Obstetrics🤰🏻 Flashcards
3a
1
Q
What bacteria causes a group B strep infection in pregnant women?
A
Streptococcus agalactiae
2
Q
How many women carry GBS asymptomatically?
A
25%
3
Q
Where does GBS colonise asymptomatically?
A
Gastrointestinal and genitourinary tracts
4
Q
What are the risk factors for neonatal GBS infection? (3)
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
5
Q
What is the presentation of GBS infection? (3)
A
Sepsis Pneumonia Meningitis
6
Q
How is GBS passed from mother to baby?
A
Vertical transmission of bacteria during childbirth
7
Q
What is the management of GBS infection during pregnancy?
A
Intrapartum antibiotic prophylaxis - IV benzylpenicillin during labour and delivery
8
Q
What is pre-eclampsia?
A
New hypertension in pregnancy with end organ dysfunction or proteinuria
9
Q
What is eclampsia?
A
When seizures develop as a cause of pre-eclampsia
10
Q
What is gestational hypertension?
A
New hypertension in pregnancy after 20 weeks that is not associated with proteinuria
11
Q
What is the triad seen in pre-eclampsia?
A
Hypertension Proteinuria Oedema
12
Q
What is the cause of pre-eclampsia? (2)
A
Pre-eclampsia is caused by poor vascular resistance in the spinal arteries and poor perfusion of the placenta
13
Q
What are high risk factors for pre-eclampsia? (3)
A
Pre-existing hypertension Pre-eclampsia in a previous pregnancyExisting autoimmune conditions DiabetesCKD
14
Q
What are moderate risk factors for pre-eclampsia? (3)
A
High BMIAge > 40More than 10 years since previous pregnancy First pregnancy Multiple pregnancy Family history of pre-eclampsia
15
Q
What may be offered as prophylaxis for pre-eclampsia?
A
Aspirin (from week 12)
16
Q
Who should be offered prophylaxis for pre-eclampsia?
A
Women with one high risk factor, or multiple moderate risk factors
17
Q
What are the symptoms of pre-eclampsia? (4)
A
Visual disturbances Headache Nausea and vomiting Epigastric pain Oedema Reduced urine output Brisk reflexes
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
19
Q
What are the indicators of organ dysfunction in pre-eclampsia? (3)
A
Raised liver enzymes Thrombocytopenia Raised creatinine Seizures Haemolytic anaemia
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
21
Q
What tests are used to monitor pre-eclampsia? (3)
A
Blood pressureSymptom monitoring Urine dipstickUltrasound monitoring of fetus
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
23
Q
What is the first line pharmacological management of pre-eclampsia?
A
Labetolol
24
Q
What other anti-hypertensives can be used in the management of pre-eclampsia?
A
Nifedipine - second line Methyldopa - third line
25
What is the first line management of pre-eclampsia after delivery?
Enalapril
26
What are the second and third line management options for pre-eclampsia after delivery?
Nifedipine or amlodipine
Labetolol or atenolol
27
What antihypertensive is given in severe pre-eclampsia or eclampsia?
IV hydralazine
28
What medication is given during delivery and in the 24 hours after to prevent seizures?
IV magnesium sulfate
29
What medication is used to manage seizures associated with eclampsia?
IV magnesium sulfate
30
What are the maternal complications of pre-eclampsia? (3)
Eclampsia
HELLP syndrome
Disseminated intravascular coagulation
Organ failure
31
What are the foetal complications of pre-eclampsia? (3)
Intrauterine growth restriction
Pre-term delivery
Placental abruption
Neonatal hypoxia
32
What is HELLP syndrome?
Haemolysis Elevated liver enzymes Low platelets
33
What is the definitive curative treatment of pre-eclampsia?
Delivery of the placenta
34
What must be monitored whilst magnesium sulfate is given?
Respiratory rate due to the risk of respiratory depression as a side effect
35
How often should women with pre-eclampsia be monitored?
They should have U&Es, FBC, transaminases and LFTs three times per week
36
What is gestational diabetes?
Insufficient insulin secretion to compensate for insulin resistance in pregnancyGestational diabetes is diabetes seen for the first time during pregnancy
37
What are the risk factors for GDM? (3)
Previous GDMPrevious macrosomic babyBMI > 30Ethnicity (Asian and Hispanic) Family history of diabetesPCOS
38
What are the physiological differences in insulin in pregnancy?
Increased insulin resistance (in the second and third trimester)
39
What are the physiological differences in glucose in pregnancy?
Fasting and post meal levels of glucose are decreased
40
What are the symptoms of gestational diabetes?
Most women are asymptomatic
41
What is the main investigation for gestational diabetes?
Oral glucose tolerance test
42
What OGTT results will be seen in a woman with gestational diabetes?
Fasting glucose > 5.6 mmol/LAt 2 hours > 7.8 mmol/L
43
When should OGTT be performed to diagnose gestational diabetes?
Between 24-28 weeks
44
Who is an OGTT performed on?
