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3A > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is pre-eclampsia

A

A new high blood pressure in pregnancy with evidence of end-organ dysfunction (notably proteinuria)

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2
Q

What evidence of end-organ dysfunction may be present in pre-eclampsia ?

A

Proteinuria
Severe headache
Visual disturbance
Papilloedema
Clonus
Liver tenderness
Abnormal liver enzymes
Low platelet count

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3
Q

RF for pre-eclampsia

A

Pre-existing hypertension
Previous pre-eclampsia
Multiple pregnancy
First pregnancy
Family history
Obesity
Diabetes
Older age
Autoimmune conditions

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4
Q

What syndrome can occur as a complication of pre-eclampsia

A

HELLP syndrome (stands for Haemolysis, Elevated, Liver enzymes, Low, Platelets)

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5
Q

What is term?

A

37 weeks to 42 weeks

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6
Q

What is polyhydramnios

A

an abnormally large level of amniotic fluid - a amniotic fluid index above the 95th centile for gestational age

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7
Q

How is amniotic fluid produced?

A

It predominately comes from fetal urine output - fetus breathes and swallows fluid, then voids it from the bladder

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8
Q

What is the latent phase of labour

A

Anything up to 4cm dilated
Can last 2-3 days
irregular contractions

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9
Q

Describe the first stage of labour

A

cervix dilates from 4 to 10 cm
Stronger uterine contractions

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10
Q

Describe the second stage of labour

A

from full dilation to the birth of the fetus

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11
Q

describe the third stage of labour

A

from birth of the fetus to the expulsion of the placenta

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12
Q

Causes of polyhydramnios

A

-idiopathic 50-60%
-conditions preventing foetus from swallowing (oesophageal atresia, CNS abnormalities ect)
- duodenal atresia
- anaemia
-fetal hydrops
- increased lung secretions
- genetic and chromosomal abnormalities
- infections
-gestational diabetes

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13
Q

How is polyhydramnios diagnosed

A

USS- measure amniotic fluid index or the maximum pool depth

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14
Q

What is the role of oxytocin in labour

A

it onsets the contractions of the uterus

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15
Q

what are the role of prostaglandins in labour

A

they aid with cervical ripening

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16
Q

what is the role of oestrogen in labour

A

It surges at the start of labour to inhibit progesterone
This prepares the smooth muscles for labour

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17
Q

What is the role of prolactin after labour?

A

begins the production of milk in the mammary glands

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18
Q

What is cervical effacement

A

The thinning of the cervix - also called cervical ripening.
Normally it is 4cm long however thins for labour

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19
Q

What is the most common pelvis type in females

A

the gynaecoid pelvis

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20
Q

Risks of polyhydramnios

A

Cord prolapse
Malpresentations (more room to move around)
Post partum haemorrhage

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21
Q

How is polyhydramnios treated?

A

usually no intervention
Amnioreduction- not routinely used
indomethacin - enhances water retention and reduces fetal urine output

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22
Q

What is oligohydramnios

A

a low level of amniotic fluid during pregnancy- less than the 5th centile for gestational age

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23
Q

causes of oligohydramnios

A

preterm rupture of the membranes
placental insufficiency
renal agenesis (potter’s syndrome)
non-functional fetal kidneys
genetic/chromosomal abnormalities

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24
Q

How is oligohydramnios diagnosed?

A

USS- amniotic fluid index less than 5th centile or maximum pool depth less than 2cm
If rupture of membranes can test for the presence of amniotic fluid in vagina (IGFBP-1 and PAMG-1)

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25
Q

Why is delayed cord clamping important

A

Increases red blood cells, iron and stem cells that enter the baby - can aid the development for up to 6 months

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26
Q

What is placental abruption?

A

separation of the placenta from the uterine wall before delivery of the fetus

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27
Q

RF for placental abruption

A

smoking, trauma, cocaine use, hypertensive disorders, polyhydramnios, abnormal lie

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28
Q

What are the two types of placental abruption?

A

overt (blood escapes through the vagina) and concealed (blood remains behind the placenta)

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29
Q

Presentation of placental abruption

A

vaginal bleeding
abdominal pain
uterine contractions
utnerine tenderness- woody tense uterus on examination
signs of shock

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30
Q

Why might the level of haemodynamic shock appear out of proportion with the bleed in placental abruption

A

if it is a concealed abruption the blood will mainly be hidden

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31
Q

What antidepressants can be used during breastfeeding

A

sertraline and paroxetine

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32
Q

What is a Bishop score?

A

A score used to assess whether induction is needed
If < 5 labour is unlikely to start without induction
If >8 the cervix is ripe and there is a high chance of spontaneous delivery

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33
Q

Management of gestational diabetes if fasting glucose is >7

A

insulin +/- metformin

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33
Q

How long postpartum can the COCP be started if breastfeeding?

A

after at least 6 weeks postpartum

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33
Q

At what gestation can external cephalic version be attempted?

A

36 weeks primiparous and 37 weeks multiparous

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34
Q

Can lamotrigine be taken when breastfeeding?

