Obstetrics Flashcards

Question

When is the latest that women can travel via plane?

Answer 1

37 weeks for single pregnancy 32 weeks for twins

Answer 2

Acute fatty liver of pregnancy

Answer 3

- elevated liver enzymes - prolonged PT - raised bilirubin

Answer 4

- Delivery of foetus - Ongoing monitoring of LFTs - Stabilise mother

Answer 5

Ovum with no embryonic tissue -> missed miscarriage

Answer 6

Endometritis

Answer 7

Elective C-section at 37-38 weeks

Answer 8

Bleeding from the genital tract after 24 weeks’ gestation.

Answer 9

Blood is retroplacental -> not escaping from the uterus

Answer 10

Afibrinogenemia as you get DIC which uses up clotting factors and fibrinogen

Answer 11

Cabergoline

Answer 12

Admission to maternal unit for observation

Answer 13

SSRI discontinuation syndrome

Answer 14

Urinary overflow incontinence

Answer 15

LMWH throughout pregnancy + 6 weeks after

Answer 16

Where the amniotic fluid enters the maternal circulation causing PE like symptoms

Answer 17

- ICU - Oxygen and fluid resus - CTG for foetal monitoring if before delivery

Answer 18

Within 3-5 days of delivery

Answer 19

Change in hormone levels

Answer 20

Station Consistency of cervix Os position Cervical dilatation Effacement

Answer 21

Gravid uterus puts greater pressure on the left iliac vein at the point it crosses the left iliac artery, slowing venous return to the heart.

Answer 22

Premature delivery Stillbirth Sleep deprivation of mother

Answer 23

- Polyhydramnios - Prematurity - Abnormal lie - AROM - Breech presentation

Answer 24

Insert a urinary catheter and fill the bladder with saline

Answer 25

Orofacial Neural tube Congenital heart disease Haemorrhagic disease of newborn

Answer 26

Oral aciclovir 400mg tds until delivery

Answer 27

Treat with LMWH first then scan

Answer 28

Calcium + Vit D

Answer 29

Admission - even if symptoms improve

Answer 30

Increase thyroxine by 25 and repeat TFT in 4 weeks

Answer 31

Artificial ROM Other include prematurity, multiparty, twin pregnancy

Answer 32

- Push presenting part of foetus back into uterus to avoid compression - If past level of Introits, do not handle and keep warm/moist to avoid vasospasm

Answer 33

Urine culture

Answer 34

Think ectopic

Answer 35

- Headache - Oedema - Vision changes - Epigastric/RUQ pain - HTN

Answer 36

HELLP - Haemolysis, elevated LFTs, low platelets

Answer 37

Ischial spines

Answer 38

- Done between 11 and end of 13 weeks - Nuchal translucency, serum BHCG and PAPP-A

Answer 39

- AFP, unconjugated oestriol, HCG, inhibin A

Answer 40

- Non-invasive prenatal testing - Amniocentesis - Chorionic villus sampling

Answer 41

- Size <35mm - Unruptured - No symptoms - No heartbeat - HCG < 1000 - Closely monitor patients over 48 hours and recheck hCG

Answer 42

- Size >35mm - Ruptured - Pain - Visible heartbeat - HCG >5000

Answer 43

1. Check VZV antibodies 2. If not present, give oral Aciclovir from day 7-14 of exposure

Answer 44

1. Specialist advice 2. Give oral aciclovir if >20 weeks pregnant and presents within 24 hours of onset of rash

Answer 45

Treat with amoxicillin or cefalexin

Answer 46

Can do ECV if membranes have not ruptured

Answer 47

Accreta - where the placenta adheres to the myometrium Increta - where the placenta invades into the myometrium but not through Percreta - where the placenta invades through the full thickness of the myometrium

Answer 48

Termination of pregnancy can be at any point in pregnancy

Answer 49

Membrane sweep is a labour adjunct not a method of induction

Answer 50

- ABCDE - Palpate fundus to stimulate contractions + catheterise - IV Oxytocin - IV/IM Ergometrine (C/I in HTN) - Carboprost (C/I in asthma) - Surgical: intrauterine balloon tamponade

Answer 51

- Breech/transverse lie - Multiple pregnancy - Polyhydramnios - Multiparity

Answer 52

- Rhesus negative mother has a rhesus positive foetus and produced anti-RH antibodies - During next pregnancy, these cross the placenta and cause haemolysis of foetal RBC causing rhesus haemolytic disease of newborn

Answer 53

Terbutaline

Answer 54

Actim-PROM vaginal swab

Answer 55

Omeprazole

Answer 56

First - limited to superficial skin Second - Into perineal muscles but not affecting sphincters 3a - <50% of sphincter, 3b - >50% of sphincter Fourth - Skin, muscle sphincters and anal mucousa torn

Answer 57

U+E,FBC,LFTs and bilirubin Twice a week for mild, Thrice a week for severe

Answer 58

Post partum pituitary necrosis due to blood loss and hypovolaemia shock immediately after delivery

Answer 59

- Serum oestriol - hCG - AFP - inhibin-A

Answer 60

Bile acids

Answer 61

Dichorionic diamniotic twin pregnancy

Answer 62

1 - Latent: 0-3cm dilation 1 - Active: 3cm-10cm dilation 2 - Full dilation to delivery of foetus 3 - Delivery of foetus to delivery of placenta

Answer 63

bleeding from genital tract after 24w pregnancy, prior to delivery of fetus

Answer 64

placental abruption

Answer 65

placenta praevia

Answer 66

constant uterus= tender and tense

Answer 67

no pain, uterus not tender

Answer 68

A= normal lie and presentation P= may be abnormal

Answer 69

A= absent or distressed P= usually normal

Answer 70

A= coagulation problems; beware pre-eclampsia, DIC, anuria P= coagulation problems rare; small bleeds before large

Answer 71

vaginal exam SHOULD NOT be done in primary care as if placenta praevia they may haemorrhage

Answer 72

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks the bleeding is often less than menstruation cervical os is closed complicates up to 25% of all pregnancies

Answer 73

threatened miscarriage

Answer 74

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear Pain is not usually a feature cervical os is closed

Answer 75

missed (delayed miscarriage)

Answer 76

missed (delayed) miscarriage

Answer 77

when the gestational sac is > 25 mm and no embryonic/fetal part can be seen

Answer 78

heavy bleeding with clots and pain cervical os is open

Answer 79

inevitable miscarriage

Answer 80

not all products of conception have been expelled pain and vaginal bleeding cervical os is open

Answer 81

incomplete miscarriage

Answer 82

miscarriage

Answer 83

10-20% 80% occurring before 12 weeks gestation

Answer 84

chromosomal abnormalities

Answer 85

advanced maternal age, with women over 35 having a significantly higher risk a history of previous miscarriages previous large cervical cone biopsy lifestyle factors= smoking, alcohol, obesity medical conditions= uncontrolled diabetes thyroid disorders,

Answer 86

three or more consecutive losses, affects 1% of couples. Understanding these epidemiological factors is crucial for early identification and management, providing better support and care for affected women.

Answer 87

- expectant Mx - medical Mx - surgical Mx

Answer 88

'Waiting for a spontaneous miscarriage' First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously

Answer 89

expectant unless certain situations

Answer 90

medical or surgical Mx needed

Answer 91

- increased risk of haemorrhage= late 1st tri; coagulopathies; unable to have blood trans - previous adverse/traumatic experience of preg eg. stillbirth, miscarriage or antepartum haemorrhage - evidence of infection

Answer 92

need medical or surgical Mx

Answer 93

oral mifepristone then 48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed

Answer 94

just oral mifepristone not misoprostol

Answer 95

contact healthcare professional

Answer 96

oral mifepristone and 48hrs later misoprostol (oral, vaginal or sublingual)

Answer 97

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

Answer 98

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

Answer 99

single dose of misoprostol (vaginal, oral or sublingual)

Answer 100

antiemetics and pain relief

Answer 101

'Undergoing a surgical procedure under local or general anaesthetic' The two main options are vacuum aspiration (suction curettage) or surgical management in theatre Vacuum aspiration is done under local anaesthetic as an outpatient - Surgical management is done in theatre under general anaesthetic. This was previously referred to as 'Evacuation of retained products of conception'

Answer 102

vacuum aspiration (suction curettage) or surgical management in theatre

Answer 103

antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders; PCOS uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking

Answer 104

spontaneous loss of pregnancy before the fetus reaches viability. The term includes all pregnancy losses from the time of conception until 24 weeks of gestation.

Answer 105

loss of three or more pregnancies before 24 weeks of gestation.

Answer 106

woman who is pregnant, or has symptoms of pregnancy (such as amenorrhoea or breast tenderness), presents with vaginal bleeding, with or without pain, in the first 24 weeks of pregnancy.

Answer 107

1) confirm pregnancy with urine test 2) history and exam, rule out ectopic

Answer 108

signs of haemodynamic instability or significant concerns about the degree of bleeding or pain.

Answer 109

Immediate admission to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service

Answer 110

- Pain. - A pregnancy of 6 weeks gestation or more. - A pregnancy of uncertain gestation.

Answer 111

women with a pregnancy of less than 6 weeks' gestation who are bleeding but not in pain, and who have no risk factors (such as previous ectopic pregnancy).

Answer 112

- To return if bleeding continues or pain develops. - To repeat a urine pregnancy test after 7–10 days and return if it is positive. - That a negative pregnancy test means that the pregnancy has miscarried.

Answer 113

transvaginal USS

Answer 114

should be offered referral for investigation and management. If no cause is found, the prognosis for a successful future pregnancy is about 75%. However, the prognosis worsens with increasing maternal age and the number of previous miscarriages.

Answer 115

to all rhesus-negative women who have had a surgical procedure to manage a miscarriage.

