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Phase 3A > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is the source of progesterone?

A

Corpus luteum
Placenta
Adrenal cortex

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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

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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

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4
Q

Causes of infertility?

A

Sperm problems- 30%
Ovulation problems- 25%
Tubal problems- 15%
Uterine problems- 10%
Unexplained- 20%

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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

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6
Q

Why are couples trying to conceive not advised for timed intercourse?

A

Puts strain on relationship
Increases stress

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7
Q

Investigations to help diagnose infertility in primary care?

A

BMI
Chlamydia screen
Semen analysis
Female hormone testing
Rubella immunity in mother

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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

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9
Q

What does high FSH suggest?

A

Poor ovarian reserve, pituitary gland is producing extra FSH to stimulate follicular development

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10
Q

What does high LH indicate?

A

PCOS

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11
Q

What is the most accurate marker of ovarian reserve?

A

AMH- high level indicates good reserve

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12
Q

What investigations can be performed in secondary care to diagnose cause of infertility?

A

Pelvic ultrasound
Hysterosalpingogram
Laparoscopy and dye test

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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

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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

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15
Q

Management Of infertility caused by tubual factors?

A

Tubual cannulation during hysterosalpingogram
Laparoscopy to remove endometriosis/ adhesions
IVF

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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

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17
Q

Management of infertility caused by uterine factors?

A

surgical correction of polyp, adhesion and structural abnormalities

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18
Q

What is assessed in semen analysis?

A

Quantity
Quality

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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

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20
Q

Factors affecting semen analysis?

A

Hot baths
Tight underwear
Smoking/ alcohol
Caffeine
Rained BMI

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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

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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

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23
Q

Causes of poor sperm quality?

A

Pre-testicular
Testicular
Post testicular

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24
Q

Pre-testicular causes of poor sperm?

A

Pituitary /hypothalamic dysfunction
Stress, chronic illness, hyperprolactinanemia
Kallman syndrome

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25
Q

Testicular causes of poor semen quality?

A

Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic/congenital; Klinefelter syndrome, Y chromosome deletion, Sertoli cell only syndrome, Anorchia

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26
Q

Post testicular causes of poor semen quality ?

A

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

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27
Q

Investigations performed after abnormal semen analysis?

A

Hormonal analysis
Genetic testing
Imaging; transrectal USS, MRI
Vasography
Testicular biopsy

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28
Q

Management of male factor fertility?

A

Surgical sperm retrieval
Surigcal correction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination

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29
Q

What is IVF?

A

Process of fertilising egg in lab with sperm and then implanting fertilised embryo into uterus

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30
Q

When is IUI preferred?

A

Donor for same sex couples
HIV
Practical issues with vaginal intercourse

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31
Q

Steps involved with IVF?

A

Suppressing natural menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination or intracytoplasmic sperm injection
Embryo culture
Embryo transfer

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32
Q

How is menstrual cycle surpressed in IVF?

A

GnRH agonists or GnRH antagonists

Results in suppression of gonadotropins preventing maturation of follicles and hence ovulation

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33
Q

Example of GnRH agonist?

A

goserelin

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34
Q

Example of GnRH antagonist?

A

Cetrorelix

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35
Q

What are the steps of ovarian stimulation?

A

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

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36
Q

During IVF at what day is a pregnancy test performed?

A

16 days after egg collection

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37
Q

When is progesterone used in IVF?

A

from oocyte collection to 8-10 weeks gestation to compensate for corpus luteum

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38
Q

Complications of IVF?

A

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
Egg collection procedure; pain, bleeding, pelvic infection, damage to bladder/bowel

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39
Q

What is ovarian hyperstimulation syndrome?

A

Complication of ovarian stimulation during IVF treatment associated with use of hCG to mature the follicles in final step of ovarian stimulation

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40
Q

Pathophysiology of OHSS?

A

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

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41
Q

Risk factors for OHSS?

A

Younger age
Lower BMI
Raised AMH
Higher antral follicles count
PCOS
Raised oestrogen levels during ovarian stimulation

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42
Q

How can OHSS be prevented?

A

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

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43
Q

Strategies to reduce risk of OHSS?

A

Use GnRH antagonist protocol
Lower dose of gonadotropin
Lower dose of hCG injection
Alternatives to hCG such as GnRH agonists or LH

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44
Q

Features of OHSS?

A

Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension, hypovolaemia
Ascites
Pleural effusion
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state

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45
Q

when does OHSS present?

A

Within 7 days of hCG injection
Late OHSS is 10 days post injection

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46
Q

Management of OHSS?

A

Oral fluids
Monitor urine output
LMWH
Ascitic fluid removal
IV colloid

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47
Q

What is an Ectopic pregnancy?

A

When a pregnancy implantation outside the uterus

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48
Q

Ectopic sites of implantation of pregnancy?

A

Fallopian tube
Ovary
Cervix
Abdomen

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49
Q

Risk factors for Ectopic pregnancy?

A

Previous Ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to fallopian tubes
Intrauterine devices
Older age
Smoking

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50
Q

Presentation of Ectopic pregnancy?

A

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

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51
Q

What is seen on ultrasound scan in Ectopic pregnancy?

A

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

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52
Q

What is a pregnancy of unknown location?

A

Woman has a positive pregnancy test with no evidence of pregnancy on ultrasound scan

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53
Q

Hos is a pregnancy of unknown location monitoried?

A

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

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54
Q

Management options for Ectopic pregnancy/ miscarriage?

A

Expectant management
Medical management
Surgical management

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55
Q

Expectant management for Ectopic pregnancy?

A

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

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56
Q

Criteria for medical management of Ectopic pregnancy with methotrexate?

A

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

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57
Q

How is methotrexate administered to manage ectopic pregnancy?

A

IM injection in buttock

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58
Q

Advice given to women who are managed with methotrexate?

A

Do not get pregnant within 3 months following treatment

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59
Q

Common side effects of methotrexate?

A

Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis

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60
Q

What is the criteria for surgical management of ectopic pregnancy?

A

Adnexal mass >35mm
Visible heartbeat
hCG levels > 5000 IU/ l

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61
Q

Surgical options for management for ectopic pregnancy?

A

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

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62
Q

What is the risk of not removing the ectopic pregnancy with salpingotomy?

A

1 in 5 women, may require further treatment with methotrexate

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63
Q

What is a miscarriage?

A

Spontaneous termination of pregnancy before 24 weeks gestation

If before 12 weeks it is called an early miscarriage

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64
Q

What is a missed miscarriage?

A

The foetus is no longer alive but no symptoms have occurred

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65
Q

What is a threatened miscarriage?

A

Vaginal bleeding with a closed cervix and foetus that is alive

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66
Q

What is an inevitable miscarriage?

A

Vaginal bleeding with open cervix

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67
Q

What is an incomplete miscarriage?

A

Retained products of conception after the miscarriage

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68
Q

What is a complete miscarriage?

