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4th Year > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

How many antenatal appointments for a nulliparous woman?

A

10

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2
Q

How many antenatal appointments for a parous woman?

A

7

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3
Q

What is done at the booking visit?

A 
Full obstetric history
FGM screen
Height and weight, BMI
Urinalysis for proteinuria
Urine MC+S for asymptomatic bacteriuria
Booking bloods
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4
Q

What blood tests are in the booking bloods?

A 
FBC
Haemoglobinopathies and Red Cell Alloantibodies
ABO blood group and Rhesus status
Hepatitis B
Rubella, Syphilis, Chickenpox serology
HIV test is offered
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5
Q

What is offered on the Combined test?

A

Nuchal transluceny
beta-HCG
Pregnancy associated plasma protein A (PAPP-A)

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6
Q

Combined (and extra) findings in Down’s Syndrome

A 
Thickened nuchal translucency
Increased beta HCG
Low PAPP-A
Low Oestriol
Low alpha Fetoprotein
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7
Q

How should dating scan be made if CRL is >84mm

A

Use head circumference

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8
Q

If the placenta is praevia on Foetal anomaly scan, when should another scan be offered?

A

32 weeks

Most low-lying placentas will have resolved by then

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9
Q

What is done at routine antenatal visits?

A

BP
Urine dip for proteinuria
SFH measurement from 24 weeks

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10
Q

Which visits are only for nulliparous women?

A

25 weeks
31 weeks
40 weeks

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11
Q

When is Anti-D offered?

A

28 and 34 weeks

or sensitising events

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12
Q

When should External Cephalic Version be offered?

A 
36 weeks (primip)
37 weeks (multip)
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13
Q

Sensitising events to Rh -ve mothers?

A 
Delivery
Amniocentesis
Chorionic villus sampling
Foetal blood sampling
External cephalic version
Miscarriage > 12 weeks
Surgically managed ectopic pregnancy
Termination of pregnancy
Antepartum Haemorrhage
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14
Q

When is amniocentesis performed?

A

15-20 weeks

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15
Q

When is chorionic villus sampling performed?

A

11-14 weeks

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16
Q

Risks of Amniocentesis/ CVS

A 
Pain/ discomfort
Infection
Miscarriage
Inadequate result
Needing anti-D prophylaxis
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17
Q

Clinical signs of pregnancy

A 
Amenorrhoea
Nausea and vomiting
Chadwick sign (blue vaginal discolouration)
Hegar sign (Cervical softening)
Skin pigmentation
Palpable uterus 6-12 weeks
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18
Q

Time frame of usual nausea and vomiting in pregnancy

A

Begins 4 weeks

Most ended 16-20 weeks

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19
Q

Treatment of non-complicated nausea and vomiting

A

Ginger
P6 wrist acupuncutre
Antihistamines e.g. Chlorphenamine

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20
Q

Risk factors for hyperemesis gravidarum

A 
Obesity
Nulliparity
Hyperthyroidism
Multiple pregnancy
Trophoblastic disease
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21
Q

Protective factors for hyperemesis gravidarum

A

Smoking

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22
Q

Anti-emetic therapy for hyperemesis gravidarum

1st, 2nd and 3rd line?

A

Cyclizine/ Promethazine are 1st line
Metoclopramide or Ondansetron 2nd line
Corticosteroids reserved for severe cases

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23
Q

Complications of hyperemesis gravidarum

A 
Wernicke's encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
Increased VTE risk
fetal: small for gestational age, pre-term birth
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24
Q

How to diagnose obstetric cholestasis vs normal itching?

A

Raised AST/ALT

Alk phos is raised normally in pregnancy- unreliable marker

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25
Q

Management of itching and obstetric cholestasis

A

Topical emollients and steroids
Ursedeoxycholic acid
Delivery is only cure

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26
Q

Symptoms of symphysis pubis dysfunction

A

Difficulty walking
Weight bearing problems
Limited/ painful hip abduction
Lying/ sitting position discomfort

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27
Q

Therapies for leg cramps in pregnancy

A

Sodium chloride
Calcium
Quinine

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28
Q

Definition of SGA

A

Foetus less than 10th centile for weight or other Biophysical parameter
Severe if < 3rd centile

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29
Q

Major risk factors for SGA

A 
Maternal age 40+
Smoking 11+ daily
Cocaine
Maternal or paternal SGA
Previous SGA baby/ stillbirth
PAPP-A <0.4 MoM
Chronic hypertension
Antiphospholipid syndrome
Diabetes
Renal impairment
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30
Q