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
45
What are the fetal complications of gestational diabetes? (3)
Macrosomia Pre-term delivery Neonatal hypoglycaemiaIncreased risk of developing type 2 diabetes later in lifeCongenital heart disease Neonatal jaundice
46
What are the maternal complications of gestational diabetes? (3)
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
47
What is the first line management of gestational diabetes?
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
48
What medication can be used as an alternative to metformin in gestational diabetes?
Glibenclamide (sulfonylurea)
49
What are the target glucose levels for women with gestational diabetes?
Fasting - 5.3 mmol/L 1 hour post meal - 7.8 mmol/L 2 hours post meal - 6.4 mmol/L
50
What type of screening should mothers with pre-existing diabetes be offered during pregnancy?
Retinopathy screening when the woman becomes pregnancy, and at 28 weeks
51
When should women with pre-existing diabetes have given birth by?
Between 37 and 38+6 weeks
52
How long should diet and exercise be trialled in women with gestational diabetes?
1-2 weeks - offer metformin if glucose levels have not improvedOffer insulin if glucose levels have still not improved
53
What medication can be added to insulin in women with gestational diabetes?
Metformin
54
When should pregnant people with previous gestational diabetes be screened during their next pregnancy?
At booking, and again at 24-28 weeks
55
What is a postpartum haemorrhage?
Heavy bleeding after giving birth
56
What is a minor vs major postpartum haemorrhage?
Minor < 1 litre, major > 1 litre
57
How can a major PPH be further classified?
Moderate PPH - 1000-2000ml Severe PPH - > 2000ml
58
What is a primary PPH?
PPH within 24 hours of delivery
59
What is a secondary PPH?
PPH after 24 hours post delivery (up to 12 weeks postpartum)
60
What are the causes of PPH?
4 Ts- Tone - uterine atony - Trauma - Tissue - retained placenta - Thrombin - clotting/bleeding disorder
61
What are the risk factors for primary PPH? (5)
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
62
How can PPH be prevented? (3)
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
63
How should a patient be stabilised during a PPH?
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
64
What management options are there for stopping bleeding in a PPH?
Mechanical Medical Surgical
65
What are the mechanical management options for PPH? (2)
Rubbing the uterus through the abdomen - Stimulates contractions
Catheterisation - Prevents bladder distension that prevents uterine contractions
66
What are the medical management options for PPH? (3)
IV oxytocinIV or IM Ergometrine - stimulates muscle contraction IM carboprost - prostaglandin analogue Sublingual misoprostol - prostaglandin analogue IV tranexamic acid
67
What are the surgical management options for PPH? (4)
Intrauterine balloon tamponade (first line) - presses against the bleeding from the uterus - Fm line B-lynch suture - a suture around the uterus to compress it Uterine artery ligation Hysterectomy
68
What is the most likely cause of secondary PPH?
Retained products of conception or infection
69
What are the investigations for secondary PPH?
Ultrasound for RPOC Endocervical and high vaginal swab for infection
70
What is the management of secondary PPH?
Surgical evaluation for RPOC Antibiotics for infection
71
What is the most common cause of PPH?
Uterine atony
72
What is uterine atony?
Failure of the uterus to contract adequately after childbirth
73
What is Sheehan's syndrome?
A complication of PPH where ischaemic necrosis of the anterior pituitary is caused by blood loss
74
How does Sheehan's syndrome manifest after a PPH?
HypopituitarismLack of postpartum milk production Amenorrhoea
75
What is shoulder dystocia?
Where the anterior fetal shoulder becomes lodged behind the maternal pubic symphysis following delivery of the fetal head
76
What are the risk factors for shoulder dystocia? (5)
Maternal gestational diabetesMacrosomia Birth weight > 4.5kg Advanced maternal ageMaternal short stature Maternal obesity Post dates pregnancy
77
What are the features of shoulder dystocia? (3)
Difficulty delivering the face and head
Failure of restitution
Turtle neck sign
Failure of descent of fetal shoulders following delivery of the head
78
What is failure of restitution?
Where the head remains face downwards after delivery and does not turn sideways as expected
79
What is the turtle neck sign?
Where the head is delivered but retracts back into the vagina
80
What is the management of shoulder dystocia?
Immediately call for help McRoberts manoeuvreRubins manoeuvreWood's screw manoeuvreZavanelli manoeuvre
81
What is McRoberts manoeuvre?
The maternal hips are hyperflexed and abducted. This provides a posterior pelvic tilt to move the pubic symphysis up and out of the way
82
What is Rubins manoeuvre?
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
83
What is Wood's screw manoeuvre?
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
84
What is the Zavanelli manoeuvre?
The baby's head is pushed back into the vagina so that the baby can be delivered by emergency C section
85
What are the complications of shoulder dystocia? (3)
Fetal hypoxia (and subsequent cerebral palsy)Brachial plexus injury (and Erb's palsy)Fetal deathPerineal tears PPHUterine rupture
86
What is Erb's palsy?
Paralysis of the arm caused by damage to the C5-C6 nerve roots of the brachial plexus
87
What is placenta praevia?
A placenta that is lying partly or wholly in the lower uterine segment and is over the internal cervical os
88
What is a low lying placenta?
