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AMC > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

1st Trimester

A

1-12 weeks

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2
Q

2nd Trimester

A

13-26/27 weeks

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3
Q

3rd trimester

A

28-40 weeks

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4
Q

Baseline foetal heart rate (FHR)

A

110- 160 bpm

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5
Q

Baseline FHR variability

A

Normal: 6-25 bpm
Reduced: 3-5 bpm
Absent: < 3bpm
Increased (salutatory): > 25 bpm

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6
Q

FHR accelerations

A

Transient increase in FHR of 15 bpm lasting 15 sec

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7
Q

FHR decelerations

A

transient episodes of decreased FHR below baseline more than 15 bpm for at least 15 sec
- often pathological

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8
Q

Types of FHR decelerations

A

Early
Variable
Prolonged
Late

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9
Q

Early FHR decelerations

A
  • benign & physiological
  • 4-8cm cervical dilation
  • mirror contraction
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10
Q

Variable FHR decelerations

A
  • repetitive/intermittent
  • in association with other non-reassuring/abnormal features are pathological
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11
Q

Late FHR decelerations

A
  • uniform, repetitive decrease
  • slow onset at mid to end of contraction
  • caused in the presence of hypoxia (foetus already hypoxic)
  • decelerations less than 5-15 bpm
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12
Q

Reassuring CTG findings

A
  • baseline FHR 110- 160
  • No late or variable FHR decelerations
  • Moderate FHR variability (6-25 bpm)
  • age-appropriate FHR accelerations
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13
Q

Abnormal CTG findings any

A

ANY OF THE FOLLOWING
- Baseline FHR <100 bpm or >170 bpm
- Absent variability < 3 bpm
- Prolonged decelerations for > 3 bpm OR late OR complicated variables

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14
Q

Abnormal CTG findings >2

A

AT LEAST 2 OF THE FOLLOWING:
- Baseline FHR between 100-109 bpm
- Baseline FHR between 160 -170 bpm
- FHR variability is reduced (3-5 bpm for > 40 mins)
- Variable decelerations without complicating features

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15
Q

Abnormal CTG, what’s the next step

A
  1. Stop syntocinon (give blood to baby)
  2. foetal scalp sampling unless contraindicated (lactate high, pH low) give C-sec
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16
Q

CTG high risk vs low risk

A

High risk: mandatory obstetrical intervention
Low risk: limited value, and can lead to unnecessary obstetrical intervention

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17
Q

Pregnancy screening test

A

Before conception: Rubella
10-12 weeks: Chorionic villus sampling (CVS) Rh negative women need Rh D immunoglobulin (anti-D)
15-17 weeks: Maternal serum screening (alpha fetoprotein, estriol, and beta-HCG ) for Down syndrome
16-18 weeks: Amniocentesis
18-20 weeks: Ultrasound for identification of physical abnormalities (NTD)

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18
Q

First antenatal visit time frame

A

Within 10 weeks

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19
Q

Antenatal screening protocol

A
  • every four weeks until 28 weeks
  • every two weeks until 36 weeks
  • every week until 40 weeks or delivery
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20
Q

Spina bifida investigation

A

US of foetal spine at 16-18 weeks

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21
Q

Tenderness of the right lower part of the uterus indicates

A
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22
Q

Indications to use ant-D

A

-Spontaneous abortion.
-External cephalic version.
-Significant closed intra-abdominal trauma.
-Termination of pregnancy.
-Chorionic Villus Sampling.
-Ectopic pregnancy.
-Threatened abortion after 12 weeks of gestation

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23
Q

Doppler studies result

A
  • increase in end-diastolic flow velocity relative to peak systolic velocity
  • S/D ratio to decreases with advancing gestation
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24
Q

Increase in S/D ratio is associated with

A
  • increased resistance in the placental vascular bed
  • can be noted in pr-eclampsia or festal growth retardation
  • Nicotine and maternal smoking increase S/D ratio
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25
Q

Teenage pregnancy complication

A
  • maternal poor weight gain
  • premature delivery
  • low birth weight
  • increased risk of pregnancy-induced hypertension
  • increased risk of violence
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26
Q

Rectus sheath haematoma causes

A
  • anticoagulation therapy
  • severe cough
  • pregnancy
  • previous or recent abdominal surgery
  • abdominal trauma
  • chronic kidney disease
  • steroid/immunosuppressive therapy
  • vigorous uncoordinated rectus muscle contraction
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27
Q

Features of Placental abruption

A
  • PAINFUL vaginal bleeding or without bleeding (concealed bleeding)
  • uterine tenderness
  • foetal compromise on CTG
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28
Q

Features of Placenta previa

A
  • painless vaginal bleeding (low in comparison to other forms)
  • with or without uterine tenderness (AMC handbook)
  • foetal compromise on CTG (can also be without AMC handbook)
  • tender rigid abdomen
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29
Q

Vasa previa feature

A

Carries minimal maternal risk but has serious fetal risk
- no bleeding when ROM

∗ Causes fresh painless vaginal bleeding when membranes rupture just before labour starts

∗ Can be detected by transvaginal ultrasound

∗ If detected early, c – c-section will be done between 34 to 37 weeks

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30
Q
A
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31
Q

Trying for pregnancy after miscarriage/abortion

A

Wait one menstrual period after abortion

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32
Q

pregnant women with Myasthenia Gravis with pre-eclampsia

A

magnesium sulphate is contraindicated. as it impairs already slowed nerve muscle connections

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33
Q

Platelet count that is considered safe in pregnancy

A

50000/mm3

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34
Q

Safe platelets count for regional anaesthesia

A

70000-100000/mm3

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35
Q

Causes of thrombocytopenia in pregnancy

A
  • Gestational/incidental thrombocytopenia (most common)
  • Acute fatty liver
  • HELLP syndrome
  • Pre-eclampsia
  • Eclampsia
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36
Q

HELLP Syndrome stands for

A

H- haemolysis
EL -elevated liver enzyme levels
LP -low platelet levels

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37
Q

HELLP Syndrome features

A
  • average between 32-34 weeks
  • postpartum in up to 30% of cases
  • right upper quadrant pain or epigastric pain
  • nausea, vomiting, and malaise
  • hypertension 80%
  • low level proteinuria 5-15%
  • AST/ALT elevated secondary to liver dysfunction
  • High blood urea and creatinine with acute renal failure
  • bilirubin level is increased secondary to haemolysis
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38
Q

Pre-eclampsia dx

A

> 20 weeks + Hypertension (1st symptom) + end-organ damage such as ankle and facial edema or placental insufficiency
- proteinuria (2nd symptom) after 20 weeks
-headache, dizziness and abdominal pain just below the ribs.

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39
Q

Severe pre-eclampsia dx

A

BP > 160/110mmHg + proteinuria

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40
Q

Pre-eclampsia ddx

A

gestational hypertension
acute fatty liver

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41
Q

Proteinuria in pre-eclampsia

A

> 300g protein in 24hr urine

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42
Q

protein to creatinine ratio

A

Used to diagnose pre-eclampsia
- >30mmol

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43
Q

Risk of pre-eclampsia

A
  • Previous eclampsia [7x]
  • Chronic hypertension [5]
  • Pre-existing diabetes [4x]
  • Multiple pregnancy (twin) [3x]
  • Autoimmune disease (SLE, antiphospholipid syndrome) [3x]
  • Nulliparity [3x]
  • 1st degree family history [3x}
  • Age >40 [2x]
  • Pre-existing kidney disease [2x]
  • BMI > 30 [2x]
  • Prolonged interpregnancy interval
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44
Q

gestational hypertension features

A

> 20 weeks
- without pre-eclampsia features
- resolves within 3 months after delivery
- good prognosis

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45
Q

gestational hypertension investigation

A

monitor to exclude development of pre-eclampsia
- if BP >140/90: start antihypertensives
- aim to maintain BP at 110-140/80-90

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46
Q

Symphyseal fundal height

A

gestational age +- 2
- if low check for pre-eclampsia

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47
Q

Medication for hypertension

A

Moderate:
- Methyldopa
- labetalol/atenolol
- Nifedipine
Severe:
- IV Hydralazine 5mg bolus every 20 min

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48
Q

Methyldopa in postpartum period

A
  • Cease as it can increase risk of postpartum depression
  • Switch to enalapril
  • Add nifedipine if above don’t work (acts very quickly)
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49
Q

Criteria for gestational thrombocytopenia

A
  • mild/asymptomatic thrombocytopenia
  • no past hx (unless previous pregnancy)
  • no foetal thrombocytopenia association
  • spontaneous resolution upon delivery
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50
Q

Obstetric cholestasis features

A
  • late second and early third trimester of pregnancy
  • pruritus and rash on the palms of the feet worse at night
  • increased serum bile acids and other liver function tests.
  • jaundice uncommon but could be present
  • 40% of recurring in subsequent pregnancies
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51
Q

Obstetric cholestasis investigation

A

weekly LFT
- increased ALP
- mildly increased AST/ALT & bilirubin
Monitor foetus
- deliver if distressed

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52
Q

Obstetric cholestasis prognosis

A
  • usually clears up rapidly after delivery
  • often recurs in future pregnancies or using OCP (which are contraindicated)
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53
Q

Obstetric cholestasis treatment

A
  • relieve bile acids with ursodeoxycholic acids
  • antihistamine/emollients
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54
Q

Obstetric cholestasis complications

A
  • foetal distress/death
  • preterm delivery
  • meconium ingestion
  • meconium aspiration syndrome
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55
Q

Acute fatty liver features

A

Life threatening
- Late 3rd trimester/ early postpartum period (35-36 weeks)
- 1 in 10000 pregnancies
- mortality rate 50%
- Jaundice prevalent

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56
Q

Acute fatty liver causes

A

disordered fatty acid metabolism by mitochondria in mother
- due to LCHAD enzyme deficiency
- hepatotoxic agents given to mother

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57
Q

Acute fatty liver complications

A
  • ascites
  • pancreatitis
  • liver encephalopathy
  • disseminated intravascular coagulation (DIC)
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58
Q

Acute fatty liver dx

A

Liver failure
-increased AST + ALT (200)
- increased bilirubin
- ALP normal

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59
Q

Acute fatty liver investigation

A

Liver biopsy confirms dx

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60
Q

Acute fatty liver management

A
  • DRABCD
  • Admission to ICU
  • Termination of pregnancy (lifesaving for both mother and baby)
  • prevent/treat DIC
  • may require liver transplant
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61
Q

Foetal

A
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62
Q

Uterine hyperstimulation

A

more than 5 active labour contractions in 10 minutes (tachysystole)
- contractions lasting more than 2 mins/ occurring within 60 secs of each other (hypertonus)

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63
Q

Umbilical cord prolapse

A
  • Variable decelerations
  • persistent foetal bradycardia
  • prolonged decelerations for over 1 minute
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64
Q

Umbilical cord prolapse

A

-PPROM.
-Polyhydramnios
-Breech presentation.
-Multiparity.
-Multiple gestations.
-GDM increasing the risk of polyhydramnios, fetal
malpresentation, premature rupture of membrane.