Answer 116

Receive solely medical management for an ectopic pregnancy or miscarriage. Have a threatened miscarriage. Have had a complete miscarriage. Have a pregnancy of unknown location.

Answer 117

Testing for acquired thrombophilia, particularly for lupus anticoagulant and anticardiolipin antibodies, before pregnancy. Cytogenetic analysis on pregnancy tissue of the third and subsequent first-trimester miscarriage(s). Parental peripheral blood karyotyping (if testing of pregnancy tissue reports an unbalanced structural chromosomal abnormality or there is unsuccessful or no pregnancy tissue available for testing). Assessment for congenital uterine anomalies. TFTs and assessment for thyroid peroxidase (TPO) antibodies. Lifestyle advice, including (as appropriate) maintaining a body mass index (BMI) between 19 kg/m2 and 25 kg/m2, smoking cessation, limiting alcohol consumption, and limiting caffeine to less than 200 mg/day.

Answer 118

aspirin + heparin until at least 34 weeks of gestation will be considered in future pregnancies.

Answer 119

Thyroxine supplementation Regular TSH measurement from 7–9 weeks of gestation is recommended in cases with TPO and/or SCH.

Answer 120

200 mg oral mifepristone and, 48 hours later, 800 micrograms of misoprostol (vaginal, oral, or sublingual) unless the gestational sac has already been passed.

Answer 121

For women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst. If a transvaginal ultrasound scan is unacceptable to the woman.

Answer 122

1) frequent feeding in a breastfed infant is not alone a sign of low milk supply 2) nipple pain: may be caused by a poor latch 3) blocked duct ('milk bleb'): causes nipple pain when breastfeeding. 4) nipple candidiasis 5) mastitis 6) breast engorgement 7) Raynaud's disease of nipple

Answer 123

Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried.

Answer 124

miconazole cream for the mother and nystatin suspension for the baby

Answer 125

if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection

Answer 126

1st line Abx= flucloxacillin 10-14d breastfeeding/expressing should continue

Answer 127

breast abscess may develop- needs incision and drainage

Answer 128

cause of breast pain in breastfeeding women

Answer 129

1st few days after infant born and usually affects both breasts

Answer 130

pain or discomfort is typically worse just before a feed Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle. Fever may be present but usually settles within 24 hours. The breasts may appear red.

Answer 131

blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply

Answer 132

Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.

Answer 133

pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour

Answer 134

minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Answer 135

- consider breastfeeding problems - examine baby for underlying problems

Answer 136

'expert' review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory

Answer 137

exclusive breastfeeding until an infant is at least 6 months of age, with the introduction of solid food around this time and continued breastfeeding up to 2 years of age or longer.

Answer 138

Infant= reduction in the incidence and severity of infections, asthma, and atopic eczema. Mother= reduced rates of breast and ovarian cancer, and reduced incidence of obesity.

Answer 139

Breast pain. Nipple pain. Low milk supply (true and perceived). Oversupply of milk.

Answer 140

concerns about dehydration, faltering growth, infant development, or the presence of an anatomical abnormality such as ankyloglossia (tongue-tie) that may be affecting infant attachment and feeding.

Answer 141

tongue tie

Answer 142

Raynaud's disease of the nipple, or prolactin deficiency causing a low milk supply, is suspected, and other measures have not worked.

Answer 143

common cause of breast pain in younger females

Answer 144

breast pain that varies in intensity according to phase of menstrual cycle

Answer 145

point tenderness of the chest wall (more likely to be Tietze's syndrome)

Answer 146

difficult to pinpoint, examination should focus on identifying focal lesions (such as cysts) that may be treated to provide symptomatic benefit.

Answer 147

Women should be advised to wear a supportive bra Conservative treatments include standard oral and topical analgesia flaxseed oil and evening primrose oil are sometimes used but neither are recommended

Answer 148

consider referral Hormonal agents such as bromocriptine and danazol may be more effective. However, many women discontinue these therapies due to adverse effects.

Answer 149

Usually starts during the luteal phase of the cycle (within 2 weeks before menses), increases until menstruation begins, and improves after menses. Is dull, heavy, or aching in nature. Is usually bilateral. May be poorly localized and extend to the axilla.

Answer 150

not fully understood — it is thought that hormonal changes affecting the breast tissue are involved. It affects up to two-thirds of women, with one in ten women having moderate-to-severe pain.

Answer 151

inflammation of the breast tissue and is typically associated with breastfeeding, where it develops in around 1 in 10 women.

Answer 152

painful, tender, red hot breast fever, and general malaise may be present

Answer 153

continue breastfeeding; analgesia and warm compressess

Answer 154

if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection

Answer 155

oral flucloxacillin for 10-14 day

Answer 156

staph aureus

Answer 157

painful inflammatory condition of the breast which may or may not be accompanied by infection. It is usually associated with lactation ('lactational' or 'puerperal mastitis'), but it can also occur in non-lactating women ('non-lactational mastitis').

Answer 158

localized collection of pus within the breast. It is a severe complication of mastitis, although it may occur without apparent preceding mastitis.

Answer 159

breast abscess; sepsis; scarring; recurrent mastitis

Answer 160

In lactating women, milk stasis is usually the primary cause of mastitis. The accumulated milk causes an inflammatory response which may or may not progress to infection.

Answer 161

usually accompanied by infection, which can be categorized as either central/subareolar or peripheral. 1) Central/subareolar infection is usually secondary to periductal mastitis (a condition where the subareolar ducts are damaged and become infected). 2) Peripheral infection (less common) is associated with diabetes mellitus, rheumatoid arthritis, trauma, corticosteroid treatment, and granulomatous mastitis (a rare inflammatory disease of the breast), but often there is no obvious underlying cause.

Answer 162

S. aureus, enterococci, and anaerobic bacteria (such as Bacteroides and anaerobic streptococci).

Answer 163

A painful breast. Fever and/or general malaise. A tender, red, swollen, and hard area of the breast, often in a wedge-shaped distribution.

Answer 164

lactating= most common cause is milk stasis non-lactating= more commonly accompanied by infection

Answer 165

nipple fissure that is infected, or if in a lactating woman: - Symptoms do not improve, or are worsening, after 12–24 hours despite effective milk removal. - Bacterial culture in breast milk is positive.

Answer 166

- A history of recent mastitis. - A painful, swollen lump in the breast, with redness, heat, and swelling of the overlying skin. - Fever and/or general malaise.

Answer 167

woman should be referred urgently to a general surgeon for confirmation of the diagnosis and management.

Answer 168

when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in signs and symptoms.

Answer 169

Rare complication of pregnancy associated with a high mortality rate.Incidence 2/ 100,000 in the U.K .

Answer 170

cause not really known, may be immune mediated - link between maternal age and induction of labour

Answer 171

maternal circulation must be exposed to fetal cells/amniotic fluid

Answer 172

Symptoms= chills, shivering, sweating, anxiety, coughing Signs= cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia and MI

Answer 173

most in labour, can also happen during c-section and after delivery in the immediate postpartum

Answer 174

?amniotic fluid embolism

Answer 175

clinical diagnosis of exclusion

Answer 176

critical care unit by MDT, Mx is mostly supportive

Answer 177

the caudal end of the fetus occupies the lower segment

Answer 178

around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term

Answer 179

most common presentation with the hips flexed and knees fully extended

Answer 180

where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity

Answer 181

- frank breech (most common) - footling breech (rare but more serious)

Answer 182

uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation)

Answer 183

cord prolapse

Answer 184

many fetuses will turn spontaneously

Answer 185

external cephalic version (ECV)- this has a success rate of around 60%. ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women

Answer 186

36 weeks in nulliparous women and from 37 weeks in multiparous women

Answer 187

planned caesarean section or vaginal delivery 'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.' 'Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.'

Answer 188

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

Answer 189

external cephalic version

Answer 190

lower segment caesarean section: now comprises 99% of cases classic caesarean section: longitudinal incision in the upper segment of the uterus

Answer 191

absolute cephalopelvic disproportion placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)

Answer 192

delivery of the baby should occur within 30 minutes of making the decision an immediate threat to the life of the mother or baby

Answer 193

suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia (immediate threat to life of baby or mother)

Answer 194

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

Answer 195

delivery is required, but mother and baby are stable

Answer 196

elective caesarean

Answer 197

emergency hysterectomy need for further surgery at a later date, including curettage (retained placental tissue) admission to intensive care unit thromboembolic disease bladder injury ureteric injury death (1 in 12,000)

Answer 198

increased risk of uterine rupture during subsequent pregnancies/deliveries increased risk of antepartum stillbirth increased risk in subsequent pregnancies of placenta praevia and placenta accreta)

Answer 199

persistent wound and abdominal discomfort in the first few months after surgery increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies readmission to hospital haemorrhage infection (wound, endometritis, UTI)

Answer 200

lacerations, one to two babies in every 100

Answer 201

prolonged ileus subfertility: due to postoperative adhesions

Answer 202

planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery around 70-75% of women in this situation have a successful vaginal delivery

Answer 203

previous uterine rupture or classical caesarean scar

Answer 204

up to 5% of pregnancies

Answer 205

infection of the placenta and the amniotic fluid potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency.

Answer 206

an ascending bacterial infection of the amniotic fluid / membranes / placenta

Answer 207

preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens

Answer 208

Prompt delivery of the foetus (via cesarean section if necessary) and administration of IV Abx

Answer 209

incision in the posterior wall of the vagina and perineum that is performed in the second stage of labour to facilitate the passage of the fetus.