A placenta that is within 20mm of the internal cervical os
89
What are the risk factors for placenta praevia? (4)
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
90
What is the presentation of placenta praevia?
Painless vaginal bleeding (usually after 36 weeks, but suspect placenta praevia after 24 weeks)
91
When is placenta praevia usually picked up?
At the 20 week anomaly scan
92
How should placenta praevia be monitored?
Repeat transvaginal ultrasound at:- 32 weeks - 36 weeks
93
What does placenta praevia increase the risk of? (5)
Emergency caesarean section Antepartum haemorrhage Emergency hysterectomy Maternal anaemia Preterm birth Low birthweight Stillbirth
94
What are the different grades of placenta praevia?
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
95
What is the management of placenta praevia? (3)
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
96
What is the management of bleeding with an unknown placental position?
ABCDE approach Urgent transvaginal ultrasound If bleeding is not controlled, emergency C section required
97
What is the investigation of choice to exclude placenta praevia?
Transvaginal ultrasound
98
What is the management of placenta praevia in a woman in labour?
Caesarean section
99
Up to what gestation can termination of pregnancy occur?
Up to 24 weeks
100
What are the criteria for abortion?
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
101
When can an abortion be performed at any time during pregnancy?
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
102
What is the process of a medical abortion?
Mifepristone Misoprostol given 1-2 days laterTest pregnancy 3 weeks later to confirm pregnancy has ended
103
What is mifepristone?
An anti-progesten
104
What is misopristol?
A prostaglandin analogue
105
What are the surgical options for abortion? (3)
Surgical options
use of transcervical procedures to end a pregnancy, including:
Manual vacuum aspiration (MVA)
electric vacuum aspiration (EVA)
dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
106
How long may a pregnancy test be positive for following termination?
4 weeks
107
When should women be given rhesus D at termination?
When they are rhesus negative and having a termination after 10 weeks gestation
108
What is the placenta accreta spectrum?
Where the placenta implants into and past the endometrium, making it difficult to separate the placenta after delivery of the baby
109
What is placenta accreta?
Where the placenta implants into the surface of the endometrium
110
What is placenta increta?
Where the placenta implants deeply into the myometrium
111
What is placenta percreta?
Where the placenta implants past the myometrium and perimetrium, and can reach organs such as the bladder
112
What are the risk factors for placenta accreta? (3)
Previous placenta accreta
Previous endometrial curettage procedures
Previous C section
Multigravida
Increased maternal age
Placenta praevia
Uterine structural defects
113
What is the endometrium?
The inner layer of the uterine wall that contains connective tissue, epithelial cells and blood vessels
114
What is the myometrium?
The middle layer of the uterine wall that contains smooth muscle
115
What is the perimetrium?
The outer layer of the uterine wall, which is a serous membrane similar to the peritoneum
116
How is placenta accreta diagnosed?
Antenatal ultrasoundMRI scan to assess depth and width of invasion
117
When is delivery planned for women with placenta accreta?
Between 35 and 36+6 gestation
118
What are the management options for placenta accreta during C section delivery? (3)
Hysterectomy Uterus preserving surgery - Resection of part of the myometrium alongside the placentaExpectant management - Leaving the placenta to be absorbed over time
119
What is placental abruption?
Where the placenta detaches from the wall of the uterus during pregnancy
120
What are the risk factors for placental abruption? (5)
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy TraumaMultiple pregnancy Fetal growth restrictionMultigravidaIncreased maternal ageSmoking
121
What is the presentation of placental abruption? (4)
Sudden onset of severe continuous abdominal painVaginal bleeding ShockAbnormalities on CTG indicating fetal distress'Woody' abdomen on palpation
122
What is concealed abruption?
Where the cervical os remains closed, and so bleeding is contained with the uterine cavity
123
What is the general management of placental abruption?
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
124
What are the differentials of placental abruption? (3)
Preterm labour Placenta praeviaChorioamnionitis UTI Degeneration of uterine fibroidsAcute appendicitis
125
What is the management of placental abruption at less than 36 weeks?
If fetal distress - immediate caesarean No fetal distress - administer steroids and observe
126
What is the management of placental abruption after 36 weeks?
If fetal distress - immediate caesarean No fetal distress - delivery vaginally
127
What BMI is defined as obese during antenatal appointments?
30
128
What are the maternal risks of obesity during pregnancy? (5)
Miscarriage
VTE
Gestational diabetes
Pre-eclampsia
Dysfunctional labour
PPH
Wound infections
129
What are the fetal risks of obesity during pregnancy? (3)
Macrosomia Congenital abnormalitiesPrematurityStillbirth Obesity and metabolic disorders during childhoodNeonatal death
130
What is the advice regarding weight loss for obese women during pregnancy?
Women should not try to lose weight by dieting - medical professionals will manage the risk
131
How much folic acid should obese women take during pregnancy?
5mg per day (instead of 400mcg)
132
What is the additional management of obesity in pregnancy?
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
133
What is the first stage of labour?
From the onset of labour to up to 10cm dilated
134
What is the second stage of labour?
