obstetrics Flashcards

Question 1

Q

What is gravidity?

What is parity?

How would you record the gravidity and parity of a pregnant patient, with one live delivery at 40 weeks, 1 miscarriage at 20 weeks and 1 TOP at 10 weeks?

Answer

A

GRAVIDITY = How many times a woman has been pregnant, incl:

Miscarriage
Ectopic
Termination
Live birth
Still birth
Molar
CURRENT PREGNANCY!

PARITY = How many babies a woman has delivered at 24+ weeks gestation

G4P1+2 = pregnant patient, with one live delivery at 40 weeks, 1 miscarriage at 20 weeks and 1 TOP at 10 weeks.

(nb twins count as one in terms of G + P)

Question 2

Q

definition of nulliparous and multiparous? (incl gestation dates)

difference between miscarriage and stillbirth?

Answer

A

NULLIPAROUS = no delivery of a baby >24 weeks gestation

MULTIPAROUS = has had 1 or more deliveries of baby >24weeks

miscarriage = loss at <24wks
still birth = loss at >24wks

Question 3

Q

What are the gestation weeks for the three pregnancy trimesters?

What is the definition of ‘term’?

Answer

A

1st Trimester = weeks 1 -12

2nd Trimester = weeks 13-27

3rd Trimester = weeks 28 – delivery.

37-42 weeks

nb term +3 menas baby is 3 days over due date

eg 20+4 means baby has gestation of 20wks and 4 days

Question 4

Q

What is a normal foetal heart beat?

What should you always do while auscultating foetal heart beat?

Answer

A

100-160bpm

make sure to palpate maternal radial pulse while auscultating FHR

Question 5

Q

What is ‘normal’ labour?

Answer

A

Where 37-40 weeks gestation, with singleton pregnancy. Where presentation is cephalic. No medical issues.

Question 6

Q

What changes occur during spontaneous labour to the:

myometrium (of uterus)? 2
cervix? 2
hormones? 2

Answer

A

Myometrium

Stretching increases muscle excitability & contractility
Contractions

Cervix
- Decrease in collagen and increase in water content -> cervix softens effaces and dilates

Hormones

Increased oestrogen -> prostaglandins and oxytocin
Prostaglandins and oxytocins are myometrial stimulants

Question 7

Q

What is the difference between latent and established labour in terms of contraction frequency and dilatations?

what are the 3 stages of established labour? (incl dilatations etc)

Answer

A

Latent phase of labour
= Dilation up to 4cm
= Contractions every hour to every 10 mins

Established labour
= Dilation from 4cm and more
= Contractions every 3-4mins with 1min of contractions

Stages of established labour

FIRST = From onset of established labour (4cm) to full dilation of cervix (10cm)

SECOND = From full dilitation to birth of bay

THIRD = From birth of the baby to expulsion of the placenta and membranes

Nb during contractions, the myometrium doesn’t fully relax between contractions so progressively gets shorter which pushes the baby out

Question 8

Q

What is the best thing a woman can do when in the 1st stage of labour?

why does this help?

Answer

A

MOBILISING

walking
squatting
kneeling
hands + knees
birthing ball
Assists progression of labour in 1st stage
Waling around and remaining in upright position

reduces risk of needing LSCS, epidural and generally speeds up duration of labour

Question 9

Q

What are the two stages of the second stage of established labour?

Answer

A

PASSIVE STAGE

Full dilatation until the head reaches the pelvic floor + desire to push.
Rotation and flexion commonly completed – stage may last a few minutes but can be much longer.

ACTIVE STAGE = mother is pushing

Pressure of head on pelvic floor produces irresistible desire to bear down. Pushing with contractions.
Perineal bulging plus anal dilatation.
1-2 hours for primiparous, av. 1hr in multiparous.
Head delivered and restitutes, shoulders delivered (anterior shoulder first).
Midwife to note time of delivery of head – if shoulder dystocia occurs

nb in active stage can use a warm wet towel on perineum to reduce risk / severity of tears

Question 10

Q

THIRD STAGE OF LABOUR:

how long does it normally take?
normal blood loss?
difference between active and passive management? (incl drug name for active)