A

a full miscarriage with no products of conception left in the uterus

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69
Q

What is an anembryonic pregnancy?

A

Presence of gestational sac with no embryo

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70
Q

What investigation is used to diagnose ectopic pregnancy/ miscarriage?

A

Transvaginal ultrasound

hCG levels

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71
Q

What features are assessed on ultrasound scan in early pregnancy?

A

Mean gestational sac diameter
Foetal pole and crown- rump length

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72
Q

When is the pregnancy considered viable?

A

When foetal heart beat is visible

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73
Q

Usually when is the foetal heart beat expected to be visible?

A

Crown- rump length is 7mm or more

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74
Q

When is the foetal pole expected to be visible

A

Mean gestational sac diameter is 25mm or more

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75
Q

When is expectant management appropriate in the context of miscarriage?

A

Less than 6 weeks gestation
No pain
No other risk factors or complications

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76
Q

What investigation is performed in expectant management of miscarriage?

A

Repeat urine pregnancy test 7-10 days later

If positive may indicate incomplete miscarriage and further management may be required

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77
Q

Medical management of miscarriage?

A

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

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78
Q

Mechanism of action of Mifepristone?

A

Mifepristone is a progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions

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79
Q

Mechanism of action of Misoprostol?

A

Misoprostol is a prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception

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80
Q

Complications of miscarriage?

A

Incomplete miscarriage
Haemorrhagic shock
Infection - endometritis
3% of women
Psychological complications; Depression/anxiety
Haemolytic disease of the newborn
Increased risk of having another miscarriage

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81
Q

Surgical management of miscarriage?

A

Manual vacuum aspiration; under local anaesthetic
Electric vacuum aspiration; under general anaesthetic

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82
Q

What is recurrent miscarriage?

A

Three or more consecutive miscarriages

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83
Q

When is investigation for recurrent miscarriage initiated?

A

Three or more first trimester miscarriages
One or more second trimester miscarriage

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84
Q

Causes of recurrent miscarriage?

A

Idiopathic
Antiphospholipid syndrome
Hereditary thrombophilia
Uterine abnormalities
Genetic factors
Chronic histiocytic intervillositis
Other chronic disease such as diabetes, thyroid disease, SLE

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85
Q

What hereditary thrombophilia can result in recurrent miscarriage?

A

Factor V leiden
Factor II gene mutation
Protein S deficiency

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86
Q

What uterine abnormalities can lead to recurrent miscarriage?

A

Uterine septum
Unicornuate uterus
Bicornuate uterus
Didelphic uterus
Cervical insufficiency
Fibroids

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87
Q

Investigations to find cause of recurrent miscarriage?

A

Antiphospholipid antibodies
Testing for heereditary thrombophilias
Pelvic ultrasound
Genetic testing on products of conception and parents

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88
Q

What is chronic histiocytic intervillositis?

A

Build up of histiocytes and macrophages in the placenta causing inflammation and adverse obstetric outcome

Common cause for second and third trimester miscarriage

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89
Q

What is termination of pregnancy?

A

Abortion; elective procedure to end pregnancy

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90
Q

When can an abortion be performed?

A

Continuation of pregnancy will lead to adverse mental and physical health outcomes to the mother or existing children of the family

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91
Q

Legal requirements for abortion?

A

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

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92
Q

What are the options for abortion?

A

Medical abortion
Surgical abortion

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93
Q

How is a medical abortion performed?

A

Mifepristone and misoprostol taken 48 hours apart

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94
Q

What are the methods of surgical abortion?

A

Cervical dilation and suction; upto 14 weeks gestation

Cervical dilation and evacuation using forceps; usually between 14 and 24 weeks

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95
Q

Complications of abortion?

A

Bleeding
Pain
Infection - most commonly endometritis
Failure of abortion
Damage to cervix, uterus or other stuctures

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96
Q

Post abortion care?

A

Urine pregnancy test 3 weeks following abortion

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97
Q

What is hyperemesis gravidarum?

A

Form of nausea and vomiting of pregnancy with protracted including;
More than 5% weight loss compared with before pregnancy weight
Dehydration
Electrolyte balance

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98
Q

Triad of hyperemesis gravidarum?

A

More than 5% weight loss compared with before pregnancy weight
Dehydration
Electrolyte balance

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99
Q

How is severity of nausea and vomiting in pregnancy assessed?

A

Pregnancy Unique Quantification of Emesis (PUQE) scored out of 15
Less than 7; mild
7-12; Moderate
More than 12; Severe

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100
Q

Management of Nausea and vomiting in pregnancy?

A

Antiemetics; Prochlorperazine, Cyclizine, Ondansetron, Metoclopramide

Ranitidine/ omeprazole if acid reflux is a problem

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101
Q

What is a hydatiform mole?

A

Type of tumour that grows like a pregnancy inside the uterus

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102
Q

Classification of molar pregnancy?

A

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

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103
Q

Presentation of molar pregnancy?

A

Compared to a normal pregnancy there will be

More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis

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104
Q

Investigations to diagnose molar pregnancy?

A

Ultrasound showing sandstorm appearance

Definitive diagnosis made with histology following evacuation of mole

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105
Q

Management of molar pregnancy?

A

Evacuation of mole and histology
Referal to gestational trophoblastic disease centre
Sometimes can metastasise and require systemic chemotherapy

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106
Q

From which week gestation is each trimester?

A

First trimester; start till 12 weeks

Second trimesrer; 13 weeks will 26+6

Third trimester; 27 weeks until birth

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107
Q

When does the booking appointment take place?

A

Before 10 weeks

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108
Q

When does the dating scan take place?

A

Between 10 and 13+6 weeks

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109
Q

How is an accurate estimate for gestational age calculated?

A

Crown to rump length measurement

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110
Q

What is measured at dating scan?

A

Presence of heart beat
Gestational age and EDD
Multiple pregnancy

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111
Q

When is the anomaly scan?

A

Between 18 and 20+6 weeks

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112
Q

What is routinely assessed at antenatal appointments?

A

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

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113
Q

Which SSRI’s are safe to use in breastfeeding?

A

Sertraline or paroxetine

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114
Q

Which vaccinations are offered to all pregnant women?

A

Whooping cough; after 16 weeks
Influenza in autumn and winter

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115
Q

Which vaccines should be avoided by pregnant women?

A

Live vaccines such as MMR

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116
Q

What is the general advice given to pregnant women?

A

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

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117
Q

Complications of drinking alcohol in pregnancy?

A

Miscarriage
Small for dates baby
Pre-term delivery
FAS

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118
Q

Features of FAS?

A

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

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119
Q

What are the risks of smoking in pregnancy?

A

Foetal growth restriction
Miscarriage
Stillbirth
Preterm labour and delivery
Placental abruption
Pre-eclampsia
Cleft lip or palate
Sudden infant death syndrome

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120
Q

Guidelines surrounding flying during pregnancy?