From 10cm cervical dilation up to the delivery of the baby
135
What is the third stage of labour?
From delivery of the baby until delivery of the placenta
136
What is the latent phase of the first stage of labour?
Up to 3cm cervical dilation Irregular contraction Progresses at 0.5cm per hour
137
What is the active phase of the first stage of labour?
From 3cm to 7cm cervical dilationRegular contractions Progresses at 1cm per hour
138
What is the transition phase of the first stage of labour? (3)
From 7 to 10cm cervical dilation Strong regular contractions Progresses at 1cm per hour
139
What are Braxton-Hicks contractions?
Occassional irregular contractions that can be felt during the second and third trimesters of pregnancy. They do not progress or become regular
140
What are the signs of labour?
Mucus plug from the cervixRupture of membranes Regular, painful contractions Dilating cervix on examination
141
What is rupture of membranes (ROM)?
When the amniotic sac has ruptured
142
What is spontaneous ROM?
The amniotic sac has ruptured spontaneously
143
What is pre-labour ROM?
The amniotic sac has ruptured before the onset of labour
144
What is preterm pre-labour ROM?
The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation
145
What is prolonged ROM?
The amniotic sac ruptures more than 18 hours before delivery
146
What is the definition of prematurity?
Delivery before 37 weeks gestation
147
What is cardiotocography?
Used to measure fetal heart rate and contractions of the uterus
148
How is CTG recorded?
Two doppler ultrasound transducers are placed on the abdomen:- One above the fetal heart - One above the fundus of the uterus
149
What are the indications for continuous CTG monitoring? (5)
Sepsis Maternal tachycardia Significant meconiumPre-eclampsia Fresh antepartum haemorrhageDelay in labour Use of oxytocin Disproportionate maternal pain
150
What are the 5 key features of CTG?
Contractions Baseline fetal heart rateVariability Accelerations Decelerations
151
What is a reassuring baseline fetal heart rate?
110-160
152
What is a non-reassuring baseline fetal heart rate?
100-109 or 161-180
153
What is an abnormal fetal heart rate?
Below 100 or above 180
154
What is normal variability of fetal heart rate?
5-25
155
What is a non-reassuring variability of fetal heartrate?
Less than 5 for 30-50 minutes or more than 25 for 15-25 minutes
156
What is an abnormal variability of fetal heartrate?
Less than 5 for over 50 minutes or more than 25 for over 25 minutes
157
What are decelerations?
Fetal heartrate dropping in response to hypoxia
158
What are early decelerations?
Dips and recoveries in heart rate that correspond with uterine contractions - they are normal
159
What are late decelerations?
Gradual falls in heart rate that start after the contraction has began. They are caused by hypoxia in the fetus and are pathological
160
What are variable decelerations?
Decelerations that may be unrelated to uterine contraction. They are related to compression of the umbilical cord
161
What are prolonged decelerations?
A drop of more than 15bpm from baseline that lasts between 2 and 10 minutes
162
What is progress in labour influenced by? (3)
Power - uterine contractions Passenger - size, presentation and position of baby Passage - size and shape of pelvis
163
What is failure to progress in the first stage of labour?
Less than 2cm of cervical dilation in 4 hours Slowing of progress in a multiparous woman
164
What is a partogram?
Monitoring system during the first stage of labour
165
What is the attitude of the fetus?
The posture of the fetus
166
What is included in a partogram?
Used to monitor the active phase of the first stage of labour
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
What is failure to progress in the second stage of labour?
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
What is oblique lie?
The fetus is at an angle
169
What is longitudinal lie?
The fetus is straight up and down
170
What is cephalic presentation?
The head presents first
171
What is transverse lie?
The fetus is straight side to side
172
What is shoulder presentation?
The shoulder presents first
173
What is a complete breech presentation?
Breech presentation (feet first) with hips and knees flexed
174
What is a frank/extended breech presentation?
A breech presentation with hips flexed and knees extended - bottom first
175
What is a footling breech?
A breech presentation with a foot hanging through the cervix
176
What is delay in the third stage of labour?
More than 30 minutes with active management More than 60 minutes with physiological management
177
What is the management of failure to progress in labour?
ARM - artifical rupture of membranes
Oxytocin infusion
Instrumental delivery C-section
178
What is active management of the third stage of labour?
When the doctor/midwife assists in the delivery of the placenta
179
How is the third stage of labour actively managed?
IM oxytocin after delivery of the baby
180
Which women do not need any treatment for rhesus?
Rhesus positive women
181
Which women need treatment for rhesus?
Rhesus negative women
182
Why is anti-D given?
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
What condition can be caused in a rhesus negative mother and rhesus positive baby?
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
How does anti-D work?
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
When is anti-D primarily given?
At 28 weeks gestation and at birth
186
In what other situations is anti-D given?(5)
Any time where mixing of blood could occur:
- Antepartum haemorrhage - Amniocentesis
- - Abdominal trauma
- - Ectopic pregnancy
- - Miscarriage
- - Termination
- - Intrauterine death
- - External cephalic version-
187
Within how long shoud anti-D be given after an exposure event?