A

yes

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34
Q

When should a progesterone blood test be taken to confirm ovulation?

A

7 days before next period is due

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35
Q

How soon after giving birth can the progesterone only pill be started

A

Immediately- in breastfeeding and non breastfeeding

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36
Q

When should rhesus D negative women receive anti D

A

at 28 and 34 weeks

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37
Q

How long after giving birth do women need to start birth control>

A

after 21 days

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38
Q

What conditions are screened for on antenatal testing

A

anaemia
bacteruiria
blood group
downs syndrome
detal anomalies
hep B
HIV

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39
Q
A
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40
Q

First line drug for vomiting in pregnancy

A

Promethazine

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41
Q

How soon after childbirth can the contraceptive implant be put in

A

Immediately

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42
Q

What is the most common cause of cord prolapse

A

Artificial amniotomy (artificial rupture of membranes)

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43
Q

What medication can be given to suppress lactation

A

Cabergoline

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44
Q

At what gestation should the oral glucose tolerance test be done in women

A

24-28 weeks

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45
Q

Over what BMI should the OGTT be done for gestational diabetes

A

Over 30

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46
Q

When should patients with pre-eclampsia be admitted

A

If BP is greater than 160 over 110

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47
Q

What is HELLP syndrome

A

Haemolysis, elevated liver enzymes and low platelet

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48
Q

How does fibroid degeneration present in pregnancy

A

Low grade fever, pain and vomiting

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49
Q

What antibiotic should be given to women with pyrexia during labour as GBS prophylaxis?

A

benzylpenicillin

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50
Q

What is the initial treatment of gestational diabetes if fasting glucose is less than 7

A

trial of diet and exercise

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51
Q

What cut off of iron is used to determine if iron supplementation should be given in the first trimester

A

110

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52
Q

Can aspirin be taken while breastfeeding

A

no- must be avoided

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53
Q

What should be given as prophylaxis to reduce the risk of pre-eclampsia

A

low dose aspirin

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54
Q

First step after chickenpox exposure during pregnancy

A

check maternal varicella antibodies

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55
Q

List some potentially sensitising events which would require anti-D prophylaxis

A

ectopic pregnancy
vaginal bleeding <12 weeks if heavy and painful
vaginal bleeding >12 weeks
chorionic villus sampling and amniocentesis
antepartum haemorrhage
abdominal trauma
external cephalic version
intra-uterine death
post delivery

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56
Q

When is prophylactic anti-D given

A

to any previously non-sensitised rhesus negative women between 38 and 34 weeks.

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57
Q

Medical treatment of postpartum haemorrhage secondary to uterine atony

A

oxytocin, ergometrine, carboprost or misoprostol

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58
Q

What health condition is a contraindication to using carboprost in postpartum haemorrhage

A

asthma

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59
Q

2nd line investigation for reduced fetal movements after 28 weeks if Doppler shoes no heart beat

A

immediate transabdominal USS

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60
Q

What is given to women who are established as high risk for pre-eclampsia

A

daily aspirin from 12 weeks gestation

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61
Q

Rf for hyperemesis gravidarum

A

multiple pregnancy
trophoblastic disease
nulliparity
obesity
family history

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62
Q

what is protective against hyperemesis gravidarum

A

smokign

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63
Q

When would admission be recommended for hyperemesis gravidarum

A
  1. can’t keep down liquids or oral antiemetics
  2. ketonuria and/or weight loss greater than 5% of pre-pregnancy weight loss despite oral antiemetics
  3. a confirmed or suspected comorbidity
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64
Q

What can be used to calculate the severity of hyperemesis gravidarum

A

the pregnancy - unique quantification of emesis score (PUQE)

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65
Q

Triad of hyperemesis gravidarum

A

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

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66
Q

first line medications for hyperemesis gravidarum

A

antihistamines- oral cylclizine or promethazine
phenothiazines- oral prochlorperazine or chlorpromazine

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67
Q

second line medications for hyperemesis gravidarum

A

oral ondansetron or oral metoclopramide or domperidone

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68
Q

what is a risk of oral ondansetron if used in the first trimester?

A

cleft lip/palate

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69
Q

For how long should oral metoclopramide be used and why?

A

for a maximum of 5 days
extrapyramidal side effects

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70
Q

Complications of hyperemesis gravidarum

A

AKI, wernicke’s, oesophagitis, VTE

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71
Q

How does a threatened miscarriage present

A

painless vaginal bleeding and a closed cervical os

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72
Q

If a woman has a past history of VTE what prophylaxis should she be given during pregnancy and from when

A

low molecular weight heparin immediately until 6 weeks postnatal

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73
Q

When does the booking visit occur

A

8-12 weeks

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74
Q

When is the nuchal scan done

A

11-13+6 weeks

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75
Q

when is the anomaly scan

A

18-20+6 weeks

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76
Q

What placental problem is increased in those who undergo IVF

A

placenta praevia

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77
Q

What are the components of the quadruple test for downs syndrome

A

AFP
oestriol
hCG
inhibin A

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78
Q

what results on the quadruple test would suggest increased risk of downs syndrome