Answer

A

ie from delivery of infant to delivery of placenta

Up to 30 minutes

Normal blood loss is 500ml

Uterine muscle fibres contract to compress the blood vessels formally supplying the placenta, which shears away from uterine wall

In Hospital, active management of placenta delivery is common to reduce bleeding:

Use of uterotonic drugs e.g. syntometrine (combination of oxytocin and ergometrine)
Deferred clamping and cutting of the cord
Controlled cord traction – apply counter pressure just above pubic bone to guard the uterus and apply gentle downwards traction on the cord

passive is just letting woman do on their own - women may prefer as no hormones, but will take longer and may be more blood loss
- nb midwife doesn’t apply traction to cord in passive

nb don’t use syntometrine if raised BP as ergometrine will raise BP further

Question 11

Q

What is deferred clamping and cutting of the cord?

why is it done? when can it not be done?

Answer

A

technically when wait until cord stops pulsating before cutting it (norma takes a few mins)
- in reality just wait a couple of mins

reduces risk of anaemia in baby as cord blood is part of foetal blood supply

can’t be done if baby in severe distress and needs resus fast (then clamp as quick as poss

Question 12

Q

what is the definition of a post-partum haemorrhage (PPH)?

ie how many mls?

Answer

A

anything more than 500ml blood loss

don’t forget to weigh swabs

Question 13

Q

Pain relief options during labour:

non-pharm? 5
pharmalogical? 4

Answer

A

massage
relaxation + breathing (eg hypnobreathing)
water
mobilisation
verbal support throughout (reduces the need for pharm)
nitrous oxide (gas + air)
epidural
paracetamol
opiates (diamorphine)

nb if give epidural or opiates, need to do CTG monitoring for at least 30 mins afterwards

Question 14

Q

How is the mother monitored during labour? 4

two ways baby is monitored during labour? (when use which)

Answer

A

contractions
vital signs
vaginal loss (when change pads)
vaginal examination (assessing dilitation and descent of baby)(norm every 4 hrs)
CTG (high risk)
intermittent auscultation with doppler (ie sonicaid) (low risk)

Question 15

Q

What is the normal progression (ie in cm dilated) expected in nulliparous women?

Answer

A

1/2cm an hour

so 2cm in 4hrs

nb often more in multiparous woman (ie labour happens faster)

Question 16

Q

Normal number of contractions in 10mins in active labour?

Answer

A

4-5 in 10

Question 17

Q

Indications for CTG monitoring? 8

Answer

A

oxytocin infusion
had epidural or opioids in last 30 mins
multiple pregnancy
intra-uterine growth restriction (IUGR)
VBAC
any meconium-stained liquor
abnormality on intermittent auscultation
ANY pregnancy that is not ‘low risk’

Question 18

Q

What is another method of continuously monitoring the foetus? (ie aside from CTG)
- when is it used? 4

contraindications? 2

Answer

A

Foetal scalp electrode (FSE) - actually measures the foetal ECG
- describe to mothers as a ‘clip’ on baby’s head

indications:

twins
obese mother or abdominal scarring
repeated ‘loss of contact’ with CTG
if want active birth

contraindications

blood-born viruses
clotting disorders

Question 19

Q

Acronym for CTG interpretation? 10

briefly explain each section (eg normal values)

Answer

A

DR C BRAVADO

DR = Determine Risk (high or low risk preg)

C = Contractions (frequency + duration from tocograph on CTG, intensity from palpation)

BRA = Baseline RAte (100-160, say brady, tachy or normal)

V = Variability (5-25bpm)

A = Accelerations (rise of >15bpm for >15sec) (always encouraging, absence not necessarily bad))

D = Decelerations (drop of >15bpm for >15sec)

O = Overall impression

Question 20

Q

What are the three possible ‘overall impressions’ from a CTG?

Answer

A

reassuring
non-reassuring / suspicious
pathological

Question 21

Q

What are the three types of decelerations? 3 (nb one of these has two sub-types)

what are most decels?

what is one other reassuring feature of decels? and one non-reassuring feature?