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65
Q

Hypertension in pregnancy

A
  • primary pulmonary hypertension is a contraindication
  • increases the risk of pre-eclampsia
  • increases the risk of foetal growth restriction
  • Daily intake of 1000mg of calcium to reduce incidence of hypertensive disorders and preterm labour
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66
Q

Varicella Zoster (Chickenpox)

A
  • Check mothers IgG status for antibodies:
    positive = no further action needed
    negative = within first 96 hours, give immunoglobulin (VZIG)
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67
Q

Varicella Zoster (Chickenpox) screening

A

1st trimester if no prior/uncertain history

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68
Q

Varicella prophylaxis

A

Acyclovir (1st line) valaciclovir:
-2nd half of pregnancy
- underlying history of lung disease
- smoker
- immunocompromised

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69
Q

Varicella management IgM+

A

without complications:
- Rash < 24 hours - give oral antivirals (acyclovir)
Rash >24 hours - no treatment is required.

With complications /
immunocompromised:
- Intravenous acyclovir

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70
Q

Varicella management in a px that is infected/ symptomatic about to deliver

A

Presentation of the symptoms >7 days before delivery:
- No VZIG required.
- No isolation required.
- Encourage breastfeeding

Maternal chickenpox 7 days before to 2 days after birth:
- Give newborn VZIG 200 1U bone vial)
intramuscularly (IM) immediately after birth.
VZIG should be given as soon as possible within
the first 24 hours of birth but may be given up
to 72 hours.
- Discharge term neonates as soon as possible.
- No isolation required.
- Encourage breastfeeding.

Maternal chickenpox > 2 to 28 days after birth:
- If neonate < 28 weeks gestation or 1000 g birth
weight, give VZIG (preferably within 96 hours
but can be given up to 10 days post-maternal
rash.
- Due to the increased risk of severe varicella in
newborns of seronegative women (if the mother
has no personal history of infection with VZV),
give VZIG to neonates exposed to varicella
between 2 to 28 days of age.
- Discharge term neonates as soon as possible.
- No isolation required.
- Encourage breastfeeding.

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71
Q

Vaccines that are contraindicated in pregnancy

A
  • Varicella Zoster (chicken pox)
  • Rubella
  • Measles
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72
Q

Pertussis DPTa

A
  • can give vaccine
  • usually recommended at 28 weeks
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73
Q

Effects of oxytocin

A
  • uterine stimulation
  • antidiuretic
  • mammary gland stimulation
  • labor induction
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74
Q

Foods that should be avoided during pregancy

A
  • Dairy: soft cheese, soft serve ice cream, unpasteurised
  • Smoked salmon, trout
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75
Q

Eating soft cheese/salmon increases the risk of

A

Listeriosis
(meningitis, meningoencephalitis)

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76
Q

PROM vs PPROM

A

PPROM ( premature)
- <37 weeks

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77
Q

Preterm Pre-Rupture of Membranes (PPROM)

A
  • Rupture of foetal membranes before labour at any gestational age
  • 50% progression into labour with 24 hrs
  • 80% in 7 days
  • preterm delivery
  • presence of liquor flow from the cervical os
  • pooling of liquor flow in the posterior vaginal fornix
  • Neonatal complications
    -intrauterine infections (chorioamnionitis)
    NOTE: DON’T DO bimanual examination due to high risk of infections
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78
Q

Preterm Pre-Rupture of Membranes (PPROM) ddx

A
  • fluid loss
  • ## urinary incontinence
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79
Q

PPROM risks

A
  • cord prolapse
  • preterm labour
  • placental abruption
  • chorioamnionitis
  • foetal pulmonary hypoplasia/ other features of prematurity
  • limb positioning defects
  • perinatal mortality
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80
Q

PPROM Investigation

A

Tests for amniotic fluid
* Amnisure test- immuno chromatographic assay test
* Nitrazine test- litmus test. If pH >6.5 it is amniotic fluid
* Fern test- fern like pattern of vaginal fluid when taken on a slide

Swabs to be taken
∗ High vaginal swab for M/C&S
∗ Low vaginal swab for GBS
Blood investigations
∗ FBE, ESR/CRP, UCE, FBS, LFT
Urine MCS

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81
Q

Preterm Pre-Rupture (PPROM) of Membranes management AB

A
  • Steroids
  • ∗ I/V Benzyl penicillin for 48 hours or till delivery happens whichever is earlier
  • ∗ Then oral erythromycin for 10 days
  • ∗ If penicillin hypersensitivity :I/V Cephazolin
  • ∗ If penicillin anaphylaxis I/V **Clindamycin **for 48 hours and then oral
  • erythromycin for10 days
  • ∗ Further benzyl penicillin prophylaxis during labour
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82
Q

Preterm Pre-Rupture (PPROM) of Membranes management

A
  • < 34 weeks, no IOL unless complications in mom or baby. steroids, tocolysis if going for labour. Monitor vitals, FBE/ CRP daily for 3 days and then biweekly
  • < 30 weeks, infusion with Mg SO4 for potential fetal neuroprotection
  • 34- 36 + 6 weeks, IOL after assessing risks and benefits - Other wise same as above
  • GBS positive prompt induction of labour or C- section, from 34 weeks after steroids
  • signs of infection or fetal compromise, immediate delivery by induction or
    C- section after steroids up to 36+ 6 weeks
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83
Q

Foetal fibronectin (fFN)

A

∗ Screening test for preterm labour
∗ By taking cervical or vaginal swab and doing enzyme immunoassay
∗ Negativity is more specific than positivity
∗ If –ve, patient won’t deliver within next 7-10 days
∗ If +ve, patient might deliver within 7-10 days

criteria:
- Intact foetal membranes
- Cervical dilation less than 3 cm
- Gestational age of between 22 +0d - 34+6d
weeks

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84
Q

Preterm labour criteria

A
  • < 36 + 6 weeks
  • Contractions occurring at 5-10 minutes interval and
    lasting for 30sec- 1 minute
  • Cervix dilated >2.5 cm
  • Fibronectin test positive
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85
Q

Preterm labour dx

A
  1. history two or more miscarriages occurring after the 12th weeks gestation, usually starting with painless leaking of amniotic fluid
  2. The easy passage of a size 9 cervical dilator through the internal os of the cervix when the woman is not pregnant, and the absence of a ‘snap’ on its
    withdrawal
  3. cervical length of less than 25mm or cervical
    funnelling >40% prior to 24 weeks gestation
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86
Q

Preterm labour causes

A
  • idiopathic 40%
  • cervical incompetence
  • multiple pregnancy
  • polyhydramnios
  • uterus abnormalities, septum
  • infections: GBS, measles, SMV, UTI
  • DM
  • haemorrhage: pre-eclampsia
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87
Q

Preterm labour MX

A
  • Admission in tertiary hospital with NICU
  • Steroids- To prevent RDS in newborn
    Betamethasone 11.4 mg I/M 2 doses, 12- 24 hours apart
  • Tocolytic
    Medication to prevent uterine contractions
    Most commonly used- ** nifedipine**
    Other tocolytics- salbutamol
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88
Q

Labour induction indications

A
  • pre-eclampsia
  • IVF
  • IUGR
  • Cephalic presentation
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89
Q

Contraindications of labour

A
  • Signs of chorioamnionitis
  • antepartum haemorrhage
  • request of mother
  • neonatal jeopardy
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90
Q

Features of Inefficient or incoordinate labour

A
  • Usually no moulding of the foetal head
  • +/- caput formation of foetal head
  • usually absent cervical oedema
    • tachycardia
  • Can be above or below IS
  • Usually < 1 finger breadths of head palpable above the pelvic brim when the lowest point of the head is at the IS
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91
Q

Features of obstructed labour

A
  • ++ moulding of foetal head
  • ++ caput formation on foetal head
  • anterior lip cervical oedema
  • ++ progressive foetal tachycardia
  • just at or above the ischial spines (IS)
    > 2 finger breadths of head palpable above the pelvic brim when the lowest point of the head is at the IS
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92
Q

Features of chorioamnionitis

A
  • increased WBC (>15x 10^9/L)
    -Maternal tachycardia >100 bpm
  • foetal tachycardia > 160 bpm
  • uterine tenderness
  • offensive vaginal discharge
  • CRP > 40
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93
Q

Tocolysis contraindication

A
  • chorioamnionitis (absolute)
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94
Q

Measles (MMR) during pregnancy

A
  • Notifiable disease therefore contact tracing
  • Immunoglobulin is used as prophylactic only, not for established
  • symptomatic treatment
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95
Q

Measles incubation period

A

10-14 days

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96
Q

Measles symptoms

A
  • fever
  • malaise
  • cough
  • coryza
  • conjunctivitis
  • white spots surrounded by red ring in the buccal mucosa (Koplik’s)
  • maculopapular rash 2-4 days after initial symptoms
  • infection periods start 2 days after rash onset, 4 days after eruption
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97
Q

Measles complications in children

A
  • Otitis media 7%
  • Bronchopneumonia 6%
  • acute encephalitis 2-10/10000
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98
Q

Measles complications in mother

A
  • preterm labour
  • spontaneous abortion
  • foetal/neonatal loss
  • maternal mortality
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99
Q