A

low AFP
low oestriol
increased hCG
increased inhibin A

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79
Q

What are the components of the combined test for downs syndrome

A

nuchal translucency on USS
PAPP-A
hCG

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80
Q

what results on the combined test would suggest increased risk of downs syndrome

A

high hCG ,
low PAPP-A
increased nuchal translucency

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81
Q

when is the combined test performed

A

10-13+6 weeks

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82
Q

Treatment of chickenpox in a pregnant women if they present within 24 hours of rash developing

A

oral aciclovir

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83
Q

What is the first line proceedure that can be done in post partum haemorrhage before medication

A

uterine massage

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84
Q

If two pills are missed between days 8-14 of the cycle is emergency contraception required?

A

no - as long as there have been at least 7 days of correct usage

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85
Q

Rf of shoulder dystocia

A

fetal macrosomnia
high maternal BMI
diabetes mellitus
prolonged labour

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86
Q

What manoeuvre is used for shoulder dystocia

A

the McRoberts’ manoeuvre

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87
Q

what can be a neonatal complication of shoulder dystocia

A

brachial plexus injury- Erb’s palsy

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88
Q

What is sheehan’s syndrome

A

postpartum hypopituitarism
Occurs due to ischaemic necrosis of the pituitary gland due to hypovolaemic shock following birth

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89
Q

How quickly do category 2 caesareans need to occur?

A

within 75 mins

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90
Q

What antibiotic is used as GBS prophylaxis

A

benzylpenicillin

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91
Q

what haemoglobin level should be used as a cut off for iron supplementation in the postpartum period

A

100

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92
Q

first line surgical intervention for post partum ahemorrhage

A

intrauterine balloon tamponade

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93
Q

RF for ectopic pregnancy

A

previous ectopic
previous pelvic inflammatory disease
previous surgery of the fallopian tube
IUD/IUS
older age (>35)
smoking
IVF

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94
Q

Where might an ectopic pregnancy implant, and where is most common?

A

fallopian tube (most common)
ovary
cervix
abdomen

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95
Q

How does an ectopic pregnancy present

A

missed period
constant lower abdominal pain in right or left iliac fossa
vaginal bleeding
lower abdominal tenderness or pelvic tenderness
cervical motion tenderness
shoulder tip pain (if blood enters peritoneal cavity and irritates diaphragm)

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96
Q

At what gestation does an ectopic pregnancy typically present?

A

6-8 weeks

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97
Q

How is an ectopic pregnancy diagnosed?

A

hCG
Transvaginal USS

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98
Q

findings on transvaginal USS for ectopic pregnancy (4 signs that may be seen)

A
  • gestational sac containing fetal pole or yolk sac in the fallopian tube
  • adnexal mass moving separately from the ovary (sliding sign)
  • non-specific mass in the tube (blob sign, bagel sign)
  • empty uterus
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99
Q

How can the location of a pregnancy of unknown location be determiend

A

by following hCG levels
- an increase by 63% in 48 hours suggest intrauterine
- an increase of less than 63% indicates ectopic
- a decrease of more than 50% indicate misscarriage

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100
Q

What is a pregnancy of unknown location

A

when a woman has a positive pregnancy test but no evidence of pregnancy on USS

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101
Q

When would expectant management be used for ectopic pregnancies?

A
  • if unruptured
  • no visible heart rate
  • asymptomatic
  • hCG less than 1000
  • adnexal mass less than 35mm
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102
Q

How is expectant management of an ectopic pregnancy monitored

A

Repeat hCG testing is performed on day 2,4 and 7.
If there is a continuous drop by at least 15% from the previous reading expectant management can be continued

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103
Q

what does medical management of an ectopic pregnancy consist of?

A

methotrexate

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104
Q

When can medical management of an ectopic pregnancy be used?

A

less than 35mm
unruptured
not in significant pain
no fetal HR
hCG less than 1500

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105
Q

When should surgical management of an ectopic pregnancy be used?

A

serum hCG 5000 or higher
adnexal mass greater than 35mm
foetal heartbeat is visible
patient is in significant pain
patient is haemodynamically unstable

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106
Q

what is the preferred surgical management of ectopic pregnancy?

A

salpinectomy (removal of tube)

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107
Q

What is the surgical management of ectopic pregnancy if there is damage to the other fallopian tube (e.g. PID, previous ectopic)

A

salpingotomy

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108
Q

What is a complication of salpingotomy and how is it monitored

A

retainment of products- serial serum hCG measurements taken

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109
Q

Explain cord prolapse

A

when the umbilical cord descends below the presenting part of the fetus, through the cervix and into the vagina

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110
Q

RF for cord prolapse

A

breech position
unstable lie
artificial rupture of the membranes
polyhydramnios
prematurity
long umbilical cord
multiple pregnancy
multiparity

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111
Q

What is the main risk factor for cord prolapse and why?

