Obstetrics Flashcards

Question

Teenage pregnancy complication

Answer 1

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

Answer 2

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

Answer 3

- PAINFUL vaginal bleeding or without bleeding (concealed bleeding) - uterine tenderness - foetal compromise on CTG

Answer 4

- 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

Answer 5

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

Answer 6

Wait one menstrual period after abortion

Answer 7

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

Answer 8

70000-100000/mm3

Answer 9

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

Answer 10

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

Answer 11

- 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

Answer 12

>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.

Answer 13

BP > 160/110mmHg + proteinuria

Answer 14

gestational hypertension acute fatty liver

Answer 15

>300g protein in 24hr urine

Answer 16

Used to diagnose pre-eclampsia - >30mmol

Answer 17

- 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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

- Cease as it can increase risk of postpartum depression - Switch to enalapril - Add nifedipine if above don't work (acts very quickly)

Answer 23

- mild/asymptomatic thrombocytopenia - no past hx (unless previous pregnancy) - no foetal thrombocytopenia association - spontaneous resolution upon delivery

Answer 24

- 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

Answer 25

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

Answer 26

- usually clears up rapidly after delivery - often recurs in future pregnancies or using OCP (which are contraindicated)

Answer 27

- relieve bile acids with ursodeoxycholic acids - antihistamine/emollients

Answer 28

- foetal distress/death - preterm delivery - meconium ingestion - meconium aspiration syndrome

Answer 29

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

Answer 30

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

Answer 31

- ascites - pancreatitis - liver encephalopathy - disseminated intravascular coagulation (DIC)

Answer 32

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

Answer 33

Liver biopsy confirms dx

Answer 34

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

Answer 35

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

Answer 36

- Variable decelerations - persistent foetal bradycardia - prolonged decelerations for over 1 minute

Answer 37

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

Answer 38

- 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

Answer 39

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

Answer 40

1st trimester if no prior/uncertain history

Answer 41

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

Answer 42

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

Answer 43

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.

Answer 44

- Varicella Zoster (chicken pox) - Rubella - Measles

Answer 45

- can give vaccine - usually recommended at 28 weeks

Answer 46

- uterine stimulation - antidiuretic - mammary gland stimulation - labor induction

Answer 47

- Dairy: soft cheese, soft serve ice cream, unpasteurised - Smoked salmon, trout

Answer 48

Listeriosis (meningitis, meningoencephalitis)

Answer 49

PPROM ( premature) - <37 weeks

Answer 50

- 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

Answer 51

- fluid loss - urinary incontinence -

Answer 52

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

Answer 53

**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

Answer 54

* 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

Answer 55

* **< 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

Answer 56

∗ 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

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

* 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

Answer 61

- pre-eclampsia - IVF - IUGR - Cephalic presentation

Answer 62

- Signs of chorioamnionitis - antepartum haemorrhage - request of mother - neonatal jeopardy

Answer 63

- 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

Answer 64

- ++ 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

Answer 65

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

Answer 66

- chorioamnionitis (absolute)

Answer 67

- Notifiable disease therefore contact tracing - **Immunoglobulin is used as prophylactic only, not for established** - symptomatic treatment

Answer 68

10-14 days

Answer 69

- 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**

Answer 70

- Otitis media 7% - Bronchopneumonia 6% - acute encephalitis 2-10/10000

Answer 71

- preterm labour - spontaneous abortion - foetal/neonatal loss - maternal mortality

Answer 72

- separation of placenta from uterus - 3rd trimester bleeding - foetal morbidity and mortality - MVA

Answer 73

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

Answer 74

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

Answer 75

- 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

Answer 76

- 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)

Answer 77

- <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

Answer 78

Reassure if not exposed to Rubella

Answer 79

- 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

Answer 80

- 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

Answer 81

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

Answer 82

- pregnant uterus entrapped in the pelvis by subpromontary sacrum - retroverted uterus?

Answer 83

- < 3cm conservative management - > 3cm surgical excision/exploration

Answer 84

- Hypokalemia - On ECG: such as inverted T waves and prolonged QT and PR intervals

Answer 85

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

Answer 86

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

Answer 87

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

Answer 88

- 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)

Answer 89

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

Answer 90

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

Answer 91

- Check TSH and free T4 foetus: - foetal tachycardia - small gestational size - premature/stillborn - Graves - if px

Answer 92

- 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

Answer 93

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

Answer 94

IV diazepam with Magnesium sulphate (phenytoin teratogenic)

Answer 95

- 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

Answer 96

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

Answer 97

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

Answer 98

- maternal primary infection often asymptomatic - IgG seropositive up to 50% of pregnant women - Transplacental foetal infection is 50% with primary infection

Answer 99

- retardation - microcephaly - seizures - hearing deficits - chorioretinitis - optic atrophy - brain architectural changes

Answer 100

combination of foetal ultrasound, amniocentesis + /- foetal serology **definite diagnosis of foetal infection is by amniocentesis**

Answer 101

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

Answer 102

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

Answer 103

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

Answer 104

- Neural Tube Defects (NTD)