Answer 210

fetal distress in the second stage of labour maternal distress in the second stage of labour failure to progress in the second stage of labour control of head in breech deliver

Answer 211

superficial damage with no muscle involvement

Answer 212

do not require any repair

Answer 213

injury to the perineal muscle, but not involving the anal sphincter

Answer 214

suturing on the ward by a suitably experienced midwife or clinician

Answer 215

injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS) 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn

Answer 216

require repair in theatre by a suitably trained clinician

Answer 217

injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Answer 218

require repair in theatre by a suitably trained clinician

Answer 219

primigravida large babies precipitant labour shoulder dystocia forceps delivery

Answer 220

temperature of > 38ºC in the first 14 days following delivery

Answer 221

endometritis: most common cause UTI wound infections (perineal tears + caesarean section) mastitis VTE

Answer 222

if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 223

refer to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 224

clindamycin and gentamicin until afebrile for greater than 24 hours

Answer 225

complication of vaginal cephalic delivery. It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered cause of both maternal and fetal morbidity

Answer 226

due to impaction of the anterior fetal shoulder on the maternal pubic symphysis

Answer 227

fetal macrosomia (hence association with maternal diabetes mellitus) high maternal body mass index diabetes mellitus prolonged labour

Answer 228

1) senior help as soon as identified 2) McRobert's manoeuvre 3) episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.

Answer 229

flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.

Answer 230

maternal: - postpartum haemorrhage - perineal tears fetal: - brachial plexus injury - neonatal death

Answer 231

refers to the long axis of the foetus relative to the longitudinal axis of the uterus.

Answer 232

longitudinal lie (99.7% of foetuses at term) transverse lie (<0.3% of foetuses at term) oblique (<0.1% of foetuses at term)

Answer 233

same oblique is easier to correct as foetus is closer to longitudinal lie

Answer 234

longitudinal

Answer 235

abnormal foetal presentation whereby the foetal longitudinal axis lies perpendicular to the long axis of the uterus this means the foetal head is on the lateral side of the pelvis and the buttocks are opposite

Answer 236

'scapulo-anterior' (most common) where the foetus faces towards the mother's back or 'scapulo-posterior' where the foetus faces towards the mothers front.

Answer 237

Early in gestation, transverse lie is very common. Most have moved to longitudinal lie by 32 weeks. At term, one in 300 foetuses are in transverse lie.

Answer 238

Most commonly occurs in women who have had previous pregnancies Fibroids and other pelvic tumours Pregnant with twins or triplets Prematurity Polyhydramnios Foetal abnormalities

Answer 239

Abnormal foetal lie will be detected during routine antenatal appointments with a midwife during abdominal examination. Abdominal examination: the head and buttocks are not palpable at each end of the uterus. The foetus can be felt to be lying directly across the uterus. Ultrasound scan: allows direct visualisation of the foetal lie. Foetal heart rate is also auscultated to assess for distress.

Answer 240

Pre-term rupture membranes (PROM) Cord-prolapse (20%) If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK.

Answer 241

no management required. The patient should be informed that most foetuses will spontaneously move into longitudinal lie during pregnancy.

Answer 242

patient must have an appointment with the obstetric medical antenatal team to discuss management options: - active Mx (ECV) - elective c-section

Answer 243

perform external cephalic version (ECV) of the foetus. This can be performed late in pregnancy and even early labour if the membranes have not yet ruptured. ECV should be offered to all women who would like a vaginal delivery. Success rate is around 50%

Answer 244

maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality.

Answer 245

management for women where the patient opts for caesarian section or ECV has been unsuccessful or is contraindicated.

Answer 246

perceived risks to the mother and foetus, the preference of the patient, the patient's previous pregnancies and co-morbidities and the patient's ability to access obstetric care rapidly.

Answer 247

using a small cup connected to a suction device that is attached to the babies head. By applying careful traction to the cup it can help 'pull' the baby out.

Answer 248

The fetal head should be one-fifth or less palpable abdominally and the cervix fully dilated.

Answer 249

< 34 weeks gestation cephalopelvic disproportion breech, face or brow presentation

Answer 250

cephalhaematoma retinal haemorrhages maternal infection

Answer 251

single dose IV co-amoxiclav

Answer 252

episiotomy

Answer 253

childbirth complication when baby can't pass through the opening in pelvis. There are many reasons it can occur, including a large baby or pelvic irregularities.

Answer 254

HG is the extreme form

Answer 255

raised beta hCG levels

Answer 256

between 8-12w but may persist up to 20w

Answer 257

- increased beta hCG= multiple pregnancy, trohoblastic disease - nulliparity - obesity - family or personal history of NVP

Answer 258

Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

Answer 259

if women has co-existing condition eg. DM that may be adversely affected by N&V

Answer 260

1) 5% pre-pregnancy weight loss 2) dehydration 3) electrolyte imbalance

Answer 261

Pregnancy-Unique Quantification of Emesis (PUQE) score

Answer 262

- rest, avoid triggers eg. odours; plain food esp in morning; ginger; P6(wrist) acupressure - 1st line meds and reassess after 24-73hrs - 2nd line meds and reassess after 24hrs - 3rd line meds= 40-50mg pred daily - admission may be needed for IV hydration

Answer 263

saline with potassium

Answer 264

antihistamines= oral cyclizine or premethazine phenothiazines: oral prochlorperazine or chlorpromazine

Answer 265

oral ondansetron= increased risk of cleft lip/palate in 1st trimester so discuss risks with women oral metoclopramide (no more than 5d) or domperidone (no more than 7d due to risk of cardiac adverse effects)

Answer 266

5 days as can cause extrapyramidal side effects

Answer 267

cleft lip/palate

Answer 268

- dehydration, weight loss, electrolyte imbalances - AKI - Wernicke's E - oesophagitis, Mallory-Weiss tear - VTE - Fetal outcome= severe resulting in multiple admissions may be linked to small increase in preterm birth and low birth weight

Answer 269

between 4–7th weeks, peaks between 9–16th weeks, and resolves by 16–20 weeks of pregnancy. Onset of symptoms after 11 weeks of gestation usually suggests an alternative cause of symptoms unrelated to pregnancy.

Answer 270

most severe spectrum of symptoms — nausea and/or vomiting which is severe enough to cause an inability to eat and drink normally, and strongly limits daily activities of living. Signs of dehydration contribute to the diagnosis.

Answer 271

weight loss, electrolyte imbalance, acute kidney injury, nutritional and vitamin deficiencies, gastro-oesophageal reflux disease, venous thromboembolism, and impact on psychosocial functioning.

Answer 272

obstetric cholestasis

Answer 273

1% of pregnancies

Answer 274

increased risk of premature birth

Answer 275

- pruritus= may be intense, worse palms, soles and abdo - clinically detectable jaundice occurs in 20% - raised bilirubin in >90%

Answer 276

- induction of labor at 37-38w - ursodeoxycholic acid - vit K supplementation

Answer 277

45-90% recurrence in subsequent pregnancies

Answer 278

Arrange same-day referral to a local maternity unit so that maternal serum bile acid concentrations and liver function, as well as fetal wellbeing can be assessed, and other causes of hepatic impairment can be ruled out.

Answer 279

confirmed obstetric cholestasis will be offered ongoing monitoring of serum bile acid levels/liver function tests (LFTs) and fetal wellbeing, usually via the maternity unit, until delivery. If a woman has unexplained itch but bile acids and/or LFTs are normal, levels should be monitored weekly (usually by the obstetrics team) until the itch resolves. Seek specialist advice if the itch significantly worsens.

Answer 280

emollient to be used liberally and regularly. Menthol 0.5% or 1% in aqueous cream may also be helpful if an inert emollient does not improve itch Consider offering a sedating antihistamine such as chlorphenamine or promethazine at night (off-label indication). Sitting directly in front of a fan, soaking in a cool bath, and applying ice packs for short periods to affected areas. Applying naturally cooling substances, such as aloe to affected areas before rinsing off in a shower.

Answer 281

ensure that LFTs are carried out from 2 weeks postnatally (usually by the obstetrics team). If liver function: - Has returned to normal, obstetric cholestasis can be confirmed as having resolved. Advise the woman that the condition has a 45–90% recurrence rate in future pregnancies. - Is still abnormal, repeat the tests. If, after 8 weeks, the results are still abnormal, seek specialist advice from the obstetric team.

Answer 282

Serum bile acids and liver function tests (LFTs). Viral screening, for hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus. Liver autoimmune screening for chronic active hepatitis and primary biliary cirrhosis (for example anti-smooth muscle and anti-mitochondrial antibodies). Urine dipstick for proteinuria. Blood pressure measurement. Liver ultrasound. Cardiotocography to assess fetal wellbeing.

Answer 283

Ursodeoxycholic acid (sometimes with rifampicin as adjunct therapy). Sedating antihistamines such as chlorphenamine or promethazine. Vitamin K supplements.

Answer 284

third trimester

Answer 285

intrahepatic cholestasis of pregnancy

Answer 286

ursodeoxycholic acid is used for symptomatic relief weekly liver function tests women are typically induced at 37 weeks

Answer 287

stillbirth

Answer 288

rare complication which may occur in the third trimester or the period immediately following delivery

Answer 289

abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia

Answer 290

ALT is typically elevated e.g. 500 u/l

Answer 291

support care once stabilised delivery is the definitive management

Answer 292

Gilbert's and Dubin-Johnson syndrome

Answer 293

Haemolysis, Elevated Liver enzymes, Low Platelets

Answer 294

- intrahepatic cholestasis of pregnancy - acute fatty liver of pregnancy (rare) - HELLP - Gilbert's, Dubin-Johnson syndrome, may be exacerbated during pregnancy

Answer 295

records pressure changes in the uterus using internal or external pressure transducers

Answer 296

cardiotocography

Answer 297

varies between 100-160 /min

Answer 298

HR <100/min

Answer 299

Increased fetal vagal tone, maternal beta-blocker use

Answer 300

HR >160/min

Answer 301

Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

Answer 302

< 5 beats / min

Answer 303

prematurity, hypoxia

Answer 304

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction

Answer 305

Usually an innocuous feature and indicates head compression

Answer 306

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction

Answer 307

Indicates fetal distress e.g. asphyxia or placental insufficiency

Answer 308

HR independent of contractions

Answer 309

may indicate cord compression

Answer 310

group B strep

Answer 311

group B strep

Answer 312

Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.

