for uterine hyperstimulation?
Individual contractions lasting more than 2 minutes
More than 5 uterine contractions in 10 minutes
350
Complications of uterine hyperstimulation?
Foetal compromise; hypoxia and acidosis
Emergency C-section
Uterine rupture
351
Management of uterine hyperstimulation?
Remove vaginal prostaglandin/ stop oxytocin
Tocolysis with terbutaline
352
What is measured on CTG?
One transducer measures foetal heart rate using doppler ultrasound
Other transducer measures tension in uterine wall and hence uterine contraction
353
Indications for continuous CTG monitoring in labour?
Sepsis
Maternal tachycardia >120
Significant meconium
Pre-eclampsia, particularly BP > 160/110
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate pain in mother
354
Features assessed on CTG?
Contractions; number in 10 mins
Baseline foetal heart rate
Variability; how foetal heart rate varies
Accelerations; periods where FHR spikes
Decelerations; periods where FHR drops
355
What do decelerations on CTG indicate?
Hypoxia
356
What are the types of deceleration seen on CTG?
Early; not pathological usually caused by uterine contractions compressing foetal head and activating vagus nerve
Late; caused by hypoxia and is a concerning finding
Variable; unrelated to contractions, caused by compression of umbilical cord
Prolonged; compression of umbilical cord
357
Features of a reassuring CTG?
Accelerations, suggest healthy foetus especially if alongside uterine contractions
No decelerations
Early decelerations
Less than 90 minutes of variable decelerations
358
What are the features of a sinusoidal CTG and what does it indicate?
Smooth regular waves up and down with an amplitude of 5-15 bpm associated with severe foetal anaemia caused by vasa praevia or foetal haemorrhage
Indicates severe foetal compromise
359
Uses of oxytocin infusion?
Induce labour
Progress labour
Improve frequency and strength of uterine contractions
Prevent or treat PPH
360
Mechanism of action of Atosiban?
Oxytocin receptor antagonist
361
What is ergometrine?
Medications that causes muscle contractions and is used to deliver placenta and reduce post partum bleeding
Only used after delivery of foetus
362
Uses of ergometrine?
Delivery of placenta
Prevent post partum haemorrhage
363
Mechanism of action of prostaglandins?
Stimulate uterine contractions
Promote cervical ripening
364
Which medications should not be used in labour with a healthy foetus?
Misoprostol and mifepristone
365
Mechanism of action of terbutaline?
Beta-2- adrenergic agonist which relaxes muscles
366
Indication of terbutaline?
Tocolysis in uterine hyperstimulation
367
Mechanism of action of carboprost?
Synthetic prostaglandin analogue which binds to prostaglandin receptors stimulating uterine contractions
368
When is carboprost given?
In PPH
369
In which patients should carboprost not be used?
In patients with asthma
370
What is failure to progress?
Situation when labour is not developing at a satisfactory rate
371
How is progression of labour assessed?
Power; uterine contraction strength
Passenger; size, lie, presentation and position of baby
Passage; size and shape of pelvis and soft tissue
372
Interventions that may be required in second stage of labour?
Changing position
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
C-section
373
What is defined as delay in the third stage of labour?
More than 30 minutes in active management
More than 60 minutes with expectant management
374
What does active management of the third stage of labour invovle?
IM oxytocin
Controlled cord traction
375
What is used for simple analgesia in early labour?
Paracetamol
Codeine
376
What is the composition of Entonox?
50% nitrous oxide
50% oxygen
377
Side effects of entonox?
Syncope
Nausea
Sleepiness
378
Cautions of opioid use in labour?
Drowsiness in mother
Respiratory depression
Make first feed more difficult
379
Adverse effects of epidural?
Headache after insertion
Hypotension
Motor weakness in legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
380
What medications are given during an epidural anaesthesia?
Levobupivacaine/ bupivacaine
Fentanyl
381
What is umbilical cord prolapse?
When umbilical cord descends below the presenting part of the foetus through the cervix
382
What is the danger of umbilical cord prolapse?
Compression of cord leading to hypoxia
383
Diagnosis of umbilical cord prolapse?
Suspect possibility in abnormal lie
Signs of foetal distress on CTG
Speculum examination
384
What is shoulder dystocia?
When anterior shoulder of the baby becomes stuck behind pubic symphysis after the head has been delivered
385
Most common cause of shoulder dystocia?
Macrosomia secondary to gestational diabetes
386
Presentation of shoulder dystocia?
Difficulty delivering face and head
Failure of restitution
Turtle neck sign
387
Management of shoulder dystocia?
Episiotomy
McRoberts manoeuver
Pressure to the anterior shoulder
Rubins manoeuver
Woods screw manoeuver
Zavanelli manoeuver
388
What is the McRoberts manoeuver?
First line intervention
Hyperflexion of mother at hip which provides posterior pelvic tilt lifting pubic symphysis up and out of the way
389
What is the Rubins manoeuvre?