A

abnormal fetal lie (not cephalic)
this allows space for the umbilical cord to prolapse below the presenting part- something not possible in normal cephalic lie

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112
Q

Consequence of cord prolapse to the fetus

A

the presenting part compresses the cord leading to fetal hypoxia
additionally the cold atmosphere that the cord is exposed to leads to umbilical artery vasospasm

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113
Q

what percentage of cord prolapses occur after artificial rupture of the membranes

A

50%

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114
Q

when should cord prolapse be considered

A

when there is a non-reassuring fetal heart rate pattern and absent membranes

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115
Q

How is cord prolapse managed

A
  1. manually elevate the presenting part by lifting it off the cord by vaginal digital examination
  2. catheterise the bladder and insert 500ml of saline
  3. encourage patient into the left lateral position or the knee chest position (all fours)
  4. emergency caesarean
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116
Q

If delivery is not immediately available, what can be given to delay in cord prolapsy

A

tocolysis (e.g. terbutaline)- relaxes the uterus and stops contractions

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117
Q

What is placental abruption

A

separation of the placenta from the uterine wall before delivery

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118
Q

RF for placental abruption

A

smoking
cocaine use
trauma
hypertensive disorders
polyhydramnios
abnormal lie of the baby

119
Q

Two types of placental abruption

A

overt (where the blood escapes through the vagina)
concealed (where the bleeding occurs behind the placenta )

120
Q

Presentation of placental abruption

A

vaginal bleeding- painful
uterine contractions
woody tense uterus

121
Q

How might shock associated with placental abruption present?

A

out of proportion from the bleeding (if concealed)

122
Q

What is placental praevia

A

Where the placenta is fully or partially attached to the lower uterine segment - a placenta that is covering the os or within 2cm of it

123
Q

RF of placental praevia

A

high parity
previous caesarean
maternal age >40
multiple pregnancy
history of uterine infection
curettage to the endometrium after miscarriage or termination

124
Q

What is the different between minor and major placenta praevia

A

minor placental praevia does not cover the internal os whereas major does

125
Q

How does placental praevia present

A

painless vaginal bleeding

126
Q

If minor placenta praevia is identified at 20 weeks when should the scan be repeated

A

36 weeks- will have likely moved superiorly

127
Q

if major placental praevia is located at 20 weeks when should the scan be repeated

A

32 weeks

128
Q

What is uterine rupture

A

full thickness disruption of the uterine msucle and overlying serosa - typically occurs during labour

129
Q

RF for uterine rupture

A

previous caesarean, previous uterine surgery, induction, obstruction of labour, multiple pregnancy, multiparity

130
Q

What is a side effect of magnesium suphate that needs to be monitored

A

respiratroy rate- can cause respiratory depression

Also should monitor reflexes

131
Q

What medication can be given to suppress lactation

A

cabergoline- a dopamine receptor agonist

132
Q

How is a suspected PE in a pregnant women with a confirmed DVT managed

A

immediate low molecular weight heparin - investigate aftet

133
Q

How soon after an abnormal semem sample should a repeat be taken?

A

3 months

134
Q

Can lithium be used during breastfeeding?

A

no

135
Q

What is lochia

A

the passage of blood, mucus and uterine tissue that occurs postpartum

136
Q

When should lochia be investigated

A

if continued after 6 weeks

137
Q

For what conditions are pregnant women screened for at their first booking appointment

A

HIV, syphilis and hepatitis B

138
Q

If not breast feeding how soon after birth can the COCP be started?

A

21 days

139
Q

What medication should patients with autoimmune conditions such as SLE and anti-phospholipid syndrome take during pregnancy

A

low dose aspirin from 12 weeks as high risk of pre-eclampsia

140
Q

What is complication of IVF

A

ovarian hyperstimulation syndrome

141
Q

How does ovarian hyperstimulation syndrome present?

A

lower abdominal pain
nausea and vomiting
abdo distention
ascites
hypotension
in severe scenarios = respiratory distress

142
Q

Define post partum haemorrhage

A

loss of more than 500ml of blood from the genital tract within 24 hours of birth of the baby

143
Q

What is primary post partum haemorrhage

A

haemorrhage within the first 24 hours after birth

144
Q

what is secondary post partum haemorrhage

A

haemorrhage occuring if after 24 hours of birth to 12 weeks

145
Q

Most common cause of secondary post-partum haemorrhage

A

endometritis
retained placental fragments

146
Q

The 4 T’s of primary post partum haemorrhage

A

Tone- uterine atony
Trauma- perineal tear (RF= instrumental delivery, episiotomy, c-section)
Tissue- retained placenta
Thrombin - bleeding or clotting disorder

147
Q

RF for post partum haemorrhage

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydramnia
  • emergency caesarean
  • instrumental delivery
  • placental praevia and accreta
    macrosomnia
148
Q

What is uterine atony

A

where the uterus fails to contract adequately following labour

149
Q

Management of postpartum haemorrhage when due to uterine atony

A
  1. uterine massage- bimanual compression to stimulate contraction
  2. uterotonics- medications to stimulate contraction (e.g syntocinon, carboprosy, ergometrine , misoprostol)
  3. surgical intervention- intrauterine balloon tamponade
150
Q