Answer 313

prematurity prolonged rupture of the membranes previous sibling GBS infection maternal pyrexia e.g. secondary to chorioamnionitis

Answer 314

no not routinely; maternal request is not an indication

Answer 315

should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive

Answer 316

at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date

Answer 317

- GBS detected in previous pregnancy - previous baby with early or late onset GBS disease - all women in preterm labour regardless of GBS status - women with a pyrexia during labour (>38ºC)

Answer 318

benzylpenicillin

Answer 319

benzylpenicillin

Answer 320

where labour is started artificially around 20% pregnancies

Answer 321

prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes, where labour does not start maternal medical problems: - diabetic mother > 38 weeks - pre-eclampsia - obstetric cholestasis intrauterine fetal death

Answer 322

used to help assess whether indication of labour will be required

Answer 323

1) cervical position= posterior (0), intermediate (1), anterior (2) 2) cervical consistency= firm (0), intermediate (1), soft (2) 3) cervical effacement= 0-30% (0), 40-50% (1), 60-70% (2), 80% (3) 4) cervical dilation= <1cm (0), 1-2cm (1), 3-4cm (2), >5cm (3) 5) fetal station= -3 (0), -2 (1), -1 or 0 (2), +1 or +2 (3) numbers in brackets is the points

Answer 324

labour unlikely to start without induction

Answer 325

cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour

Answer 326

vaginal prostaglandins or oral misoprostol mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean

Answer 327

amniotomy and an intravenous oxytocin infusion

Answer 328

- membrane sweep - vaginal prostaglandin E2 (PGE2) aka dinoprostone - oral prostaglandin E1 aka misoprostol - maternal oxytocin infusion - amniotomy (breaking of waters) - cervical ripening balloon

Answer 329

involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping

Answer 330

vaginal exam for membrane sweeping regarded as an adjunct rather than an actual method of induction

Answer 331

dinoprostone

Answer 332

misoprostol

Answer 333

passed through the endocervical canal and gently inflated to dilate the cervix

Answer 334

uterine hyperstimulation

Answer 335

prolonged and frequent uterine contractions - sometimes called tachysystole

Answer 336

intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia uterine rupture (rare)

Answer 337

removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started consider tocolysis

Answer 338

stage 1 stage 2 stage 3

Answer 339

from the onset of true labour to when the cervix is fully dilated

Answer 340

from full dilation to delivery of the fetus

Answer 341

from delivery of fetus to when the placenta and membranes have been completely delivered

Answer 342

2 latent phase and active phase

Answer 343

0-3cm dilation, normally takes 6hrs

Answer 344

3-10cm dilation, normally 1cm/hr

Answer 345

occipito-lateral position

Answer 346

occipito-anterior

Answer 347

Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.

Answer 348

refers to the 2nd stage but in the absence of pushing (normal)

Answer 349

refers to the active process of maternal pushing

Answer 350

less painful than the 1st (pushing masks pain)

Answer 351

consider Ventouse extraction, forceps delivery or c-section

Answer 352

episiotomy

Answer 353

when baby's head is visible in vaginal opening

Answer 354

transient fetal bradycardia

Answer 355

active management begins with delivery of anterior shoulder (i.e. 2nd stage, crowning in multip) with injection of syntocinon Brandt-Andrews method: elevate uterus to separate placenta examine placenta, membrane, cord (normal = 1 vein, 2 arteries) examine perineum mean blood loss < 200ml

Answer 356

1 vein, 2 arteries

Answer 357

use of uterotonics clamping and cutting of the cord controlled cord traction

Answer 358

injection of syntocinon

Answer 359

elevate uterus to separate placenta

Answer 360

whether a woman is a primip or not: primip: 1 cm per 2 hours multip: 1 cm per hour

Answer 361

started at 3cm dilation

Answer 362

fetal heart auscultation (every 15 mins) maternal observations: - heart rate (every hour) - BP and temperature (every 4 hours) contractions (every 30 mins: frequency, strength, regularity) PV exam (every 4 hours) - cervical dilation - presenting part - descent of the fetal head relative to the ischial spines

Answer 363

On the partogram there is an 'alert' and 'action' line. Failure of the cervix to progressively dilate with time leads to the readings crossing to the right of the alert and action lines.

Answer 364

then usually an amniotomy (artificial rupture of the membranes) is performed with a repeat examination in 2 hours.

Answer 365

usually results in the care being escalated to obstetric-led care if the woman is currently under midwife-led care.

Answer 366

artificial rupture of the membranes oxytocin infusion= stimulates uterine contractions

Answer 367

stimulates uterine contractions CTG should be monitored to ensure fetal wellbeing an epidural is also sometimes offered at this point started at a low rate and titrated up at intervals of around 30 minutes the aim is for 'adequate contractions': at least 3-5 contractions per 10 minutes, each contraction lasts 40-60 seconds and the contractions feel strong

Answer 368

at least 3-5 contractions per 10 minutes, each contraction lasts 40-60 seconds and the contractions feel strong

Answer 369

extended to or beyond 42w

Answer 370

Reduced placental perfusion Oligohydramnios

Answer 371

Increased rates of intervention including forceps and caesarean section Increased rates of labour induction

Answer 372

Edinburgh Postnatal Depression Scale

Answer 373

- 10-item questionnaire, with a maximum score of 30 - indicates how the mother has felt over the previous week - score > 13 indicates a 'depressive illness of varying severity' - sensitivity and specificity > 90% - includes a question about self-harm

Answer 374

baby blues postnatal depression puerperal psychosis

Answer 375

3-7d following birth and is mroe common in primips

Answer 376

anxious, tearful and irritable

Answer 377

reassurance and support, the health visitor has a key role

Answer 378

within a month and typically peak at 3m

Answer 379

similar to depression seen in other circumstances

Answer 380

reassurance and support are important CBT may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant

Answer 381

fluoxetine

Answer 382

onset usually within 2-3 weeks following birth

Answer 383

severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Answer 384

Admission to hospital is usually required, ideally in a Mother & Baby Unit There is around a 25-50% risk of recurrence following future pregnancies

Answer 385

- physiological - galactorrhoea - hyperprolactinaemia - mammary duct ectasia - carcinoma - intraductal papilloma

Answer 386

during breast feeding

Answer 387

Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated

Answer 388

Commonest type of pituitary tumour Microadenomas <1cm in diameter Macroadenomas >1cm in diameter Pressure on optic chiasm may cause bitemporal hemianopia

Answer 389

Dilatation breast ducts. Most common in menopausal women Discharge typically thick and green in colour Most common in smokers

Answer 390

Often blood stained May be underlying mass or axillary lymphadenopathy

Answer 391

Commoner in younger patients May cause blood stained discharge There is usually no palpable lump

Answer 392

- examine breast & determine whether there is a mass lesion present - all mass lesions should undergo Triple assessment

Answer 393

1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant

Answer 394

Exclude endocrine disease Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

Answer 395

developing fetus

Answer 396

Neural tube defects (meningocele, myelomeningocele and anencephaly) Abdominal wall defects (omphalocele and gastroschisis) Multiple pregnancy

Answer 397

Down's syndrome Trisomy 18 Maternal diabetes mellitus

Answer 398

prenatal diagnosis

Answer 399

after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk, for example if > 35 years old.

Answer 400

Around 20 ml of fluid is removed by transabdominal needle under ultrasound guidance. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions.

Answer 401

between 15-20 weeks (typically 16 weeks)

Answer 402

the karyotype may be wrong in 1/1000 cases due to maternal cells being present

Answer 403

neural tube defects (raised AFP levels in the amniotic fluid) chromosomal disorders inborn errors of metabolism

Answer 404

developing up to one year after birth.

Answer 405

stopping or switching antidepressant treatment

Answer 406

pregnancy/planning a pregnancy

Answer 407

folic acid 400mcg before conception until 12 weeks Certain women may require higher doses (women who take antiepileptics)

Answer 408

reduce the risk of neural tube defects

Answer 409

not offered routinely

Answer 410

NO (intake above 700 micrograms) might be teratogenic. Liver is high in vitamin A so consumption should be avoided

Answer 411

yes 'women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement'. Particular care should be taken with higher risk women (i.e. those with darker skin or who cover their skin for cultural reasons)

Answer 412

no alcohol at all 'If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.'