Minor risk factors for SGA

A 
Maternal age 35+
IVF singleton pregnancy
Nullipartiy
BMI under 20
BMI 25-34
Low fruit intake
Previous pre-eclampsia
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31
Q

Investigations for SGA if 1 major criteria:

A

Serial USS and umbilical artery doppler from 26-28 weeks

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32
Q

Investigations for SGA if 3 minor criteria:

A

Assess foetal size and umbilical artery doppler in 3rd trimester

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33
Q

Management/ delivery in SGA

A

Delivery at 37 weeks
32 weeks if severe
34 weeks if static growth over 3 weeks
Administer steroids

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34
Q

Which cause of Large for Gestational Age (LGA) babies is associated with Amoxicillin use in pregnancy?

A

Hydrops fetalis

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35
Q

Most common type of IUGR

A

Asymmetrical (70% of cases)

Occurs later in pregnancy
Head sparing pattern
Low SC fat, risk of hypoglycaemia and hypoxia

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36
Q

Maternal death

A

Death within 42 days of end of pregnancy

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37
Q

Direct causes of maternal death

A

Obstetric complications or resulting from interventions/ omissions/ incorrect treatments

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38
Q

Indirect causes of maternal death

A

Previously existing disease or disease developed during pregnancy

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39
Q

At which point should RFM be investigated for neuromuscular conditions?

A

24 weeks

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40
Q

Name of practice contractions that occur prior to labour

A

Braxton-Hicks contractions

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41
Q

Investigations of PPROM and pre-term labour

A 
Bloods (FBC, CRP)
Urine dip and MSU
CTG
Cervical swabs for GBS
Placental alpha-Microglobulin-1 test
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42
Q

Why is a TVUS performed in suspected pre-term labour

A

If Cervical length < 15 mm at 30+0 weeks, this is diagnostic of pre-term labour

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43
Q

Why is foetal fibronectin used as a test for pre-term labour

A

Its not normally detectable in vaginal secretions before 36 weeks

Positive if greater than 50ng/ml

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44
Q

Drugs used in pre-term labour

A

Erythromycin 250mg QDS 10 days for chorioamnionitis prophylaxis
Nifedipine- Tocolysis, allows steroid administration
Steroids before 34 weeks e.g. Betamethasone
Magnesium sulphate before 34 weeks- neuroprotective

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45
Q

What do steroids help protect against in pre-term labour?

A

Respiratory distress syndrome

Peri-ventricular leukomalacia

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46
Q

Rules for delivery in pre-term labour

A

Vaginal OK if cephalic
No foetal scalp electrode use before 34 weeks
Delayed cord-clamping

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47
Q

Preventing preterm labour

A

Vaginal progesterone or cervical cerclage treatment

  • Women with hx of spontaneous birth/ mid-trimester loss between 16 and 34 weeks
  • TVUS shows a cervical length < 25mm between 16 and 24 weeks
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48
Q

When does a DCDA twin form?

A

Before day 3

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49
Q

When does a MCDA twin form?

A

Between days 4-8

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50
Q

When does a MCMA twin form?

A

Days 9-13

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51
Q

When do conjoined twins form?

A

After day 13

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52
Q

What signs suggest multiple pregnancy?

A

Increased membrane thickness and T sign on USS
Uterus large-for-dates
Increased hyperemesis incidence

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53
Q

How frequently are growth scans performed in multiple pregnancy?

A

4-weekly in Dichorionic

2-weekly in Monochorionic

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54
Q

When are DCDA twins delivered?

A

37 weeks

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55
Q

When are MCDA twins delivered?

A

36 weeks

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56
Q

When are MCMA twins delivered?

A

32-34 weeks

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57
Q

Potential causes of GDM

A

Increased physiological demands in pregnancy
Human Placental Lactogen production
Less renal tubular reabsorption

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58
Q

Risk factors for GDM needing screening

A 
BMI 30+
Previous macrosomic baby 4.5kg
1st degree family history
Ethnicity
Glycosuria at antenatal visit
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59
Q

Diagnosis of GDM

A

2 hour 75g OGTT used at 24-28 weeks
- 7.8mmol/L (2 hour glucose)

OR

5.6mmol/L fasting glucose

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60
Q

Major/ Greatest risk factors for Antenatal VTE prophylaxis

A 
Hospital Admission
Previous VTE related to major surgery
High Risk Thrombophilia e.g. F5 Leiden
Medical co-morbidity
Surgical procedure
Ovarian Hyperstimulation Syndrome
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61
Q

Which medical co-morbidities are considered high-risk for antenatal VTE prophylaxis?