Potential surgical management of post partum haemorrhage

A

intrauterine balloon tamponade
B-lynch suture
uterine artery ligation
hysterectomy

151
Q

Investigations for secondary post partum haemorrhage

A

ultrasound scan
endocervical and high vaginal swabs

152
Q

How can major post partum haemorrhage be prevented

A
  • treat anaemia during pregnancy before delivery
  • active management of the third stage using oxytocin IM)
  • IV tranexamic acid during caesaran
153
Q

Define major PPH

A

over 1000 ml of blood loss

154
Q

mechanism of action of carboprost

A

prostaglandin analogue

155
Q

what is vasa praevia

A

a condition where the fetal vessels are within the fetal membranes and travel across the internal cervical os

156
Q

RF for vasa praevia

A

low lying placenta
IVF pregnancy
multiple pregnancy

157
Q

Pathophysiology of vasa praevia

A

normally vessels run in umbilical cord which inserts directly into the placenta (so they are not exposed).

In vasa praevia either:
- the umbilicus inserts into the chorioamniotic membrenas and the vessels travel unprotected through the membranes to the placenta
or
- there is an accessory (succenturiate lobe) of the placenta and the vessels travel in the chorioamniotic membranes between the lobes

158
Q

type 1 vasa praevia

A

also called a velamentous umbilical cord
- the umbilicus does not directly enter the placenta, instead it inserts into the chorioamniotic membranes and the foetal vessels run through these to the placenta

159
Q

what is type 2 vasa praevia

A

there is an accessory (succenturiate) lobe of the placenta and the vessels travel in the chorioamniotic membranes between these lobes

160
Q

How does vasa praevia present

A

typically presents as painless vaginal bleeding after rupture of the membranes
foetal bradycardia may also be present

161
Q

management of vasa praevia

A

elective caesarean prior to rupture of the membranes- around 35 to 36 weeks

162
Q

HOw does vasa praevia and placenta praevia differ

A

both have painless vaginal bleeding however placenta praevia wont happen with rupture of the membranes and will not have foetal bradycardia

163
Q

when should women be admitted for pre-eclampsia

A

when BP >160/110

164
Q

what drug is given to reverse magnesium sulphate induced respiratory depression

A

calcium gluconate

165
Q

what hormone increase the chance of breast cancer

A

progesterone

166
Q

How will a foetus present in placenta praevia

A

normally- should not have decelerations

167
Q

What is a normal fetal HR

A

110-140

168
Q

Can cooked liver be eaten in pregnancy and why?

A

no due to high levels of vitamin A

169
Q

What investigation is used to explore suspected placenta praevia

A

transvaginal USS

170
Q

what screening tool is used for postnatal depression

A

The Edinburgh scale

171
Q

give an example of a tocolytic drug which can be given to delay labour

A

terbutaline

172
Q

How long after a medical treatment of a miscarriage should a pregnancy test be performed

A

3 weeks

173
Q

If a women is presenting with hypertension before 20 weeks gestation what is the liekly diagnosis

A

pre-existing hypertension (pregnancy related problems do not occur before 20 weeks)

174
Q

how does an amniotic fluid embolism present

A

mainly occurs in labour
cyanosis, hypotension, chills, arrythmia, MI

175
Q

What is the most common complication of termination of pregnancy?

A

infection - can happen in up to 10% of cases

176
Q

indications for CAT 1

A

uterine rupture
placenta abruption
cord prolapse
fetal hypoxia
persistent foetal bradycardia

177
Q

Treatment of women with PPROM

A

10 days erythromycin

178
Q

risk of obstetric cholestasis

A

stillbirth

179
Q

first line medical management of uterine atony

A

IV oxytocin

180
Q

for how long does folic acid need to be taken in pregnancy

A

until the end of the first trimester

181
Q

If a mother has had a previous child with early or late onset GBS disease what additional measures are needed in subsequent pregnancies?

A

intrapartum antibiotics

182
Q

What conditions are included in gestational trophoblastic disorders

A

complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma

183
Q

what is a hydatidiform molr

A

a type of tumour that grows like a pregnancy in the uterus

184
Q

What is a complete hydatidiform mole

A

Occurs when two sperm fertilise an ovum that contains no genetic material (an empty ovum). The sperm combine to create genetic material that begins to divide.
There will be no fetal material

185
Q

what is an incomplete hydatidiform mole

A

occurs when two sperm fertilise an normal ovum containing some genetic material.
Creates a cell with three sets of genetic material which will dive and form some fetal parts

186
Q

How does a hydatidiform mole present?

A

bleeding in the first or early second trimester
exaggerated symptoms of pregnancy- e.g. severe morning sickness
Enlarged uterus for dates
hypertension and hyperthyroidism

187
Q

What will blood show in a molar pregnancy

A

very high serum hCG

188
Q

Why can hyperthyroidism occur in molar pregnancy

A

hCG can mimic TSH leading to high T3 and T4

189
Q

How is a molar pregnancy diagnosed?