A

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

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121
Q

What is the booking clinic appointment?

A

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

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122
Q

What blood tests are taken at the booking appointment?

A

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

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123
Q

What is the purpose of Down’s syndrome screening?

A

Decide which women should receive more invasive tests to establish diagnosis

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124
Q

What is the combined test?

A

First line and most accurate screening test for Down’s syndrome combining results from ultrasound scan and maternal blood tests

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125
Q

When is the combined test performed?

A

11 to 14 weeks gestation

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126
Q

What components are measured in combined test?

And what results would indicate higher risk of Down’s?

A

Nuchal translucency- >6mm
hCG- high level
PAPP-A- lower level

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127
Q

When is the triple/ quadruple screening test for downs syndrome used?

A

14 to 20 weeks

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128
Q

What is measured in the triple test?

A

hCG- higher level
Alpha fetoprotein - lower result
Serum oestriol - lower result

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129
Q

What is measured in the quadruple test?

A

hCG- higher level
Alpha fetoprotein - lower result
Serum oestriol - lower result
Inhibin-A; lower

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130
Q

When is further testing for Down’s syndrome indicated?

A

When screening test reveals chance higher than 1 in 150

Occurs in around 5% of tested women

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131
Q

What are the options for invasive testing?

A

Amniocentesis
Chorionic villus sampling

Karyotyping is performed on foetal tissue for definitive answer

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132
Q

What is non invasive prenatal testing?

A

Using fragments of foetal DNA/ placental fragments in maternal blood to act as a method of screening

Not a definitive test

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133
Q

How should dose of levothyroxine be adjusted in pregnancy?

A

Increase dose by atleast 25-50mcg

Treatment is uptitrated based on TSH levels

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134
Q

Which antihypertensive medications are not safe to use in pregnancy?

A

ACE inhibitors
Angiotensin receptor blockers
Thiazide and thiazide like diuretics

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135
Q

How does pre-existing epilepsy change during pregnancy?

A

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

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136
Q

Which anti-epileptic medications are safe to use in pregnancy?

A

Levetiracetam, lamotrigine, carbamazepine

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137
Q

Which anti-epileptic medications are avoided in pregnancy and why?

A

Sodium valproate; neural tube defects and developmental delay
Phenytoin; cleft lip and palate

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138
Q

At which stage in pregnancy should NSAIDs be avoided and why?

A

third trimester premature closure of the ductus in the foetus and delay labour

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139
Q

What effects can beta blockers have on the foetus?

A

Foetal growth restriction
Hypoglycaemia in neonate
Bradycardia in neonate

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140
Q

What adverse outcomes can occur is ACE inhibitors are taken during pregnancy?

A

Oligohydramnios
Miscarriage or foetal death
Hypocalvaria
Renal failure in neonate
Hypotension in neonate

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141
Q

What effect can use of opiates have on neonate?

A

Withdrawal symptoms between 3-72 hours post birth known as neonatal abstinence syndrome

Presents as irritability, tachypnoea, high temperatures and poor feeding

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142
Q

What cardiac defect is lithium associated with?

A

Ebstein’s anomaly

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143
Q

What can use of warfarin in pregnancy lead to?

A

Foetal loss
Congenital malformations- particularly craniofacial malformations
Bleeding during pregnancy
PPH
Foetal haemorrhage
Intracranial bleeding

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144
Q

If lithium is used during pregnancy what precautions are taken?

A

Check lithium levels every 4 weeks then every week from 36 weeks

Avoid breast feeding

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145
Q

Risks of using SSRI in pregnancy?

A

First trimester; congenital heart defects, especially paroxetine
Third trimester; persistent pulmonary hypertension in neonate
Neonates can experience withdrawal symptoms

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146
Q

What causes congenital rubella syndrome

A

Maternal rubella infection before the 20th week of pregnancy

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147
Q

Features of congenital rubella syndrome?

A

Congenital cataracts
Congenital deafness
Congenital heart disease
Learning disability

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148
Q

What can chickenpox during pregnancy lead to ?

A

More severe case in woman with varicella pneumonitis, hepatitis or encephalitis
Foetal varicella syndrome
Severe neonatal varicella syndrome

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149
Q

How can varicella during pregnancy be treated?

A

If presenting within 24 hours of symptoms oral aciclovir if she is over 20 weeks

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150
Q

Features of congenital varicella syndrome?

A

Foetal growth restricition
Microcephaly
Hydrocephalus
Learning difficulty
Scars and significant skin changes
Limb hypoplasia
Cataracts and Inflammation in the eye

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151
Q

What is listeria?

A

Gram positive bacteria infection causing flu like symptoms which is more common in pregnant women and typically transmitted

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152
Q

What are the adverse effects of listeriosis in pregnancy?

A

High rate of foetal death and miscarriage

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153
Q

Features of congenital CMV?

A

Foetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures

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154
Q

How is CMV spread?

A

Saliva of asymptomatic children

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155
Q

What is congenital toxoplasmosis?

A

Infection with parasite toxoplasma gondii contracted through infected faeces from cat

can lead to congenital toxoplasmosis and is higher risk in later pregnancy

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156
Q

Features of congenital toxoplasmosis?

A

Intracranial calcification
Hydrocephalus
Chorioretinitis

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157
Q

Complications of parovirus B19 infection in pregnancy?

A

Miscarriage/ foetal death
Severe foetal anaemia
Hydrops fetalis
Maternal pre-eclampsia like syndrome

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158
Q

What is mirror syndrome?

A

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

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159
Q

What is the cause of mirror syndrome?

A

Hydrops fetalis as a result of parovirus B19 infection

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160
Q

Investigations for women with suspected parovirus B19 infection?

A

IgM for parovirus; acute infection in past 4 weeks
IgG for parovirus; long term immunity after infection
Rubella antibodies as a differential

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161
Q

How is Zika virus transmitted?

A

Aedes mosquito and sexual contact

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162
Q

Symptoms of congenital zika syndrome?

A

Microcephaly
Growth restriction
Intracranial abnormalities such as ventriculomegaly and cerebellar atrophy

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163
Q

Women with which rhesus status need intervention?

A

negative

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164
Q

Pathophysiology of rhesus incompatibility in pregnancy?

A

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

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165
Q

Management of rhesus incompatibility?

A

Prevent sensitisation; IM anti-D injections

Given with 72 hours of sensitisation event

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166
Q

When are anti-D injections given routinely?

A

28 weeks gestation
At birth if baby’s blood group is postive

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167
Q

At what other occasions should anti-D be administered?

A

Antepartum haemorrhage
Amniocentesis procedure
Abdominal trauma

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168
Q

What is the Kleinhauer test?

A

A test performed after 20 weeks gestation

Determined how much foetal blood has passed into mothers blood

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169
Q

What is a small for gestation age baby?

