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Phase 3a🩺 > Obstetrics🤰🏻 > Flashcards

Obstetrics🤰🏻 Flashcards

1
Q

What bacteria causes a group B strep infection in pregnant women?

A

Streptococcus agalactiae

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2
Q

How many women carry GBS asymptomatically?

A

25%

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3
Q

Where does GBS colonise asymptomatically?

A

Gastrointestinal and genitourinary tracts

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4
Q

What are the risk factors for neonatal GBS infection?

A

Positive GBS culture in current or previous pregnancy Previous birth resulting in GBS infection Pre-term labour Prolonged rupture of membranes Intrapartum fever > 38 Chorioamnionitis

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5
Q

What is the presentation of GBS infection?

A

Sepsis Pneumonia Meningitis

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6
Q

How is GBS passed from mother to baby?

A

Vertical transmission of bacteria during childbirth

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7
Q

What is the management of GBS infection during pregnancy?

A

Intrapartum antibiotic prophylaxis - IV benzylpenicillin during labour and delivery

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8
Q

What is pre-eclampsia?

A

New hypertension in pregnancy with end organ dysfunction or proteinuria

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9
Q

What is eclampsia?

A

When seizures develop as a cause of pre-eclampsia

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10
Q

What is gestational hypertension?

A

New hypertension in pregnancy after 20 weeks that is not associated with proteinuria

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11
Q

What is the triad seen in pre-eclampsia?

A

Hypertension Proteinuria Oedema

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12
Q

What is the cause of pre-eclampsia?

A

Pre-eclampsia is caused by poor vascular resistance in the spinal arteries and poor perfusion of the placenta

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13
Q

What are high risk factors for pre-eclampsia?

A

Pre-existing hypertension Pre-eclampsia in a previous pregnancyExisting autoimmune conditions DiabetesCKD

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14
Q

What are moderate risk factors for pre-eclampsia? (4)

A

High BMIAge > 40More than 10 years since previous pregnancy First pregnancy Multiple pregnancy Family history of pre-eclampsia

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15
Q

What may be offered as prophylaxis for pre-eclampsia?

A

Aspirin (from week 12)

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16
Q

Who should be offered prophylaxis for pre-eclampsia?

A

Women with one high risk factor, or multiple moderate risk factors

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17
Q

What are the symptoms of pre-eclampsia?

A

Visual disturbances Headache Nausea and vomiting Epigastric pain Oedema Reduced urine output Brisk reflexes

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18
Q

What is the diagnosis criteria for pre-eclampsia?

A

Hypertension (over 140 systolic or 90 diastolic)PLUS any of:- Proteinuria - Evidence of end organ damage - Placental dysfunction

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19
Q

What are the indicators of organ dysfunction in pre-eclampsia?

A

Raised liver enzymes Thrombocytopenia Raised creatinine Seizures Haemolytic anaemia

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20
Q

What test can be used to rule out pre-eclampsia?

A

Placental growth factor - Tested for in women suspected of pre-eclampsia between 20 and 35 weeks - Levels will be low in pre-eclampsia

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21
Q

What tests are used to monitor pre-eclampsia?

A

Blood pressureSymptom monitoring Urine dipstickUltrasound monitoring of fetus

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22
Q

What is the management of gestational hypertension?

A

Aim for BP 135/85Admission for BP 160/110Urine dipstick testing weekly Bloods weekly PlGF testing on one occasion Serial fetal growth scans

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23
Q

What is the first line pharmacological management of pre-eclampsia?

A

Labetolol

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24
Q

What other anti-hypertensives can be used in the management of pre-eclampsia?

A

Nifedipine - second line Methyldopa - third line

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25
Q

What is the first line management of pre-eclampsia after delivery?

A

Enalapril

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26
Q

What are the second and third line management options for pre-eclampsia after delivery?

A

Nifedipine or amlodipine Labetolol or atenolol

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27
Q

What antihypertensive is given in severe pre-eclampsia or eclampsia?

A

IV hydralazine

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28
Q

What medication is given during delivery and in the 24 hours after to prevent seizures?

A

IV magnesium sulfate

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29
Q

What medication is used to manage seizures associated with eclampsia?

A

IV magnesium sulfate

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30
Q

What are the maternal complications of pre-eclampsia?

A

Eclampsia
HELLP syndrome
Disseminated intravascular coagulation
Organ failure

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31
Q

What are the foetal complications of pre-eclampsia?

A

Intrauterine growth restriction
Pre-term delivery
Placental abruption
Neonatal hypoxia

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32
Q

What is HELLP syndrome?

A

Haemolysis Elevated liver enzymes Low platelets

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33
Q

What is the definitive curative treatment of pre-eclampsia?

A

Delivery of the placenta

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34
Q

What must be monitored whilst magnesium sulfate is given?

A

Respiratory rate due to the risk of respiratory depression as a side effect

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35
Q

How often should women with pre-eclampsia be monitored?

A

They should have U&Es, FBC, transaminases and LFTs three times per week

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36
Q

What is gestational diabetes?

A

Insufficient insulin secretion to compensate for insulin resistance in pregnancyGestational diabetes is diabetes seen for the first time during pregnancy

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37
Q

What are the risk factors for GDM? (4)

A

Previous GDMPrevious macrosomic babyBMI > 30Ethnicity (Asian and Hispanic) Family history of diabetesPCOS

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38
Q

What are the physiological differences in insulin in pregnancy?

A

Increased insulin resistance (in the second and third trimester)

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39
Q

What are the physiological differences in glucose in pregnancy?

A

Fasting and post meal levels of glucose are decreased

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40
Q

What are the symptoms of gestational diabetes?

A

Most women are asymptomatic

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41
Q

What is the main investigation for gestational diabetes?

A

Oral glucose tolerance test

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42
Q

What OGTT results will be seen in a woman with gestational diabetes?

A

Fasting glucose > 5.6 mmol/LAt 2 hours > 7.8 mmol/L

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43
Q

When should OGTT be performed to diagnose gestational diabetes?

A

Between 24-28 weeks

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44
Q

Who is an OGTT performed on?

A

Any woman with risk factors for gestational diabetes, plus anyone with features that suggests gestational diabetes:- Large for dates fetus - Polyhydramnios - Glucose on urine dipstick

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45
Q

What are the fetal complications of gestational diabetes? (4)

A

Macrosomia Pre-term delivery Neonatal hypoglycaemiaIncreased risk of developing type 2 diabetes later in lifeCongenital heart disease Neonatal jaundice

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46
Q

What are the maternal complications of gestational diabetes?

A

Increased risk of hypertension Increased risk of pre-eclampsia Increased risk of developing type 2 diabetes later in life Increased risk of recurrent GDM with next pregnancy

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47
Q

What is the first line management of gestational diabetes?

A

Fasting glucose < 7 mmol/L - trial of diet and exercise Fasting glucose > 7 mmol/L - insulin + metforminFasting glucose 6-6.9 mmol/L with evidence of macrosomia - insulin + metformin

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48
Q

What medication can be used as an alternative to metformin in gestational diabetes?

A

Glibenclamide (sulfonylurea)

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49
Q

What are the target glucose levels for women with gestational diabetes?

A

Fasting - 5.3 mmol/L 1 hour post meal - 7.8 mmol/L 2 hours post meal - 6.4 mmol/L

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50
Q

What type of screening should mothers with pre-existing diabetes be offered during pregnancy?

A

Retinopathy screening when the woman becomes pregnancy, and at 28 weeks

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51
Q

When should women with pre-existing diabetes have given birth by?

A

Between 37 and 38+6 weeks

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52
Q

How long should diet and exercise be trialled in women with gestational diabetes?

A

1-2 weeks - offer metformin if glucose levels have not improvedOffer insulin if glucose levels have still not improved

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53
Q

What medication can be added to insulin in women with gestational diabetes?

A

Metformin

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54
Q

When should pregnant people with previous gestational diabetes be screened during their next pregnancy?

A

At booking, and again at 24-28 weeks

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55
Q

What is a postpartum haemorrhage?

A

Heavy bleeding after giving birth

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56
Q

What is a minor vs major postpartum haemorrhage?

A

Minor < 1 litre, major > 1 litre

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57
Q

How can a major PPH be further classified?

A

Moderate PPH - 1000-2000ml Severe PPH - > 2000ml

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58
Q

What is a primary PPH?

A

PPH within 24 hours of delivery

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59
Q

What is a secondary PPH?

A

PPH after 24 hours post delivery (up to 12 weeks postpartum)

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60
Q

What are the causes of PPH?

A

4 Ts- Tone - uterine atony - Trauma - Tissue - retained placenta - Thrombin - clotting/bleeding disorder

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61
Q

What are the risk factors for primary PPH? (7)

A

PPH in previous pregnancy BMI >35Prolonged labourPre-eclampsia Increased maternal age Emergency C-section PolyhydramniosPlacenta praevia Placenta accreta MacrosomiaProlonged third stage of labourMultiple pregnancy Instrumental delivery

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62
Q

How can PPH be prevented?

A

Treating anaemia during pregnancy
Giving birth with an empty bladder
Active management of third stage - IM oxytocin during third stage
IV tranexamic acid during C section in high risk patients

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63
Q

How should a patient be stabilised during a PPH?

A

ABCDE Lie woman flat and keep her warmInsert two large-bore cannulasFBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation Oxygen

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64
Q

What management options are there for stopping bleeding in a PPH?

A

Mechanical Medical Surgical

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65
Q

What are the mechanical management options for PPH?

A

Rubbing the uterus through the abdomen - Stimulates contractions

Catheterisation - Prevents bladder distension that prevents uterine contractions

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66
Q

What are the medical management options for PPH?

A

IV oxytocinIV or IM Ergometrine - stimulates muscle contraction IM carboprost - prostaglandin analogue Sublingual misoprostol - prostaglandin analogue IV tranexamic acid

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67
Q

What are the surgical management options for PPH?

A

Intrauterine balloon tamponade - presses against the bleeding from the uterus - First line B-lynch suture - a suture around the uterus to compress it Uterine artery ligation Hysterectomy

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68
Q

What is the most likely cause of secondary PPH?

A

Retained products of conception or infection

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69
Q

What are the investigations for secondary PPH?

A

Ultrasound for RPOC Endocervical and high vaginal swab for infection

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70
Q

What is the management of secondary PPH?

A

Surgical evaluation for RPOC Antibiotics for infection

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71
Q

What is the most common cause of PPH?

A

Uterine atony

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72
Q

What is uterine atony?

A

Failure of the uterus to contract adequately after childbirth

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73
Q

What is Sheehan’s syndrome?

A

A complication of PPH where ischaemic necrosis of the anteiror pituary is caused by blood loss

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74
Q

How does Sheehan’s syndrome manifest after a PPH?

A

HypopituitarismLack of postpartum milk production Amenorrhoea

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75
Q

What is shoulder dystocia?

A

Where the anterior fetal shoulder becomes lodged behind the maternal pubic symphysis following delivery of the fetal head

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76
Q

What are the risk factors for shoulder dystocia? (5)

A

Maternal gestational diabetesMacrosomia Birth weight > 4kg Advanced maternal ageMaternal short stature Maternal obesity Post dates pregnancy

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77
Q

What are the features of shoulder dystocia?

A

Difficulty delivering the face and head Failure of restitution Turtle neck sign Failure of descent of fetal shoulders following delivery of the head

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78
Q

What is failure of restitution?

A

Where the head remains face downwards after delivery and does not turn sideways as expected

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79
Q

What is the turtle neck sign?

A

Where the head is delivered but retracts back into the vagina

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80
Q

What is the management of shoulder dystocia?

A

Immediately call for help McRoberts manoeuvreRubins manoeuvreWood’s screw manoeuvreZavanelli manoeuvre

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81
Q

What is McRoberts manoeuvre?

A

The maternal hips are hyperflexed and abducted. This provides a posterior pelvic tilt to move the pubic symphysis up and out of the way

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82
Q

What is Rubins manoeuvre?

A

Rubins manoeuvre involves reaching into the vagina to put pressure onto the posterior aspect of the anterior fetal shoulder. This helps to move the shoulder under the maternal pubic symphysisAn episiotomy may be performed to allow space for internal manoeuvres

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83
Q

What is Wood’s screw manoeuvre?

A

This is performed during the Rubins manoeuvre. The anterior aspect of the posterior fetal shoulder is pushed in order to rotate the baby and help delivery

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84
Q

What is the Zavanelli manoeuvre?

A

The baby’s head is pushed back into the vagina so that the baby can be delivered by emergency C section

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85
Q

What are the complications of shoulder dystocia? (4)

A

Fetal hypoxia (and subsequent cerebral palsy)Brachial plexus injury (and Erb’s palsy)Fetal deathPerineal tears PPHUterine rupture

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86
Q

What is Erb’s palsy?

A

Paralysis of the arm caused by damage to the C5-C6 nerve roots of the brachial plexus

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87
Q

What is placenta praevia?

A

A placenta that is lying partly or wholly in the lower uterine segment and is over the internal cervical os

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88
Q

What is a low lying placenta?

A

A placenta that is within 20mm of the internal cervical os

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89
Q

What are the risk factors for placenta praevia? (4)

A

Previous C-section - Embryos are more likely to implant on a lower segment section scar Previous placenta praevia Older maternal age Smoking Structural uterine abnormalities e.g fibroidsAssisted conception

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90
Q

What is the presentation of placenta praevia?

A

Painless vaginal bleeding (usually after 36 weeks, but suspect placenta praevia after 24 weeks)

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91
Q

When is placenta praevia usually picked up?

A

At the 20 week anomaly scan

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92
Q

How should placenta praevia be monitored?

A

Repeat transvaginal ultrasound at:- 32 weeks - 36 weeks

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93
Q

What does placenta praevia increase the risk of? (5)

A

Emergency caesarean section Antepartum haemorrhage Emergency hysterectomy Maternal anaemia Preterm birth Low birthweight Stillbirth

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94
Q

What are the different grades of placenta praevia?

A

Grade 1 - placenta is in the lower uterine segment, but has not reached the internal os Grade 2 - the placenta is reaching, but not covering the internal os Grade 3 - the placenta is partially covering the internal os Grade 4 - the placenta is completely covering the internal os

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95
Q

What is the management of placenta praevia?

A

Steroids given between 34 and 35+6 weeks gestation Give advice about pelvic rest - no penetrative sexPlanned caesarean considered between 36 and 37 weeks Emergency C section if antenatal bleeding or premature labour

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96
Q

What is the management of bleeding with an unknown placental position?

A

ABCDE approach Urgent transvaginal ultrasound If bleeding is not controlled, emergency C section required

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97
Q

What is the investigation of choice to exclude placenta praevia?

A

Transvaginal ultrasound

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98
Q

What is the management of placenta praevia in a woman in labour?

A

Caesarean section

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99
Q

Up to what gestation can termination of pregnancy occur?

A

Up to 24 weeks

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100
Q

What are the criteria for abortion?

A

An abortion can take place if gestational age is before 24 weeks, and if continuation of the pregnancy would cause risk to the physical or mental health of the mother

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101
Q

When can an abortion be performed at any time during pregnancy?

A

If the mother’s life is at risk If terminating the pregnancy will prevent ‘grave permanent injury to the physical or mental health of the mother If there is substantial risk that the child will suffer from serious mental or physical abnormalities

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102
Q

What is the process of a medical abortion?

A

Mifepristone Misoprostol given 1-2 days laterTest pregnancy 3 weeks later to confirm pregnancy has ended

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103
Q

What is mifepristone?

A

An anti-progesten

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104
Q

What is misopristol?

A

A prostaglandin analogue

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105
Q

What are the surgical options for abortion?

A

Cervical dilation and suction of the contents of the uterus (up to 14 weeks)Cervical dilation and evacuation using forceps (14-24 weeks)

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106
Q

How long may a pregnancy test be positive for following termination?

A

4 weeks

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107
Q

When should women be given rhesus D at termination?

A

When they are rhesus negative and having a termination after 10 weeks gestation

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108
Q

What is the placenta accreta spectrum?

A

Where the placenta implants into and past the endometrium, making it difficult to separate the placenta after delivery of the baby

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109
Q

What is placenta accreta?

A

Where the placenta implants into the surface of the endometrium

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110
Q

What is placenta increta?

A

Where the placenta implants deeply into the myometrium

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111
Q

What is placenta percreta?

A

Where the placenta implants past the myometrium and perimetrium, and can reach organs such as the bladder

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112
Q

What are the risk factors for placenta accreta? (5)

A

Previous placenta accreta
Previous endometrial curettage procedures
Previous C section
Multigravida
Increased maternal age
Placenta praevia
Uterine structural defects

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113
Q

What is the endometrium?

A

The inner layer of the uterine wall that contains connective tissue, epithelial cells and blood vessels

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114
Q

What is the myometrium?

A

The middle layer of the uterine wall that contains smooth muscle

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115
Q

What is the perimetrium?

A

The outer layer of the uterine wall, which is a serous membrane similar to the peritoneum

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116
Q

How is placenta accreta diagnosed?

A

Antenatal ultrasoundMRI scan to assess depth and width of invasion

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117
Q

When is delivery planned for women with placenta accreta?

A

Between 35 and 36+6 gestation

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118
Q

What are the management options for placenta accreta during C section delivery?

A

Hysterectomy Uterus preserving surgery - Resection of part of the myometrium alongside the placentaExpectant management - Leaving the placenta to be absorbed over time

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119
Q

What is placental abruption?

A

Where the placenta detaches from the wall of the uterus during pregnancy

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120
Q

What are the risk factors for placental abruption? (6)

A

Previous placental abruption Pre-eclampsia Bleeding early in pregnancy TraumaMultiple pregnancy Fetal growth restrictionMultigravidaIncreased maternal ageSmoking

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121
Q

What is the presentation of placental abruption?

A

Sudden onset of severe continuous abdominal painVaginal bleeding ShockAbnormalities on CTG indicating fetal distress’Woody’ abdomen on palpation

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122
Q

What is concealed abruption?

A

Where the cervical os remains closed, and so bleeding is contained with the uterine cavity

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123
Q

What is the general management of placental abruption?

A

Haemorrhage protocol:- Involve seniors and anaethetist - 2x grey cannula- FBC, U&E, LFTs, coagulation studies- Crossmatch 4 units of blood- Fluid and blood resuscitation as required- CTG monitoring of fetus

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124
Q

What are the differentials of placental abruption? (4)

A

Preterm labour Placenta praeviaChorioamnionitis UTI Degeneration of uterine fibroidsAcute appendicitis

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125
Q

What is the management of placental abruption at less than 36 weeks?

A

If fetal distress - immediate caesarean No fetal distress - administer steroids and observe

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126
Q

What is the management of placental abruption after 36 weeks?

A

If fetal distress - immediate caesarean No fetal distress - delivery vaginally

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127
Q

What BMI is defined as obese during antenatal appointments?

A

30

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128
Q

What are the maternal risks of obesity during pregnancy? (5)

A

Miscarriage
VTE
Gestational diabetes
Pre-eclampsia
Dysfunctional labour
PPH
Wound infections

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129
Q

What are the fetal risks of obesity during pregnancy?

A

Macrosomia Congenital abnormalitiesPrematurityStillbirth Obesity and metabolic disorders during childhoodNeonatal death

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130
Q

What is the advice regarding weight loss for obese women during pregnancy?

A

Women should not try to lose weight by dieting - medical professionals will manage the risk

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131
Q

How much folic acid should obese women take during pregnancy?

A

5mg per day (instead of 400mcg)

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132
Q

What is the additional management of obesity in pregnancy?

A

Obese women should be offered a OGTT at 24-28 weeksBMI > 35 should give birth in a consultant led unit BMI > 40 should have an antenatal consultation with an obstetric anaethetist

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133
Q

What is the first stage of labour?

A

From the onset of labour to up to 10cm dilated

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134
Q

What is the second stage of labour?

A

From 10cm cervical dilation up to the delivery of the baby

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135
Q

What is the third stage of labour?

A

From delivery of the baby until delivery of the placenta

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136
Q

What is the latent phase of the first stage of labour?

A

Up to 3cm cervical dilation Irregular contraction Progresses at 0.5cm per hour

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137
Q

What is the active phase of the first stage of labour?

A

From 3cm to 7cm cervical dilationRegular contractions Progresses at 1cm per hour

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138
Q

What is the transition phase of the first stage of labour?

A

From 7 to 10cm cervical dilation Strong regular contractions Progresses at 1cm per hour

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139
Q

What are Braxton-Hicks contractions?

A

Occassional irregular contractions that can be felt during the second and third trimesters of pregnancy. They do not progress or become regular

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140
Q

What are the signs of labour?

A

Mucus plug from the cervixRupture of membranes Regular, painful contractions Dilating cervix on examination

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141
Q

What is rupture of membranes (ROM)?

A

When the amniotic sac has ruptured

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142
Q

What is spontaneous ROM?

A

The amniotic sac has ruptured spontaneously

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143
Q

What is pre-labour ROM?

A

The amniotic sac has ruptured before the onset of labour

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144
Q

What is preterm pre-labour ROM?

A

The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation

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145
Q

What is prolonged ROM?

A

The amniotic sac ruptures more than 18 hours before delivery

146
Q

What is the definition of prematurity?

A

Delivery before 37 weeks gestation

147
Q

What is cardiotocography?

A

Used to measure fetal heart rate and contractions of the uterus

148
Q

How is CTG recorded?

A

Two doppler ultrasound transducers are placed on the abdomen:- One above the fetal heart - One above the fundus of the uterus

149
Q

What are the indications for continuous CTG monitoring?

A

Sepsis Maternal tachycardia Significant meconiumPre-eclampsia Fresh antepartum haemorrhageDelay in labour Use of oxytocin Disproportionate maternal pain

150
Q

What are the 5 key features of CTG?

A

Contractions Baseline fetal heart rateVariability Accelerations Decelerations

151
Q

What is a reassuring baseline fetal heart rate?

A

110-160

152
Q

What is a non-reassuring baseline fetal heart rate?

A

100-109 or 161-180

153
Q

What is an abnormal fetal heart rate?

A

Below 100 or above 180

154
Q

What is normal variability of fetal heart rate?

A

5-25

155
Q

What is a non-reassuring variability of fetal heartrate?

A

Less than 5 for 30-50 minutes or more than 25 for 15-25 minutes

156
Q

What is an abnormal variability of fetal heartrate?

A

Less than 5 for over 50 minutes or more than 25 for over 25 minutes

157
Q

What are decelerations?

A

Fetal heartrate dropping in response to hypoxia

158
Q

What are early decelerations?

A

Dips and recoveries in heart rate that correspond with uterine contractions - they are normal

159
Q

What are late decelerations?

A

Gradual falls in heart rate that start after the contraction has began. They are caused by hypoxia in the fetus and are pathological

160
Q

What are variable decelerations?

A

Decelerations that may be unrelated to uterine contraction. They are related to compression of the umbilical cord

161
Q

What are prolonged decelerations?

A

A drop of more than 15bpm from baseline that lasts between 2 and 10 minutes

162
Q

What is progress in labour influenced by?

A

Power - uterine contractions Passenger - size, presentation and position of baby Passage - size and shape of pelvis

163
Q

What is failure to progress in the first stage of labour?

A

Less than 2cm of cervical dilation in 4 hours Slowing of progress in a multiparous woman

164
Q

What is a partogram?

A

Monitoring system during the first stage of labour

165
Q

What is the attitude of the fetus?

A

The posture of the fetus

166
Q

What is included in a partogram?

A

Cervical dilationDescent of fetal head Maternal pulse, BP, temp and urine outputFetal heart rate Frequency of contractions Status of the membranes Drugs and fluids that have been given

167
Q

What is failure to progress in the second stage of labour?

A

When the active (pushing) phase of the second stage lasts more than 2 hours in a nulliparous woman or 1 hour in a multiparous woman

168
Q

What is oblique lie?

A

The fetus is at an angle

169
Q

What is longitudinal lie?

A

The fetus is straight up and down

170
Q

What is cephalic presentation?

A

The head presents first

171
Q

What is transverse lie?

A

The fetus is straight side to side

172
Q

What is shoulder presentation?

A

The shoulder presents first

173
Q

What is a complete breech presentation?

A

Breech presentation (feet first) with hips and knees flexed

174
Q

What is a frank breech presentation?

A

A breech presentation with hips flexed and knees extended - bottom first

175
Q

What is a footling breech?

A

A breech presentation with a foot hanging through the cervix

176
Q

What is delay in the third stage of labour?

A

More than 30 minutes with active management More than 60 minutes with physiological management

177
Q

What is the management of failure to progress in labour?

A

ARM - artifical rupture of membranes
Oxytocin infusion
Instrumental delivery C-section

178
Q

What is active management of the third stage of labour?

A

When the doctor/midwife assists in the delivery of the placenta

179
Q

How is the third stage of labour actively managed?

A

IM oxytocin after delivery of the baby

180
Q

Which women do not need any treatment for rhesus?

A

Rhesus positive women

181
Q

Which women need treatment for rhesus?

A

Rhesus negative women

182
Q

Why is anti-D given?

A

A rhesus negative woman can produce antibodies if she has a rhesus positive baby In a subsequent pregnancy, the antibodies from mum can pass through the placenta and attack the baby’s blood cells

183
Q

What condition can be caused in a rhesus negative mother and rhesus positive baby?

A

If the mother has produced rhesus antigens, these can attach to the baby’s red blood cells and cause haemolytic disease of the newborn

184
Q

How does anti-D work?

A

If attaches itself to any fetal antigens in the mother’s bloodstream causing them to be destroyed. This prevents the mother’s response of creating antibodies to the blood cell antigens

185
Q

When is anti-D primarily given?

A

At 28 weeks gestation and at birth

186
Q

In what other situations is anti-D given?(5)

A

Any time where mixing of blood could occur:
- Antepartum haemorrhage - Amniocentesis
- - Abdominal trauma
- - Ectopic pregnancy
- - Miscarriage
- - Termination
- - Intrauterine death
- - External cephalic version-

187
Q

Within how long shoud anti-D be given after an exposure event?

A

72 hours

188
Q

What is the Kleihauer test?

A

A test to check how much fetal blood has passed into the mother’s bloodstream during a sensitisation event

189
Q

How is Kleihauer’s test performed?

A

Acid is added to a sample of blood
Adult blood cells are haemolysed by the acid, but fetal red blood cells remain and can be counted

190
Q

What is vasa praevia?

A

Vasa praevia is where the fetal vessels run close to the internal os putting the vessels at risk of rupture during rupture of membranesThe vessels are unprotected by the umbilical cord or placenta

191
Q

How does vasa praevia occur?

A

Velamentous umbilical cord - where the umbilical cord inserts into the chorioamniotic membranes and the fetal vessels run unprotected from there to the placenta An accessory lobe of the placenta is connected by fetal vessels that run through the chorioamniotic membrane between the lobes

192
Q

What are the symptoms of vasa praevia?

A

Painless vaginal bleeding Rupture of membranes Fetal bradycardiaAntepartum haemorrhage

193
Q

What is type 1 vasa praevia?

A

Due to a velamentous umbilical cord

194
Q

What is type 2 vasa praevia?

A

Due to an accessory lobe of the placenta

195
Q

What are the risk factors for vasa praevia?

A

IVF pregnancyLow lying placenta Multiple pregnancy

196
Q

What are the differentials of vasa praevia?

A

Placenta praevia Placental abruption

197
Q

What is the management of vasa praevia?

A

Corticosteroids given from 32 weeks gestation Elective C section from 34-36 weeks (before rupture of membranes)

198
Q

What is the investigation of choice for the diagnosis of vasa praevia?

A

Transvaginal ultrasound

199
Q

What is oligohydramnios?

A

A lower than normal amount of amniotic fluid in the uterus

200
Q

What are the causes of oligohydramnios?

A

Intrauterine growth restriction
Premature rupture of membranes
Fetal urinary system abnormalities
Post-term gestation
Pre-eclampsia

201
Q

What are the complications of oligohydramnios?

A

Congenital hip dysplasia Clubbed feetFacial deformity Pulmonary hypoplasia

202
Q

What is Potter syndrome?

A

Pulmonary hypoplasia and bilateral renal agenesis

203
Q

How does Potter syndrome occur?

A

A renal formation abnormality can cause oligohydramnois which can lead to pulmonary hypoplasia

204
Q

What investigations are performed to diagnose oligohydramnios?

A

Amniotic fluid index < 5Single deepest pocket < 2cm

205
Q

What is the management of oligohydramnios?

A

Mild cases - maternal rehydration to increase amniotic fluid volume Amnioinfusion - infusion of saline into the amniotic cavity Induction of labour or C section if fetus is in distress

206
Q

What is polyhydramnios?

A

Where there is excessive amounts of amniotic fluid in the uterus

207
Q

What are the signs and symptoms of polyhydramnios?

A

Fetus that is difficult to palpateUterus that feels tense Large for dates uterus

208
Q

What are the two main mechanisms of polyhydramnios?

A

Excessive amniotic fluid production Reduced fetal swallowing (removal of amniotic fluid)

209
Q

What are the causes of excess production of amniotic fluid?

A

Maternal diabetes
Macrosomia
Fetal renal disorders
Fetal anaemia
Twin to twin transfusion syndrome

210
Q

What are the causes of reduced fetal swallowing?

A

Oesophageal atresia Duodenal atresia Diaphragmatic hernia Anenecephaly (congenital disorder where a baby is born without parts of their brain and skull) Chromosomal disordersCongenital diaphragmatic hernia

211
Q

What are the maternal complications of polyhydramnios?(4)

A

Maternal respiratory compromise due to pressure on diaphragm Increased risk of UTIGORDPeripheral oedema Constipation Stretch marks

212
Q

What are the fetal risks of polyhydramnios?

A

Pre-term labour and delivery Premature rupture of membranes Placental abruption Malpresentation of fetus Umbilical cord prolapse

213
Q

What is the management of polyhydramnios?

A

Treatment of underlying causesAmnio-reduction

214
Q

What AFI is indicative of polyhydramnios?

A

More than 25

215
Q

What is the most common cause of polyhydramnios?

A

Idiopathic

216
Q

What are baby blues?

A

A transient mood disorder that affects mothers following pregnancy

217
Q

When is the onset of baby blues?

A

Around 3 days after childbirth

218
Q

When does baby blues usually resolve by?

A

Around 2 weeks postpartum

219
Q

What are the signs and symptoms of baby blues?

A

IrritabilityAnxiety regarding parenting skillsTearfulness

220
Q

What are the differentials of baby blues?

A

Postpartum depression Postpartum psychosis

221
Q

What is the management of baby blues?

A

Reassurance and observation

222
Q

What is malpresentation?

A

When the baby is not cephalic as birth approaches

223
Q

What is the most common type of malpresentation?

A

Breech presentation

224
Q

What is a complete breech?

A

Where the legs and hips are fully flexed

225
Q

What is an incomplete breech?

A

One leg fully flexed at the knee and hip, with one leg extended at the knee and flexed at the hip

226
Q

What is an extended breech?

A

Both legs extended at the knee and flexed at the hip

227
Q

What is a footling breech?

A

Leg extended with a foot presenting through the cervix

228
Q

What is the management of a breech presentation before 36 weeks?

A

Observation - many fetuses turn spontaneously

229
Q

What is the management of a breech presentation after 36 weeks?

A

External cephalic version can be performed:- After 36 weeks for nulliparous women - After 37 weeks for multiparous women

230
Q

What are the contraindications to ECV? (5)

A

When c-section delivery is requiredAntepartum haemorrhage in last 7 days Abnormal CTG Major uterine abnormalityRuptured membranes Multiple pregnancy

231
Q

What is the management of a breech baby if ECV has failed?

A

Planned LSCS or vaginal delivery

232
Q

How is ECV performed?

A

Tocolysis with SC terbutaline is given to relax the uterus, making it easier for baby to turn

233
Q

What is the risk of VZV to mothers in pregnancy?

A

Varicella pneumonitis Hepatitis Encephalitis

234
Q

What are the risks of VZV to baby?

A

Fetal varicella syndrome Neonatal varicella syndrome Shingles in infancy

235
Q

What are the symptoms of fetal varicella syndrome? (4)

A

Fetal growth restriction
Microcephaly
Learning disability
Skin scarring and skin changes following the dermatomes
Limb hypoplasia
Cataracts and eye inflammation (chorioretinitis)

236
Q

What is the treatment of chicken pox infection during pregnancy?

A

Oral acyclovir if more than 20 weeks and presents in less than 24 hours

237
Q

What is the management of VZV exposure in a woman who has had chicken pox?

A

Reassure - no action needed

238
Q

What is the management of VZV exposure in a woman who is not sure if she’s had chicken pox?

A

Test for VZV antibodies (IgG)- If has antibodies - reassure - If no antibodies - treat

239
Q

What is the management of VZV exposure in a woman who has not had chicken pox?

A

If they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within 10 days of exposure.
If the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.

240
Q

Why is the varicella zoster vaccine not given in pregnancy?

A

It is a live attenuated vaccine and can cause fetal infection

241
Q

What are the features of congenital varicella syndrome?

A

Atypical skin scarring IUGR Cataracts Cerebral cortical atrophy Global developmental delayLimb hypoplasia

242
Q

What is cord prolapse?

A

Where the umbilical cord descends past the fetus, and through the cervix/vagina after rupture of membranes

243
Q

What are the risk factors for cord prolapse?(5)

A

Polyhydramnios
Multiparity
Multiple pregnancy
Low birthweight
Prematurity
Abnormal lie
High fetal head at delivery

244
Q

What are the signs of cord prolapse?

A

Feeling of the cord inside the vagina Abnormal fetal heart rate on CTG

245
Q

What investigations are used to diagnose cord prolapse?

A

Vaginal examination CTG

246
Q

What is the definitive management of cord prolapse?

A

Emergency C-section

247
Q

What can be done to prevent further cord prolapse?

A

Knees chest position Filling the bladder with 500ml warmed saline Avoid exposure and handling of the cord Terbutaline to stop uterine contractions

248
Q

How are twin pregnancies classified?

A

Zygosity Chorionicity Amnionicity

249
Q

What is zygosity?

A

Monozygotic twins - from same egg and sperm Dizygotic twins - from different egg and sperm

250
Q

What is chorionicity?

A

Monochorionic - single shared placenta Dichorionic - separate placentas

251
Q

What is amnionicity?

A

Monoamniotic - single shared amniotic sac Diamniotic - separate amniotic sacs

252
Q

What are the risks of monozygotic twins?

A

Increased sponatenous miscarriage Prematurity IUGR Increased malformations Twin to twin transfusion syndrome

253
Q

What are the maternal complications of multiple pregnancy? (5)

A

Anaemia Polyhydramnios Hypertension Malpresentation Premature labour Instrumental delivery Caesarean section PPH

254
Q

What are the predisposing factors to dizygotic twins?

A

IVF treatment
Previous twins
Family history
Increasing maternal age
Multigravida
Afro-Caribbean race

255
Q

What are the fetal risks of multiple pregnancy?(5)

A

Miscarriage
Stillbirth
IUGR
Prematurity
Twin-twin transfusion syndrome Congenital abnormalities

256
Q

What is twin-twin transfusion syndrome?

A

When one twin receives the majority of blood through the shared placenta, while the other is starved of blood

257
Q

What are the complications to the recipient in twin-twin transfusion syndrome?

A

The recipient can become fluid overloaded leading to:- Heart failure - Polyhydramnios

258
Q

What are the complications to the donor in twin-twin transfusion syndrome?

A

Growth restriction Anaemia Oligohydramnios

259
Q

What is twin anaemia polycythaemic sequence?

A

Like twin-twin transfusion syndrome but less severe - one twin will be polycythaemic and the other will be anaemic

260
Q

How often are women with multiple pregnancy scanned?

A

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

261
Q

What type of twins require caesarean section?

A

Monochorionic monoamniotic

262
Q

When should dichorionic diamniotic twins be delivered?

A

Between 37 and 37+6 weeks

263
Q

When should monochorionic diamniotic twins be delivered?

A

Between 36 and 36+6 weeks

264
Q

When should monochorionic monoamniotic twins be delivered?

A

Between 32 and 33+6 weeks (by CS)

265
Q

What is the main risk factor for uterine rupture?

A

Previous caesarean section

266
Q

What are the other risk factors for uterine rupture? (5)

A

VBAC (vaginal birth after c section) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin

267
Q

What is the presentation of uterine rupture?

A

Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

268
Q

What is the definitive management of uterine rupture?

A

Emergency caesarean section Repair uterus/hysterectomy

269
Q

What are the risk factors for VTE in pregnancy?(5)

A

Smoking Parity > 3Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

270
Q

When should VTE prophylaxis be started in pregnancy?

A

At 28 weeks if there are three risk factors In the first trimester if there are 4 or more risk factors

271
Q

What other situations would VTE prophylaxis be considered in? (5)

A

Hospital admission Previous VTESurgery Cancer Ovarian hyperstimulation syndrome

272
Q

What medicaiton is used as VTE prophylaxis in pregnancy?

A

LMWH (low molecular weight heparin)

273
Q

How long is VTE prophylaxis continued after delivery?

A

6 weeks

274
Q

What are the mechanical VTE prophylaxis options?

A

Anti-embolic compression stockings Intermittent pneumatic compression

275
Q

What is the presentation of DVT?

A

Unilateral Calf or leg swelling Dilated superficial veins Tenderness to the calfOedema Redness

276
Q

What is the presentation of PE?

A

Shortness of breath Cough Haemoptysis Pleuritic chest pain Hypoxia Tachycardia Raised resp rate Low grade fever

277
Q

What is the investigation of choice for DVT?

A

Doppler ultrasound

278
Q

What are the investigations used in the diagnosis of PE?

A

CXR ECG

279
Q

What is the definitive diagnosis of PE?

A

CTPA - CT pulmonary angiography

280
Q

What types of anticoagulants should be avoided in pregnancy?

A

Warfarin and DOACs

281
Q

Why is DVT more common in the left leg in pregnancy?

A

The gravid uterus puts pressure on the left iliac vein crossing the left iliac artery -slows venous return

282
Q

What are the symptoms of lower UTI in pregnancy?

A

Dysuria Suprapubic pain Frequency Urgency Incontinence Haematuria

283
Q

What are the symptoms of pyelonephritis in pregnancy?

A

FeverVomiting Loss of appetite Back, loin suprapubic pain Haematuria Renal angle tenderness

284
Q

What investigations are used to diagnose UTI in pregnancy?

A

Dipstick - Leucocytes and nitrites MSU culture and sensitivity - All urine samples with positive leucocytes or nitrites are sent off for culture

285
Q

What is the most common cause of UTI in pregnancy?

A

E coli

286
Q

What are the other causes of UTI in pregnancy? (3)

A

Klebsiella pneumoniae Enterococcus Psuedomonas aeruginosa Staphylococcus saprophiticus Candida albicans

287
Q

How many days of antibiotics does UTI in pregnancy require?

A

7 day course

288
Q

What antibiotics are used to treat UTI in pregnancy?

A

Nitrofurantoin Amoxicillin Cefalexin

289
Q

When should nitrofurantoin be avoided in pregnancy?

A

In the third trimester (due to risk of neonatal haemolysis)

290
Q

Which antibiotics are safe to use in UTI throughout pregnancy?

A

Cephalosporins

291
Q

When are women screened for anaemia during pregnancy?

A

At booking At 28 weeks

292
Q

Why does anaemia commonly occur in pregnancy?

A

Plasma volume increases which results in a reduction in haemoglobin concentration

293
Q

What are the symptoms of anaemia in pregnancy?

A

Often asymptomatic Shortness of breath Fatigue Dizziness Pallor

294
Q

What is the normal range for haemoglobin during first trimester

A

> 110

295
Q

What is the normal range for haemoglobin during second and third trimesters?

A

> 105

296
Q

What is the normal range for haemoglobin postpartum?

A

> 100

297
Q

What does a low MCV and anaemia indicate?

A

Iron deficiency

298
Q

What does a normal MCV during pregnancy indicate?

A

Phyysiological anaemia due to increased plasma volume

299
Q

What does a raised MCV and anaemia indicate?

A

Vitamin B12 or folate deficiency

300
Q

What is the management of iron deficiency anaemia during pregnancy?

A

Ferrous sulfate 200mg daily

301
Q

What is the management of B12 deficiency anaemia during pregnancy?

A

Testing for pernicious anaemia - intrinsic factor antibodies
IM hydroxycobalamin
Oral cyanocobalamin

302
Q

What is the management of folate deficiency anaemia during pregnancy?

A

5mg folic acid daily throughout pregnancy

303
Q

What is prelabour rupture of membranes?

A

When the amniotic membranes rupture prior to the start of labour, in a woman who is more than 37 weeks pregnant

304
Q

What is the presentation of prelabour rupture of membranes?

A

Greenish/ foul smelling amniotic fluid
Maternal fever
Reduced fetal movements

305
Q

What are the investigations to confirm prelabour rupture of membranes?

A

Amnisure Actim-PROM Ultrasound High vaginal swab

306
Q

What are the differentials of prelabour rupture of membranes?

A

Urinary incontinence Vaginal discharge or infection Loss of mucus plug

307
Q

What is the management of prelabour rupture of membranes?

A

Monitoring maternal temperature Assessing fetal movements Monitoring of fetal heart rateConsider IOL after 24 hours

308
Q

What are the risk factors for prelabour rupture of membranes? (4)

A

Smoking Previous PROM Vaginal bleeding during pregnancy Lower genital tract infection Invasive procedures - amniocentesis Multiple pregnancy

309
Q

What is premature prelabour rupture of membranes?

A

The rupture of amniotic membranes before the onset of labour, before 37 weeks

310
Q

What are the causes of P-PROM?

A

Infection Early activation of normal physiological processesGenetic predisposition

311
Q

What are the risk factors for P-PROM? (5)

A

Smoking Previous P-PROM Vaginal bleeding during pregnancy Lower genital tract infection Invasive procedures Polyhydramnios Multiple pregnancy Cervical insufficiency

312
Q

What are the investigations to confirm P-PROM?

A

Actim-PROM AmnisureUltrasoundHigh vaginal swab for GBS

313
Q

What is the management of P-PROM?

A

Monitor for signs of chorioamnionitis
Corticosteroids if less than 34+6 weeks
Oral erythromycin for 10 days
Delivery considered at 34 weeks gestation

314
Q

What are the complications of P-PROM?

A

Chorioamnionitis Oligohydramnios Neonatal death Placental abruption Umbilical cord prolapse

315
Q

What are the components of the bishop score?

A

Fetal station Cervical position Cervical dilation Cervical effacement Cervical consistency

316
Q

What is premature labour?

A

Delivery before 37 weeks gestation

317
Q

When are babies considered non-viable?

A

If delivered before 23 weeks

318
Q

What is the classification of prematurity?

A

32-37 weeks - moderate to late preterm 28-32 weeks - very preterm Before 28 weeks - extreme preterm

319
Q

What is the prophylaxis of premature labour?

A

Vaginal progesterone (prevents contractions and premature labour) Cervical cerclage (temporarily sewing the cervix closed with stitches)

320
Q

Who is vaginal progesterone given to?

A

Women with a cervical length of less than 25mm on ultrasound between 16 and 24 weeks gestation

321
Q

What is cervical cerclage?

A

Putting a stitch in the cervix to support it and keep it closed

322
Q

When is cervical cerclage performed?

A

Between 16 and 24 weeks to women with a cervical length of less than 25mm who have had a previous premature birth or cervical trauma Rescue cervical cerclage - between 16 and 27+6 weeks in women with cervical dilation

323
Q

What is the management of preterm labour with intact membranes?

A

CTGTocolysis with nifedipine Maternal corticosteroidsIV magnesisum sulfate Delayed cord clamping

324
Q

When are tocolytics used?

A

Between 24 and 33+6 weeks to stop contractions and delay delivery

325
Q

What are the risks of prematurity?

A

Respiratory distressIntraventricular haemorrhage Necrotising entercolitis Chronic lung diseaseRetinopathy of prematurity Hearing problems

326
Q

What is obstetric cholestasis?

A

The reduced flow of bile acids from the liver during pregnancy

327
Q

When does obstetric cholestasis develop during pregnancy?

A

After 28 weeks

328
Q

What is the aetiology of obstetric cholestasis?

A

The outflow of bile acids from the liver is reduced - this causes bile acids to build up in the blood resulting in itching

329
Q

What is the presentation of obstetric cholestasis?

A

Pruritis - specifically of the hands and soles of the feet FatigueDark urine Pale, greasy stools Jaundice No rash present

330
Q

What are the differentials of obstetric cholestasis?

A

Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis

331
Q

What investigations should be performed to diagnose obstetric cholestasis and what would they show?

A

LFTs - raised ALT, AST and GGT Bile acids - raised

332
Q

What is the main treatment of obstetric cholestasis?

A

Ursodeoxycholic acid

333
Q

What other treatments might be useful in obstetric cholestasis?

A

Antihistamines to reduce itching Emollients

334
Q

What monitoring is required in patients with obstetric cholestasis?

A

Weekly LFTs during pregnancy and after delivery

335
Q

When should delivery be planned in patients with obstetric cholestasis?

A

37 weeks

336
Q

When should women have a booking appointment?

A

Before 10 weeks gestation

337
Q

When do women have a dating scan?

A

Between 10 and 13+6 weeks

338
Q

When should women have their anomaly scan?

A

Between 18 and 20+6 weeks

339
Q

When do women have additional antenatal appointments?

A

25 weeks283134363840 4142 weeks

340
Q

When do women have their first regular antenatal appointment?

A

16 weeks

341
Q

How is an accurate gestational age calculated at the dating scan?

A

Crown rump length

342
Q

When do women with placenta praevia have an additional scan?

A

32 weeks

343
Q

What is covered at regular antenatal appointments?

A

Plans for pregnancy and delivery Symphysis-fundal height Fetal presentation Urine dipstick Blood pressure

344
Q

What vaccines are offered to pregnant women and when?

A

Pertussis from 16 weeks Flu vaccine in autumn or winter

345
Q

What bloods are performed at booking?

A

Blood group Rhesus antibodies FBC Screening for thalassaemia and sickle cell HIV Hepatitis B Syphilis

346
Q

What is the combined test?

A

The first line antenatal screening for downs syndrome

347
Q

When is the combined test performed?

A

Between 11 and 14 weeks gestation

348
Q

What does the combined test involve?

A

Ultrasound for nuchal translucency Beta-hCG (high)PAPP-A (low)

349
Q

What is the triple test?

A

Test for down syndrome:- beta-hCG (high)- Alpha fetoprotein (low)- Serum oestriol (low)

350
Q

When is the triple test performed?

A

Between 14 and 20 weeks

351
Q

What is the quadruple test?

A

Triple test but also includes inhibin-A (high)

352
Q

What conditions are tested for at the anomaly scan? (7)

A

Edward’s Patau’s Anencephaly Gastroschisis Exophalmos Spina bifida Cleft lip Congenital diaphragmatic hernia Congenital heart diseaseBilateral renal agenesis

353
Q

What is hyperemesis gravidarum?

A

An extreme form of nausea and vomiting during pregnancy

354
Q

When is hyperemesis most common?

A

Between 8 and 12 weeks

355
Q

What are the risk factors for hyperemesis?

A

Increased b-hCG
Molar pregnancy
Nulliparity
Obesity
Family history of NVP
Previous NVP/hyperemesis

356
Q

What is the criteria for admission in a patient with hyperemesis?

A

Nausea and vomiting and:- Unable to keep down liquids or oral antiemetics OR - Ketonuria OR - Weight loss > 5% of pre-pregnancy weight despite treatment with anti-emetics

357
Q

What is the triad of symptoms in hyperemesis?

A

5% weight lossDehydration Electrolyte imbalance

358
Q

What are the first line anti-emetics for hyperemesis?

A

Cyclizine - antihistamines

359
Q

What other class of medications can be used in hyperemesis?

A

Phenothiazines - Prochlorperazine - Chlorpromazine

360
Q

What fluid is used for rehydration in hyperemesis?

A

IV saline with potassium

361
Q

What are the complications of hyperemesis?

A

Wernicke’s encephalopathy AKI VTE Oesophagitis Mallory-Weiss tear

Phase 3a🩺 (12 decks)

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