A

very high serum hCG (often >100,000)
USS- shows snowstorm appearance
Diagnosis is confirmed on histological examination of the placenta

190
Q

1st line treatment of molar pregnancy

A

suction evacuation of the uterus

191
Q

What should women who have had a molar pregnancy be recommmended

A

contraception should be used for the next 12 months

192
Q

Overview of treatment of a molar pregnancy

A

suction evacuation
contraception for 12 months
anti-D prophylaxis if rhesus negative
may need beta blockers +/- carbimazole for hyperthyroidism
may need antihypertensives for pre-eclampsia

193
Q

Define miscarriage

A

spontaneous termination of a pregnancy before 24 weeks

194
Q

what is the time frame of an early miscarriage

A

before 12 weeks

195
Q

what is the timeframe of a late miscarriage

A

12 to 24 weeks

196
Q

What is a missed miscarriage

A

the fetus is not alive but no symptoms have occured

197
Q

what is a threatened miscarriage

A

vaginal bleeding with a closed cervix

198
Q

what is a inevitable miscarriage

A

vaginal bleeding with an open cervix

199
Q

what is an incomplete miscarriage

A

it is when a miscarriage has occured but there are remaining products of conception in the uterus

200
Q

RF for miscarriage

A

advanced maternal age
previous miscarriage
previous large cervical cone biopsy
lifestyle factors (smoking, alcohol, obesity)
medical conditions (uncontrolled diabetes, thyroid problems)

201
Q

How is a miscarriage diagnosed?

A

transvaginal USS

202
Q

what 3 feature are looked at on an USS to determine miscarriage

A

mean gestational sac diameter
fetal pole and crown rump length
fetal heartbeat

203
Q

At what crown rump length would you expect to see a fetal heartbeat

A

7mm

204
Q

if a heartbeat is not present on USS but the fetal crown rump length is less than 7mm, what is the next action?

A

the USS should be repeated in a week

205
Q

At what gestational sac diameter should a fetal pole be seen

A

25mm

206
Q

What is the first line treatment of a miscarriage?

A

expectant management

207
Q

describe expectant management of a miscarriage

A

7-14 days are allowed to see if the miscarriage spontanteously passes
this is confirmed on a urinary pregnancy test

208
Q

When should expectant management be avoided in management of a miscarriage

A

when there is increased risk of bleeding- woman is late in first trimester, woman has a bleeding abnormality
When there is evidence of infection
When there is previous adverse/traumatic experiences with pregnancy

209
Q

What is medical management of a miscarriage

A

misoprostol

210
Q

what is medical management of a missed miscarriage

A

200mg mifepristone then 800mcg of misoprostol

211
Q

how long after medical management of a miscarriage should a pregnancy test be done

A

3 weeks

212
Q

What is surgical management of a miscarriage?

A

manual vacuum aspiration or electric vacuum aspiration

213
Q

describe manual vacuum evacuation of a pregnancy q

A

local anaesthetic is used
a tube with a syringe attached is insterted into the uterus and the contents are aspirated

214
Q

before what gestation can manual vacuum evacuation be done

A

before 10 weeks

215
Q

what medication needs to be given to some women in surgical treatment of a miscarriage

A

anti-D prophylaxis

216
Q

causes of recurrent miscarriage

A

anti-phospholipid syndrome
poorly controlled diabetes and thyroid disorders
PCOS
uterine abnormality - e.g. a uterine septum , large fibroids, bicornuate uterus
paternal chromosomal antibodies
smoking
cervical incompetence

217
Q

what type of antibiotic is contradinicated in pregnancy (give some examples)

A

tetracyclines (doxycycline and lymecycline

218
Q

what antiemetic can cause extrapyramidal side effects?

A

metoclopramide

219
Q

before which gestation can termination of a pregnancy be done in the UK

A

24 weeks

220
Q
A
221
Q

what indications are legally required for abortion

A
  • before 24 weeks
  • continuation of the pregnancy would involve risk greater than if the pregnancy were terminated, or injury to the physical or mental health of the pregnant women or any existing child in their family
  • the termination is necessary to prevent grave permanent injury to the physical and mental health of the pregnant women
  • there is a substantial risk that if born the child would suffer from physical or mental abnormalities as to be seriously handicapped
222
Q

what medications are take in medical abortion

A

mifepristone then 48 hours later misoprostol

223
Q

before what gestation can medical management of an abortion be done at home

A

10 weeks

224
Q

how soon after medical management of an abortion should hCG be checked

A

2 weeks after

225
Q

what three surgical options are there for surgical abortion?