Reaching into vagina to put pressure on posterior aspect of anterior shoulder to help move under the pubic symphysis
390
What is Wood's screw manoeuvre?
Performed during rubins manoeuvre
The other hand is put into the vagina to put pressure on anterior aspect of posterior shoulder
391
What is Zavanelli manoeuvre?
Pushing babys head back into vagina to deliver via C-section
392
Complications of shoulder dystocia?
Foetal hypoxia, and consequent cerebral palsy
Brachial plexus injury, Erb's palsy
Perineal tears
PPH
393
What is instrumental delivery?
Vaginal delivery assisted by either ventouse suction cup or forceps
394
What percentage of deliverys are assisted by instuments?
10%
395
What is the antibiotic of choice to prevent infection following instrumental delivery?
Co-amoxiclav, single dose
396
Indications for instrumental delivery?
Failure to progress
Foetal distress
Maternal exhaustion
If received epidural anaesthesia
397
Signs of femoral nerve injury in the mother?
Weakness of knee extension
Loss of patella reflex
Numbness of anterior thigh and medial lower leg
397
Risks to the mother following instrumental delivery?
PPH
Episiotomy
Perineal tears
Injury to anal sphincter
Incontinence of bladder/ bowel
Nerve injury; obturator/ femoral
397
Classification of perineal tears?
First degree; injury limited to frenulum of labia minora and superficial skin
Second degree; perineal muscles but no affecting anal sphincter
Third degree; includes anal sphincter but not rectal mucosa
3A; less than 50% of EAS involved
3B; more than 50% of EAS
3C; external and internal anal sphincter
Fourth degree; includes rectal mucosa
397
Risks to baby following instrumental delivery?
Cephalohaematoma - ventouse
Facial nerve palsy - forceps
Rarely can have intracranial haemorrhage, skull fracture, spinal cord injury
397
Signs of obturator nerve injury?
weakness of hip adduction and rotation
Numbness of medial thigh
398
Risk factors for perineal tears?
Nulliparity
Large babies
shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental delivery
399
Management of perineal tears?
First degree usually require no intervention
Second degree require sutures
Third and fourth require surgical repair and women offered elective C-section in subsequent deliveries
Broad spectrum antibiotics
Laxatives
Physiotherapy
Follow-up
400
Complications after perineal tears?
Short term;
Pain, infection, bleeding, wound dehiscence/ breakdown
Long lasting;
Urinary incontinence
Anal incontinence/ altered bowel habit
Fistula between bowel and vagina
Sexual dysfunction
Pyschological
401
Methods to prevent perineal tears?
Episiotomy
Perineal massage
402
What is physiological management of the third stage of labour?
Placenta is delivered by maternal effort without medication or cord traction
403
Indications for active management of 3rd stage of labour?
Haemorrhage
More than 60 minutes to deliver placenta
Routinely offered to reduce risk of PPH
404
Steps of active management of third stage of labour?
IM oxytocin 10IU
Controlled cord traction
405
Definition of post partum haemorrhage?
500ml after vaginal delivery
1000ml after C-section
406
Classification of PPH?
Minor; <1000ml
Major; >100ml
Moderate; 1000-2000ml
Severe; >2000ml
Primary; within 24 hours
Secondary; after 24 hours
407
Causes of PPH?
Uterine atony
Trauma; perineal tear
Tissue; retained placenta
Thrombin; bleeding disorder
408
Risk factor for PPH?
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in second stage
Prolonged third stage
Pre eclampsia
Placenta accreta syndrome
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy
Perineal tear
409
How to reduce risk of PPH?
Treat anaemia during antenatal period
Give birth with empty bladder
Active management of third stage of labour
IV tranexamic acid during C-section in high risk patients
410
Management of PPH?
Resuscitation with ABCDE
Lie woman flat, keep her warm
Insert two large bore cannulas
Bloods; FBC, U+E, clotting screening
Group and cross match 4 unIts of blood
Warmed IV bloods and fluid
Oxygen
FFP if clotting abnormality
411
Interventions to stop bleeding in PPH?
Mechanical;
Rubbing of uterus
Catheterisation as full bladder prevents uterine contractions
Medical;
Oxytocin
Ergometrine; CI in HTN
Carboprost; CI in asthma
Misoprostol
Tranexamic acid
Surgical;
Intra uterine balloon tamponade
B-lynch suture
Uterine artery ligation
Hysterectomy
412
Causes of secondary PPH?
Retained products of conception
Endometritis
413
Investigations to find cause of secondary haemorrhage?
Ultrasound scan
Endocervical/ high vaginal swabs
414
Management of secondary haemorrhage?
Evacuation of retained products
Antibiotics
415
Conditions of an Elective C-section?
Usually performed after 39 weeks
Under spinal anaesthetic
416
Indications for elective C-section?
Previous C-section
Previous perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV
Cervical cancer
417
Categories of C-sections?
Cat 1; Immediate threat of life to mother or baby, decision to delivery is within 30 mins
Cat 2; imminent threat of life, delivery time is 75 minutes
Cat 3; delivery is required but mother and baby are stable
Cat 4; elective
418
Types of incisions in C-sections?