A

Foetus that measures below the 10th centile for their gestational age

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170
Q

How is size of foetus measured?

A

Estimated foetal weight
Foetal abdominal circumference

Both measured on USS

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171
Q

What factors are taken into account with customised growth charts?

A

Ethnic group
Height
Weight
Parity

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172
Q

What is the definition of low birth weight?

A

Birth weight below 2500g

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173
Q

Causes of SGA babies?

A

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

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174
Q

Signs of foetal growth restriction?

A

Reduced amniotic fluid level
Abnormal doppler studies
Reduced foetal movements
Abnormal CTG

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175
Q

Complications of FGR?

A

Short term;
Foetal death/ still birth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

Long term;
Cardiovascular disease
Hypertension
T2DM
Obesity
Mood and behavioural problems

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176
Q

Risk factors for SGA?

A

Previous SGA baby
Obesity
Smoking
Diabetes
Existing HTN
Pre-eclampsia
Older mother
Multiple pregnancy
Lower PAPP-A
Antepartum haemorrhage
Antiphospholipid syndrome

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177
Q

Monitoring SGA babies?

A

Serial ultrasound scans

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178
Q

Management of SGA?

A

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

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179
Q

What is Large for gestational age?

A

Macrosomia when the weight of the baby is more than 4.5kg at birth

During pregnancy estimated foetal weight is over the 90the centile

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180
Q

Causes of macrosomia?

A

Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby

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181
Q

Risks of macrosomia to the mother?

A

Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery/ C-section
PPH
Uterine rupture

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182
Q

Risks of macrosomia to the baby?

A

Birth injury
Neonatal hypoglycaemia

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183
Q

What type of multiple pregnancy has the best outcome?

A

Diamniotic, dichorionic twin pregnancy

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184
Q

On USS what is seen in dichorionic diamniotic pregnancy?

A

Lambda sign, twin peak sign, there is a membrane between the twins

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185
Q

On USS what is seen in a monochorionic diamniotic pregnancy?

A

T sign with a membrane separating the twins

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186
Q

Complications experience by mother my multiple pregnancy?

A

Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery/ C-section
PPH

187
Q

Complications experienced by baby in multiple pregnancy?

A

Miscarriage
Still birth
FGR
Prematurity
Twin twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities

188
Q

What is Twin Twin Transfusion Syndrome?

A

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
Q

What is the management of TTTS?

A

Referal to teritary centre and in severe cases can require laser ablation

190
Q

What is Twin Anaemia Polycythaemia Sequence?

A

Less severe version of TTTS, where one twin becomes anaemic and other becomes polycythaemic

191
Q

In a multiple pregnancy at what time points is FBC for anaemia monitored?

A

Booking clinic
20 weeks
28 weeks

192
Q

Frequency of USS in multiple pregnancy?

A

Every 2 weeks for monochorionic twins from 16 weeks
Every 4 weeks for dichorionic twins from 20 weeks

193
Q

When is planned birth offered in multiple pregnancy?

A

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
Q

What is the mode of delivery in monoamniotic twins?

A

Elective C-section

195
Q

Complications associated with UTI in pregnancy?

A

Preterm delivery
Low birth weight
Pre-eclampsia

196
Q

Presentation of lower UTI in pregnant women?

A

Dysuria
Suprapubic pain
Increased frequency of urination
Urgency
Incontinence
Haematuria

197
Q

Presentation of pyelonephritis in pregnant women?

A

Fever
Loin, suprapubic or back pain
Vomiting
Loss of appetite
Haematuria
Renal angle tenderness

198
Q

Investigations for UTI in pregnancy?

A

Urine dip
MSC

199
Q

Causes of UTI in pregnancy?

A

Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
Staphylococcus
Candida albicans

200
Q

Management of UTI in pregnancy?

A

7 days antibiotics

Nitrofurantoin- avoid in third trimester
Amoxicillin- only after sensitivities are known
Cefalexin

201
Q

Why is nitrofurantoin avoided in third trimester?

A

Risk of neonatal haemolysis

202
Q

When are women routinely screened for anaemia during pregnancy?

A

Booking clinic
28 week gestation

203
Q

What are the haemoglobin cutoffs at each check point in pregnancy?

A

Booking bloods; >110
28 weeks gestation; >105
Post partum; >100

204
Q

Risk factors for VTE in pregnancy?

A

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
Q

RCOG recommendations for commencing VTE prophylaxis?

A

First trimester if there are three risk factors

206
Q

What medication is used for VTE prophylaxis in pregnancy?

A

LMWH

Also consider mechanical intervention such as compression stockings

207
Q

Management of VTE in pregnancy?

A

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
Q

What is pre-eclampsia?

A

High blood pressure during pregnancy occurring after 20th week with evidence of end organ dysfunction

209
Q

Triad of pre-eclampsia?

A

Hypertension
Proteinuria
Oedema

210
Q

What is the pathophysiology of pre-eclampsia?

A

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
Q

Risk factors for pre-eclampsia?

A

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
Q

Which women are given aspirin and for how long to prevent pre-eclampsia?

A

Those with 1 high risk factor or those with more than 1 moderate risk factor

From 12 weeks until delivery

213
Q

Symptoms of pre-eclampsia?

A

Headache
Visual disturbance/ blurriness
Nausea and vomiting
Upper abdominal pain
Oedema
Reduced urine output

214
Q

Investigations to diagnose pre-eclampsia?

A

High blood pressure; over 140/90
Urine dip; proteinuria
Bloods; raised creatinine, elevated liver enzymes, thrombocytopenia
Placental dysfunction; abnormal doppler, FGR

215
Q

How is proteinuria quantified?

A

Urine albumin creatinine ratio (>30mg/mmol)

Urine protein creatinine ratio (>8mg/ mmol)

216
Q

Management of pre-eclampisa?

A

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
Q

What is eclampsia?

A

Seizures associated with pre-eclampsia

218
Q

How is eclampsia managed?

A

Magnesium sulphate

Rest of management is same as PET

219
Q

What is HELLP syndrome?

A

Severe form of pre-eclmapsia presenting with

Haemolysis
Elevated Liver enzymes
Low Platelets

220
Q

What is gestational diabetes?

A

Diabetes triggered by pregnancy which resolves after birth of baby

221
Q

Complications of gestational diabetes?

A

Macrosomia and large for dates baby
Shoulder dystocia
Progression to T2DM

222
Q

Risk factors for gestational diabetes?

A

Previous gestational diabetes
Previous macrosomic baby
BMI >30
Ethnic group; black caribbean, middle eastern, south asian
Family history of diabetes

223
Q

Features that suggest gestational diabetes?

A

Large for dates baby
Polyhydramnios
Glucose on urine dip

224
Q

What results on OGTT suggest gestational diabetes?

A

Fasting > 5.6
2 hours > 7.8

225
Q

Management of gestational diabetes?