A 
Cancer
Heart failure
SLE
IBD/ Inflammatory polyarthropathy
Nephrotic syndrome
Sickle cell disease
Current IVDU
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62
Q

What are the minor individual risk factors for antenatal VTE prophylaxis which may require treatment?

A 
BMI 30+
Age 35+
Parity 3+
Smoker
IVF
Varicose veins
Current pre-eclampsia
Immobility
1st degree family history of unprovoked VTE
Multiple pregnancy
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63
Q

What is the management of VTE antenatally if 2 minor risk factors or less are present?

A

Mobilisation and avoid dehydration

64
Q

What is the management of VTE antenatally if 3 risk factors are present?

A

Prophylaxis from 28 weeks

65
Q

What is the management of VTE antenatally if 4 or more risk factors are present?

A

Prophylaxis from 1st trimester

66
Q

What is the single greatest risk factor requiring immediate antenatal VTE prophylaxis?

A

Previous VTE not caused by a surgical event

67
Q

Which high-risk factors warrant the use of 6 weeks postnatal prophylactic LMWH?

A

Any previous VTE
LMWH required antenatally
High risk thrombophilia
Low risk thrombophilia and VTE F/H

68
Q

Which high-risk factors warrant the use of 10 days + postnatal prophylactic LMWH?

A 
LSCS in labour
BMI 40+
Prolonged postnatal admission 72hrs +
Surgical procedure in the puerperium
Medical co-morbidity
Any 2+ minor risk factors
69
Q

Which minor risk factors do not require VTE postnatal prophylaxis? (if less than 2 risk factors)

A 
Age 35+
BMI 30+
Smoker
Immobility
Family history
Varicose veins
Current infection
Current pre-eclampsia
Multiple pregnancy
Preterm
Stillbirth
Prolonged labour 24 hours +
PPH >1L or blood transfusion
70
Q

Normal cardiac changes in pregnancy

A 
Ejection systolic murmur
Cardiomegaly on CXR
Increased pulmonary vascular markings
Ectopic beats
Q waves
T wave inversion in lead 3
71
Q

Blood pressure changes in pregnancy

A

BP falls until 24 weeks due to reduced SVR

Increases after 24 weeks due to increased stroke volume

72
Q

What protein: Creatinine Ratio (PCR) in urine is diagnostic of Pre-Eclampsia?

A

> 30mg/mmol

73
Q

Above which blood pressure should mothers be admitted for pre-eclampsia?

A

140/90 mmHg

Any mother with evidence of high blood pressure and proteinuria

74
Q

Above which blood pressure should mothers be treated for pre-eclampsia with antihypertensives?

A

150/100 mmHg

75
Q

When should delivery occur in pre-eclampsia?

A

Conservative management until 34 weeks if no Eclampsia
Offer delivery between 34 and 37 weeks
Deliver in 24 hours after 37 weeks

76
Q

When do most cases of HELLP syndrome occur?

A

27-37 weeks

77
Q

What are the key symptoms that MAY differentiate HELLP syndrome to standard pre-eclampsia?

A

Bleeding and RUQ pain/ tenderness

78
Q

Investigations for HELLP syndrome (in terms of each of the components)

A 
Haemolysis (FBC shows low Hb, LFTs- high LDH, prolonged PT/PTT)
Elevated Liver enzymes (raised AST, ALT, Bilirubin, LDH, Uric acid)
Low Platelets (low Hb, thrombocytopaenia <100x10^9/L)
79
Q

Type 1 FGM

A

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

80
Q

Type 2 FGM

A

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

81
Q

Type 3 FGM

A

Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

82
Q

Type 4 FGM

A

All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

83
Q

Definition of slow progress in first stage of labour

A

Less than 2cm dilation in 4 hours

84
Q

What describes a Station of zero in the first stage?

A

The fontanelle is aligned with the ischial spines

85
Q

When may the active management of the third stage of labour begin?

A

Upon delivery of the anterior shoulder

86
Q

Passage of labour

A

Engagement (largest diameter of head in pelvis)
Flexion and descent (2/5 of head palpable)
Internal rotation
Extension
Restitution (external rotation)
Expulsion

87
Q

Normal position of delivery

A

Occipitoanterior

88
Q

Indications for CTG monitoring (antenatal)

A 
High-risk pregnancy (maternal factors)
VBAC or previous CS
Placenta previa
Multiple pregnancy
SGA/ IUGR
89
Q

Indications for CTG monitoring (during labour)

A 
Maternal pulse >120BPM
Temp 38+
?Chorioamnionitis/ Sepsis
Abnormal pain
Oxytocin use
Significant Meconium
Fresh vaginal bleeding in labour
Pre-eclampsia signs
Confirmed 1st/2nd stage delay
90
Q