Placental abruption

A
  • separation of placenta from uterus
  • 3rd trimester bleeding
  • foetal morbidity and mortality
  • MVA
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100
Q

Placental abruption symptoms

A
  • vaginal bleeding 80%
  • Abdominal/back pain 70%
  • uterine tenderness 70%
  • abnormal uterine contractions - 35%
  • idiopathic premature labour - 25%
  • foetal death 15%

-hypofibriogemia

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101
Q

Placental abruption with no foetal heart sounds, what to do next

A

foetus is dead.
Commence amniotomy as it’ll induce spontaneous labour

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102
Q

Rubella in pregnancy

A
  • check serology (IgM and IgG) (IgG titer of = >than 10 IU/ml)
  • Rubella infection in the first trimester (<8 weeks) causes severe foetal anomalies 85%
  • If infected termination is recommended
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103
Q

rubella symptoms

A
  • usually asymptomatic 25- 50% cases
  • low grade fever
  • transient erythematous rash
  • post- auricular/ sub-occipital nodes lymphadenopathy

Maculopapular rash on the face and spreads to trunk and extremities (resolves within 3 days)

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104
Q

Rubella infection during pregnancy

A
  • <8 weeks 85% foetal infection (congenital rubella syndrome)
  • 8< - <12: 50 - 80% infected 65 -85 clinically infected
  • 13 -16 weeks 30% infected, 1/3 have sensorineural deafness
  • 16 -19 weeks: 10% infected, clinical features rare
  • > 19 weeks: no apparent risk
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105
Q

Rubella vaccinated before pregnancy

A

Reassure if not exposed to Rubella

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106
Q

Rubella abnormalites

A
  • CNS dysfunction 10 25% (intellectual impairment developmental delay, microcephaly)
  • eye 10 -25% (cataracts, retinopathy, glaucoma)
  • sensorineural deafness 60-75%
    cardiac 10-20% (PDA wide pulse pressure, PA stenosis, )
  • intrauterine growth restriction, short stature
  • inflammatory lesions (brain, liver, lungs, bone marrow
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107
Q

Hyperemesis gravidarum

A
  • nausea and vomiting at 5-6 weeks of gestation, peaking at 9 weeks
    -Weight loss (more than 5% of weight)
    -Ketosis
  • urine analysis to check for hydration status
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108
Q

School exclusion

A

Measles: 5 days
Mumps: 9 days
Rubella: 5 days

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109
Q

Incarcerated uterus

A
  • pregnant uterus entrapped in the pelvis by subpromontary sacrum
  • retroverted uterus?
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110
Q

Episiotomy haematoma management

A
  • < 3cm conservative management
  • > 3cm surgical excision/exploration
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111
Q

Most serious cause of Hyperemesis gravidarum

A
  • Hypokalemia
  • On ECG: such as inverted T waves and prolonged QT and PR intervals
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112
Q

Hyperemesis

A
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113
Q

Pregnancy-Unique Quantification of Emesis (PUQE-24) score 4-6

A
  • Ginger 250mg orally, 4 times/day
    Pyridoxine (Vit B6) 10-25mg 3-4 times/day
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114
Q

Pregnancy-Unique Quantification of Emesis (PUQE-24) score 7 -12

A

Cyclizine 12.5-50mg oral 3/d
Promethazine 10-25mg oral 3/day
Prochlorperazine 5-10mg oral 3-4/day
Metoclopramide 10mg oral/IV/IM
Domperidone 10mg 3/day
Ondesatron 4-8mg oral/IV

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115
Q

Pregnancy-Unique Quantification of Emesis (PUQE-24) score > 13

A

Hydrocortisone IV 100mg 2/day
Prednisolone 40-50mg oral 1/day

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116
Q

Hyperemesis gravidarum excessive vomiting may lead to the
following

A
  • Hyponatremia - caused by vomiting and Gl loss
  • Hypokalemia - caused by vomiting and Gl loss
  • Hypochloremic alkalosis - caused by vomiting
    and GI loss
  • Ketosis - resulting from decreased oral intake,
    starvation and dehydration
  • Abnormal liver enzymes (ALT>AST)
  • Increased serum amylase and lipase
  • Vitamin deficiency in pregnancy (very rare)
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117
Q

Hyperemesis gravidarum mx

A

1st line: metoclopramide
2nd line: Ondansetron if metoclopramide doesn’t’ work
3rd: steroids (prednisolone) last resort

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118
Q

Placenta previa management

A

management depends on gestation duration:
- < 37 weeks even with large amounts of bleeding can be safely monitored
- > 37 weeks with bleeding delivery through C section

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119
Q

Hyperthyroidism in Pregnancy

A
  • Check TSH and free T4
    foetus:
  • foetal tachycardia
  • small gestational size
  • premature/stillborn
  • Graves
  • if px
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120
Q

Hyperthyroidism medication

A
  • radioactive iodine therapy if patient is not pregnant (postpone pregnancy for 6 months)
  • PTU if already pregnant
  • Don’t give carbimazole in first trimester as if causes scalp defects
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121
Q

Imminent eclampsia dx

A

-BP > 160mm/hg on 2 occasions 6 hours apart
- Proteinuria of > 5g
- cerebral/visual disturbances drowsiness, droopy eyelids
- pulmonary oedema

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122
Q

Eclampsia dx

A

-seizures

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123
Q

Eclampsia management

A

IV diazepam with Magnesium sulphate (phenytoin teratogenic)

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124
Q

Features of magnesium sulphate toxicity

A
  • respiratory rate < 12 breaths/minute
  • urine output < 100mLs in 4 hours (renal insufficiency)
  • loss of patellar reflexes; further seizures occur
  • Muscle paralysis and respiratory difficulty at >7.5 mmol/L
  • cardiac arrest at levels greater than >12 mmol/L
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125
Q

magnesium sulphate toxicity treatment

A

serum magnesium level is >3.5mmol/L, cease infusion and consult with obstetrician

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126
Q

foetal growth restriction causes

A
  1. intrauterine restriction
    - Maternal hypertension (SLE, lupus nephritis)
  2. Congenital
    - Trisomy 21, 18, 13 Turner’s
  3. Infections
    – Cytomegalovirus (CMV) /intrauterine infection
  4. Maternal
    - smoking, alcohol, phenytoin
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127
Q

Most common viral cause of birth defects

A

CMV

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128
Q

Features of CMV

A
  • maternal primary infection often asymptomatic
  • IgG seropositive up to 50% of pregnant women
  • Transplacental foetal infection is 50% with primary infection
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129
Q

CMV symptoms

A
  • retardation
  • microcephaly
  • seizures
  • hearing deficits
  • chorioretinitis
  • optic atrophy
  • brain architectural changes
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130
Q

CMV dx

A

combination of
foetal ultrasound, amniocentesis + /- foetal serology

definite diagnosis of foetal infection is by
amniocentesis

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131
Q

CMV serology protocol

A

IgM-ve/IgG-ve: No CMV infection/susceptible

IgM-ve/IgG+ve: repeat serology after 2 weeks

IgM+ve/IgG+ve: Test immediately/repeat testing
- low: recent primary infection
- intermediate: not sure if primary
- high: past infection

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132
Q

Anaemia in pregnancy

A

< 100g/L

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133
Q

Secondary postpartum haemorrhage

A

24 hours - 12 weeks
- bright red haemorrhage
- fever
- Scant lochia bright red, brown red
- retained products of conception (RPOC)

endometritis ddx: look for bleeding colour

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134
Q

Postpartum endometritis risk factors

A

-C Section delivery (most common)
- Young maternal age.
-Multiple digital cervical examinations.
-Prolonged rupture of membranes.
-Retention of placental products.
-Prolonged labour.
-Chorioamnionitis

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135
Q

Folic acid deficiency cause

A
  • Neural Tube Defects (NTD)
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136
Q

Phenytoin in pregancy

A
  • Phenytoin is teratogenic
  • Enzyme inducer
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137
Q

Folic acid during pregnancy

A
  • 0.5mg recommended dose
  • 1 month before conception to 3 months after
  • 5 mg unless:
  • family history of NTD
  • Enzyme inducing medication (epileptic)
  • BMI > 35
    – Pre-pregnancy diabetes
    – Risk of malabsorption syndrome
    – A family history of congenital heart disease
    – Multiple pregnancy
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138
Q

Uterine rupture features

A
  • foetal bradycardia
  • previous uterine surgery (C -section)
  • constant abdominal pain
  • intraabdominal haemorrhage signs
  • little vaginal bleeding (usually concealed)
  • maternal tachycardia/hypotension
  • uterine contraction cessation
    -foetal loss of station
  • uterine tenderness
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139
Q

Uterine rupture Dx

A

Laparotomy

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140
Q

Uterine rupture Ddx

A
  • uterine atony
  • amniotic fluid embolism
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141
Q

Transverse lie/breech indicates

A

-Multiparity
- pendulous abdomen
- placenta previa
- polyhydramnios
-pelvic inlet contracture/ foetal macrosomia
- uterine abnormalities (fibroids, bicornuate uterus)
- foetal abnormalities (neck/sacrum tumours, hydrocephaly, abdominal distension)
- distended maternal bladder
- poorly formed lower segment
- more premature (wrong date)
- undiagnosed twins
- preterm delivery

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142
Q

Transverse lie/breech investigation

A

US

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143
Q

Transverse lie/breech management

A

If placenta previa excluded
- Cephalic version is < 36
- C section if >37 weeks or in labour

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144
Q

Fundal height

A

height correlates to gestational age (weeks) with > 2cm discrepancy

< gestational age:
- dating errors
- foetal growth restriction (3rd trimester)
- reduction in liquor volume (3rd trimester)
- oligohydramnios
- traverse/oblique lie
- small gestational age
- late ovulation (if px ceased OCP: 2 weeks 50%, 6 weeks 90%, 12 months 1%)

> gestational age:
-dating errors
- large gestational age
- polyhydramnios
- molar pregnancy

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145
Q

Fundal height location

A
  • 12 weeks: palpable above the pubis
  • 20 weeks: level of umbilicus
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146
Q

Fundal height not matching gestational age, next step?