A

manual vacuum aspiration
electric vacuum aspiration
dilation and evacuation

226
Q

how soon after an abortion can an IUD be inserted

A

immediately

227
Q

indications for instrumental delivery

A

split into maternal and foetal factors

Maternal:
- inadequate progress (nulliparous should have delivery within 2 hours of pushing, multiparous should have delivery within 1 hour of pushing)
- maternal exhaustion
- maternal conditions where active pushing or prolonged exertion should be avoided (e.g. CHF)

Fetal:
- suspective fetal compromise as seen on CTG or abnormal fetal blood sample
- clincial concern such a antepartum haemorrhage

228
Q

what prerequisites are required for instrumental delivery

A

fully dilated
ruptured membranes
cephalic presentation
defined fetal position
fetal head at least level with ischial spines
empty bladder
adequate pain relief

229
Q

absolute contraindications for an instrumental delivery

A

-unengaged head of a singleton
-incompletely dilated cervix
-true cephalo-pelvic disproportion
- breech or face presentation
-preterm gestation of less than 34 weeks (for ventouse)
-High likelihood of fetal coagulation disorder (for ventouse)

230
Q

what two methods of instrumental delivery are there?

A

ventouse
forceps

231
Q

RF for anaemia in pregnancy

A

vegetarian
previous anaemia
carrying more than one baby
younger than 20
had 3 or more babies
having a second baby within a year

232
Q

why is there physiological anaemia during pregnancy?

A

plasma volume increases with pregnancy which leads to a decrease in haemoglobin concentration

233
Q

Why is it important that anaemia is treated in pregnancy?

A

to ensure there is a reasonable reserve if significant blood loss during delivery

234
Q

When is anaemia checked in pregnancy

A

at booking appointment
at 28 weeks gestation

235
Q

What should haemoglobin be at booking>

A

> 110

236
Q

what should haemoglobin be at 28 weeks

A

> 105

237
Q

What should haemoglobin be post partum

A

> 100

238
Q

Management of iron deficiency in pregnant women

A

ferrous sulphate 200mg

239
Q

complications of chlamydia in pregnancy

A

premature delivery
amnionitis
puerperal infection

Neonatal conjunctivits and pneumonia

240
Q

how is chlamydia treated during pregnancy

A

erythromycin 500mg 4 times daily for 7 days

241
Q

explain how ventouse delivery works

A

An instrument with a cup on the end is attached to the fetal head via a vacuum.

It is applied with its centre over the flexion point of the fetal skull and during contractions traction is applied to the cup

242
Q

What types of ventouse are there?

A

electric pump attached to a silastic cup (only used in occipital-anterior position)
hand-held disposable devise called a kiwi (all positions)

243
Q

RF for VTEs during pregnancy - when should treatment be started?

A

if 3 RF start prophylaxis at 28 weeks.
If 4 or more start prophylaxis in first trimester.

smoking
parity >3
ange >35
BMI >30
reduced mobility
multiple pregnancy
gross varicose veins
immobility
family history of VTE
thrombophilia
IVF

244
Q

1st line investigation of a DVT

A

doppler USS

245
Q

Gold standard investigation for a PE

A

CTPA

246
Q

Why is D dimer not used in pregnancy

A

d dimer isnt helpful as it already elevates in fetus

247
Q

What prophylaxis is given for DVT if recommended

A

low molecular weight heparin

248
Q

for how long is LMWH continued after delivery

A

6 weeks

249
Q

Is LMWH taken during labour

A

no it is temporarily stopped but then started immediately after

250
Q

What are risk factors for placenta praevia

A

twin/multiple pregnancy
women with high parity
older women
scarred uterus (previous caesarean)

251
Q

define antepartum haemorrhage

A

bleeding from the genital tract after 24 weeks gestation

252
Q

what investigations would you do after

A

USS
FBC
clotting studies
group and save/ cross mathc
cardiotocography

253
Q

RF for placental abruption

A

intrauterine growth restriction
previous abruption
maternal smoking
pre-eclampsia
hypertension
multiple pregnancy

254
Q

what will clotting studies show after placental abruption

A

afibrinogenaemia- placental damage leads to release of thromboplastin into the circulation.
This causes disseminated intravascular coagulation and subsequent usage of blotting factors

255
Q

what is vasa praevia

A

foetal blood vessels running in front of the placental part

256
Q

at what gestation can you usually feel the uterus

A

12 weeks

257
Q

what bloods are typically one at booking

A

haemoglobin or FBC
blood group and rhesus status
rubella immunity
syphillis serology
blood glucose level
HIV test
hepatitis B test
haemoglobin electophoresis for sickle cell

258
Q

aside from downs syndrome what can cause raised nuchel thickness

A

cardiac abnormalities

259
Q

results of triple test suggestive of downs syndrome

A

low AFP
low oestriol
raised hCG

260
Q

what is fetal position

A

the positon of the head as it exits the birth canal
usually in occipito-anterior position, can also be occipito posterior and occipito transverse

261
Q

what is the fetal presentation

A

the first part that enters the maternal pelvis (can be cephalic, breech, brow, shoulder)

262
Q

What is the fetal lie

A

the relationship between the long axis of the fetus and the mother- can be longitudinal or breech