Response to abnormal CTGs

A
  1. Position mother in Left Lateral
  2. Administer IV fluids
  3. Foetal scalp stimulation
  4. Foetal blood sampling
  5. Delivery
91
Q

pH Monitoring in Foetal Blood samples

A

Normal: pH 7.25 +
Borderline: pH 7.20- 7.25
Abnormal: pH <7.20

92
Q

Lactate on Foetal blood samples

A

Normal: < 4.1mmol/l
Borderline: 4.2-4.8 mmol/l
Abnormal: 4.9 mmol/L

93
Q

What is an Occipito-Posterior position typically associated with?

A

Long anthropoid pelvis (up to 50% mothers)

94
Q

What is an Occipito-Transverse position typically associated with?

A

Poor power in labour

95
Q

Most common type of breech presentation

A

Extended/ Frank

70% of breech presentations

96
Q

Symptoms/ signs of a breech presentation

A

Pain under ribs can occur

Longitudinal lie, no head palpable on palpation

97
Q

Management of brow presentation

98
Q

Management of face presentation

A

Can deliver vaginally

99
Q

Compound shoulder presentation/ transverse lie

A

ECV then LSCS if unsuccessful

100
Q

Sources of pain in first stage of labour

A 
Uterine contraction (T10-L1)
Pelvic structure pressures (L2-S1)
101
Q

Side effects of Nitrous Oxide/ Entonox for analgesia

A

Dizziness
Nausea
Amnesia

102
Q

Opioids that should be available for analgesia in all births

A

Morphine
Diamorphine
Pethidine IM
Remifentanil

103
Q

Factors associated with a poor outcome in VBAC

A

Needing an induction
Slow progress
BMI 30+

104
Q

Contra-indications to VBAC

A

2 previous LSCS’
Classic uterine scar
Previous uterine rupture
Standard LSCS contra-indications

105
Q

Potential indications for a vertical CS

A

Premature, structural abnormality, fibroids, some placenta previa cases

106
Q

Category 1 CS (Crash)

A

Immediate life-threat to foetus or mother, and delivery should be made within 30 minutes of decision. E.g. severe foetal distress, placental abruption, bradycardia

107
Q

Category 2 CS

A

No immediate threat to life, but the baby should be delivered within 1 hour E.g. failure to progress, shoulder dystocia

108
Q

Category 3 CS

A

Scheduled, semi-elective CS where an early delivery is needed but there is no compromise e.g. pre-eclampsia, or failed induction

109
Q

Category 4 CS

A

Elective, carried out after 39 weeks (if less than 39, corticosteroids are given for foetal lung maturity).

110
Q

Indications for Induction of Labour

A 
Prolonged pregnancy (41-42 weeks; perinatal mortality increases due to decreased placental function).
IUGR or Intra-Uterine Death
Antepartum Haemorrhage
PPROM/ Prelabour rupture of membranes: significant risk of infection once ruptured.
Maternal Hypertension/ Pre-Eclampsia
Diabetes
Poor Obstetric history
Intrauterine Death
111
Q

Absolute contra-indications to IOL

A

Placenta praevia
Acute foetal compromise
Unstable lie
Pelvic obstruction

112
Q

Bishop’s Score domains

A 
Cervical Dilatation
Cervical Length
Station of presenting part
Consistency
Position
113
Q

Bishop’s Score needed for labour

A

5+ is ‘favourable’

7+ suggests labour likely to begin naturally

114
Q

Where is PGE2 inserted for induction of labour?

A

Posterior fornix of the vagina

115
Q

Maximum dose of Oxytocin infusion for induction of labour

116
Q

What is the most common cause of APH?

A

Marginal bleed

117
Q

When is a bleed in pregnancy classed as an APH?

A

After 24 weeks

118
Q

Grading of Placenta Previa

A

Grades 1 and 2- Minor

Grades 3 and 4- Major

119
Q

Blood products to use in APH

A

ABO Rh compatible cross-matched blood
OR
O Rh-ve blood

120
Q

Management of APH if under 34 weeks

A

Conservative if stable

  • Steroids
  • Tocolytics WITH CAUTION
  • Deliver at 37 weeks
121
Q

Management of APH after 34 weeks

A

Oxytocin following amniotomy
Oxytocin/ Ergometrine post-3rd stage
Cat 1 CS consider

122
Q

How often does PPH occur

A

6% of deliveries

123
Q

When is the third stage of labour prolonged

A

Placenta not delivered in:

  • 60 minutes (physiological managment)
  • 30 minutes (pharmacological management)
124
Q

Initial (non drug) treatments of primary PPH

A

Empty bladder
Uterine massage to stimulate contraction
Controlled cord traction if not already delivered

125
Q

Initial drug treatments of primary PPH

A

Bolus of one of:

  • Oxytocin 10 units
  • Ergometrine 0.5mg IM
  • Combined Oxytocin and Ergometrine (5U/0.5mg)
126
Q

Dose of oxytocin in PPH

A

10 units bolus

SE: Uterine hyperstimulation, headaches, nausea and vomiting, arrhythmias

127
Q

Dose of Ergometrine in PPH

Contraindications

A

0.5mg IM

Eclampsia, sepsis

128
Q

Dose of Carboprost in PPH

A

250mg IM every 15 minutes, max 8 doses

CIs: Pelvic infection, cardiac disease, pulmonary disease

129
Q

2nd management of PPH if first drugs fail

A

Another bolus of first drug THEN

  • Misoprostol 1mg PR
  • Carboprost 250mg IM
130
Q

Uterine inversion presentation

A

Vasovagal shock
Haemorrhage
Clotting abnormalities
Renal dysfunction

131
Q

Management of uterine inversion

A

Reduce manually- O’Sullivan’s Method
Tocolytics
Leave placenta before replacement

132
Q

Risk Factors for AF embolism

A 
Multiple pregnancy
Maternal age
CS
Instrumental delivery
Eclampsia
Polyhydramnios
Uterine rupture
Placental abruption
133
Q

Presentation of AF embolism

A

Collapse, Dyspnoea, Chest Pain
Hypotension
Cardiac arrest
Reduced LOC

134
Q

Management of AF embolism

A

ITU treatment with highest O2 available
Inotrope support e.g. Dobutamine
Treat DIC
Deliver baby if cardiac arrest

135
Q

Uterine rupture presentation

A 
Severe pain, persisting between contractions
Scar/ uterine tenderness
Bleeding/ haematuria
Reduced contractions
Loss of presenting part from station
Shock/ collapse
136
Q

Management of uterine rupture

A

Cat 1 CS ± hysterectomy
Cefuroxime and Metronidazole cover
Correct shock with fluids

137
Q

1st Degree Perineal Tear

138
Q

2nd degree perineal tear

A

Perineal muscle involved

139
Q

3A Degree Perineal Tear

A

External Anal Sphincter torn < 50%

140
Q

3B Degree Perineal Tear

A

External Anal Sphincter torn 50%+

141
Q

3C Degree Perineal Tear

A

External and Internal Sphincters torn

142
Q

4th Degree Perineal Tear

A

Anorectal mucosal tear involvement
Risk of permanent anovaginal fistulae
Repaired surgically/ under a GA/ epidural

143
Q

When is the uterus pelvic post-partum?

144
Q

When is the cervical os closed post-partum?

145
Q

Colour of lochia

A

Blood-stained initally

Yellow/ white until 6 weeks

146
Q

When is breast engorgement noticeable postpartum

A

3-4 days postpartum

147
Q

What drug may be used to antagonise lactation?

A

Cabergoline (Dopamine receptor antagonist)

148
Q

Which hormones are lactation dependent upon?

A

Prolactin (produced by anterior pituitary)

Oxytocin (produced on nipple sucking, stimulates prolactin release)

149
Q

When is postnatal contraception required?

A

As early as 21 days (not breastfeeding)

Breastfeeding is good until 6 months (98% effective)

150
Q

When may the Progesterone only Pill be used post-partum?

151
Q

When can COCP be used post-partum

A

After 6 weeks (UKMEC 4 before this)

152
Q

When can IUD be inserted?

A

Usually after 4 weeks

153
Q

Indications for Folic Acid 5mg

A 
Diabetes
Epilepsy
Malabsorption
BMI 30+
Sickle cell disease
154
Q

Indications for oral iron in pregnancy

A

Hb below 11g/100ml at first contact

10.5g/100ml at 28 weeks

155
Q

Drug that can be used for sleep problems in pregnancy

A

Promethazine

156
Q

Which women are unsuitable for monitoring of growth by SFH measurement, and how should this be done instead

A

BMI 35+
Large fibroids

USS and foetal doppler from 26-28 weeks

157
Q

Criteria indicating need for a major haemorrhage protocol

A 
5L blood loss in 24 hours
2.5L blood loss in 2 hours
150ml blood loss/minute
Maternal HR 110+
Maternal systolic BP less than 90

4th Year (7 decks)

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