A

US to check for dating error as wells as polyhydramnios, multiple gestation

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147
Q

Placenta Previa grading

A

I: placenta is lower segment, but lower edge doesn’t reach internal os (2.5)
II: lower edge reaches internal os but doesn’t cover it
III: placenta partially covers internal is
IV: completely covers internal os

148
Q

GDM antenatal screening

A

Routine OGTT at 24-28 weeks
If risk index > 2 OGTT at 14 weeks

149
Q

GDM criteria

A

a fasting plasma level: > 5.5mmol/L
1hr: 10.1mmol/L
2 hours after a 75g OGTT: 8.5mmol/L

150
Q

Placenta Previa < 37 weeks managment

A

if routine exam at 18 weeks shows low lying placenta, then another US should be done at 32-34 weeks
- Vital signs, IV if needed
- uterine tenderness
- US
- Anti-D (RhoGAM) (mum is Rh- but foetus Rh+)

151
Q

Gestational diabetes (GDM) postpartum screening

A
  • 30% in the next 10 years
  • 50% risk of type 2 DM within 20 years
    diagnosed should have
  • 75g OGTT 6 -12 weeks postpartum
    HbA1c every 3 months during pregnancy
  • FBS and/or HbA1C 3 yearly
152
Q

Gestational diabetes (GDM) antepartum screening

A

Consult risk index to assess px score:
If < 2: 75g OGTT 24-28 weeks
if >2: 75g OGTT at 14 weeks (earlier if px can tolerate it)

153
Q

Gestational diabetes (GDM) screening risk index

A

BMI: 25-35 = 1
BMI: > 35 = 2
Ethnicity: not white = 1
Previous GDM = 2
Previous elevated blood glucose = 2
Maternal age > 40 years = 2
Family hx: 1st degree relative or sister = 2
Previous macrosomia = 2
Previous perinatal loss = 2
PCOS = 2
Medications (corticosteroids, antipsychotics) = 2

154
Q

DM in px planning to conceive

A

aim to achieve a target HbA1c value less than 6-7%

155
Q

GDM diet control delivery plan

A

if well controlled, continue to 40 weeks

156
Q

GDM medicated control delivery plan

A

if good control: 38-39 weeks (try for 39 weeks onwards)
If poorly controlled: induce at 38 weeks

157
Q

Epstein-Barr (EBV) in pregnancy

A
  • 2-7 weeks incubation
  • doesn’t transmit to foetus
  • Infectious mononucleosis
  • 3-3.4% susceptible
  • 50% infected develop clinical disease
  • recurrent infection can cause shortened pregnancy and low birth weight
  • only need to deal with px if symptoms arise
158
Q

EBV features

A
  • fever
  • sore throat
  • cervical/ post auricular lymphadenopathy
  • characteristic increases in monocytes and lymphocytes
  • hepatosplenomegaly
    -hepatic transaminase increase
159
Q

EBV management

A

Symptomatic treatment
- Antibiotics in bacterial URTI

160
Q

Drug associated patent ductus arteriosus

A

-NSAID’s

161
Q

NSAID’s in pregnancy

A
  • USED WITH CAUTION
  • not more than 48 hours
    -PDA
    -delayed labour and birth
  • oligohydramnios via decreased foetal GFR
162
Q

treatment of hyperemesis graviudarum

A

codeine and metoclopramide

163
Q

Round ligament pain

A
  • 2nd trimester
    -RLQ pain
  • aggravated by moving
  • all vital signs normal
164
Q

Features of threatened abortion

A
  • closed cervical os
  • absent history of passing foetal tissue
  • uterine size is the expected size
165
Q

Features of inevitable abortion

A
  • open cervical os
  • bulging of membranes of the os < 20 weeks
  • uterine size is smaller than the expected size
166
Q

Features of incomplete abortion

A
  • open cervical os
  • bulging of membranes of the os >10 weeks
  • uterine size is smaller than the expected size
167
Q

Features of complete abortion

A
  • closed cervical os
  • passing of foetal tissue
  • uterine size is smaller than the expected size
168
Q

Features of septic abortion

A
  • uterine infection during any time
  • vaginal bleeding
    -cramping pain
  • fever
  • purulent cervical discharge
169
Q

Features of missed abortion

A
  • Closed cervical os
  • No spotting or bleeding (no foetal tissue passed)
  • Ultrasound scans diagnosis of a non-viable IUP (empty sac)
  • uterine size is smaller than the expected size
170
Q

Spontaneous abortion risk factors

A
  • age > 35
  • previous miscarriages
  • antiphospholipid syndrome 15%
  • parenteral chromosomal derangements
  • embryonic chromosomal abnormalities
  • congenital uterine malformations
    -cervical weakness
  • DM, thyroid disease
  • Immune factors
  • Infections
    _ inherited thrombophilic defects
  • caffeine, smoking, alcohol
    -uterine adhesions
171
Q

Most common method of abortion in Aus

A

4 to 9 weeks: mifepristone and misoprostol
6 to 14 weeks: D&C
Legal for up to 24 weeks
> 16weeks: get 2nd opinion and if ok then D&C

172
Q

Most accurate estimation of gestational age

A

Transvaginal US at 8 weeks

173
Q

Vaginal bleeding in 2nd trimester

A
  • cervical insufficiency or labour
  • placenta previa
    -placental abruption
  • uterine rupture
  • vasa previa
174
Q

Features of cervical insufficiency

A

Sx usually persisting for several days or weeks:
- increased pelvic pressure (similar to labour discomfort)
- premenstrual-like cramping
- backache
- increased vaginal discharge
- seen between 14-20 weeks
- soft effaced cervix, with minimal dilation
- advanced clinical
- uterine size is the expected size
presentation
- more than 4 cm dilated and more
than 80% effaced

175
Q

Risk factors of cervical insufficiency

A

-Congenital disorders of collagen synthesis (Ehlers-Danlos syndrome).
-Prior cone biopsies.
-Prior deep cervical lacerations, usually secondary to vaginal or C section.
-Müllerian duct defects (e.g., bicornuate or septate uterus).
-More than three prior foetal losses during the 2nd trimester

176
Q

Vaginal bleeding in 1st trimester

A
  • ectopic pregnancy
  • occurs in 20-30% of all pregnancies
  • significantly increases the risk of preterm birth by 28-31 weeks
177
Q

Vaginal bleeding 3rd trimester

A
  • Placental abruption
  • Placenta Previa
178
Q

Vaginal bleeding postpartum

A

Bleeding 2 weeks postpartum is normal

bleeding 2 weeks indicate placental site subinvolution
- retention of small placental fragments
(estimate blood loss and then perform a pelvic examination top check for uterine subinvolutionor tenderness)

179
Q

Spider veins in pregnancy

A
  • angiomas
  • common findings during pregnancy
  • hyperestrogenemia
  • resolve spontaneously after delivery
180
Q

C section risk in Mother

A
  • Increased risk of maternal mortality
  • thromboembolism
  • haemorrhage
  • infection
  • incidental surgical injuries
  • more postpartum pain
  • adhesions
  • hospital readmission
    -infertility/sub infertility
  • uterine rupture
    -abnormal plancetation
181
Q

C section risk in foetus

A
  • neonatal death
  • reparatory problems
  • asthma
  • iatrogenic prematurity
  • trauma (laceration)
  • breastfeeding failure
182
Q

Risk of asthma in foetus

A
  • C section
  • Smoking
  • avoidance of house dust mite or pet allergens
  • Probiotic dietary supplements, vitamin A, D or E supplements, or fish oil
183
Q

Maternal Vitamin D deficiency

A
  • Hypocalcaemia in newborn.
    – Rickets later in life.
    – Defective tooth enamel.
    – Small for gestational due to effect on skeletal growth
    – Foetal convulsions or seizures due to hypocalcaemia.
184
Q

Pituitary apoplexy features

A
  • sudden haemorrhage
  • excruciating headache
  • diplopia ( oculomotor nerve)
  • life threatening hypotension
  • Fall in ACTH, sortisol
185
Q

Pituitary apoplexy inverstigation

A
  • CT/MRI (MRI for pregnancy)
186
Q

Anticoagulation in pregnancy

A
  • both warfarin and heparin safe to use for breastfeeding mothers
187
Q

Medications safe for breastfeeding

A
  • Beta blockers: Propranolol, labetalol and metoprolol
  • Anticoagulation: Warfarin and Heparin
188
Q

3rd trimester use of anticoagulants

A
  • Both warfarin and heparin can be given to the mother.
  • Heparin doesn’t cross the placenta
  • Heparin is preferred due to the quick reversal by protamine sulphate, compared to warfarin, especially if labour occurs
189
Q

Antenatal thromboembolism management

A

LMWH enoxaparin is treatment of choice
Below knee: 3 months
Above knee: 6 months
Postpartum: 6 weeks

190
Q

Warfarin during pregnancy

A

CONTRAINDICATION
- crosses placenta
1st trimester:
foetal warfarin syndrome:
6-12 weeks’ gestation
- nasal hypoplasia
- short fingers. Hypoplastic nails
- calcified epiphyses (chondrodysplasia)
- intellectual disability
- low birth weight

2nd trimester (>12 weeks):
- microcephaly
- hydrocephalus
- corpus callosum agenesis
- Dandy walker malformation
- mental retardation
-optic atrophy, peter anomaly, microphthalmia
- blindness

191
Q

3rd trimester DVT patient on LMWH protocol

A

Switch to unfractionated heparin (UFH) at 36 weeks to avoid epidural haematoma

192
Q

Pregnancy and DVT

A

Pregnancy is hypercoagulable state due to
- drop in C and S proteins
- increased procoagulant factor V and VII
- antithrombin
- more common in left leg (85%) due to left iliac vein compression

193
Q

antiphospholipid antibody syndrome criteria

A

1 or > 1 foetal losses beyond 10 weeks of gestation

194
Q

antiphospholipid antibody syndrome treatment

A
  • low-dose aspirin (50 to 100 mg per day)
  • Low dose prophylactic LMWH
195
Q

Pulmonary hypertension (PH)

A
  • Contraindicated for pregnancy
  • maternal death 30-56%
  • most dangerous at peripartum period and
    immediate postpartum period (2 months)
  • C section preferred
196
Q