Answer 413

risks of smoking including low birthweight and preterm birth should be discussed NRT may be used but women must have stopped smoking and risks/benefits need to be discussed neither varenicline nor bupropion should be offered to pregnant or breastfeeding women

Answer 414

NRT but risks and benefits need discussed varenicline and bupropion should be offered to pregnant or breastfeeding women

Answer 415

listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat salmonella: avoid raw or partially cooked eggs and meat, especially poultry

Answer 416

inform women of their maternity rights and benefits for the majority of women it is safe to continue working. Women should be asked whether they work. The Health and Safety Executive should be consulted if there are any concerns about possible occupational hazards during pregnancy

Answer 417

women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks associated with increased risk of venous thromboembolism wearing correctly fitted compression stockings is effective at reducing the risk

Answer 418

women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks

Answer 419

avoid unless the benefits outweigh the risks

Answer 420

should be used as little as possible during pregnancy

Answer 421

'Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy'

Answer 422

women should be informed that beginning or continuing moderate exercise is not associated with adverse outcomes certain activities should be avoided e,g, high-impact sports where there is a risk of abdominal trauma and scuba diving

Answer 423

not known to be associated with any adverse outcomes

Answer 424

natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE antihistamines should be used first-line= promethazine

Answer 425

D stores during pregnancy and whilst breastfeeding'

Answer 426

'All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy'

Answer 427

women at risk (e.g. Asian, obese, poor diet)

Answer 428

not unless it is complicated

Answer 429

Booking visit: - general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes - BP, urine dipstick, check BMI Booking bloods/urine: - FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies - hepatitis B, syphilis - HIV test is offered to all women - urine culture to detect asymptomatic bacteriuria

Answer 430

Early scan to confirm dates, exclude multiple pregnancy

Answer 431

Down's syndrome screening including nuchal scan

Answer 432

Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick

Answer 433

Anomaly scan

Answer 434

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

Answer 435

Routine care: BP, urine dipstick, SFH Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women

Answer 436

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

Answer 437

Routine care: BP, urine dipstick, symphysis-fundal height (SFH) Second dose of anti-D prophylaxis to rhesus negative women Information on labour and birth plan

Answer 438

Routine care: BP, urine dipstick, symphysis-fundal height (SFH) Check presentation - offer external cephalic version if indicated Information on breast feeding, vitamin K, 'baby-blues'

Answer 439

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

Answer 440

Routine care: BP, urine dipstick, symphysis-fundal height (SFH) Discussion about options for prolonged pregnancy

Answer 441

Routine care: BP, urine dipstick, symphysis-fundal height (SFH) Discuss labour plans and possibility of induction

Answer 442

BP, urine dipstick, symphysis-fundal height (SFH)

Answer 443

general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes BP, urine dipstick, check BMI

Answer 444

FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies hepatitis B, syphilis HIV test is offered to all women urine culture to detect asymptomatic bacteriuria

Answer 445

8-12w (ideally <10w)

Answer 446

10-13+6 weeks

Answer 447

16w (NO SFH) 25w (only if primip) 28w 31w (only if primip) 34w 36w 38w 40w 41w

Answer 448

40w (only if primip)

Answer 449

28 & 34w evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors'

Answer 450

Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Syphilis

Answer 451

Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia

Answer 452

Bacterial vaginosis Chlamydia Cytomegalovirus Fragile X Hepatitis C Group B Streptococcus Toxoplasmosis

Answer 453

antenatal ultrasound test which assesses: - amniotic fluid volume - fetal tone - fetal activity - fetal breathing movements - reactivity of the heart

Answer 454

Combined test

Answer 455

nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)

Answer 456

↑ HCG, ↓ PAPP-A, thickened nuchal translucency

Answer 457

HCG lower than in downs, ↓ PAPP-A, thickened nuchal translucency

Answer 458

between 15 - 20 weeks (so if book later in pregnancy)

Answer 459

- combined test if between 11-13+6w (standard) - quadruple if 15-20w (if book in late)

Answer 460

alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A

Answer 461

AFP= ↓ Unconjugated oestriol= ↓ HCG= ↑ Inhibin A= ↑

Answer 462

AFP= ↓ Unconjugated oestriol= ↓ HCG= ↓ Inhibin A= ↔

Answer 463

AFP= ↑ Unconjugated oestriol= ↔ HCG= ↔ Inhibin A= ↔

Answer 464

?neural tube defects

Answer 465

? Edwards syndrome

Answer 466

? downs syndrome

Answer 467

?Edwards or patau

Answer 468

either a 'lower chance' or 'higher chance' result 'lower chance': 1 in 150 chance or more e.g. 1 in 300 'higher chance': 1 in 150 chance or less e.g. 1 in 100

Answer 469

offered second screening test (NIPT) or diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)

Answer 470

NIPT Given the non-invasive nature of and extremely high sensitivity and specificity

Answer 471

analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA) cffDNA derives from placental cells and is usually identical to fetal DNA analysis of cffDNA allows for the early detection of certain chromosomal abnormalities sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation

Answer 472

tetrahydrofolate (THF)

Answer 473

green leafy vegetables

Answer 474

THF (what folic acid is converted to) plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Answer 475

phenytoin methotrexate pregnancy alcohol excess

Answer 476

macrocytic, megaloblastic anaemia neural tube defects

Answer 477

all women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

Answer 478

5mg (normal recommended is 400mcg)

Answer 479

either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 480

number of pregnancies

Answer 481

number of deliveries that have progressed to a viable gestational age (24w) regardless of the number of offspring per pregnancy

Answer 482

Gravida (G) refers to the number of times a woman has been pregnant, regardless of the outcome. Para (P) refers to the number of pregnancies that have resulted in the birth of potentially viable offspring, where viability is defined by the local standards, typically around 24 weeks of gestation.

Answer 483

The pregnancy is counted as one gestational event, and the number of viable offspring (in this case, two from a single pregnancy) does not affect the Para count. Para is incremented by one for each pregnancy that results in a birth (or births), rather than by the number of babies born. Thus, a woman who gives birth to twins in her first pregnancy would be G1P1, not G1P2.

Answer 484

This notation indicates that a woman has been pregnant three times, and two of these pregnancies have resulted in the birth of viable offspring. The implication is that there was one pregnancy that did not result in a viable birth, which could be due to a miscarriage.

Answer 485

This denotes that a woman has been pregnant twice. Out of these, one pregnancy led to the birth of one or more viable offspring, while the other might have ended in a miscarriage or was a pregnancy not yet carried to term (if she's currently pregnant).

Answer 486

This means the woman has been pregnant five times and has had three pregnancies that resulted in the birth of viable offspring. The remaining two pregnancies might have ended in miscarriages or were ectopic pregnancies, for example.

Answer 487

the booking visit (often done at 8-10 weeks), and at 28 weeks

Answer 488

First trimester= < 110 g/L Second/third trimester= < 105 g/L Postpartum= < 100 g/L

Answer 489

conception to 12w

Answer 490

oral ferrous sulfate or ferrous fumarate treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

Answer 491

3m allow iron stores to be replenished

Answer 492

Progesterone, a potent muscle relaxant, is released from both the corpus luteum (first 8 weeks) and placenta (after 8 weeks). This has profound effects on the cardiovascular and gastrointestinal systems. Pregnancy is a hypercoagulable state and also causes a physiological anaemia. These physiological changes underly many of the presenting symptoms of pregnancy.

Answer 493

Amenorrhoea Nausea Vomiting Breast enlargement and tenderness, veins may engorge and become prominent Fatigue Increased skin pigmentation (face, linea alba, areola)

Answer 494

Palpitations and syncope Increased sweating Urinary frequency (caused by the foetal head pressing on the bladder) Back pain (commoner in the third trimester) Breathlessness Constipation and gastro-oesophageal reflux disease (caused by general stasis of the gastrointestinal tract) Varicose veins and haemorrhoids (caused by increased venous distensibility) Spider angiomas Palmar erythema Ankle oedema Carpal tunnel syndrome Leg cramps Itchy rashes Food cravings and aversions

Answer 495

Between 6-8 weeks the uterus is the size of a small pear Between 8-10 weeks the uterus is the size of an orange Between 10-12 weeks the uterus is the size of a grapefruit After the 12th week, the uterus should be palpable just above the pubic symphysis After the 16th week, the uterus should be palpable between the pubic symphysis and the umbilicus. Between the 20th and 24th week, the uterus should be palpable by the umbilicus. By 36 weeks the uterus should be palpable just below the ribs. After 36 weeks, this is lower as the head of the foetus descends towards the pelvis

Answer 496

The cervix softens and may look bluish on examination There may be signs pertaining to the symptoms as described above (e.g. pigmentation, peripheral oedema) that may be elicited on physical examination

Answer 497

Urine hCG (positive 9 days after fertilisation) Serum hCG Ultrasound of the foetus Identification of foetal heart rate

Answer 498

>= 30 kg/m² at the first antenatal visit.

Answer 499

miscarriage venous thromboembolism gestational diabetes pre-eclampsia dysfunctional labour, induced labour postpartum haemorrhage wound infections There is also a higher caesarean section rate.

Answer 500

congenital anomaly prematurity macrosomia stillbirth increased risk of developing obesity and metabolic disorders in childhood neonatal death

Answer 501

reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy

Answer 502

obese women should take 5mg of folic acid, rather than 400mcg all obese women (>=30 BMI) should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made

Answer 503

in the community by a midwife

Answer 504

10 antenatal appointments for nulliparous women or 7 antenatal appointments for parous women. 2 ultrasound scans — a ‘dating scan’ (between 11+2 weeks and 14+1 weeks) and a ‘fetal anomaly scan’ (between 18+0 weeks and 20+6 weeks).

Answer 505

accept or decline any part of any of these.

Answer 506

Immunization for flu, whooping cough, and other infections such as COVID-19. Infections that can impact on the baby in pregnancy or during birth (such as group B streptococcus). Reducing the risk of infections. Safe use of medicines and health supplements. Mental health. Lifestyle including nutrition and diet, physical activity, smoking, alcohol consumption, and recreational drug use. Sleep position after 28 weeks of pregnancy. Travel including air travel. Occupation.

Answer 507

Blood pressure measurement and a urine dipstick test for proteinuria should be offered at each appointment. Advice on the symptoms of pre-eclampsia and when to seek immediate medical help should be discussed with all pregnant women.

Answer 508

The symphysis–fundal height (to identify small- or large-for-gestational-age infants) should be measured and plotted. The baby’s movements should be discussed and the woman advised to contact maternity services at any time of day or night if she has any concerns about her baby’s movements or notices reduced movements.

Answer 509

routine antenatal anti-D prophylaxis should be offered to rhesus-negative women

Answer 510

abdominal palpation should be offered to check the position of the baby – if breech presentation is suspected, an ultrasound scan should be arranged to determine position.

Answer 511

prolonged pregnancy and options on how to manage this should be discussed

Answer 512

compression stockings; these may improve the symptoms but will not prevent varicose veins from emerging.