72 hours
188
What is the Kleihauer test?
A test to check how much fetal blood has passed into the mother's bloodstream during a sensitisation event
189
How is Kleihauer's test performed?
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
What is vasa praevia?
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
How does vasa praevia occur?
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
What are the symptoms of vasa praevia? (3)
Painless vaginal bleeding Rupture of membranes Fetal bradycardiaAntepartum haemorrhage
193
What is type 1 vasa praevia?
Due to a velamentous umbilical cord
194
What is type 2 vasa praevia?
Due to an accessory lobe of the placenta
195
What are the risk factors for vasa praevia? (3)
IVF pregnancyLow lying placenta Multiple pregnancy
196
What are the differentials of vasa praevia?
Placenta praevia Placental abruption
197
What is the management of vasa praevia? (2)
Corticosteroids given from 32 weeks gestation Elective C section from 34-36 weeks (before rupture of membranes)
198
What is the investigation of choice for the diagnosis of vasa praevia?
Transvaginal ultrasound
199
What is oligohydramnios?
A lower than normal amount of amniotic fluid in the uterus
200
What are the causes of oligohydramnios? (3)
Intrauterine growth restriction
Premature rupture of membranes
Fetal urinary system abnormalities
Post-term gestation
Pre-eclampsia
201
What are the fetal complications of oligohydramnios? (2)
Congenital hip dysplasia Clubbed feetFacial deformity Pulmonary hypoplasia
202
What is Potter syndrome/sequence?
Pulmonary hypoplasia and bilateral renal agenesis
203
How does Potter syndrome occur?
A renal formation abnormality can cause oligohydramnois which can lead to pulmonary hypoplasia
204
What investigations are performed to diagnose oligohydramnios?
Amniotic fluid index < 5Single deepest pocket < 2cm
205
What is the management of oligohydramnios? (3)
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
What is polyhydramnios?
Where there is excessive amounts of amniotic fluid in the uterus
207
What are the signs and symptoms of polyhydramnios? (3)
Fetus that is difficult to palpateUterus that feels tense Large for dates uterus
208
What are the two main mechanisms of polyhydramnios?
Excessive amniotic fluid production Reduced fetal swallowing (removal of amniotic fluid)
209
What are the causes of excess production of amniotic fluid? (3)
Maternal diabetes
Macrosomia
Fetal renal disorders
Fetal anaemia
Twin to twin transfusion syndrome
210
What are the causes of reduced fetal swallowing? (3)
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
What are the maternal complications of polyhydramnios?(3)
Maternal respiratory compromise due to pressure on diaphragm Increased risk of UTIGORDPeripheral oedema Constipation Stretch marks
212
What are the fetal risks of polyhydramnios? (3)
Pre-term labour and delivery Premature rupture of membranes Placental abruption Malpresentation of fetus Umbilical cord prolapse
213
What is the management of polyhydramnios? (2)
Treatment of underlying causesAmnio-reduction
214
What AFI is indicative of polyhydramnios?
More than 25
215
What is the most common cause of polyhydramnios?
Idiopathic
216
What are baby blues?
A transient mood disorder that affects mothers following pregnancy
217
When is the onset of baby blues?
Around 3 days after childbirth
218
When does baby blues usually resolve by?
Around 2 weeks postpartum
219
What are the signs and symptoms of baby blues? (3)
IrritabilityAnxiety regarding parenting skillsTearfulness
220
What are the differentials of baby blues?
Postpartum depression Postpartum psychosis
221
What is the management of baby blues?
Reassurance and observation
222
What is malpresentation?
When the baby is not cephalic as birth approaches
223
What is the most common type of malpresentation?
Breech presentation
224
What is a complete breech?
Where the legs and hips are fully flexed
225
What is an incomplete breech?
One leg fully flexed at the knee and hip, with one leg extended at the knee and flexed at the hip
226
What is an extended breech?
Both legs extended at the knee and flexed at the hip
227
What is a footling breech?
Leg extended with a foot presenting through the cervix
228
What is the management of a breech presentation before 36 weeks?
Observation - many fetuses turn spontaneously
229
What is the management of a breech presentation after 36 weeks?
External cephalic version can be performed:- After 36 weeks for nulliparous women - After 37 weeks for multiparous women
230
What are the contraindications to ECV? (3)
When c-section delivery is requiredAntepartum haemorrhage in last 7 days Abnormal CTG Major uterine abnormalityRuptured membranes Multiple pregnancy
231
What is the management of a breech baby if ECV has failed?
Planned LSCS or vaginal delivery
232
How is ECV performed?
Tocolysis with SC terbutaline is given to relax the uterus, making it easier for baby to turn
233
What is the risk of VZV to mothers in pregnancy? (3)
Varicella pneumonitis Hepatitis Encephalitis
234
What are the risks of VZV to baby?
Fetal varicella syndrome Neonatal varicella syndrome Shingles in infancy
235
What are the symptoms of fetal varicella syndrome? (3)
Fetal growth restriction
Microcephaly
Learning disability
Skin scarring and skin changes following the dermatomes
Limb hypoplasia
Cataracts and eye inflammation (chorioretinitis)
236
What is the treatment of chicken pox infection during pregnancy?