Pulmonary embolism (PE) investigation in pregnancy

A
  • CTPA 1st-2nd trimester (uses less radiation than VQ, therefore safer during pregnancy)
  • Ventilation perfusion 3rd trimester scan (to rule out PE)
197
Q

hypothyroidism in pregnancy

A
  • thyroid gland increases by 15%
  • increased T3 and T4
  • Free T3 and T4 unchanged
  • increases demand of thyroxine by 25-30%
    -TSH should be monitored every 8 to 10 weeks during pregnancy
198
Q

medications safe for hypothyroidism

A

levothyroxine

199
Q

What is elevated during 3rd trimester

A
  • prolactin
  • alkaline phosphatase
  • iron binding capacity
  • cortisol
200
Q

Iron deficiency anaemia (IDA) in pregnancy

A
  • 18% of pregnant women
  • screened at 1st trimester and at 28 weeks
  • 1000–1200 mg iron is required
  • serum ferritin test investigation of choice
  • microsomia
201
Q

Iron deficiency anaemia (IDA) in pregnancy complications

A
  • increases the risk of preterm delivery
  • increases the risk of microsomia or low birth weight
202
Q

Iron deficiency anaemia (IDA) in pregnancy treatment

A
  • routine supplementation not recommended
  • oral iron 20mg/day first line
  • IV iron at 2nd & 3rd trimester
203
Q

Toxoplasma transmission

A
  • unwashed fruits and vegetables
  • untreated water
  • raw meat
  • cat litter
204
Q

Rh -ve woman and anti-D indications

A

1st trimester:
 Chorionic Villus Sampling;
 Miscarriage;
 Abortion (medical after 10 weeks of gestation or surgical)
 Ectopic pregnancy.
 Molar pregnancy
- blood transfusion

Second and third trimester: (basic dose 625 IU)
 Obstetric haemorrhage;
 Amniocentesis or other invasive foetal intervention;
 External cephalic version of a breech presentation, whether successful
or not
 Abdominal trauma, or any other suspected intra-uterine bleeding or sensitising event.
 Abortion

205
Q

Molar pegnancy

A
206
Q

What type of twins will get blood to blood transfusion

A

monochorionic

207
Q

Antepartum haemorrhage

A
  • after 20 weeks
  • placenta previa
  • vase previa
  • placental abruption
  • cervical previa (cancer
208
Q

Postpartum haemorrhage blood loss

A

vaginal 500ml - balloon, uterine ligation, hysterectomy
C sec 1L

209
Q

Postpartum haemorrhage causes

A

Primary/secondary

tone
trauma
tissue
thrombin
Product of conception

  • Uterine atony (most common) 70%
  • Genital Tract trauma/laceration 20%
  • Retained products of conception/invasive placenta 10%
  • Coagulation abnormalities <1%
210
Q

Postpartum haemorrhage management

A
  • atony: fundal massage + oxytocin
    maintained placenta - exploration under anaesthesia to remove
    laceration - repair

if unstable:
DRABCD
oxygen
blood match

redue

211
Q

Postpartum haemorrhage predisposing factors

A
  • Antepartum haemorrhage (especially placental abruption and placenta praevia)
  • Postpartum haemorrhage with a previous pregnancy
  • Known placenta accreta
  • Multiple pregnancy
  • Coagulopathies
212
Q

Most common cause of postpartum haemorrhage requiring
hysterectomy?

A

Placenta accreta due to deep invasion to the uterine wall not the myometrium

213
Q

Hysterectomy reasons

A

Placenta accreta
Gas gangrene (clostridia 5-10%)
haemolysis
renal failure

214
Q

Postpartum depression risk

A

20%

215
Q

When to discontinue epileptic medication

A
  • seizure free at least 2 years
  • no epileptic activity on EEG
  • no neurological finding
216
Q

Lithium in pregnancy

A
  • Cause of Ebstein anomaly
  • in cases of severe bipolar disorder, lithium may outweigh the risks
  • Lithium use during the first trimester of pregnancy has been reported to be associated with foetal cardiovascular
    anomalies (e.g. Ebstein’s anomaly) and midfacial and other defects.
    MOnitor every 4 weeks
    may change to quetiapin or olanzapine
217
Q

Risk of developing Ebstein’s anomaly on patients on lithium?

A

approximately 1 in 1000 to 2000
compared with 1 in 20000 in the general population.

218
Q

If patient continues to use lithium during pregnancy, what should be investigated?

A

an ultrasound and echocardiogram should be performed at 16-20weeks gestation to exclude foetal anomalies, especially cardiac anomalies

219
Q

In relation to lithium dosage during pregnancy, what should be done in each trimester?

A

1st trimester: keep same dose as before pregnancy but heavily monitor foetus by US at 16-20 weeks.
2nd trimester: continue same lithium dosage.
3rd trimester: decrease lithium dosage by 25% to avoid floppy baby syndrome due to neonatal toxicity.
Stop lithium during labour
After delivery immediately increase lithium dosage due to
increased risk of relapse in postpartum period.

220
Q

Sodium Valproate in pregnancy

A

1st trimester: decrease dose to prevent neural tube defects
2nd semester: continue decreased dosage through to 3rd semester
3rd trimester: increase the dosage to prevent seizures

221
Q

Which SSRI is contraindicated in pregnancy

A

Paroxetine

222
Q

HIV screening

A
  • First antenatal visit
223
Q

Risk of HIV transmission to foetus

A

20-30%

224
Q

Perinatal HIV transmission interventions

A
  • assess mother’s viral load:
  • if viral load >1000 copies/mL/unknown then intrapartum zidovudine and elective C section
  • If mother hasn’t taken antiretroviral therapy (including only intrapartum) add lamivudine plus nevirapine to zidovudine
  • if viral load <1000 copies/mL then no retroviral therapy needed, allow for vaginal delivery
  • peripartum intravenous zidovudine
  • Elective C section
  • Bottle feeding

Intervention decreases risk to <2%

225
Q

Herpes (HSV) during pregnancy

A
  • Usually asymptomatic 75%
  • acyclovir before delivery recommended
  • Foetal infection risk significantly higher in primary infection
  • Presence of lesions on the genital (vulva, cervix) require immediate C section
  • <30 weeks, risk of shedding during normal birth is 7% with an overall risk of <3% for neonatal HSV
226
Q

Which heart disease can lead to significant complication during pregnancy

A

Mitral stenosis secondary to pulmonary hypertension

227
Q

Postpartum fever

A

38.7 for the first 24 hours, > 38 after 10 days post.
Depends fever onset and uterine tenderness:

  • endometritis= uterine tenderness with/o lochia
  • UTI: 1-2 postpartum and urinary symptoms (dysuria)
  • Wound infection: 4-5 days
  • Septic thrombophlebitis: 5-6 days
  • breast engorgement: 7-21 days
    -atelectasis: 1st 24 hours
228
Q

Postpartum fever management

A

Amoxicillin + metronidazole + gentamycin
IF CI: vancomycin

229
Q

Most common pathogen of septic shock

A

Escherichia coli

230
Q

Smoking complications during pregnancy

A

Obstetric
- abortion/miscarriage
- placental abruption
- placenta previa
-preterm birth < 37 weeks
pre-eclampsia
-PROM
-ectopic pregnancy
- Still birth

foetal
- low birth weight -
- Intrauterine growth restriction
- birth defects

Childhood/adult
- SIDS
- developmental delay
- Type 2 DM
- Obesity
- hypertension
- decreased HDL

231
Q

Foetal alcohol syndrome (FAS)

A
  • Small teeth/faulty enamel
232
Q

Hypertensive medication in pregnancy

A

Most are contraindicated
- ACE inhibitors
-ARB’s
-Diuretics (1st sem teratogenic, 2-3 sem foetal renal dysfunctions, oligohydramnios, skull hypoplasia)
- Beta blockers (foetal bradycardia, growth restriction)

recommendation: Methyldopa, if contraindicated due to other reasons then hydralazine or labetalol

233
Q

acute antihypertensive therapy in pregnancy

A
  • Intravenous labetalol unless in patients with bradycardia (ie, <60/min)
  • Intravenous hydralazine if bradycardia is present
  • Oral nifedipine unless px nausea/vomiting
234
Q

Tocolysis contraindications

A
  • Gestation > 34 weeks or <24 weeks
  • Labor is too advanced - advanced cervical
    dilation (>4cm)
  • Chorioamnionitis
  • In utero foetal death
  • Abnormal CTG suggesting non-reassuring foetal
    Status
  • Lethal foetal anomalies
  • Intrauterine foetal demise
  • Suspected foetal compromise
  • Significant antepartum haemorrhage, such as
    placental abruption/ active vaginal bleeding
  • Suspected intrauterine infections (e.g.
    chorioamnionitis)
  • Maternal hypotension
  • Haemorrhage with hemodynamic instability
  • Pregnancy-induced hypertension/ eclampsia/
  • pre-eclampsia
  • Placenta previa
  • Placental insufficiency
  • Intrauterine growth retardation
    – Congestive cardiac failure.
    – Diabetes mellitus
  • Severe pre-eclampsia
  • Maternal allergy to specific tocolytic agents, or
    where tocolytics are contraindicated due to
    specific co-morbidities (e.g. beta agonists should
    not be given in case of cardiac disease)
235
Q

Tocolysis medication

A

1st choice: nifedipine
2nd: salbutamol and terbutaline
3rd: Ato Sibam (oxytocin antagonist)

236
Q

Salbutamol contraindication

A

– Hyperthyroidism.
– Foetal cardiac disease.
– Maternal cardiac disease.
– Insulin-dependent diabetes mellitus

237
Q

Salbutamol side effects

A

– Hyperglycaemia.
– Hypokalaemia.
– The maternal tachycardia.
– Pulmonary oedema.
– Hypotension.
– Tremors

238
Q

Tocolysis in px with mitral stenosis

A

Ato Sibam (oxytocin antagonist) —> CHECHK this info
- Magnesium sulphate (stabilises cardiac membrane & also decreases uterine contractions)