Answer 513

Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause. If a sexually transmitted infection is suspected, offer the woman access to testing, treatment, and support. This service may be provided by general practice (where appropriate training and facilities exist), community sexual and reproductive health services, or a genito-urinary medicine (GUM) clinic.

Answer 514

consider referral to physiotherapy services for exercise advice and/or a non-rigid lumbopelvic belt.

Answer 515

Offer the woman advice to minimize constipation and straining= increasing daily fibre and fluid intake and taking regular exercise can help relieve constipation Advise the woman about perianal hygiene No topical haemorrhoidal preparations are licensed for use during pregnancy and women wishing to use these products should be made aware of the lack of data regarding pregnancy outcomes.

Answer 516

ABO system Rhesus system= D antigen

Answer 517

if a Rh -ve mother delivers a Rh +ve child, a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross the placenta and cause haemolysis in fetus this can also occur in the 1st pregnancy due to leaks

Answer 518

test for D antibodies in all Rh -ve mothers at booking give anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks) anti-D is prophylaxis - once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present

Answer 519

give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present

Answer 520

determines proportion of fetal RBCs present and so how much anti-D to give

Answer 521

delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required) external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling abdominal trauma

Answer 522

mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant

Answer 523

oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy

Answer 524

top of the pubic bone to the top of the uterus in centimetres

Answer 525

the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Answer 526

twins: 1/105 triplets: 1/10,000

Answer 527

dizygotic or monozygotic 80% are dizygotic

Answer 528

non-identical, develop from two separate ova that were fertilized at the same time

Answer 529

identical, develop from a single ovum which has divided to form two embryos

Answer 530

increased spontaneous miscarriage, perinatal mortality rate increased malformations, IUGR, prematurity twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)

Answer 531

recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)

Answer 532

previous twins family history increasing maternal age multigravida induced ovulation and in-vitro fertilisation race e.g. Afro-Caribbean

Answer 533

polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage

Answer 534

perinatal mortality (twins * 5, triplets * 10) prematurity (mean twins = 37 weeks, triplets = 33) light-for date babies malformation (*3, especially monozygotic)

Answer 535

PPH increased malpresentation cord prolapse, entanglement

Answer 536

rest ultrasound for diagnosis + monthly checks additional iron + folate more antenatal care (e.g. weekly > 30 weeks) precautions at labour (e.g. 2 obstetricians present) 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks

Answer 537

Down's syndrome congenital heart defects abdominal wall defects

Answer 538

cystic fibrosis Down's syndrome cytomegalovirus infection

Answer 539

family history: mutations of the BRCA1 or the BRCA2 gene many ovulations: early menarche, late menopause, nulliparity

Answer 540

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Answer 541

1/200 pregnancies

Answer 542

not known but associated factors: proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age

Answer 543

shock out of keeping with visible blood loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria

Answer 544

placental abruption (blood may be concealed if cervical os closed)

Answer 545

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gestation; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 546

presence of excessive amniotic fluid

Answer 547

when a uterus is large for dates or it is difficult to feel the fetal parts on palpation

Answer 548

multiple pregnancy poorly controlled maternal diabetes mellitus tracheo-oesophageal fistula duodenal atresia, oesophageal atresia anencephaly (due to impaired swallowing reflex) chorioangioma of the placenta rhesus haemolytic disease

Answer 549

umbilical cord prolapse= polyhydramnios may stop the fetus engaging with the pelvis leaving room for the umbilical cord to prolapse out of the uterus before the presenting part placental abruption prematurity maternal Cx

Answer 550

increased dyspnoea due to pressure on the diaphragm increased risk of urinary tract infections

Answer 551

fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero.

Answer 552

still birth fetal growth restriction placental insufficiency

Answer 553

quickening

Answer 554

18-20w gestation and increase until 32w then the frequency of movement plateaus

Answer 555

sooner, 16-18w

Answer 556

RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment. but mothers will recognise a pattern to the movements and nature which is very variable so they will know

Answer 557

24w if no movement after 24w worrying

Answer 558

- posture - distraction - placental position - medication - fetal position - body habitus - amniotic fluid volume - fetal size

Answer 559

positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing

Answer 560

Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent

Answer 561

Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements

Answer 562

Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements

Answer 563

Anterior fetal position means movements are less noticeable

Answer 564

Obese patients are less likely to feel prominent fetal movements

Answer 565

Both oligohydramnios and polyhydramnios can cause reduction in fetal movements

Answer 566

Up to 29% of women presenting with RFM have a SGA fetus

Answer 567

Initially, handheld Doppler should be used to confirm fetal heartbeat. If no fetal heartbeat detectable, immediate ultrasound should be offered. If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement

Answer 568

handheld Doppler should be used to confirm presence of fetal heartbeat

Answer 569

handheld Doppler

Answer 570

structural or genetic fetal abnormalities

Answer 571

Concern regarding absent or reduced fetal movements stems for the potential for this presentation to represent fetal distress or impending demise. Between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. However, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication.

Answer 572

development of seizures in association pre-eclampsia

Answer 573

magnesium sulphate

Answer 574

Magnesium sulphate should be given once a decision to deliver has been made in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

Answer 575

IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 576

treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 577

urine output, reflexes, respiratory rate and oxygen saturations as respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

Answer 578

calcium gluconate

Answer 579

fluid restriction to avoid the potentially serious consequences of fluid overload

Answer 580

statistical definition; no universally agreed percentile, although 10th percentile often used; i.e. 10% of normal babies will be below tenth percentile; can be applied antenatally or postnatally.

Answer 581

clinical diagnosis indicating that a fetus is not achieving its growth potential due to pathological reasons

Answer 582

SGA= statistical definition IUGR= clinical diagnosis IUGR is a subset of SGA, meaning all IUGR babies are SGA, but not all SGA babies have IUGR

Answer 583

incorrect dating, constitutionally small (normal) or an abnormal fetus can by symmetrical or asymmetrical

Answer 584

fetal head circumference & abdominal circumference are equally small

Answer 585

abdominal circumference slows relative to increase in head circumference

Answer 586

Idiopathic race (white > black > Asian) sex (boy > girl) Chromosomal and congenital abnormalities Toxins: alcohol (FAS), cigarettes, heroin Infection: CMV, parvovirus, rubella, syphilis, toxoplasmosis Malnutrition

Answer 587

Placental insufficiency Pre-eclampsia Toxins: smoking, heroin Chromosomal and congenital abnormalities

Answer 588

most represent lower limits of normal range (>95% idiopathic) fortnightly ultrasound growth assessment to demonstrate normal growth rate try to detect any pathological cause: check maternal blood for infections search fetus carefully with ultrasound for markers of chromosomal abnormality - if present karyotype baby by cordocentesis

Answer 589

CMV, parvovirus, rubella, syphilis, toxoplasmosis

Answer 590

fortnightly ultrasound growth assessment to demonstrate normal growth rate biophysical profile Doppler waveforms from umbilical circulation: look for absent end-diastolic flow consider daily CTGs if sub-optimal results then consider delivery

Answer 591

1 in 7 couples

Answer 592

1 yr 92% in 2yrs

Answer 593

male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15%

Answer 594

semen analysis serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.

Answer 595

serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21

Answer 596

Repeat, if consistently low refer to specialist

Answer 597

indicates ovulation

Answer 598

>30 nmol/l

Answer 599

folic acid aim for BMI 20-25 advise regular sexual intercourse every 2 to 3 days smoking/drinking advice

Answer 600

after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour

Answer 601

volume > 1.5 ml pH > 7.2 sperm concentration > 15 million / ml morphology > 4% normal forms motility > 32% progressive motility vitality > 58% live spermatozoa

Answer 602

aged under 40 years and they have regular (every 2–3 days) unprotected sexual intercourse.

Answer 603

are factors in the man causing infertility (30% of couples), ovulatory disorders (25% of couples), tubal damage (20% of couples), and uterine or peritoneal disorders (10% of couples). No identifiable cause is identified in about 25% of couples. The presence of factors in both the man and the woman has been reported in about 40% of infertile couples.

Answer 604

increasing age, smoking, obesity, occupational risks, excessive alcohol consumption, and the use of certain prescription, over-the-counter, and recreational drugs.

Answer 605

varies... For women younger than 36 years with normal history, examination, and investigations in both partners, referral should usually be considered if the couple has not conceived after 1 year. Earlier referral should be offered if the woman is 36 years or over or if there is a known clinical cause of infertility or a history of predisposing factors.

Answer 606

mid-luteal phase progesterone (in all women to confirm ovulation), serum gonadotrophins (in women with irregular menstrual cycles), thyroid function tests (in women with symptoms of thyroid disease), prolactin measurement (in women with an ovulatory disorder, galactorrhoea, or a suspected pituitary tumour), and screening for chlamydia.

Answer 607

semen analysis and screening for chlamydia.

Answer 608

Medical treatment to restore fertility, for example, the use of drugs (such as clomifene) to induce ovulation. Surgical treatment to restore fertility, for example, laparoscopy for ablation of endometriosis and surgical correction of epididymal blockage in men with obstructive azoospermia. Assisted reproduction techniques (any treatment that deals with means of conception other than vaginal intercourse), for example, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection.

Answer 609

is a potentially life-threatening complication of superovulation. Cx of assisted conception

Answer 610

Mild — abdominal bloating and mild abdominal pain. Moderate — nausea and vomiting and increased abdominal discomfort. Severe — oliguria, generalized oedema, abdominal pain and/or distension (caused by enlarged ovaries and acute ascites), and hydrothorax (occasionally). Critical — oligo/anuria, tense ascites or large hydrothorax, thromboembolism, and acute respiratory distress syndrome.