Oral acyclovir if more than 20 weeks and presents within 24 Hrs onset of rash
237
What is the management of VZV exposure in a woman who has had chicken pox?
Reassure - no action needed
238
What is the management of VZV exposure in a woman who is not sure if she's had chicken pox?
Test for VZV antibodies (IgG)- If has antibodies - reassure - If no antibodies - treat
239
What is the management of VZV exposure in a woman who has not had chicken pox?
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
Why is the varicella zoster vaccine not given in pregnancy?
It is a live attenuated vaccine and can cause fetal infection
241
What are the features of congenital varicella syndrome? (3)
Atypical skin scarring IUGR Cataracts Cerebral cortical atrophy Global developmental delayLimb hypoplasia
242
What is cord prolapse?
Where the umbilical cord descends past the fetus, and through the cervix/vagina after rupture of membranes
243
What are the risk factors for cord prolapse? (3)
Polyhydramnios
Multiparity
Multiple pregnancy
Low birthweight
Prematurity
Abnormal lie
High fetal head at delivery
244
What are the signs of cord prolapse?
Feeling of the cord inside the vagina Abnormal fetal heart rate on CTG
245
What investigations are used to diagnose cord prolapse? (2)
Vaginal examination CTG
246
What is the definitive management of cord prolapse?
Emergency C-section
247
What can be done to prevent further cord prolapse? (3)
Knees chest position Filling the bladder with 500ml warmed saline Avoid exposure and handling of the cord Terbutaline to stop uterine contractions
248
How are twin pregnancies classified?
Zygosity Chorionicity Amnionicity
249
What is zygosity?
Monozygotic twins - from same egg and sperm Dizygotic twins - from different egg and sperm
250
What is chorionicity?
Monochorionic - single shared placenta Dichorionic - separate placentas
251
What is amnionicity?
Monoamniotic - single shared amniotic sac Diamniotic - separate amniotic sacs
252
What are the risks of monozygotic twins? (3)
Increased sponatenous miscarriage Prematurity IUGR Increased malformations Twin to twin transfusion syndrome
253
What are the maternal complications of multiple pregnancy? (3)
Anaemia Polyhydramnios Hypertension Malpresentation Premature labour Instrumental delivery Caesarean section PPH
254
What are the predisposing factors to dizygotic twins? (3)
IVF treatment
Previous twins
Family history
Increasing maternal age
Multigravida
Afro-Caribbean race
255
What are the fetal risks of multiple pregnancy?(5)
Miscarriage
Stillbirth
IUGR
Prematurity
Twin-twin transfusion syndrome Congenital abnormalities
256
What is twin-twin transfusion syndrome?
When one twin receives the majority of blood through the shared placenta, while the other is starved of blood
257
What are the complications to the recipient in twin-twin transfusion syndrome?
The recipient can become fluid overloaded leading to:- Heart failure - Polyhydramnios
258
What are the complications to the donor in twin-twin transfusion syndrome? (3)
Growth restriction Anaemia Oligohydramnios
259
What is twin anaemia polycythaemic sequence?
Like twin-twin transfusion syndrome but less severe - one twin will be polycythaemic and the other will be anaemic
260
How often are women with multiple pregnancy scanned?
Every 2 weeks from 16 weeks for monochorionic twins Every 4 weeks from 20 weeks for dichorionic twins
261
What type of twins require caesarean section?
Monochorionic monoamniotic
262
When should dichorionic diamniotic twins be delivered?
Between 37 and 37+6 weeks
263
When should monochorionic diamniotic twins be delivered?
Between 36 and 36+6 weeks
264
When should monochorionic monoamniotic twins be delivered?
Between 32 and 33+6 weeks (by CS)
265
What is the main risk factor for uterine rupture?
Previous caesarean section
266
What are the other risk factors for uterine rupture? (3)
VBAC (vaginal birth after c section) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin
267
What is the presentation of uterine rupture? (4)
Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
268
What is the definitive management of uterine rupture?
Emergency caesarean section Repair uterus/hysterectomy
269
What are the risk factors for VTE in pregnancy?(5)
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
When should VTE prophylaxis be started in pregnancy?
At 28 weeks if there are three risk factors In the first trimester if there are 4 or more risk factors
271
What other situations would VTE prophylaxis be considered in? (5)
Hospital admission Previous VTESurgery Cancer Ovarian hyperstimulation syndrome
272
What medicaiton is used as VTE prophylaxis in pregnancy?
LMWH (low molecular weight heparin)
273
How long is VTE prophylaxis continued after delivery?
6 weeks
274
What are the mechanical VTE prophylaxis options? (2)
Anti-embolic compression stockings Intermittent pneumatic compression
275
What is the presentation of DVT?
Unilateral Calf or leg swelling Dilated superficial veins Tenderness to the calfOedema Redness
276
What is the presentation of a pulmonary embolism? (5)
Shortness of breath Cough Haemoptysis Pleuritic chest pain Hypoxia Tachycardia Raised resp rate Low grade fever
277
What is the investigation of choice for DVT?