Answer 105

- Phenytoin is teratogenic - Enzyme inducer

Answer 106

- 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

Answer 107

- **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

Answer 108

Laparotomy

Answer 109

- uterine atony - amniotic fluid embolism

Answer 110

-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

Answer 111

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

Answer 112

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

Answer 113

- 12 weeks: palpable above the pubis - 20 weeks: level of umbilicus

Answer 114

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

Answer 115

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

Answer 116

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

Answer 117

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

Answer 118

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+)

Answer 119

- 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**

Answer 120

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)

Answer 121

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

Answer 122

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

Answer 123

if well controlled, continue to 40 weeks

Answer 124

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

Answer 125

- 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**

Answer 126

- fever - sore throat - **cervical/ post auricular lymphadenopathy** - characteristic increases in monocytes and lymphocytes - hepatosplenomegaly -hepatic transaminase increase

Answer 127

Symptomatic treatment - Antibiotics in bacterial URTI

Answer 128

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

Answer 129

codeine and metoclopramide

Answer 130

- 2nd trimester -RLQ pain - aggravated by moving - all vital signs normal

Answer 131

- closed cervical os - absent history of passing foetal tissue - uterine size is the expected size

Answer 132

- open cervical os - bulging of membranes of the os < 20 weeks - uterine size is smaller than the expected size

Answer 133

- open cervical os - bulging of membranes of the os >10 weeks - uterine size is smaller than the expected size

Answer 134

- closed cervical os - passing of foetal tissue - uterine size is smaller than the expected size

Answer 135

- uterine infection during any time - vaginal bleeding -cramping pain - fever - purulent cervical discharge

Answer 136

- 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

Answer 137

- 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

Answer 138

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

Answer 139

Transvaginal US at 8 weeks

Answer 140

- cervical insufficiency or labour - placenta previa -placental abruption - uterine rupture - vasa previa

Answer 141

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

Answer 142

-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

Answer 143

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

Answer 144

- Placental abruption - Placenta Previa

Answer 145

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)

Answer 146

- angiomas - common findings during pregnancy - hyperestrogenemia - resolve spontaneously after delivery

Answer 147

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

Answer 148

- neonatal death - reparatory problems - asthma - iatrogenic prematurity - trauma (laceration) - breastfeeding failure

Answer 149

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

Answer 150

- 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.

Answer 151

- sudden haemorrhage - excruciating headache - diplopia ( oculomotor nerve) - life threatening hypotension - Fall in ACTH, sortisol

Answer 152

- CT/MRI (**MRI for pregnancy**)

Answer 153

- both warfarin and heparin safe to use for breastfeeding mothers

Answer 154

- Beta blockers: Propranolol, labetalol and metoprolol - Anticoagulation: Warfarin and Heparin

Answer 155

- 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

Answer 156

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

Answer 157

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

Answer 158

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

Answer 159

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

Answer 160

1 or > 1 foetal losses beyond 10 weeks of gestation

Answer 161

- low-dose aspirin (50 to 100 mg per day) - Low dose prophylactic LMWH

Answer 162

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

Answer 163

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

Answer 164

- 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

Answer 165

levothyroxine

Answer 166

- prolactin - alkaline phosphatase - iron binding capacity - cortisol

Answer 167

- 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

Answer 168

- increases the risk of preterm delivery - increases the risk of microsomia or low birth weight

Answer 169

- **routine supplementation not recommended** - oral iron 20mg/day first line - IV iron at 2nd & 3rd trimester

Answer 170

- unwashed fruits and vegetables - untreated water - raw meat - cat litter

Answer 171

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

Answer 172

monochorionic

Answer 173

* after 20 weeks - placenta previa - vase previa - placental abruption - cervical previa (cancer

Answer 174

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

Answer 175

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%

Answer 176

- atony: fundal massage + oxytocin maintained placenta - exploration under anaesthesia to remove laceration - repair if unstable: DRABCD oxygen blood match | redue

Answer 177

- Antepartum haemorrhage (especially placental abruption and placenta praevia) - Postpartum haemorrhage with a previous pregnancy - Known placenta accreta - Multiple pregnancy - Coagulopathies

Answer 178

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

Answer 179

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

Answer 180

- seizure free at least 2 years - no epileptic activity on EEG - no neurological finding

Answer 181

- 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

Answer 182

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

Answer 183

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

Answer 184

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.

Answer 185

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

Answer 186

Paroxetine

Answer 187

- First antenatal visit

Answer 188

- **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%

Answer 189

- 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

Answer 190

Mitral stenosis secondary to pulmonary hypertension

Answer 191

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

Answer 192

Amoxicillin + metronidazole + gentamycin IF CI: vancomycin

Answer 193

Escherichia coli

Answer 194

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

Answer 195

- Small teeth/faulty enamel

Answer 196

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

Answer 197

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

Answer 198

- 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)

Answer 199

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

Answer 200

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

Answer 201

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

Answer 202

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

Answer 203

- Minimum 24 hrs look for: -Regular uterine contractions -Vaginal bleeding - non-reassuring foetal heart rate tracing - Abdominal/uterine pain - Significant trauma to the abdomen

Answer 204

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

Answer 205

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

Answer 206

- 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

Answer 207

- **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.