239
Q

trauma px monitoring

A
  • Minimum 24 hrs

look for:
-Regular uterine contractions
-Vaginal bleeding
- non-reassuring foetal heart rate tracing
- Abdominal/uterine pain
- Significant trauma to the abdomen

240
Q

Cervical cerclage indication

A

History: 12-14 weeks
- Two or more second trimester pregnancy
losses
- Each loss earlier than the previous pregnancy

Ultrasound: 14-26 weeks
- progressive cervical shortening on serial ultrasounds
- external os is closed

Rescue:
- Cervix dilated > 2 cm no perceived uterine contractions
- > 50 % Premature cervical effacement
- Increased pelvic pressure
-Heavy mucoid vaginal discharge / bulging membranes through the cervical os

241
Q

Breech presentation factors

A

Maternal:
Nulliparity
Previous breech birth
Uterine (anatomical) anomaly
Placental abnormalities (previa, cornual)
Oligohydramnios
Polyhydramnios
Multiple pregnancy
Grand multiparity

Foetal:
- Extended foetal legs
- Short umbilical cord
- Early gestation
- Foetal abnormality
- Poor foetal growth

242
Q

Breech presentation contraindications

A
  • Cord presentation
  • Any presentation other than frank or complete
    -breech with a flexed or neutral head attitude
  • Clinically inadequate maternal pelvis
  • Foetal anomaly incompatible with vaginal delivery
  • The foetal weight less than 2500g or over 3800g
243
Q

Types of breech presentation

A
  • Frank breech: The foetal hips are flexed, and the knees extended.
  • Complete breech: The foetus seems to be sitting with hips and knees flexed.
  • Footling breech: One or both legs are
    completely extended and present before the
    buttocks.
  • Kneeling breech: The baby is in a kneeling
    position, with one or both legs extended at the
    hips and flexed at the knees.
244
Q

Breech presentation management

A
  • external cephalic version if not at term < 36 weeks
  • if in labour and/or >37 weeks: elective C-sec

Don’t allow for vaginal delivery

245
Q

Pregnancy supplementation

A

-folic acid (0.5-5mg depending on situation)
- 150mcg iodine throughout pregnancy

246
Q

Breastfeeding contraindication

A

Breast abscess
HIV

247
Q

Stroke in pregnancy

A

Usually SAH
CT (cover the uterus)

248
Q

Ectopic pregnancy (EP) features

A

-most common exam finding: Marked rebound tenderness in the suprapubic region
with only little or absent guarding
- cervical motion tenderness
- PID major predisposing factor

249
Q

Glucosuria in pregnancy

A
  • Common
  • increased GFR
  • decreased tubular reabsorption of filtered glucose
  • Common in 1/6 women
250
Q

Features of parvovirus

A

also known as fifth disease or slapped cheek syndrome
- fetal parvovirus syndrome.

251
Q

Hydrops fetalis features

A

abnormal accumulation of
fluid in 2 or more foetal compartments including:
- ascites
-pleural effusion
- pericardial effusion
- skin oedema

252
Q

Hydrops fetalis causes

A

-Haemolytic disease of the newborn
-Severe anaemia.
-Chromosomal abnormalities.
-Congenital heart disease.
Effects of tobacco smoking during pregnancy include:
-Premature birth,
-Placental abruption (double the risk for smokers who consume more than 20 cigarettes a day)
-Spontaneous abortion.
-Low birth weight.
-Stillbirth.
-Placenta praevia

253
Q

parvovirus screening

A

IgM- IgG- - mother not immune, infection possible = repeat serology in 2 weeks
IgM+ IgG-: infection established = foetal monitoring 1- 2 weeks for next 6-12 weeks
IgM+ IgG+: infection established = foetal monitoring 1- 2 weeks for next 6-12 weeks
IgM- IgG+: mother immune = reassurance

254
Q

GBS sepsis risk factors

A
  • Maternal fever more than or equal to 38°C
    either intrapartum or within 24 hours of giving birth
  • Group-B streptococcus bacteriuria and colonization in current pregnancy
  • Rupture of membranes prior to birth for more than 18 hours
    -Preterm labour (less than 37 weeks)
  • Previous GBS related early onset sepsis
255
Q

asymptomatic bacteriuria treatment

A
  • first-line: cephalexin 500mg orally, 12 hourly for
    10 days (category A)
  • Second-line: nitrofurantoin 50mg orally, 6 hourly for 10 days (category A)
    Trimethoprim 300 mg oral daily for 5 days **(avoid 1st trimester due to folic acid deficeiency)
  • Third-line: amoxicillin + clavulanate 500+125mg
    orally, 12-hourly for 10 days (category B1)
  • Augmentin if px allergic to penicillin
256
Q

asymptomatic bacteriuria complication

A
  • acute pyelonephritis 50%
  • acute cystitis 30%
257
Q

asymptomatic bacteriuria pathogen

A

Escherichia coli 80%
Staphylococcus Saprophyticus 5-10%

258
Q

asymptomatic bacteriuria treatment indication

A

Pregnant women
Elderly

259
Q

Types of episiotomy

A

1st degree: tear involves the vaginal mucosa or perineal skin only
2nd degree: underlying subcutaneous tissue is also involved
3rd degree: rectal sphincter is affected
4th degree: extends into the rectal mucosa

260
Q

GBS treatment

A

IF vaginal discharge but no urinary symptoms: no treatment necessary
Vaginal discharge WITH urinary symptoms: IV penicillin (clinda if CI) 5-7 days
- Consult with Obstetrician
- Commence parental treatment in labour and IM (penicillin) injection to the baby after delivery is sign of infection

261
Q

Asymptomatic bacteriuria vs GBS

A

Asymptomatic bacteriuria doesn’t present with vaginal discharge as well as no urinary symptoms.
Treatment cephalexin

GBS comes with vaginal discharge with/o urinary symptoms

262
Q

GBS screening

A

35-37 weeks

263
Q

Hepatitis B (HBV)

A
  • HBsAg-positive with high viral load should be offered antiviral therapy during late pregnancy to
    reduce viral load before delivery
  • amniocentesis is probably safer than CVS
  • Universal screening for Hepatitis B is recommended for all pregnant women,
    regardless of previous testing or vaccination
264
Q

Hepatitis C (HCV) in pregnancy

A
  • **PCR test for HCV RNA **
  • liver function tests (LFT) for concomitant HIV
  • transmission rate to foetus is 5%
  • co-infection with HIV, transmission rate increases to
    25%. (avoid foetal blood sampling/foetal scalp electrode)
  • Infant HCV screening at 12-18months
  • Ribavirin teratogenic
265
Q

HCV contraindications

A
  • C section
  • amniocentesis
  • FBS
  • amniotomy
266
Q

Down syndrome screening

A

Combined test has blood test and U/S
∗ Blood test- done between 9-11 weeks
∗ Estimates 2 maternal blood factors
∗ Beta HCG- increased
∗ PAPP-A- decreased
∗ U/S called nuchal translucency scan(NT NB scan) done
between 11- 14 weeks
∗ Also detects trisomy 18
∗ Second best non invasive test for assessing risk for Down’s
∗ Detection rate- 87%

267
Q

Down syndrome screening- second

A

∗ Blood tests done between 15-17 weeks
∗ NIPT
∗ Quadruple test
∗ 4 maternal blood factors are assessed
∗ Beta HCG- increased
∗ Inhibin A- increased
∗ Alpha feto protein- decreased
∗ Oestriol- decreased
∗ Triple test
∗ Detects above factors except inhibin A
∗ Detection rate for triple test is 67- 71%
∗ Detection rate for quadruple is 81%

268
Q

Down syndrome screening

A

Chorionic villous sampling ( CVS)
Done between- 10-12 weeks
∗ Risk of miscarriage- 1 in 100
Second trimester up to 20 weeks
Amniocentesis
∗ Done between 15- 20 weeks
∗ Risk of miscarriage is 1 in 200
∗ Safest and most accurate diagnostic tool
∗ Amniotic fluid can also be analysed for elevated levels of alpha fetoprotein
and acetyl choline esterase for neural tube defect screening
∗ Percutaneous umbilical blood sampling or cordocentesis gives most
accurate diagnosis but not commonly used as it carries risks

269
Q

Most accurate test for Down syndrome

A

Amniocentesis at 16 weeks

270
Q

Worst drug for pregnancy

A

Cocaine:
most severe neurological defects
Increased ICH

271
Q

most important single warning sign of diminishing blood volume within the first four hours postpartum?

A

Tachycardia

272
Q

risk of unplanned pregnancy

A

– Rural or remote residents.
– Sexual abuse survivors.
– Early age at first sexual intercourse.
– Aboriginal and Torren Street islander.
– Disrupted home and family life.
– Teenage mothers.
– Inconsistent use of contraceptives

273
Q

Planned home birth hospital transfer

A

delayed first/2nd delivery

274
Q

Causes of Oligohydramnios

A
  • Prolonged pregnancy
  • Pre-eclampsia
  • Congenital infections (CMV, toxoplasmosis)
  • Placental insufficiency
  • Nsaid, ACE
275
Q

Complications of oligohydramnios

A

∗ IUGR
∗ Limb contractures
∗ Preterm delivery
∗ Cord compression during labour

276
Q

Olighydramnion - Clinic

A

Clinical presentation
∗ Sense of decreased fetal movement
Examination
∗ Uterus smaller than dates
Investigations
∗ U/S every 1- 3 weeks
∗ Doppler U/S if utero placental insufficiency is suspected
∗ CTG
∗ TORCH screen

277
Q

Causes of Polyhydramnios

A

Definition
∗ If amniotic fluid > 2000 ml or AFI >/= to 24 cm
Causes
∗ Multiple pregnancy
∗ Gestational DM
∗ Fetal malformations ( GI obstruction, brain and spinal
cord defects)
∗ Fetal infections- CMV, toxoplasmosis, rubella, syphilis
∗ Chromosomal abnormalities- Down’s
∗ Placental tumours

278
Q

Polyhydramnion -Clinic

A

Clinical presentation
∗ Abdominal distention more than usual
∗ Dyspnoea
∗ Swelling of legs
∗ Varicosities
Examination
∗ Fundus larger than dates
∗ Fluid thrill may be positive