Doppler ultrasound
278
What are the investigations used in the diagnosis of PE?
CXR ECG
279
What is the definitive diagnosis of PE?
CTPA - CT pulmonary angiography
280
What types of anticoagulants should be avoided in pregnancy?
Warfarin and DOACs
281
Why is DVT more common in the left leg in pregnancy?
The gravid uterus puts pressure on the left iliac vein crossing the left iliac artery -slows venous return
282
What are the symptoms of lower UTI in pregnancy? (4)
Dysuria Suprapubic pain Frequency Urgency Incontinence Haematuria
283
What are the symptoms of pyelonephritis in pregnancy? (3)
FeverVomiting Loss of appetite Back, loin suprapubic pain Haematuria Renal angle tenderness
284
What investigations are used to diagnose UTI in pregnancy?
Dipstick - Leucocytes and nitrites MSU culture and sensitivity - All urine samples with positive leucocytes or nitrites are sent off for culture
285
What is the most common cause of UTI in pregnancy?
E coli
286
What are the other causes of UTI in pregnancy? (3)
Klebsiella pneumoniae Enterococcus Psuedomonas aeruginosa Staphylococcus saprophiticus Candida albicans
287
How many days of antibiotics does UTI in pregnancy require?
7 day course
288
What antibiotics are used to treat UTI in pregnancy?
Nitrofurantoin Amoxicillin Cefalexin
289
When should nitrofurantoin be avoided in pregnancy?
In the third trimester (due to risk of neonatal haemolysis)
290
Which antibiotics are safe to use in UTI throughout pregnancy?
Cephalosporins
291
When are women screened for anaemia during pregnancy?
At booking At 28 weeks
292
Why does anaemia commonly occur in pregnancy?
Plasma volume increases which results in a reduction in haemoglobin concentration
293
What are the symptoms of anaemia in pregnancy? (3)
Often asymptomatic Shortness of breath Fatigue Dizziness Pallor
294
What is the normal range for haemoglobin during first trimester
> 110
295
What is the normal range for haemoglobin during second and third trimesters?
> 105
296
What is the normal range for haemoglobin postpartum?
> 100
297
What does a low MCV and anaemia indicate?
Iron deficiency
298
What does a normal MCV during pregnancy indicate?
Physiological anaemia due to increased plasma volume
299
What does a raised MCV and anaemia indicate?
Vitamin B12 or folate deficiency
300
What is the management of iron deficiency anaemia during pregnancy?
Ferrous sulfate 200mg daily
301
What is the management of B12 deficiency anaemia during pregnancy?
Testing for pernicious anaemia - intrinsic factor antibodies
IM hydroxycobalamin
Oral cyanocobalamin
302
What is the management of folate deficiency anaemia during pregnancy?
5mg folic acid daily throughout pregnancy
303
What is prelabour rupture of membranes?
When the amniotic membranes rupture prior to the start of labour, in a woman who is more than 37 weeks pregnant
304
What is the presentation of prelabour rupture of membranes? (3)
Greenish/ foul smelling amniotic fluid
Maternal fever
Reduced fetal movements
305
What are the investigations to confirm prelabour rupture of membranes? (3)
Ultrasound (oligohydraminos)
Speculum to look for pooling of amniotic fluid in the posterior vaginal vault
PAMG-1 ( [lacental alpha microglobulin-1) or insulin-like growth factor binding protein-1 (IGFBP-1)
306
What are the differentials of prelabour rupture of membranes? (3)
Urinary incontinence Vaginal discharge or infection Loss of mucus plug
307
What is the management of prelabour rupture of membranes?
Monitoring maternal temperature Assessing fetal movements Monitoring of fetal heart rateConsider IOL after 24 hours
308
What are the risk factors for prelabour rupture of membranes? (4)
Smoking Previous PROM Vaginal bleeding during pregnancy Lower genital tract infection Invasive procedures - amniocentesis Multiple pregnancy
309
What is premature prelabour rupture of membranes?
The rupture of amniotic membranes before the onset of labour, before 37 weeks
310
What are the causes of P-PROM? (3)
Infection Early activation of normal physiological processesGenetic predisposition
311
What are the risk factors for P-PROM? (3)
Smoking Previous P-PROM Vaginal bleeding during pregnancy Lower genital tract infection Invasive procedures Polyhydramnios Multiple pregnancy Cervical insufficiency
312
What are the investigations to confirm P-PROM? (3)
Confirming PPROM
a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
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
ultrasound may also be useful to show oligohydramnios
313
What is the management of P-PROM? (3)
Admit
Monitor for signs of chorioamnionitis
Corticosteroids if less than 34+6 weeks
Oral erythromycin for 10 days
Delivery considered at 34 weeks gestation
314
What are the complications of P-PROM? (3)
Chorioamnionitis Oligohydramnios Neonatal death Placental abruption Umbilical cord prolapse
315
What are the components of the bishop score? (5)
Fetal station Cervical position Cervical dilation Cervical effacement Cervical consistency
316
What is premature labour?