Pfannenstiel incision; curved incision 2 finger widths above pubic symphysis
Joel- Cohen incision; straight incision
419
Layers dissected during C-section?
Skin
Subcutaneous tissue
Fascia/ rectus sheath
Rectus abdominis muscles
Peritoneum
Vesicouterine peritoneum
Uterus
Amniotic sac
420
Risks of C-section?
General surgical risks;
Bleeding, infection, pain, VTE
Complications in post partum period;
PPH, wound infection, wound dehiscence, endometritis
Damage to local structures;
Ureter, bladder, bowel, blood vessels
Effects on abdominal organs;
Ileus, adhesions, hernia
421
Risks in future pregnancies if previous C-section?
Repeat C-section
Uterine rupture
Placenta praevia
Still birth
422
Contraindications to vaginal birth after caesarean?
Previous uterine rupture
Classical caesarean scar (vertical)
Any CI for vaginal delivery
423
Causes of sepsis in pregnancy?
Chorioamnionitis
UTI
424
What is chorioamnionitis?
Infection of the chorioamniotic membranes and amniotic fluid occurring in the late stages of pregnancy and labour
425
Management of maternal sepsis?
Sepsis 6
Maternal and foetal monitoring
Emergency C-section, usually requiring GA
Significant antimicrobial usage
426
What is amniotic fluid embolism?
Amniotic fluid passes into mothers blood triggering immune reaction
427
Epidemiology of amniotic fluid embolism?
2 in 100000 deliveries
428
Risk factors for amniotic fluid embolism?
Increasing maternal age
IOL
C-section
Multiple pregnancy
429
Presentation of amniotic fluid embolism?
Presents at time of labour or soon in post partum period
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
430
Management of amniotic fluid embolism?
Supportive
ABCDE
431
What is uterine rupture?
Complication of labour where myometrium dissects
Incomplete is where serosa is intact
Complete is where contents of uterus are released into peritoneum
432
Risk factors for uterine rupture?
PREVIOUS C-SECTION
VBAC
Previous uterine surgery
High BMI
Increased parity
Increased age
IOL
Use of oxytocin
433
Presentation of uterine rupture?
Abdominal pain
Vaginal bleeding
Ceasing of vaginal contractions
Hypotension
Tachycardia
Collapse
434
Management of uterine rupture?
Emergency C-section
Uterus repair/ hysterectomy
435
What is uterine inversion?
Fundus of uterus drops down through uterine cavity turning uterus inside out
436
What is lochia?
Discharge of blood, endometrial tissue and mucus which should settle in upto 6 weeks after birth
437
Presentation of uterine inversion?
PPH
Maternal shock
Collapse
438
Management of uterine inversion?
Johnson manoeuvre
Hydrostatic methods
Surgery
439
How long after birth does fertility take to return?
21 days, so does not require contraception upto this point
440
When is each type of contraception safe?
POP can be taken at any time after birth
COCP should not be started before 6 weeks post partum in breast feeding women
Copper coil or IUS can be inserted with 48 hours from birth or 4 weeks after delivery
441
Why are post partum women at risk of endometritis?
Process of delivery opens uterus making it easier for infection
442
Which method of delivery makes endometritis more likely?
C-section
443
Presentation of endometritis?
Foul smelling lochia
Bleeding that gets heavier/ does not improve
Lower abdominal/ pelvic pain
Fever
Sepsis
444
Risk factors for retained products of conception?
Placenta accreta
444
Presentation of retained products of conception?
Vaginal bleeding that gets heavier
Lower abdominal/ pelvic pain
Fever
444
Management of retained products of conception?
Dilation and curettage; surgical procedure to evacuate retained products
444
What is Sheehan's syndrome?
Complication of PPH resulting in avascular necrosis of anterior pituitary gland
445
Complications of D&C?
Endometritis
Asherman's syndrome
445
What is asherman's syndrome?
Adhesions within uterus
445
What score of edinburgh post natal depression scale suggest postnatal depression?
Score of 10 or more
445
What is post partum thyroiditis?
Changes in thyroid function within 12 months from delivery affecting women without prior thyroid disease
445
Pathophysiology of postpartum thyroiditis?
Pregnancy has an immunosuppressant effect on maternal system, after delivery, heightened immune system attacks thyroid cells causing inflammation and disturbed function
445
Stages of post partum thyroiditis?
Thyrotoxicosis; in first 3 months
Hypothyroid; 3-6 months post partum
Thyroid function returns to normal over a couple of months
446
Presentation of Sheehan's syndrome?
Reduced lactation
Amenorrhoea
Adrenal insufficiency
Hypothyroidism
447
Management of Sheehan's syndrome?
Oestrogen and progesterone
Hydrocortisone
Levothyroxine
Growth hormone
448
Causes of pulmonary hypoplasia?
Oligohydramnios
Congenital diaphragmatic hernia
449