A

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
Q

What are glucose target levels in women with gestational diabetes?

A

Fasting; 5.3
1 hour post meal; 7.8
2 hours post meal; 6.4

226
Q

What is the alternative to metformin?

A

Gibenclamide

226
Q

For women with pre-existing diabetes when should delivery be planned?

A

Between 37 and 38+6

227
Q

When should women women be referred for retinopathy screening?

A

Soon after booking appointment

Again at 28 weeks

228
Q

What is the management of gestational diabetes after delivery?

A

Can stop medications immediately

Repeat OGTT after 6 weeks post partum

229
Q

Risks experienced by babies born with gestational diabetes?

A

Neonatal hypoglycaemia
Polycythaemia
Neonatal jaundice
Congenital heart disease
Cardiomyopathy

230
Q

What is obstetric cholestasis?

A

Reduced outflow of bile acids during pregnancy which resolves after delivery

231
Q

Epidemiology of obstetric cholestasis?

A

1% of pregnancies

Usually develops in later pregnancy

232
Q

Pathophysiology of obstetric cholestasis?

A

Rise in progesterone and oestrogen lead to stasis of bile acids and reduced outflow

233
Q

What is the risk associated with obstetric cholestasis?

A

Stillbirth

234
Q

Presentation of obstetric cholestasis?

A

Puritis on the palms of hands and soles of feets
Fatigue
Pale grey stools
Dark urine
Jaundice
NO RASH

235
Q

Differentials for obstetric cholestasis?

A

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

236
Q

Investigations to diagnose obstetric cholestasis?

A

LFT
Bile acids

237
Q

Management of obstetric cholestasis?

A

Ursodeoxycholic acid
Emollients and antihistamines
Water soluable Vit K if prothrombin time is also derranged
Planned delivery at 37 weeks

238
Q

What is acute fatty liver of pregnancy?

A

Third trimester complications with rapid accumulation of fat in hepatocytes causing acute hepatitis

239
Q

Pathophysiology of acute fatty liver of pregnancy?

A

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
Q

Most common cause of acute fatty liver of pregnancy?

A

Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency

241
Q

Mode of inheritance of Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency?

A

Autosomal recessive

242
Q

Presentation of acute fatty liver of pregnancy?

A

General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia
Ascites

243
Q

Investigations to diagnose acute fatty liver of pregnancy?

A

LFT; raised liver enzymes
Raised bilirubin
Riased WCC
Deranged clotting
Low platelets

244
Q

Management of acute fatty liver of pregnancy?

A

Obstetric emergency
Admission and delivery of the baby
Consider liver transplant

245
Q

What is polymorphic eruption of prenancy?

A

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
Q

Triad of polymorphic eruption of pregnancy?

A

Utricarial papules
Wheals
Plaques

247
Q

Management of polymorphic eruption of pregnancy?

A

Topical emollients, steroids
Oral antihistamines
Oral steroids in severe cases

248
Q

What is atopic eruption of pregnancy?

A

Eczema that flares up during pregnancy presenting during first and second trimester

249
Q

What are the types of atopic eruption of pregnancy?

A

E-type; eczematous, inflamed, red and itchy skin

P-type; intensely itchy papules affecting abdomen, back and limbs

250
Q

Management of atopic eruption of pregnancy?

A

Topical emollients
Topical steroids
Phototherapy with UVB
Oral steroids

251
Q

What is melasma?

A

AKA mask of pregnancy
Increased pigmentation in patches usually symmetrical and affecting sun affected areas

252
Q

What is the cause of melasma?

A

Increased female sex hormones

253
Q

Management of melasma?

A

Avoid sun exposure
Use SPF
Use make up to cover up

Resolves following delivery

254
Q

What is pyogenic granuloma?

A

Benign rapidly growing tumour of capillaries presenting as a discrete lump with a red or dark appearance

255
Q

Causes of pyogenic granuloma?

A

Pregnancy
Hormonal contraceptive
Minor trauma
Infection

256
Q

Presentation of pyogenic granuloma?

A

1-2 cm in size
Occur on fingers, upper chest, back, neck, head
Can cause profuse bleeding and ulceration

257
Q

Management of pyogenic granuloma?

A

Surgical removal and histology

258
Q

What is pemphigoid gestationis?

A

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
Q

When does pemphigoid gestationis occur?

A

Second to third trimester

260
Q

Presentation of pemphigoid gestationis?

A

Itching
Red papular blistering rash
Fluid filled blisters

261
Q

Management of pemphigoid gestationis?

A

Topical emollients, corticosteroids
Oral steroids
Immunosuppressants

262
Q

Risk to the baby of pemphigoid gestationis?

A

FGR
Preterm delivery
Blistering rash post delivery

263
Q

What is placenta praevia?

A

Low lying placenta, lower than the presenting part of the foetus

264
Q

What is a low lying placenta vs placenta praevia?

A

Low lying placenta is within 20mm of the internal cervical os

Placenta praevia is when the placenta lies over the internal cervical os

265
Q

Epidemiology of placenta praevia?

A

1% of pregnancies

266
Q

Causes of antepartum haemorrhage?

A

Placenta praevia
Placental abruption
Vasa praevia

267
Q

What risks are associated with placenta praevia?

A

Antepartum haemorrhage
Emergency C-section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth

268
Q

Risk factors for placental praevia?

A

Previous C-section
Previous placental praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities
Assisted reproduction

269
Q

When is placenta praevia diagnosed?

A

20 week anomaly scan

270
Q

Presentation of placenta praevia?

A

PAINLESS PV bleeding

271
Q

At what gestation is a repeat transvaginal ultrasound required for placenta praevia?

A

32 weeks
36 weeks to guide decision around delivery

272
Q

Management of placenta praevia?

A

Planned C-section between 36 and 37 weeks

273
Q

Complication of placenta praevia?

A

Haemorrhage

274
Q

Management of haemorrhage caused by placenta praevia?

A

Emergency C-section
Blood transfusion
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy

275
Q

What is vasa praevia?

A

Foetal vessels are within foetal membranes and travel across internal cervical os

276
Q

Pathophysiology of vasa praevia?

A

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
Q

What are the types of vasa praevia?

A

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
Q

Risk factors for vasa praevia?

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

279
Q

Investigations to diagnose vasa praevia?

A

Ultrasound scan; however no reliable at picking up
Can see on examination or palpation of cervix you will feel pulsation

280
Q

Management of vasa praevia?

A

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
Q

Complications of vasa praevia?

A

Still birth
Antepartum haemorrhage
Emergency C-section

282
Q

What is placental abruption?

A

Placenta separates from wall of the uterus during pregnancy

283
Q

Risk factors for placental abruption?

A

Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
FGR
Multigravida
Increasing maternal age
Smoking
Cocaine or amphetamine use

284
Q

Presentation of placental abruption?