Answer 611

Consider alternative diagnoses, such as complications of an ovarian cyst (torsion, haemorrhage), pelvic infection or abscess, intra-abdominal haemorrhage, ectopic pregnancy, bowel perforation, or appendicitis. If OHSS is suspected, seek urgent advice from the specialist unit. The severity of OHSS can worsen over time, and even initially mild presentations should be kept under review.

Answer 612

Ovarian hyperstimulation syndrome (OHSS) Ectopic pregnancy Pelvic infection Multiple pregnancy

Answer 613

Clomifene (an anti-oestrogen drug) is an effective treatment for anovulation and may be used in selected women. Gonadotrophins may be offered to women with clomifene-resistant anovulatory infertility. They are also effective in improving fertility in men with hypogonadotropic hypogonadism. Pulsatile gonadotrophin-releasing hormone and dopamine agonists are other treatments that induce ovulation. Dopamine agonists can be considered for women with ovulatory disorders secondary to hyperprolactinaemia.

Answer 614

Tubal microsurgery in women with mild tubal disease — tubal catheterization or cannulation improves the chance of pregnancy in women with proximal tubal obstruction. Surgical ablation, or resection of endometriosis plus laparoscopic adhesiolysis in women with endometriosis. Surgical correction of epididymal blockage in men with obstructive azoospermia — this is likely to restore patency of the duct and improve fertility.

Answer 615

- Intrauterine insemination (IUI) - In vitro fertilisation - Intracytoplasmic sperm injection (ICSI) - Donor insemination - Oocyte donation

Answer 616

in this process, which is timed to coincide with ovulation, sperm is placed in the woman's uterus using a fine plastic tube. Low doses of ovary-stimulating hormones (oral anti-oestrogens or gonadotrophins) might be given (stimulated IUI) to maximize pregnancy rates.

Answer 617

involves retrieval of one or more ova combined with sperm and incubated for 2–3 days; the resultant embryo is then injected into the uterus via the cervix. This method is suitable for women who have blocked fallopian tubes, men with a minor degree of subfertility, and couples who have been diagnosed with unexplained infertility or have been unsuccessful with other techniques (such as ovulation induction or IUI).

Answer 618

involves injecting an individual sperm directly into the ovum to bypass natural barriers that prevent fertilization. The embryo is then transferred into the uterus. This method is suitable when the man has a very low sperm count or problems maintaining an erection and ejaculation (such as diabetes or spinal cord injury).

Answer 619

involves insemination of sperm, from a donor, into a woman via her vagina into the cervical canal or into the uterus itself (IUI). This method is considered when the man has no (or very few) sperm on testicular biopsy or surgical extraction, has had a vasectomy and reversal has failed or not been tried, or has an infectious disease (such as HIV), or where there is a high risk of transmitting a genetic disorder to the offspring. It is also considered in couples where there is no male partner.

Answer 620

involves stimulation of the donor's ovaries and collection of ova. The donated ova are then fertilized by the recipient's partner's sperm. After 2–3 days, the embryos are transferred to the uterus of the recipient via the cervix after hormonal preparation of the endometrium. This method is considered for women with ovarian failure (premature or after radiotherapy or chemotherapy); those with bilateral oophorectomy; those with gonadal dysgenesis, including Turner's syndrome; and when the risk of transmitting a genetic disorder is high. It is also used in certain cases of IVF failure. Couples who have had successful IVF or ICSI may decide to donate their spare embryos to help other infertile couples (embryo donation).

Answer 621

transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal

Answer 622

larger area of columnar epithelium being present on the ectocervix

Answer 623

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

Answer 624

vaginal discharge post-coital bleeding

Answer 625

Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Answer 626

Suboptimal infant positioning and attachment= may not remove milk efficiently so suckles a lot, stimulating the breast to produce excessive milk. Breastfeeding pattern: - Moving the infant too early to the second breast before they have finished feeding from the first breast. - Overstimulation due to excessive expression (by hand or pump) between breastfeeds. The mother may describe: - Breast fullness and possible engorgement or blocked ducts. - A painful, forceful milk let-down reflex. - Milk leakage and/or milk spraying from the opposite breast when feeding. The infant may: - Choke and splutter when let-down occurs. - Clamp down on the nipple or pull off the breast during feeds. - Have colic, or frequent explosive loose stools. - Faltering growth if unable to feed adequately.

Answer 627

True maternal low milk supply is unusual, and there may be a subjective maternal perception of insufficient milk supply, if other causes have been excluded or are unlikely. Insufficient access to the breast: - Suggested by short or infrequent feeds, and/or no night feeds. - Use of a dummy; or giving supplementary feeds other than breast milk may also contribute. - Maternal depression, stress, and/or anxiety may result in a reduced response to infant feeding cues and a reduced frequency of feeds, which leads to reduced stimulation of milk production. Suboptimal infant positioning and attachment: - Suggested by nipple pain/trauma; frequent feeding more than every 2 hours; no long intervals between feeds; feeding for less than five minutes or longer than 40 minutes duration. - The infant may be generally unsettled, have faltering growth, or show signs of dehydration. Maternal prolactin deficiency: - Causes of true low milk supply due to maternal prolactin deficiency may include drugs, thyroid disorders, retained placenta, alcohol use, and eating disorders. Maternal anatomical conditions such as hypoplastic breasts causing a lack of glandular tissue, or a history of breast surgery.

Answer 628

pre-existing condition or a condition specific to pregnancy. The most common pregnancy-related causes of itch are: - Obstetric cholestasis (also known as 'intrahepatic cholestasis of pregnancy') — which does not present with a rash. - Polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis — all of which present with a rash.

Answer 629

The itch (often severe) usually starts abruptly in the third trimester, is often more noticeable on the soles and palms but can occur anywhere on the body, and may be worse at night. Obstetric cholestasis generally poses no risk to the pregnant woman. Although it is associated with an increased risk of stillbirth, for most women this appears to be only slightly raised above background rates with specialist management. Symptoms in the woman usually resolve spontaneously after delivery. Any woman with suspected obstetric cholestasis should be referred to obstetrics for same-day investigation.

Answer 630

The rash is intensely itchy, and consists of pruritic urticarial papules that coalesce into plaques. Typically, it starts on the abdomen, but the umbilicus is usually spared. It may later develop into widespread non-urticated erythema, with eczematous lesions and vesicles. It poses no serious risk to the woman or baby; symptoms last 4–6 weeks on average, and usually resolve immediately following delivery. Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.

Answer 631

The rash is itchy and consists of eczematous, papular lesions. Although it poses no serious risk to the woman, the child may be at increased risk of developing atopic eczema. Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.

Answer 632

An intense itch often precedes the rash, which initially presents with erythematous urticarial papules and plaques on the abdomen (and nearly always the umbilicus), but may spread to cover the entire body and progress to form tense blisters. The woman is likely to have exacerbations and remissions throughout pregnancy. It is associated with preterm birth and of the infant being small for gestational age. Pemphigoid gestationis spontaneously regresses after delivery. There is an approximately 10% chance of mild and transient skin lesions in the neonate. Referral should be made to obstetrics for additional antenatal surveillance, and dermatology for treatment with topical or systemic corticosteroids.

Answer 633

cause of haemolysis (red blood cells breaking down) and jaundice in the neonate. It is caused by incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus. The rhesus antigens on the red blood cells vary between individual. This is different to the ABO blood group system.

Answer 634

antigens that can be present or absent depending on the persons blood type. The most important antigen within the rhesus blood group system is the rhesus D antigen.

Answer 635

rhesus D positve (has the rhesus D antigen). It is likely at some point in the pregnancy the blood from the baby will find a way into her bloodstream. When this happens, the baby’s red blood cells display the rhesus D antigen. The mother’s immune system will recognise this rhesus D antigen as foreign and produce antibodies to the rhesus D antigen. The mother has then become sensitised to rhesus D antigens. Usually, this sensitisation process does not cause problems during the first pregnancy (unless the sensitisation happens early on, such as during antepartum haemorrhage). But can during subsequent pregnancies.

Answer 636

the mother’s anti-D antibodies can cross the placenta into the fetus. If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack their own red blood cells. This leads to haemolysis, causing anaemia and high bilirubin levels. This leads to a condition called haemolytic disease of the newborn.

Answer 637

miscarriage ectopic pregnancy= the most 'important' cause as missed ectopics can be potentially life-threatening implantation bleeding= a diagnosis of exclusion miscellaneous conditions= - cervical ectropion - vaginitis - trauma - polyps

Answer 638

If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service. A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.

Answer 639

ectopic pregnancy? If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised: - to return if bleeding continues or pain develops - to repeat a urine pregnancy test after 7-10 days and to return if it is positive - a negative pregnancy test means that the pregnancy has miscarried

Answer 640

vaginal bleeding uterus size greater than expected for gestational age abnormally high serum hCG ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 641

'snow storm' appearance of mixed echogenicity

Answer 642

Turner's syndrome Prader-Willi syndrome Noonan's syndrome

Answer 643

polycystic ovarian syndrome androgen insensitivity Kallman's syndrome Klinefelter's syndrome

Answer 644

an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer

Answer 645

simple complex simple atypical complex atypical

Answer 646

abnormal vaginal bleeding eg. intermenstrual

Answer 647

simple endometrial hyperplasia without atypia= high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used atypia= hysterectomy is usually advised

Answer 648

grow during pregnancy

Answer 649

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration.

Answer 650

low-grade fever, pain and vomiting

Answer 651

conservatively with rest and analgesia and should resolve within 4-7 days.

Answer 652

enterocoele and vaginal vault prolapse

Answer 653

urinary retention

Answer 654

simple: unilocular, more likely to be physiological or benign complex: multilocular, more likely to be malignant

Answer 655

depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.

Answer 656

a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as 'simple' then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.