263
Q

RF for breech presentation

A

prematurity
multiple pregnancy
uterine abnormality
placenta praevia
polyhydramnios
primiparity

264
Q

When can external cephalic version be attempted

A

36 weeks for nulliparous, 37 weeks for multiparous

265
Q

RF of ECV

A

platernal abruption
fetal distress
premature rupture of membranes

266
Q

what different types of breech presentations are there

A

frank breech
footling breech
complete breech

267
Q

management of breech presentation if ECV is unsuccessful

A

usually caesarean section-

268
Q

absolute contraindications of external cephalic version

A

antepartum haemorrhage has occurred within the last 7 days
non-reassuring cardiotocograph
major uterine abnormality,
placental abruption or placental praevia
membranes have ruptured
multiple pregnancy

269
Q

relative contraindications for ECV

A

intrauterine growth restriction with abnormal umbilical artery doppler
pre-eclampsia
maternal obesity
oligohydramnios
major foetal abnormalities
uterine scarring from previous caesarean section or myomectomy

270
Q

what causes premature labour

A

not completely understood:
- uterine overdistention (twins, triplets, polyhydramnios )
- decidual haemorrhage
- cervical insufficiency (premature cervical ripening)
- infection and inflammation (present in 25-40%, ascending route or haematogenous, may be iatrogenic)

271
Q

RF for premature labour

A

previous pre-term birth
multiple pregnancy
previous cervical surgery
uterine abnormalities
smoking
age
bacterial vaginosis
short cervix

272
Q

primary prevention of premature labour

A

stopping smoking
avoiding multiple pregnancies (IVF)

273
Q

Secondary prevention of premature labour

A

Cervical cerclage (a suture is placed to prevent dilation of the cervix)
Progesterone pessary

274
Q

Tertiary prevention of premature labour

A

tocolysis (nifedipine)
antenatal corticosteroids

275
Q

complications of preterm labour

A

sepsis
respiratory distress
nectotising eneterocolitis
vision and hearing abnormalities
cerebral palsy

276
Q

What defines pre-term labour

A

the onset of regular uterine contractions and cervical changes before 37 weeks gestation

277
Q

How can premature labour be confirmed

A

foetal fibronectin test (fFN test)

278
Q

maternal risks of obesity in pregnancy

A

miscarriage
VTW
gestational diabetes mellitus
pre-eclampsia
dysfunctional labour
induced labour
postpartum haemorrhage
wound infection

279
Q

fetal complications of obesity in labour

A

macrosomnia
prematurity
congenital anomalies
stillbirth
increased risk of metabolic disorders during childhood
neonatal death

280
Q

management of pregnancy of women with BMI >35 (6)

A

consultant led care
may need serial growth scans as measurements are less likely to be accurate
5mg of folic acid rather than 400mcg
oral glucose tolerance test at 24-48 weeks
VTE assessment before and after birth
intrapartum antibiotics in caesareans due to increased risk of infection

281
Q

RF for gestational diabetes

A

previous gestational diabetes
family history of gestational diabetes in first degree relative
previous macrosomnic baby
obesity >30
family origin with high diabetes prevalence
PCOS
maternal age >40

282
Q

complications of gestational diabetes

A

fetal macrosomnia (>4kg)
shoulder dystocia
perinatal mortality
neonatal hypoglycaemia

283
Q

what test is done at 24-28 weeks for gestational diabetes

A

oral glucose tolerance test (75g of glucose given and then blood glucose is measured 2 hours later)

284
Q

what results of the OGTT and fasting blood glucose suggest gestational diabetes

A

fasting >5.6
2 hour >7.8

285
Q

if a women has previously had gestational diabetes when should they be tested?

A

OGTT as soon as possible at booking, and then again at 24-28 weeks

286
Q

first line treatment of gestational diabetes if fasting glucose <7

A

trial of diet and exercise

287
Q

first line treatment of gestational diabetes if fasting glucose >7

A

insulin

288
Q

how long should diet and exercsie changes be tried before starting further treatment for gestational diabets

A

1-2 weeks

289
Q

management of gestational diabetes <7 where diet and exercise has failed

A

metformin

290
Q

what should the fasting glucose target be in gestational diabetes

A

<5.3

291
Q

what should the 1 hour post meal glucose target be in gestational diabetes

A

<7.8

292
Q

what should the 2 hour post meal glucose target be in gestational diabetes

A

<6.4

293
Q

what medication can be given to improve the success rate of external cephalic version

A

terbutaline- relaxes the uterine muscles

294
Q

what is the management of molar pregnancies

A

suction curettage

295
Q

in twin to twin tranfusion what is the risk to the recipient twin

A

hydrops fetalis and heart failure due to fluid overload

296
Q

first line investigation when chorioamnionitis is suspected?

A

blood cultures

297
Q

first line management of post partum haemorrhage if woman is hypovolaemic and shocked

A

insert large bore IV cannulae
group and save
cross match
coagulation studies
fluid resuscitation

298
Q

what medication is routinely given to all women before caesarean

A

omeprazole

299
Q
A

3A (33 decks)

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