A

Sudden onset severe abdominal pain that continues
Vaginal bleeding
Shock
Abnormal CTG
Woody abdomen on palpation

285
Q

How is severity of antepartum haemorrhage quantified?

A

Spotting
Minor; less than 50mls
Major; 50-100mls
Maasive; more than 100mls

286
Q

What is a concealed abruption?

A

Cervical os remains closed and any bleeding that occurs is within uterine cavity

287
Q

What is the initial management of a major or massive haemorrhage?

A

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
Q

Management of placnetal abruption?

A

Delivery of baby, usually by C-section
Active management of third stage of labour

289
Q

What is placenta accreta?

A

Placenta implants deeper through and past the endometrium making delivery of placenta more difficult

290
Q

How is placenta accreta spectrum defined?

A

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
Q

Risk factors for placenta accreta syndrome?

A

Previous placenta accreta syndrome
Previous endometrial curettage procedures
Multigravida
Increased maternal age
Low lying placenta/ placenta praevia

292
Q

Presentation of placenta accreta syndrome?

A

Asymptomatic
May be seen on ultrasound
Present at time of birth as PPH

293
Q

Investigations to diagnose placenta accreta syndrome?

A

Seen on ultrasound scan
MRI is used to assess thickness of adherence
Early detection allows planning of birth

294
Q

When is delivery planned for placenta accreta syndrome?

A

35 to 36+6

295
Q

What options are available during delivery for patient with placenta accreta syndrome

A

Hysterectomy- recommended
Uterus preserving surgery
Expectant management; high risk of infection, bleeding

296
Q

What is breech presentation?

A

Presenting part of the foetus is the legs and bottom as opposed to cephalic presentation

297
Q

Epidemiology of breech presentation?

A

5% of pregnancies

298
Q

Types of breech presentation?

A

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
Q

Management of breech presentation?

A

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
Q

What is external cephalic version?

A

Mechanical technique to turn the foetus from breech to cephalic position using pressure on the abdomen

301
Q

What is the success rate of ECV?

A

50%

302
Q

When is external cephalic version attempted?

A

after 36 weeks in nulliparous women

after 37 weeks i n women who have given birth

303
Q

How common is still birth?

A

1 in 200 pregnancies

304
Q

Causes of intrauterine foetal death?

A

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
Q

What is the most common cause of PPH?

A

Uterine atony

306
Q

Risk factors for still birth?

A

FGR
Smoking
Alcohol
Increasing maternal age
Maternal obesity
Twins
Sleeping on back

307
Q

What happens following still birth?

A

With parental consent;
Genetic testing on foetus and placenta
Post mortem investigation
Testing other for disease

308
Q

Causes of cardiac arrest in pregnancy?

A

Thrombosis
Tension pneumothorax
Toxins
Tamponade
Hypoxia
Hypovolaemia- haemorrhage
Hypothermia
Hyperkalaemia
Hypoglycaemia
Eclampsia
Intracranial haemorrhage

309
Q

Causes of massive obstetric haemorrhage?

A

Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture

310
Q

Factors making resuscitation more difficult in pregnancy?

A

Aortocaval compression
Increased oxygen requirement
Splinting of diaphragm
Difficulty with intubation
Increased risk of aspiration
Ongoing obstetric haemorrhage

311
Q

How is risk of aortocaval syndrome managed during resuscitation?

A

15 degree tilt to left side

312
Q

In context of cardiac arrest when is baby delivered?

A

No response within 4 minutes of starting CPR

313
Q

Which medications can be given to breast feeding women?

A

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
Q

Which medications should be avoided in pregnancy?

A

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone

315
Q

Haemoglobin cut-offs for staring therapy to treat anaemia?

A

First trimester; <110
Second/third trimester <105
Post partum; <100

316
Q

What is high foetal fibronectin correlated to?

A

Early labour

317
Q

How long after giving birth is MMR vaccine contraindicated?

A

28 days

318
Q

Contraindications to ECV?

A

where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy

319
Q

Monitoring requirements for obstetric cholestasis?

A

Weekly LFT

320
Q

What is used in magnesium sulphate induced respiratory depression?

A

Calcium gluconate

321
Q

At what gestation would referral to secondary care be made for lack of foetal movements?

A

24 weeks

322
Q

For gestational diabetes when is insulin first line treatment?

A

Fasting glucose over 7

323
Q

What are the stages of labour?

A

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
Q

What are the phases of the first stage of labour?

A

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
Q

What are Braxton- Hicks contractions?

A

Occasional irregular contractions of the uterus usually felt during second and third trimester and are not an indicator for labour

326
Q

What are the signs of labour?

A

Show
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

327
Q

When is first stage of labour established?

A

Painful regular contractions
Dilation of cervix from 4cm onwards

328
Q

What is rupture of membranes?

A

Rupture of the amniotic sac

329
Q

What is spontaneous rupture of membranes?

A

Spontaneous rupture of the amniotic sac

330
Q

What is Pre-labour rupture of membranes?

A

Rupture of the amniotic sac before the onset of labour

331
Q

What is pre-term prelabour rupture of membranes?

A

Rupture of the amniotic sac before the onset of labour and before the 37th week of gestation

332
Q

How is rupture of membranes diagnosed?

A

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
Q

Management of preterm prelabour rupture of membranes?

A

Prophylactic antibiotics to prevent development of chorioamnionitis- erythromycin 250mg QDS for 10 days

Consider induction of labour at 34 weeks

334
Q

What is preterm labour with intact membranes?

A

Regular painful contractions and cervical dilation without rupture of amniotic sac

335
Q

What is fetal fibronectin an indicator of?

A

Impending labour, a result over 50ng/ ml indicates possible labour

336
Q

Management of pre-term labour?

A

Foetal monitoring
Tocolysis with nifedipine
Maternal corticosteroids
IV magnesium sulphate
Delayed chord clamping or milking

337
Q

What medications can be used for tocolysis?

A

Nifedipine
Atosiban; oxytocin receptor antagonist

338
Q

Indications for tocolysis?

A

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
Q

What do antenatal corticosteroids do?

A

Develop foetal lungs and reduce respiratory distress syndrome

Common regimen; two doses IM betamethasone 24 hours apart

340
Q

Why is MgSO4 given antenatally?

A

Protect foetal brain reducing risk of cerebral palsy

341
Q

Signs of maternal magnesium toxicity?

A

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

342
Q

Indications for induction of labour?

A

Prelabour rupture of membranes
FGR
Pre eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine foetal death

343
Q

What is the bishop score?

A

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
Q

How is the bishop score interpreted?

A

Score more than 8 predicts successful IOL

Score below 8 suggests cervical ripening may be required

345
Q

Options to induce labour?

A

Membrane sweep
Vaginal prostaglandin E2; dinoprostone
Cervical ripening balloon
Artificial rupture of membranes +/- oxytocin infusion

Mifepristone and misoprostol if IUFD has occured

346
Q

Methods of monitoring IOL?

A

CTG
Bishop score

347
Q

Options for managing slow/ no progression of labour?

A

Further vaginal prostaglandins
Cervical ripening balloon
Artifical rupture of membranes and oxytocin infusion
Elective C-section

348
Q

What is uterine hyperstimulation?

A

Complication of IOL with vaginal prostaglandin where uterine contractions are prolonged and frequent

349
Q

Criteria for uterine hyperstimulation?

A

Individual contractions lasting more than 2 minutes
More than 5 uterine contractions in 10 minutes

350
Q

Complications of uterine hyperstimulation?

A

Foetal compromise; hypoxia and acidosis
Emergency C-section
Uterine rupture

351
Q

Management of uterine hyperstimulation?

A

Remove vaginal prostaglandin/ stop oxytocin
Tocolysis with terbutaline

352
Q

What is measured on CTG?

A

One transducer measures foetal heart rate using doppler ultrasound

Other transducer measures tension in uterine wall and hence uterine contraction

353
Q

Indications for continuous CTG monitoring in labour?

A

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
Q

Features assessed on CTG?

A

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
Q

What do decelerations on CTG indicate?

A

Hypoxia

356
Q

What are the types of deceleration seen on CTG?

A

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
Q

Features of a reassuring CTG?

A

Accelerations, suggest healthy foetus especially if alongside uterine contractions
No decelerations
Early decelerations
Less than 90 minutes of variable decelerations

358
Q

What are the features of a sinusoidal CTG and what does it indicate?

A

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
Q

Uses of oxytocin infusion?

A

Induce labour
Progress labour
Improve frequency and strength of uterine contractions
Prevent or treat PPH

360
Q

Mechanism of action of Atosiban?

A

Oxytocin receptor antagonist

361
Q

What is ergometrine?

A

Medications that causes muscle contractions and is used to deliver placenta and reduce post partum bleeding

Only used after delivery of foetus

362
Q

Uses of ergometrine?

A

Delivery of placenta
Prevent post partum haemorrhage

363
Q

Mechanism of action of prostaglandins?

A

Stimulate uterine contractions
Promote cervical ripening

364
Q

Which medications should not be used in labour with a healthy foetus?

A

Misoprostol and mifepristone

365
Q

Mechanism of action of terbutaline?

A

Beta-2- adrenergic agonist which relaxes muscles

366
Q

Indication of terbutaline?

A

Tocolysis in uterine hyperstimulation

367
Q

Mechanism of action of carboprost?

A

Synthetic prostaglandin analogue which binds to prostaglandin receptors stimulating uterine contractions

368
Q

When is carboprost given?

A

In PPH

369
Q

In which patients should carboprost not be used?

A

In patients with asthma

370
Q

What is failure to progress?

A

Situation when labour is not developing at a satisfactory rate

371
Q

How is progression of labour assessed?

A

Power; uterine contraction strength
Passenger; size, lie, presentation and position of baby
Passage; size and shape of pelvis and soft tissue

372
Q

Interventions that may be required in second stage of labour?

A

Changing position
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
C-section

373
Q

What is defined as delay in the third stage of labour?

A

More than 30 minutes in active management
More than 60 minutes with expectant management

374
Q

What does active management of the third stage of labour invovle?

A

IM oxytocin
Controlled cord traction

375
Q

What is used for simple analgesia in early labour?

A

Paracetamol
Codeine

376
Q

What is the composition of Entonox?

A

50% nitrous oxide
50% oxygen

377
Q

Side effects of entonox?

A

Syncope
Nausea
Sleepiness

378
Q

Cautions of opioid use in labour?

A

Drowsiness in mother
Respiratory depression
Make first feed more difficult

379
Q

Adverse effects of epidural?

A

Headache after insertion
Hypotension
Motor weakness in legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery

380
Q

What medications are given during an epidural anaesthesia?

A

Levobupivacaine/ bupivacaine
Fentanyl

381
Q

What is umbilical cord prolapse?

A

When umbilical cord descends below the presenting part of the foetus through the cervix

382
Q

What is the danger of umbilical cord prolapse?

A

Compression of cord leading to hypoxia

383
Q

Diagnosis of umbilical cord prolapse?

A

Suspect possibility in abnormal lie
Signs of foetal distress on CTG
Speculum examination

384
Q

What is shoulder dystocia?

A

When anterior shoulder of the baby becomes stuck behind pubic symphysis after the head has been delivered

385
Q

Most common cause of shoulder dystocia?

A

Macrosomia secondary to gestational diabetes

386
Q

Presentation of shoulder dystocia?

A

Difficulty delivering face and head
Failure of restitution
Turtle neck sign

387
Q

Management of shoulder dystocia?

A

Episiotomy
McRoberts manoeuver
Pressure to the anterior shoulder
Rubins manoeuver
Woods screw manoeuver
Zavanelli manoeuver

388
Q

What is the McRoberts manoeuver?

A

First line intervention

Hyperflexion of mother at hip which provides posterior pelvic tilt lifting pubic symphysis up and out of the way

389
Q

What is the Rubins manoeuvre?

A

Reaching into vagina to put pressure on posterior aspect of anterior shoulder to help move under the pubic symphysis

390
Q

What is Wood’s screw manoeuvre?

A

Performed during rubins manoeuvre

The other hand is put into the vagina to put pressure on anterior aspect of posterior shoulder

391
Q

What is Zavanelli manoeuvre?

A

Pushing babys head back into vagina to deliver via C-section

392
Q

Complications of shoulder dystocia?

A

Foetal hypoxia, and consequent cerebral palsy
Brachial plexus injury, Erb’s palsy
Perineal tears
PPH

393
Q

What is instrumental delivery?

A

Vaginal delivery assisted by either ventouse suction cup or forceps

394
Q

What percentage of deliverys are assisted by instuments?

A

10%

395
Q

What is the antibiotic of choice to prevent infection following instrumental delivery?

A

Co-amoxiclav, single dose

396
Q

Indications for instrumental delivery?

A

Failure to progress
Foetal distress
Maternal exhaustion
If received epidural anaesthesia

397
Q

Signs of femoral nerve injury in the mother?

A

Weakness of knee extension
Loss of patella reflex
Numbness of anterior thigh and medial lower leg

397
Q

Risks to the mother following instrumental delivery?

A

PPH
Episiotomy
Perineal tears
Injury to anal sphincter
Incontinence of bladder/ bowel
Nerve injury; obturator/ femoral

397
Q

Classification of perineal tears?

A

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
Q

Risks to baby following instrumental delivery?

A

Cephalohaematoma - ventouse
Facial nerve palsy - forceps

Rarely can have intracranial haemorrhage, skull fracture, spinal cord injury

397
Q

Signs of obturator nerve injury?