Answer 657

by definition physiological cysts are unlikely any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment

Answer 658

complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment

Answer 659

Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Answer 660

* Abdominal pain * Abdominal bloating

Answer 661

* As for mild * Nausea and vomiting * Ultrasound evidence of ascites

Answer 662

* As for moderate * Clinical evidence of ascites * Oliguria * Haematocrit > 45% * Hypoproteinaemia

Answer 663

* As for severe * Thromboembolism * Acute respiratory distress syndrome * Anuria * Tense ascites

Answer 664

nausea/vomiting tiredness musculoskeletal pains

Answer 665

Spontaneous abortion Ectopic pregnancy Hydatidiform mole

Answer 666

Spontaneous abortion Hydatidiform mole Placental abruption

Answer 667

Bloody show Placental abruption Placenta praevia Vasa praevia

Answer 668

STI and cervical polyps

Answer 669

Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled. Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain. Complete miscarriage - little bleeding

Answer 670

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

Answer 671

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

Answer 672

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed *vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Answer 673

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal *vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Answer 674

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

Answer 675

The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.

Answer 676

aim for monotherapy there is no indication to monitor antiepileptic drug levels sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

Answer 677

Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 678

The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate. The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Answer 679

have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast.

Answer 680

galactocele can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Answer 681

relatively common condition of pregnancy that results from a combination of dilution, decreased production and increased destruction of platelets. The latter is thought to be due to the increased work of the maternal spleen leading to mild sequestration.

Answer 682

autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.

Answer 683

Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign. If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids and a diagnosis of ITP assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation.

Answer 684

Gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta. Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia.

Answer 685

Hemolysis, Elevated Liver enzymes, and a Low Platelet count

Answer 686

It is a serious condition that can develop in the late stages of pregnancy. Whilst there is significant overlap with severe pre-eclampsia in terms of the features some patients present with no prior history so many specialists consider it a separate entity in its own right.

Answer 687

nausea & vomiting right upper quadrant pain lethargy

Answer 688

bloods: Hemolysis, Elevated Liver enzymes, and a Low Platelet

Answer 689

HELLP syndrome

Answer 690

delivery of baby

Answer 691

all pregnant women

Answer 692

a complete course of vaccination + hepatitis B immunoglobulin

Answer 693

minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.

Answer 694

- maternal antiretroviral therapy - mode of delivery (caesarean section) - neonatal antiretroviral therapy - infant feeding (bottle feeding)

Answer 695

all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously

Answer 696

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended a zidovudine infusion should be started four hours before beginning the caesarean section

Answer 697

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

Answer 698

a zidovudine infusion

Answer 699

zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.

Answer 700

hormone first produced by the embryo and later by the placental trophoblast. Its main role is to prevent the disintegration of the corpus luteum

Answer 701

hCG levels double approximately every 48 hours in the first few weeks of pregnancy. Levels peak at around 8-10 weeks gestation. Measurement of hCG levels form the basis of many pregnancy testing kits

Answer 702

the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.

Answer 703

reduced amniotic fluid Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.

Answer 704

premature rupture of membranes Potter sequence = bilateral renal agenesis + pulmonary hypoplasia intrauterine growth restriction post-term gestation pre-eclampsia

Answer 705

the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage.

Answer 706

previous c-section placenta praevia

Answer 707

the degree of invasion

Answer 708

accreta increta percreta

Answer 709

chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis

Answer 710

chorionic villi invade into the myometrium

Answer 711

chorionic villi invade through the perimetrium

Answer 712

alphabetical order - more invasion accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis increta: chorionic villi invade into the myometrium percreta: chorionic villi invade through the perimetrium

Answer 713

describes a placenta lying wholly or partly in the lower uterine segment

Answer 714

5% will have low-lying placenta when scanned at 16-20 weeks gestation incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix

Answer 715

multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section

Answer 716

shock in proportion to visible loss NO pain uterus not tender lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large

Answer 717

placenta praevia

Answer 718

digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage placenta praevia is often picked up on the routine 20 week abdominal ultrasound the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Answer 719

I - placenta reaches lower segment but not the internal os II - placenta reaches internal os but doesn't cover it III - placenta covers the internal os before dilation but not when dilated IV ('major') - placenta completely covers the internal os

Answer 720

rescan at 32 weeks no need to limit activity or intercourse unless they bleed

Answer 721

scan every 2w

Answer 722

1. Thyrotoxicosis 2. Hypothyroidism 3. Normal thyroid function (but high recurrence rate in future pregnancies)

Answer 723

thyroid peroxidase antibodies

Answer 724

thyrotoxic phase= - propranolol for symptom control - not usually treated with anti-thyroid drugs as the thyroid is not overactive. hypothyroid phase= - usually treated with thyroxine

Answer 725

not normally as thyroid is not overactive

Answer 726

Mx- thyroxine usually used

Answer 727

Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT

Answer 728

ECG and chest x-ray should be performed in all patients In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist

Answer 729

slightly increases the lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation

Answer 730

V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA (1/50,000 versus less than 1/1,000,000)

Answer 731

limited use as it is often raised in pregnancy

Answer 732

SV up 30%, HR up 15% & cardiac output up 40% systolic BP is unaltered diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins

Answer 733

systolic BP is unaltered diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term

Answer 734

enlarged uterus may interfere with venous return

Answer 735

Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre) Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable

Answer 736

Maternal blood volume up 30%, mostly in 2nd half= red cells up 20% but plasma up 50% → Hb falls Low grade increase in coagulant activity rise in fibrinogen and Factors VII, VIII, X fibrinolytic activity is decreased - returns to normal after delivery (placental suppression?) prepares the mother for placental delivery leads to increased risk of thromboembolism Platelet count falls WCC & ESR rise

Answer 737

blood flow increases by 30% GFR increases by 30-60% salt and water reabsorption is increased by elevated sex steroid levels urinary protein losses increase trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose

Answer 738

common due to the increased GFR and reduction in tubular reabsorption of filtered glucose

Answer 739

calcium requirements increase during pregnancy especially during 3rd trimester + continues into lactation calcium is transported actively across the placenta serum levels of calcium and phosphate actually fall (with fall in protein) ionised levels of calcium remain stable Gut absorption of calcium increases substantially - due to increased 1,25 dihydroxy vitamin D

Answer 740

Unlike renal and uterine blood flow, hepatic blood flow doesn't change ALP raised 50% Albumin levels fall

Answer 741

100g → 1100g hyperplasia → hypertrophy later increase in cervical ectropion & discharge Braxton-Hicks: non-painful 'practice contractions' late in pregnancy (>30 wks) retroversion may lead to retention (12-16 wks), usually self corrects

Answer 742

Increased risk of miscarriage (increased risk of around 47%) Increased risk of pre-term labour Increased risk of stillbirth IUGR Increased risk of sudden unexpected death in infancy

Answer 743

Fetal alcohol syndrome (FAS): - learning difficulties - characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly - IUGR & postnatal restricted growth Binge drinking is a major risk factor for FAS

Answer 744

- learning difficulties - characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly - IUGR & postnatal restricted growth

Answer 745

fetal alcohol syndrome

Answer 746

Similar to smoking risks due to tobacco content

Answer 747

Maternal risks: - hypertension in pregnancy including pre-eclampsia - placental abruption Fetal risk: - prematurity - neonatal abstinence syndrome

Answer 748

Risk of neonatal abstinence syndrome

Answer 749

- increased mortality depends on the gestation - respiratory distress syndrome - intraventricular haemorrhage - necrotizing enterocolitis - chronic lung disease, hypothermia, feeding problems, infection, jaundice - retinopathy of prematurity - hearing problems

Answer 750

- important cause of visual impairment in babies born before 32 weeks gestation - the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization) - screening is done in at-risk groups

Answer 751

around 2% of pregnancies but is associated with around 40% of preterm deliveries

Answer 752

fetal: prematurity, infection, pulmonary hypoplasia maternal: chorioamnionitis

Answer 753

- sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection - if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1 - ultrasound may also be useful to show oligohydramnios

Answer 754

placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1

Answer 755

admission regular observations to ensure chorioamnionitis is not developing oral erythromycin should be given for 10 days antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Answer 756

to ensure chorioamnionitis is not developing

Answer 757

oral erythromycin for 10 days

Answer 758

to reduce risk of respiratory distress syndrome

Answer 759

34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Answer 760

reproductive age so issues surrounding conception are commonly encountered

Answer 761

defer conception until disease more stable

Answer 762

tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery

Answer 763

men and women at least 6m before conception

Answer 764

studies looking at pregnancy outcomes in patients treated with TNF-α blockers do not show any significant increase in adverse outcomes. It should be noted however that many of the patients included in the study stopped taking TNF-α blockers when they found out they were pregnant

Answer 765

low-dose corticosteroids may be used in pregnancy to control symptoms

Answer 766

may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus

Answer 767

due to the risk of atlanto-axial subluxation

Answer 768

also known as German measles, is a viral infection caused by the togavirus. Following the introduction of the MMR vaccine it is now rare.

Answer 769

there is a risk of congenital rubella syndrome

Answer 770

incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

Answer 771

in first 8-10 weeks risk of damage to fetus is as high as 90% damage is rare after 16 weeks

Answer 772

sensorineural deafness congenital cataracts congenital heart disease (e.g. patent ductus arteriosus) growth retardation hepatosplenomegaly purpuric skin lesions 'salt and pepper' chorioretinitis microphthalmia cerebral palsy

Answer 773

suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary IgM antibodies are raised in women recently exposed to the virus it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss

Answer 774

parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss it is very difficult to distinguish rubella from parvovirus B19 clinically

Answer 775

suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit since 2016, rubella immunity is no longer routinely checked at the booking visit if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella non-immune mothers should be offered the MMR vaccination in the post-natal period MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant