Obstetrics

Question 1

Intrahepatic cholestasis of pregnancy increases the risk of?

Answer 1

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

Question 2

Define pre-eclampsia

Answer 2

The current formal definition is as follows
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
1. proteinuria
2. other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Question 3

At what week should referral be made for a pregnant woman who is yet to feel her baby moving?

Answer 3

24 weeks

Generally women can feel their babies move around 18-20 weeks, but this can be earlier especially in multiparous women.

Question 4

Until what week pregnancy should folic acid supplement be taken?
What is considered higher risk of NTD and what dose should be taken?

Answer 4

Week 12
High risk of neural tube defects (NTD) should take 5mg instead of 400mcg
High risk:
either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Question 5

What are the risk factors for Group B Streptococcus (GBS) infection in pregnancy?

Answer 5

Prematurity
Prolonged rupture of the membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis

Question 6

What bishop score would confer an induction of labour, and what is the first-line intervention for this?

Answer 6

Vaginal PGE2 or oral misoprostol is the preferred method of induction of labour if the Bishop score is ≤ 6

Question 7

what is the Down syndrome threshold for lower vs higher chance?

Answer 7

1 in 150

Question 8

What are the 4 Ts of PPH

Answer 8

Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)

Question 9

Outline the mechanical, medical and surgical approach to PPH

Answer 9

Mechanical: Compress the uterus and catheterise
Medical: IV oxytocin; ergometrine slow IV or IM (unless there is a history of hypertension); carboprost IM (unless there is a history of asthma); misoprostol sublingual
Surgical: intrauterine balloon tamponade (1st-line); other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

Question 10

When is a rhesus negative pregnant women given anti-D?
When might extra doses be given?

Answer 10

Any sensitisation event (bleeding, trauma); routinely at 28 weeks (+34 weeks sometimes too); if baby is positive at birth.
A Kleihauer test is a test for FMH which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin.

Question 11

What sort of vaccines are avoided in pregnancy?
Which vaccines are recommended?

Answer 11

Live Vaccines (e.g., MMR, Varicella, Yellow Fever) are typically avoided due to theoretical risks to the fetus.
Recommended are Influenza Vaccine (Inactivated) and Pertussis (Whooping Cough) Vaccine (as part of the dTaP/IPV vaccine)

Question 12

What signs are looked for which may suggest hypermagneseamia after magnesium sulphate treatment?

Answer 12

Hyperreflexia and respiratory depression

Question 13

Define PPH

Answer 13

blood loss of 500 ml or more within 24 hours after birth

Question 14

At what BP would a pregnant woman need to be admitted and observed?

Answer 14

≥ 160/110 mmHg

Question 15

What is the cut off of protein/creatinine ratio of urine for proteinuria in pre-eclampsia?

Answer 15

Spot urine protein:creatinine ratio of 30mg/mmol or more OR 0.3g/24hrs is used as the threshold for significant proteinuria in pregnancy

Can also use albumin:creatinine ratio of 8 mg/mmol as cut off

Question 16

As per NICE guidelines; the following would warrant continuous CTG monitoring if any of the following are present or arise during labour;

Answer 16

Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
Severe hypertension 160/110 mmHg or above
Oxytocin use
The presence of significant meconium
Fresh vaginal bleeding that develops in labour

Question 17

When confirming PPROM, if amniotic fluid is not seen in the posterior vaginal vault, what can be tested for to detect amniotic fluid?

Answer 17

If pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1 (Actim PROM)

Question 18

In PPROM what medication is given alongside antibiotics and what for?
How early does PPROM have to be to get it?

Answer 18

Steroids, to reduce the risk of the foetus developing respiratory distress syndrome
This is given if PPROM is before 34 weeks

Question 19

Define oligohydramnios

Answer 19

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

Question 20

In GDM. what should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 20

Glibenclamide

Question 21

Define early-onset vs late-onset neonatal sepsis. Which organisms cause early vs late?

Answer 21

Sepsis in the neonate can broadly be divided into early-onset (<48 hours since birth) and late-onset (>48 hours from birth). Early-onset sepsis is associated with acquisition of micro-organisms from the mother’s birth canal (commonly GBS).
Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.

Question 22

GBS is the most common cause of early-onset neonatal sepsis; name three other important causes to cover for during treatment

Answer 22

Ecoli
Listeria
Klebsiella

Question 23

What can viral load in a HIV positive pregnant woman help to determine in the management of the pregnancy?
What prophylaxis is given?
Is breast feeding okay in HIV positive pregnant women?

Answer 23

Aim for undetectable viral load (<50 copies/mL) by delivery.
Undetectable viral load (<50 copies/mL): Vaginal delivery is safe, if higher then plan for C-section
Women with a viral load ≥50 copies/mL at delivery should receive IV zidovudine during labor.
Low-risk (maternal viral load <50 copies/mL): Single-drug prophylaxis with zidovudine for 4 weeks.
High-risk (maternal viral load ≥50 copies/mL): Combination prophylaxis with at least two drugs (e.g., zidovudine + lamivudine).

No breastfeeding if HIV positive at all.