279
Q

-

Polyhydramnion - Management

A
  • **Mild ** no treatment
  • If SOB or abdominal pain

Medications- Indomethacin to decrease urine production in baby. Not given after 31 weeks of pregnancy. Due to risk of heart problems in fetus, ECHO and Doppler U/S needs
to be done. Complication is premature closure of PDA

  • If AFI >40, indomethacin C/I, severe symptoms
    ∗ Amnioreduction / therapeutic amniocentesis. Can cause preterm labour, PROM and abruptio.
280
Q

chlamydial urethritis treatment

A

Azithromycin 1 g oral

281
Q

Obesity in pregnancy

A

1- Gestational diabetes (GDM)
2- Pre-eclampsia
3- Sleep apnoea
4- Macrosomia (increased baby weight > 4kg)

282
Q

Thyrotoxicosis in pregnancy

A
  • US to differentiate between “hot” and “cold” nodule
  • FNAC after for all cold nodules to establish a
    histopathological diagnosis
283
Q

Meconium stainied liquor

A

greenish fluid

284
Q

Meconium-stained liquor indicates

A

Foetal respiratory distress

285
Q

Continuous CTG

∗ Pelvic examination to assess progress and r/o cord
pro

Meconium-stained liquor management

A
  • CTG remains normal then spontaneous vaginal delivery
  • minor abnormality (early deceleration) on CTG then foetal scalp blood sampling to see blood pH and or lactate level
286
Q

Shoulder dystocia features

A
  • occurs when breadth of the shoulders diameter exceeds the diameter of the pelvic inlet
  • brachial plexus
    palsies including Erb’s palsy (waiter step) (C5-C6 compression)
  • McRoberts manoeuvre ( hyperflexing the mother’s legs tightly to her abdomen) is employed
  • If manoeuvre fails, apply pressure on the lower
    abdomen (suprapubic pressure), and delivered head is also gently pulled. Useful in about 42% of cases.
287
Q

Shoulder dystocia MANAGEMENT mnemonic

A
288
Q

Shoulder dystocia risk factors

A
  • Maternal DM
  • foetal macrosomia
  • Oxytocin augmentation
  • epidural anaesthesia
289
Q

Shoulder dystocia

A
  • anterior more common

Complications
∗ Maternal
3rd or 4th degree perineal tears
PPH
∗ Fetal
Brachial plexus injury like Erb’s palsy
Fracture humerus
Pneumothorax
Hypoxic brain damage

290
Q

Ascaris lumbricoid (Roundworm) treatment in pregnancy

A
  • confirmed by eggs in faeces
  • may develop respiratory tract symptoms
  • gastrointestinal symptoms
  • Pyrantel pamoate 11mg/kg single dose

benzimidazoles absolutely
contraindicated

291
Q

Contraindications for baby discharge

A
  • excessive weight loss >10%
    -excessive weight loss
  • suspected domestic violence
  • court order
292
Q

Which presentation always requires C section

A

Face presentation

293
Q

Most common cause of C section in Aus

A

previous C sec

294
Q

Gestational trophoblastic disease complications

A

– Uterine infection.
– Haemorrhagic shock.
– Sepsis.
– Pre-eclampsia.
– Metastasis to the lungs/breast

295
Q

Gestational trophoblastic disease features

A
  • Hydatidiform mole may be complete with no fetal tissue or incomplete with some fetal tissue
  • vaginal bleeding in early pregnancy (“grape like debris”)
  • Uterus is large for date
  • hyperemesis gravidarum
  • hyperthyroidism
  • high Beta-hCG
  • ultrasound shows “typical snow-storm appearance”
296
Q

Types of Gestational trophoblastic disease (GTD)

A
  • Hydatidiform Moles (HM)
  • Complete HM.
  • Partial HM.
  • Gestational Trophoblastic Neoplasia (GTN)
  • Invasive moles.
  • Choriocarcinomas.
  • Placental-site trophoblastic tumors (PSTT; very rare)
297
Q

Gestational trophoblastic disease treatment

A
  • suction & curettage
  • Consider hysterectomy if patient has completed family
298
Q

Contraindications to vaginal delivery

A

-Cord presentation.
-Foetal growth retardation or macrosomia.
-Any presentation is other than frank or complete breech.
-Clinically inadequate pelvis.
-Extension of the foetal head.
-The foetal anomaly is incompatible with vaginal delivery

299
Q

Contraindication to influenza

A
  • Previous influenza allergy
  • Egg allergy
300
Q

Post maturity labour

A

> 42 weeks
- induce labour

301
Q

Syphilis in pregnancy

A
  • Treponema pallidum
  • spontaneous miscarriage or stillbirth
  • 2 serological tests:
    treponemal tests
    non-treponemal tests
    -routine testing at first
    antenatal contact
  • Prenatal screening tests offered as a choice
302
Q

HPV during pregnancy

A
  • screening done after delivery if urgent can done immediately?
  • vaccination done after delivery
303
Q

Rheumatoid arthritis in pregnacy

A
  • can improve in
    75% of the cases and can get worse in 25%
  • methotrexate and leflunomide contraindicated (folic congenital disabilities)
  • methotrexate can be switched to sulfasalazine
304
Q

Methadone in pregnancy

A
  • Safe at even high doses, can be given during breastfeeding
305
Q

Epilepsy in pregnancy

A
  • 30% increase in seizures/relapse (level of anti-epileptic drugs falls in pregnancy)
306
Q

Epileptic that has the highest rate of congenital malformations

A

Sodium Valproate/Valproic acid

307
Q

Induction of labour gestation in dication

A
  • Wait for spontaneous vagina delivery at 41st week
  • After 41 weeks, induce labour
308
Q

Dizziness, light-headedness,
and syncope at very late stage of gestation

A

significant arterial hypotension resulting from inferior vena cava
compression (supine hypotensive syndrome or inferior vena cava
syndrome)

309
Q

Dead foetus in peripartum management

A
  • If mother asymptomatic: oxytocin and amniotomy
  • if symptomatic: C section
310
Q

Normal weight gain during pregnancy

A

<18.5 kg/m : 12.7-18 kg
18.5-24.9 kg/m : 11.4-15.9 kg
25-29.9 kg/m : 6.8-11.4 kg
≥30 kg/m : 5-9 kg

311
Q

Postcoital bleeding during pregnancy

A
  • cardinal symptom of cervical cancer
    red and inflamed appearance of the cervix (cervical ectropion)
  • HPV and liquid based cytology test
312
Q

Dizygotic twins

A
  • dichorionic and diamniotic placenta regardless of the
    sex of the foetuses
  • placentas of dizygotic twins may be totally separated or
    intimately fused
313
Q

Monozygotic twins

A
  • are always of the same sex but may be
    monochorionic or dichorionic depending upon when the separation of the twins occurred
  • 20% to 30% have dichorionic placentation
314
Q

Sheehan syndrome pathogenesis in pregnancy

A
  • Obstetric haemorrhage complicated by hypotension
  • Postpartum pituitary infarction
315
Q

Sheehan syndrome features in pregnancy

A

Lactation failure (low prolactin)
Amenorrhea, hot flashes, vaginal atrophy (low FSH, LH)
Fatigue, bradycardia (low TSH)
Anorexia, weight loss, hypotension (low ACTH)
Decreased lean body mass (low growth hormone)

316
Q

epidural anaesthesia side effects

A
  • hypotension (Vasodilation and venous pooling)
  • bradycardia
  • respiratory difficulty
  • Leakage of CSF (no hypotension)
317
Q

HPV treatment in prenancy

A

asymptomatic: no treatment needed
symptomatic: large lesions with cryotherapy or keratolytics such as trichloracetic acid (TCA) or bichloracetic acid (BCA)

318
Q

bilateral absence of the vas deferens

A
  • cystic fibrosis
  • sweat chloride test for confirmation
  • for conception/fertility, sperm can be aspirated from the epididymis
319
Q

Which of the following age group of the children is at the highest risk of a serious infection?

A

Less than three months old:
- sepsis,
- meningitis
- pneumonia

320
Q

Most likely cause of occipito-posterior (OP) position in labour

A

Incoordinate uterine action
other causes:
- prolonged labour
- intrauterine infection
- increased analgesia required
- obstructed labour

321
Q

Most common adverse effect of oxytocin

A

foetal distress

322
Q

Most common cause of foetal distress

A

Incoordinate uterine action resulting in occipito-posterior (OP) position in labour

323
Q

occipito-posterior (OP) position in labour features

A

11cm (vs normal 9.5 cm)
- CTG monitoring recommended
even more common if oxytocin & epidural were used (CTG mandatory)
associated with poor quality uterine contraction
- if this is excluded, cephalopelvic disproportion
incoordinate uterine action almost always occurs (AMC Handbook)

324
Q

occipito-posterior (OP) position in labour management

A

Stimulate labour:
- amniotomy
- oxytocin
Epidural (often necessary)
C-sec (in case of obstructed labour/foetal distress)

325
Q

Causes of dyspareunia

A

atrophic vaginal epithelium
- low oestrogen level due to high prolactin level

326
Q

Premature delivery risks

A

Positive foetal fibronectin test

Previous premature delivery

Increased uterine size
- foetal macrosomia
- polyhydramnios
- multiple pregnancies

shortened cervix
- <1.5cm in length

Opened cervix
- open internal os

bacterial vaginosis only if
- in case of increased cervical length
- open cervix

327
Q

Multiple pregancies complications

A
  • IUGR
  • monochorionic twins twin to twin transfusion
328
Q

Twin to twin transfusion ( TTTS)

A
  • mono chorionic twins
    ∗ Acute TTTS is a transfusion that happens quickly, without much warning and can happen during pregnancy or at the time of labour in a vaginal birth
  • due to discordant amniotic fluid.
  • Mom presents with a feeling of rapid growth
    of uterus, abdominal pain or tightness
    ∗ Chronic TTTS is more common that happens over time with signs on ultrasound scan usually by 15 to 20 weeks
    ∗ Confirmation : Doppler Ultrasound

∗**Treatment **
1. early delivery if twins are of sufficient maturity
2. amnio reduction from the fuller sac
3. Laser treatment to seal off vessels in the placenta rendering the blood flow to both twins more equal

329
Q

Rf for Placenta praevia

A

high parity
multiple pregnancy
advanced maternal age
chronic HT
Smoking/Cocain abuse
Previouse C Section

330
Q
A
331
Q

Multiple pregnancy - Vaginal Birth

A

∗ Diamniotic
∗ Twin 1 is cephalic
∗ Twin 2 not > 500gm than 1st
∗ No maternal or fetal complications
∗ Elective induction from 37 weeks
∗ If twin 2 is breech, attempt Internal cephalic version and breech extraction

332
Q

Multiple birth - C- Section

A

∗ Mono amniotic twins
∗ If twin 1 is breech
∗ Twin 2 bigger than twin 1
∗ Maternal or fetal complications
∗ Other abnormal presentations and lies.

333
Q

MC Roberts Manoever

A
  • flexion and abduction of maternal hips, positioning
    maternal thighs on her abdomen. This straightens
    lumbosacral angle and increases A-P diameter of
    pelvis.
    ∗ Suprapubic pressure applied to fetal anterior
    shoulder
    ∗ Traction in axial direction applied to fetal head
    ∗ Internal rotational manoeuvres if above fails
334
Q

Contraindication for Tocolysis

A

∗ Acute fetal distress
∗ Fetal death
∗ Fetal maturity
∗ Chorioamnionitis
∗ Severe P E T/ Eclampsia
∗ Maternal haemodynamic instability as in
APH antepartum Haemorrage
∗ Cervix dilated >5cm and 75% effaced
∗ C/I to specific tocolytic

335
Q

Cervical Incompetence

A
336
Q

Cord prolapse - clinical presentation

A

∗ If fetal heart becomes abnormal after ROM, suspect
cord prolapse
∗ CTG : bradycardia
severe variable decelerations
∗ Diagnosis is made by visual inspection or by
palpation during vaginal examination

337
Q

Cord Prolapse - MX

A
  • Place patient in either knee to chest position or alternatively in exaggerated Sims position
  • Manual elevation of presenting part which is pushed out off pelvis upward, by fingers in the vagina
338
Q

IUGR - US

A

U/S biometry fortnightly- gold standard
∗ Bi parietal diameter, head circumference, abdominal circumference and femur length
∗ Abdominal circumference below 2.5 percentile is the most sensitive indicator of IUGR
Ratio of HC/AC
∗ will drop almost linearly from 1.2 to 1.0 between 20 and 36 weeks normally
∗ In symmetrical( chromosomal anomely) IUGR, this is normal
∗ In asymmetrical (Undernourished), this is elevated Estimation of amniotic fluid volume
∗ Decreased volume is closely associated with IUGR

339
Q

Decreased fetal movement

A

DFM ATER 28 WEEKS
∗ FHR checked with hand held Doppler
∗ If FHR detected, a CTG for at least 20 minutes should be performed to exclude fetal compromise to detect FH beat and FHR pattern
∗ If presence of FH beat is not confirmed, absent or still in doubt, then immediate ultrasound scan should be done to diagnose or exclude IUD
∗ If FHR absent
∗ Testing for feto maternal haemorrhage should be considered as part of preliminary investigation by flow cytometry or Kleihauer test
DFM
Ultrasound assessment should be done within 24 hours

340
Q
A
341
Q
A
342
Q

NIPT ( Non Invasive prenatal test)

A

∗ Maternal blood test from 10 weeks
∗ Test for DNA of baby
Checks for
∗ Other trisomies 13 (Patau syndrome) / 18 (Edward’s)
∗ Sex chromosome aneuploidies like Turner’s ( 45 XO), Klinefelter’s
(47XXY) Triple X syndrome (47XXX) Jacob’s syndrome( 47XYY) and
22q11.2 microdeletion causing heart defects and intellectual
disability
∗ Can identify sex of baby
∗ 99% detection rate
∗ Expensive not covered under Medicare

343
Q
A
344
Q

Mastitis - MX

A

∗ Continue breast feeding from affected breast
∗ Place hot washers over breast before starting to feed and cold
packs after feeding
∗ Antibiotics- Dicloxacillin/ flucloxacillin/ cephalexin for 5 days
∗ Analgesics
∗ Check breast feeding technique
∗ Review in 24- 48 hours
∗ Basic blood tests and U/S if doubtful of breast abscess or in 48
hours if mastitis is not responding to antibiotics
∗ If Candidial mastitis-Fluconazole orally

345
Q

Breast Abscess MX

A
  • Basic bloods, U/S
    ∗ If small, aspiration or incision and drainage under
    anaesthesia
    ∗ If large, surgical drainage and drain under anaesthesia
    ∗ Antibiotics/ analgesics
    ∗ Hydration
    ∗ Might need temporary weaning from affected breast
    ∗ Breast needs to be kept well drained using breast pump
346
Q

Breast Abscess

A

∗ If mastitis is not treated, it becomes breast abscess
∗ Tenderness and redness persisting beyond 48 hours
∗ Patient presents with fever, chills, tiredness, muscle
aches and pains and also painful lump
∗ Lump is tense, cystic, fluctuant, tender, indurated with warmth and erythema

347
Q

Contraception

A

Contraception
∗ No COC if breast feeding
Options if breast feeding
∗ Mini pills
∗ Depo MPA
∗ Implanon
∗ IUCD
∗ Barrier methods

348
Q
A
349
Q
A
350
Q

First stage of labour

A

∗ cervix starts to soften and open and
becomes complete when cervix has opened around
10 cm
∗ Has latent, active and transition phase

351
Q

Latent stage of labor - Delay

A

∗ If <4 cm dilatation of cervix up to 12 hours
Management
∗ CTG monitoring of baby
∗ If cervical dilatation less than 4 cm, consider ARM or
oxytocin infusion

352
Q
A
353
Q

ACTIVE FIRST PHASE OF LABOUR

A

Characters
∗ Contractions become more intense and regular
comes every 3 to 5 minutes and lasts for 45- 60 secs.
∗ Cervical dilatation from 4 to 7 cm
∗ Lasts for 3 to 5 hours
Delay in active first stage
∗ If cervical dilatation is <2 cm in 4 hours

354
Q

ACTIVE FIRST PHASE OF LABOUR Primigravida

A

In primigravida
∗ ARM
∗ Repeat vaginal examination after 2 hours of ARM
∗ If no progress, give oxytocin infusion, if no mal
presentations, foetal compromise or obstructed labour
∗ Do vaginal examination after 4 hours of oxytocin
∗ If <2 cm progression after 4 hours , deliver by C-section
∗ If >2cm dilatation, repeat vaginal examination 4 th hourly

355
Q

ACTIVE FIRST PHASE OF LABOUR Multigravida

A

In multigravida
∗ ARM
∗ Repeat VE after 2 hours of ARM
∗ If no progress give oxytocin infusion, if parity is less
than 5, unscarred uterus, contractions less than 3-4 in
10 minutes and lasting less than 60 seconds
∗ Repeat VE after 2 hours of oxytocin infusion
∗ If <2cm dilatation after 2 hours, C-section

356
Q

Transition Phase of first Stage

A

Characters
∗ Contractions every 30 secs to 2 minutes lasting for
60- 90 secs
∗ Cervix dilated from 8 to 10 cm
∗ Lasts for 30 seconds to 2 hours
∗ Total duration of first stage is from 8 to 12 hours
∗ ROM happens anytime during first stage

357
Q

Second Stage- Passive second stage

A

Characters
∗ During this time, presenting part descends towards
pelvic outlet and rotation and flexion occurs
∗ Full dilatation of cervix
∗ Regular contractions but no urge to push

∗ If no urge to push after 1 hour
Management
∗ Oxytocin augmentation after ruling out CPD,
obstructed labour, full bladder, malpresentations

358
Q

Second Stage- Passive second stage

A

Characters
∗ Urge to push or expulsive contractions
∗ Full dilatation of cervix
∗ Presenting part of baby becomes visible
∗ Normal duration is 5 to 30 minutes

Delay
In primi
∗ if > or = to 2 hours without epidural and > 3 hours with epidural
In multi
∗ if > or = to 1 hour without epidural and 2 hours after epidural
Management
∗ Continuous CTG monitoring of baby
∗ If no urge to push and uterine contractions inadequate give oxytocin

359
Q

Third stage of labour

A

∗ From birth of baby to expulsion of placenta and
membranes
∗ Give oxytocin 10 IU I/M immediately after birth of
anterior shoulder of baby. In breech give after
delivery of baby
∗ If at high risk of PPH ( big baby, episiotomy, history of
PPH) give oxytocin 5 IU + ergometrine 0.25 mg. This is
contraindicated if there is PET, HT, cardiac/ hepatic/
renal disorders

If not complete by 30 minutes or if there is signs of
PPH
∗ Management depends on cause

360
Q
A
361
Q

Varizella Treatment IgG- IgM-

A

Determine time of exposure
within 96 hours
varicella zoster immunoglobulin tomother
∗ Highly effective if given within 96 hours
∗ Limited effect as late as 10 days post exposure

more than 96 hours
∗ Oral acyclovir or valaciclovir should be considered for women in
∗ second half of pregnancy
∗ h/o underlying lung disease
∗ Immune comprised
∗ Smokers

362
Q

Hyperemesis - Association

A

∗ Normal pregnancy- 10%
∗ Molar pregnancy
∗ Multiple pregnancy
∗ Urinary infection
Exclude other pathological causes like
∗ Sepsis
∗ Cholecystitis, peptic ulcers, appendicitis,
gastroenteritis, hepatitis
∗ Eating disorders

363
Q

Hyperemesis - commendest symptom

A

severe, constant nausea and vomiting

364
Q

Chlamydia Urethritis

A

Azithromycin 1g single dose

365
Q

Hyperemsis - Investigation

A

**∗ Transvaginal U/S
Exclude molar pregnancy, multiple pregnancy
∗ Urine dipstick
for UTI/ ketones
∗ Urine MCS
∗ Blood
FBE
U,C& E- first line investigation
LFT
Initial investigations- serum electrolytes, urinary ketones

AMC (7 decks)

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