Answer 208

- 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

Answer 209

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

Answer 210

Breast abscess HIV

Answer 211

Usually SAH CT (cover the uterus)

Answer 212

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

Answer 213

- Common - increased GFR - decreased tubular reabsorption of filtered glucose - Common in 1/6 women

Answer 214

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

Answer 215

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

Answer 216

-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

Answer 217

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

Answer 218

- 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

Answer 219

- 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

Answer 220

- acute pyelonephritis 50% - acute cystitis 30%

Answer 221

Escherichia coli 80% Staphylococcus Saprophyticus 5-10%

Answer 222

Pregnant women Elderly

Answer 223

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

Answer 224

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

Answer 225

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

Answer 226

35-37 weeks

Answer 227

- 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

Answer 228

- **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

Answer 229

- C section - amniocentesis - FBS - amniotomy

Answer 230

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%

Answer 231

∗ 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%

Answer 232

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

Answer 233

Amniocentesis at 16 weeks

Answer 234

Cocaine: most severe neurological defects Increased ICH

Answer 235

Tachycardia

Answer 236

– 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

Answer 237

delayed first/2nd delivery

Answer 238

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

Answer 239

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

Answer 240

**Clinical presentatio**n ∗ 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

Answer 241

**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

Answer 242

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

Answer 243

* **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.

Answer 244

Azithromycin 1 g oral

Answer 245

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

Answer 246

- US to differentiate between “hot” and “cold” nodule - FNAC after for all cold nodules to establish a histopathological diagnosis NOTE: Radioisotope or radionuclide Technetium uptake scan **absolute contraindication** -

Answer 247

greenish fluid

Answer 248

Foetal respiratory distress

Answer 249

- 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

Answer 250

- 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.

Answer 251

- Maternal DM - foetal macrosomia - Oxytocin augmentation - epidural anaesthesia

Answer 252

* 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

Answer 253

- confirmed by eggs in faeces - may develop respiratory tract symptoms - gastrointestinal symptoms - **Pyrantel pamoate 11mg/kg single dose** **benzimidazoles absolutely contraindicated**

Answer 254

- excessive weight loss >10% -excessive weight loss - suspected domestic violence - court order

Answer 255

Face presentation

Answer 256

previous C sec

Answer 257

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

Answer 258

- 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”

Answer 259

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

Answer 260

- suction & curettage - Consider hysterectomy if patient has completed family

Answer 261

-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

Answer 262

- Previous influenza allergy - Egg allergy

Answer 263

> 42 weeks - induce labour

Answer 264

- 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

Answer 265

- screening done after delivery if urgent can done immediately? - vaccination done after delivery

Answer 266

- 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**

Answer 267

- Safe at even high doses, can be given during breastfeeding

Answer 268

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

Answer 269

Sodium Valproate/Valproic acid

Answer 270

- Wait for spontaneous vagina delivery at 41st week - After 41 weeks, induce labour

Answer 271

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

Answer 272

- If mother asymptomatic: oxytocin and amniotomy - if symptomatic: C section

Answer 273

<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

Answer 274

- cardinal symptom of cervical cancer red and inflamed appearance of the cervix (cervical ectropion) - **HPV and liquid based cytology test**

Answer 275

- dichorionic and diamniotic placenta regardless of the sex of the foetuses - placentas of dizygotic twins may be totally separated or intimately fused

Answer 276

- 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

Answer 277

- Obstetric haemorrhage complicated by hypotension - Postpartum pituitary infarction

Answer 278

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)

Answer 279

- hypotension (Vasodilation and venous pooling) - bradycardia - respiratory difficulty - Leakage of CSF (no hypotension)

Answer 280

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

Answer 281

- cystic fibrosis - sweat chloride test for confirmation - for conception/fertility, sperm can be aspirated from the epididymis

Answer 282

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

Answer 283

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

Answer 284

foetal distress

Answer 285

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

Answer 286

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)

Answer 287

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

Answer 288

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

Answer 289

**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

Answer 290

- IUGR - monochorionic twins twin to twin transfusion

Answer 291

* 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

Answer 292

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

Answer 293

∗ 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

Answer 294

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

Answer 295

* 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**

Answer 296

∗ 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

Answer 297

∗ 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

Answer 298

* 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

Answer 299

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

Answer 300

**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

Answer 301

∗ 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

Answer 302

∗ 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

Answer 303

* 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

Answer 304

∗ 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

Answer 305

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

Answer 306

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

Answer 307

∗ 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

Answer 308

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

Answer 309

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

Answer 310

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

Answer 311

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

Answer 312

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

Answer 313

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

Answer 314

∗ 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

Answer 315

**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

Answer 316

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

Answer 317

severe, constant nausea and vomiting

Answer 318

Azithromycin 1g single dose

Answer 319

****∗ 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**