Delivery before 37 weeks gestation
317
When are babies considered non-viable?
If delivered before 23 weeks
318
What is the classification of prematurity?
32-37 weeks - moderate to late preterm 28-32 weeks - very preterm Before 28 weeks - extreme preterm
319
What is the prophylaxis of premature labour? (2)
Vaginal progesterone (prevents contractions and premature labour) Cervical cerclage (temporarily sewing the cervix closed with stitches)
320
Who is vaginal progesterone given to?
Women with a cervical length of less than 25mm on ultrasound between 16 and 24 weeks gestation
321
What is cervical cerclage?
Putting a stitch in the cervix to support it and keep it closed
322
When is cervical cerclage performed?
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
What is the management of preterm labour with intact membranes? (3)
CTG
Tocolysis with nifedipine
Maternal corticosteroids (less than 36 weeks)
IV magnesisum sulphate (within 24 hrs of delivery and protects fatal brain, reducing the risk of cerebral palsy)
Delayed cord clamping
324
What time frame are tocolytics used in and why?
Between 24 and 33+6 weeks to stop contractions and delay delivery
325
What are the fetal risks of prematurity? (3)
Respiratory distressIntraventricular haemorrhage Necrotising entercolitis Chronic lung diseaseRetinopathy of prematurity Hearing problems
326
What is obstetric cholestasis?
The reduced flow of bile acids from the liver during pregnancy
327
When does obstetric cholestasis develop during pregnancy?
After 28 weeks
328
What is the aetiology of obstetric cholestasis?
The outflow of bile acids from the liver is reduced - this causes bile acids to build up in the blood resulting in itching
329
What is the presentation of obstetric cholestasis?
Pruritis - specifically of the hands and soles of the feet FatigueDark urine Pale, greasy stools Jaundice No rash present
330
What are the differentials of obstetric cholestasis? (2)
Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis
331
What investigations should be performed to diagnose obstetric cholestasis and what would they show?
LFTs - raised ALT, AST and GGT Bile acids - raised
332
What is the main treatment of obstetric cholestasis?
Ursodeoxycholic acid
333
What other treatments might be useful in obstetric cholestasis?
Antihistamines to reduce itching Emollients
334
What monitoring is required in patients with obstetric cholestasis?
Weekly LFTs during pregnancy and after delivery
335
When should delivery be planned in patients with obstetric cholestasis?
37 weeks
336
When should women have a booking appointment?
Before 10 weeks gestation
337
When do women have a dating scan?
Between 10 and 13+6 weeks
338
When should women have their anomaly scan?
Between 18 and 20+6 weeks
339
When do women have additional antenatal appointments?
25 weeks283134363840 4142 weeks
340
When do women have their first regular antenatal appointment?
16 weeks
341
How is an accurate gestational age calculated at the dating scan?
Crown rump length
342
When do women with placenta praevia have an additional scan?
32 weeks
343
What is covered at regular antenatal appointments?
Plans for pregnancy and delivery Symphysis-fundal height Fetal presentation Urine dipstick Blood pressure
344
What vaccines are offered to pregnant women and when?
Pertussis from 16 weeks Flu vaccine in autumn or winter
345
What bloods are performed at booking? (5)
Blood group Rhesus antibodies FBC Screening for thalassaemia and sickle cell HIV Hepatitis B Syphilis
346
What is the combined test?
The first line antenatal screening for downs syndrome
347
When is the combined test performed?
Between 11 and 14 weeks gestation
348
What does the combined test involve?
Ultrasound for nuchal translucency Beta-hCG (high)PAPP-A (low)
349
What is the triple test?
Test for down syndrome:- beta-hCG (high)- Alpha fetoprotein (low)- Serum oestriol (low)
350
When is the triple test performed?
Between 14 and 20 weeks
351
What is the quadruple test?
Triple test but also includes inhibin-A (high)
352
What conditions are tested for at the anomaly scan? (5)
Edward's Patau's Anencephaly Gastroschisis Exophalmos Spina bifida Cleft lip Congenital diaphragmatic hernia Congenital heart diseaseBilateral renal agenesis
353
What is hyperemesis gravidarum?
An extreme form of nausea and vomiting during pregnancy
354
When is hyperemesis most common?
Between 8 and 12 weeks
355
What are the risk factors for hyperemesis? (3)
Increased b-hCG
Molar pregnancy
Nulliparity
Obesity
Family history of NVP
Previous NVP/hyperemesis
356
What is the criteria for admission in a patient with hyperemesis? (3)
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
What is the triad of symptoms in hyperemesis?
5% weight lossDehydration Electrolyte imbalance
358
What are the first line anti-emetics for hyperemesis?
Cyclizine - antihistamines
359
What other class of medications can be used in hyperemesis?
Phenothiazines - Prochlorperazine - Chlorpromazine
360
What fluid is used for rehydration in hyperemesis?
IV saline with potassium
361
What are the complications of hyperemesis? (3)
Wernicke's encephalopathy AKI VTE Oesophagitis Mallory-Weiss tear