A

weakness of hip adduction and rotation
Numbness of medial thigh

398
Q

Risk factors for perineal tears?

A

Nulliparity
Large babies
shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental delivery

399
Q

Management of perineal tears?

A

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
Q

Complications after perineal tears?

A

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
Q

Methods to prevent perineal tears?

A

Episiotomy
Perineal massage

402
Q

What is physiological management of the third stage of labour?

A

Placenta is delivered by maternal effort without medication or cord traction

403
Q

Indications for active management of 3rd stage of labour?

A

Haemorrhage
More than 60 minutes to deliver placenta
Routinely offered to reduce risk of PPH

404
Q

Steps of active management of third stage of labour?

A

IM oxytocin 10IU
Controlled cord traction

405
Q

Definition of post partum haemorrhage?

A

500ml after vaginal delivery

1000ml after C-section

406
Q

Classification of PPH?

A

Minor; <1000ml
Major; >100ml
Moderate; 1000-2000ml
Severe; >2000ml

Primary; within 24 hours
Secondary; after 24 hours

407
Q

Causes of PPH?

A

Uterine atony
Trauma; perineal tear
Tissue; retained placenta
Thrombin; bleeding disorder

408
Q

Risk factor for PPH?

A

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
Q

How to reduce risk of PPH?

A

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
Q

Management of PPH?

A

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
Q

Interventions to stop bleeding in PPH?

A

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
Q

Causes of secondary PPH?

A

Retained products of conception
Endometritis

413
Q

Investigations to find cause of secondary haemorrhage?

A

Ultrasound scan
Endocervical/ high vaginal swabs

414
Q

Management of secondary haemorrhage?

A

Evacuation of retained products
Antibiotics

415
Q

Conditions of an Elective C-section?

A

Usually performed after 39 weeks
Under spinal anaesthetic

416
Q

Indications for elective C-section?

A

Previous C-section
Previous perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV
Cervical cancer

417
Q

Categories of C-sections?

A

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
Q

Types of incisions in C-sections?

A

Pfannenstiel incision; curved incision 2 finger widths above pubic symphysis

Joel- Cohen incision; straight incision

419
Q

Layers dissected during C-section?

A

Skin
Subcutaneous tissue
Fascia/ rectus sheath
Rectus abdominis muscles
Peritoneum
Vesicouterine peritoneum
Uterus
Amniotic sac

420
Q

Risks of C-section?

A

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
Q

Risks in future pregnancies if previous C-section?

A

Repeat C-section
Uterine rupture
Placenta praevia
Still birth

422
Q

Contraindications to vaginal birth after caesarean?

A

Previous uterine rupture
Classical caesarean scar (vertical)
Any CI for vaginal delivery

423
Q

Causes of sepsis in pregnancy?

A

Chorioamnionitis
UTI

424
Q

What is chorioamnionitis?

A

Infection of the chorioamniotic membranes and amniotic fluid occurring in the late stages of pregnancy and labour

425
Q

Management of maternal sepsis?

A

Sepsis 6
Maternal and foetal monitoring
Emergency C-section, usually requiring GA
Significant antimicrobial usage

426
Q

What is amniotic fluid embolism?

A

Amniotic fluid passes into mothers blood triggering immune reaction

427
Q

Epidemiology of amniotic fluid embolism?

A

2 in 100000 deliveries

428
Q

Risk factors for amniotic fluid embolism?

A

Increasing maternal age
IOL
C-section
Multiple pregnancy

429
Q

Presentation of amniotic fluid embolism?

A

Presents at time of labour or soon in post partum period
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest

430
Q

Management of amniotic fluid embolism?

A

Supportive
ABCDE

431
Q

What is uterine rupture?

A

Complication of labour where myometrium dissects

Incomplete is where serosa is intact

Complete is where contents of uterus are released into peritoneum

432
Q

Risk factors for uterine rupture?

A

PREVIOUS C-SECTION
VBAC
Previous uterine surgery
High BMI
Increased parity
Increased age
IOL
Use of oxytocin

433
Q

Presentation of uterine rupture?

A

Abdominal pain
Vaginal bleeding
Ceasing of vaginal contractions
Hypotension
Tachycardia
Collapse

434
Q

Management of uterine rupture?

A

Emergency C-section
Uterus repair/ hysterectomy

435
Q

What is uterine inversion?

A

Fundus of uterus drops down through uterine cavity turning uterus inside out

436
Q

What is lochia?

A

Discharge of blood, endometrial tissue and mucus which should settle in upto 6 weeks after birth

437
Q

Presentation of uterine inversion?

A

PPH
Maternal shock
Collapse

438
Q

Management of uterine inversion?

A

Johnson manoeuvre
Hydrostatic methods
Surgery

439
Q

How long after birth does fertility take to return?

A

21 days, so does not require contraception upto this point

440
Q

When is each type of contraception safe?

A

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
Q

Why are post partum women at risk of endometritis?

A

Process of delivery opens uterus making it easier for infection

442
Q

Which method of delivery makes endometritis more likely?

A

C-section

443
Q

Presentation of endometritis?

A

Foul smelling lochia
Bleeding that gets heavier/ does not improve
Lower abdominal/ pelvic pain
Fever
Sepsis

444
Q

Risk factors for retained products of conception?

A

Placenta accreta

444
Q

Presentation of retained products of conception?

A

Vaginal bleeding that gets heavier
Lower abdominal/ pelvic pain
Fever

444
Q

Management of retained products of conception?

A

Dilation and curettage; surgical procedure to evacuate retained products

444
Q

What is Sheehan’s syndrome?

A

Complication of PPH resulting in avascular necrosis of anterior pituitary gland

445
Q

Complications of D&C?

A

Endometritis
Asherman’s syndrome

445
Q

What is asherman’s syndrome?

A

Adhesions within uterus

445
Q

What score of edinburgh post natal depression scale suggest postnatal depression?

A

Score of 10 or more

445
Q

What is post partum thyroiditis?

A

Changes in thyroid function within 12 months from delivery affecting women without prior thyroid disease

445
Q

Pathophysiology of postpartum thyroiditis?

A

Pregnancy has an immunosuppressant effect on maternal system, after delivery, heightened immune system attacks thyroid cells causing inflammation and disturbed function

445
Q

Stages of post partum thyroiditis?

A

Thyrotoxicosis; in first 3 months
Hypothyroid; 3-6 months post partum
Thyroid function returns to normal over a couple of months

446
Q

Presentation of Sheehan’s syndrome?

A

Reduced lactation
Amenorrhoea
Adrenal insufficiency
Hypothyroidism

447
Q

Management of Sheehan’s syndrome?

A

Oestrogen and progesterone
Hydrocortisone
Levothyroxine
Growth hormone

448
Q

Causes of pulmonary hypoplasia?

A

Oligohydramnios
Congenital diaphragmatic hernia

449
Q
A

Phase 3A (7 decks)

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