Answer

A

EARLY
= peak of decel CONSISTENTLY occurs before peak of contraction (non-concerning, shows vagal stimulation)

LATE
= peak of decel CONSISTENTLY occurs after peak of contraction (concerning - associated with ischaemia)

VARIABLE:
- differ in timing and morphology
= non-concerning (prev typical) is <60s AND <60bpm
= concerning (prev atypical) is >60s OR >60bpm

nb don’t say typical or atypical, describe it (eg decels lasting for more than 60s which is concerning)

ALMOST ALL DECELS (90%) ARE VARIABLE!
for decels to be early or late the must be with almost all contractions and must be almost identical in morphology (ie duration and depth)

shouldering of decels is reassuring

if takes a long time for baseline rate to return to normal or overshoot (looks like a tick) then is more concerning

Question 22

Q

If CTG is non-reassuring / pathological, what are the 4 things you can do (/consider doing) before considering delivery?

Answer

A

1) CHANGE POSITION (left lateral is best but best to move every 10mins)
2) GIVE FLUIDS through GREY cannula (increases placental blood flow)
3) FOETAL SCALP STIMULATION if rate increases from stimulating scalp then this is reassuring
4) FOETAL BLOOD SAMPLE - see other flashcard for interpretation
5) DELIVER!! (forceps vaginally if mother is fully dilated, c-section if not fully dilated)

also have CTG buddy every hour to get fresh eyes on it!

Question 23

Q

FOETAL BLOOD SAMPLE (FBS)

when to do?
when can you do?
what does it measure?
cut off values? 3

Answer

A

DO if worried about CTG and delivery not imminent

Must be at least 3cm dilated

Measure of fetal pH (indicative of hypoxaemia)

normal values are 0.1 less than adults, so:

NORMAL = >7.25

BORDERLINE = 7.20-7.25 (repeat in 30mins)

PATHOLOGICAL
= <7.20 (deliver immediately, forceps if low, c-section if high)

Question 24

Q

What is the commonest cause of reduced variability on CTG? when should you be concerned?

Answer

A

commonest cause is baby sleep cycle

start to be concerned if lasts longer that 30-60mins (and especially if have other concerning features too)

Question 25

Q

Absolute contraindications to epidural in labour? 5

Relative contraindications? 2

Answer

A

ABSOLUTE

patient refusal
anti-coagulants
bleeding disorder
systemic infection
anaphylaxis to LA

RELATIVE

massive haemorrhage
spinal surgery

nb contractions in augmented labour (ie with oxytocin drip) tend to be more painful so these women more likely to need epidural

Question 26

Q

Potential complications of epidural:

immediate (ie during labour)? 5
delayed (ie after labour)? 4

Answer

A

IMMEDIATE

failure
slightly increases chance of instrumental delivery (though not section!)
hypotension
LA toxicity
total spinal

DELAYED

post-dural puncture headache
haematoma
epidural abscess
neurological damage (temp more common than permanent)

nb epidurals do not:

cause backache (pregnancy does!)
increase risk of c-section
prolong labour

nb if, following birth, woman’s legs get heavier (instead of effect gradually wearing off) then suspect epidural haematoma and DO MRI
(abscess takes a few days and norm have fever too)

Question 27

Q

Differential diagnosis for breathlessness during epidural:

epidural itself? 2
condition of pregnancy? 4
other medical conditions? 4

Answer

A

EPIDURAL

high block
LA toxicity

CONDITIONS OF PREGNANCY

aorto-cava compression
PE from amniotic fluid OR DVT
cardiomyopathy
anaemia (haemorrhage, iron-deficiency)

MEDICAL CONDITIONS

asthma attack
anaphylaxis
myocardial infarction
pneumonia

Question 28

Q

Indications for induction of labour:

most common? 1
maternal reasons? 6
foetal reasons? 6

Answer

A

Basically induce when risk of carrying on with pregnancy is higher than risk of delivering AND vaginal birth is seen as best option

MOST COMMON
= post-maturity (41-42 wks)

MATERNAL REASONS

Diabetes (Gestational, type 1, type 2)
Obstetric Cholestasis
Maternal cardiac disease
Pregnancy Induced hypertension or pre-eclampsia
Poor obstetric history (ie previous stillbirth etc)
Maternal Choice (eg if parter is home from army etc)

FOETAL REASONS

Prelabour rupture of membranes (PROM)
Intrauterine growth restriction (IUGR)
Reduced fetal movements (RFM)
Suspected fetal macrosomia, ie large baby (risk of shoulder dystocia, forceps delivery etc)
Small antepartum Haemorrage (APH) (if large or previa, section)
Intrauterine death (IUD)

NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Question 29

Q

Difference between induction and augmentation

Answer

A

augmentation is when labour has already started but is not progressing fast enough - so add oxytocin drip

Question 30

Q

Contraindications to induction of labour:

absolute? 4
relative? 4

Answer

A

ABSOLUTE

acute foetal compromise
unstable lie (must be cephalic)
placenta previa
pelvic obstruction (eg fibroids)

RELATIVE

previous LSCC (ie VBAC)
breech
prematurity
high parity (>4 parity)

NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Question 31

Q

What can be done pre-induction before offered formal induction of labour which might trigger spontaneous labour?

what does it involve?

when is it done?

theory behind mechanism?

Answer

A

Membrane sweep (‘stretch and sweep’)

May increase chances of spontaneous labour and avoid induction in some cases.

Offered before formal IOL

Nulliparous = 40-41 weeks antenatal visit
Multiparous = 41 weeks

Gloved finger passed between cervix and membranes on digital VE (separates chorionic membrane from decidua)

Releases prostaglandins which may trigger labour.

Question 32

Q

What is the bishops score?

what is it used to determine?

what are the 5 things that are assessed in it?

what are the two interpretations?

Answer

A

Assesses cervix and descent of baby to determine likelihood of going into spontaneous labour

given points (0-3) for each parameter, eg dilatation of >5cm gives score of 3 for dilatation

1) DILITATION of cervix (in cm)
2) LENGTH of cervix (in cm, shorter is better)
3) STATION of baby head relative to pelvis (-3 to +2, more positive is better)
4) CONSISTENCY of cervix (firm nose, medium chin, soft cheek)
5) POSITION of cervix (posterior, central, anterior - anterior is best)

score each component 0-3 then add for total

higher number is better (ie more likely to progress spontaneously)

<5 is unlikely to progress spontaneously

> 9 will likely progress spontaneously

use it after sections of induction to ascertain need for more levels etc

Question 33

Q

induction process:

describe the three stages?
what does each stage do?

Answer

A

stage 1: CERVICAL RIPENING

Pessaries for nulliparous (Propess) for 24hrs
Gel for multiparous (Prostin) for 24hrs
then reassess with a VE and bishops score
Soften and shorten the cervix
Cause uterine tightening

Stage 2: AMNIOTOMY

aka artificial rupture of membranes (ARM)
possible once cervix is fully effaced (length = 0)
performed using ‘amniohook’ at time of vaginal examination

Stage 3: SYNTOCINON (cervical dilation)

IV synthetic oxytocin to stimulate contractions
dose is titrated up/down to produce 3-4 strong contractions every 10 mins
must have CTG monitoring

NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Question 34

Q

risks / complications of induction:

main risk with cervical ripening and how mitigate?
main risk with amniotomy?
main risk with syntocinon? (how monitor? 1 and what do if get? 2)
other risks associated with induction more generally? 7

Answer

A

CERVICAL RIPENING

can cause hyperstimulation and foetal distress
monitor intermittently with CTG

AMNIOTOMY
- risk of cord prolapse if presenting part is high

CERVICAL DILITATION

risk of uterine hyper-stimulation
continuous CTG monitoring while on drip
titrate syntocinon up/down
give tocolytics (eg terbutaline) if hyperstimulation

OTHER GENERAL RISKS

increased pain (more likely to need epidural)
foetal distress
uterine hypertonia with possible rupture (hence use w caution in VBAC)
very rapid delivery
operative delivery
amniotic fluid embolus
systemic effects

NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Question 35

Q

what to do if woman who ‘should’ have induction refuses one? 3

Answer

A

explain benefits and risks and likely outcomes

if she still doesn’t want one then:

offer daily scans
offer c-section

Question 36

Q

how do you explain induction to woman?

Answer

A

Discussion with mother:
Women should be informed about induction of labour and the process involved
Healthcare professionals should always explain:
- The reason the induction is being offered
- The risks and benefits of induction of labour in specific circumstances
- That induction may not be successful and what the women’s options would be

If a women chooses not to have an induction of labour, an alternative should be considered

eg if woman with diabetes or post-rem is not induced, higher risk of stillbirth (+ higher risk of shoulder dystocia in DM)

Question 37

Q

What is the difference between lie, presentation and position?

and what are the ideal and non-ideal (ie abnormal foetal lie, malpresentation, malposition) versions of each?

Answer

A

LIE
= the relationship between the long axis of the foetus and the mother
= longitudinal, transverse or oblique

PRESENTATION
= The foetal part that enters the mothers pelvis first
= cephalic or breech

POSITION
= the position of the foetal head as it exits the birth canal
= occipito-anterior (OA), occipito-posterior (OP) or occipito-transverse
- nb can only tell this by doing VE during labour

IDEAL = longitudinal, cephalic and OA

nb if lie is transverse then presentation is neither breech or cephalic

nb 90% of non-OA end up OA by the end of labour as they rotate through the pelvis

Question 38

Q

Risk factors for abnormal foetal lie, malpresentation and malposition? 6

Answer

A

Prematurity
Fetal abnormalities
Multiple pregnancy
Primiparity
Uterine abnormalities (e.g fibroids, partial septate uterus)
Placenta praevia

Question 39

Q

abnormal foetal lie and malpresentation

how discover?
investigation to confirm?
initial management? (at how many weeks gestation is this done?)

Answer

A

during abdominal palpation in obstetric examination

do abdo USS to confirm position and lie

offer external cephalic version (ECV) ideally at 36-38 weeks gestation

Question 40

Q

external cephalic rotation (ECV)

what is given before? 2
what does procedure consist of?
what monitoring is done before and after? 1
success rate of ECV?

Answer

A

Uterine relaxants given prior to/ during procedure e.g. Terbutaline or Salbutamol
Anti-D given if rhesus positive

Gentle pressure applied to maternal abdomen to turn the foetus

Foetal heart monitored with CTG before and after procedure

50% success rate

Question 41

Q

What are the potential risks of a breech presentation? 4

Answer

A

Cord prolapse
Difficulty in delivering head
Foetal hypoxia
Increased foetal mortality and morbidity

Question 42

Q

external cephalic rotation (ECV)

absolute contraindications? 6
relative contraindications? 7

Answer

A

ABSOLUTE CI

Placenta praevia
Uterine malformations
Ruptured membranes
Abnormal CTG
Multiple pregnancy

RELATIVE CI

Previous LSCS
Preeclampsia
Maternal cardiac disease
Active labour
Oligohydramnios
Foetal abnormality
Hyperextension of foetal head

Question 43

Q

external cephalic rotation (ECV)

what is it trying to prevent?
options if it doesn’t work? 2
risks of ECV? 3

Answer

A

Trying to prevent need for section (LSCS) or vaginal breech delivery (which have their own risks

if doesn’t work:

LSCS (almost always)
vaginal breech delivery (very rare)

RISKS

foetal distress
cord entanglement
transient bradycardia

Question 44

Q

What are the three different types of twins? what’s the difference?

what about identical and non-identical twins?

Answer

A

dichorionic diamniotic (DCDA) twins 
= each has their own separate placenta with its own separate inner membrane (amnion) and outer membrane (chorion)

monochorionic diamniotic (MCDA) twins 
= share a single placenta with a single outer membrane and 2 inner membranes

monochorionic monoamniotic (MCMA) twins 
= share both the inner and outer membranes

All non-identical twins are DCDA, and a third of identical twins are DCDA.

The other two-thirds of identical twins are MCDA, and just 1 in 100 identical twins are MCMA.

Question 45

Q

What is the mode of delivery and gestation of delivery recommended for the three different types of twins?

Answer

A

Dichorionic Diamniotic:

–> Deliver at 37-38 weeks
If first twin cephalic, vaginal delivery recommended
If first twin breech = LSCS

Monochorionic Diamniotic: Delivery at 36 weeks via LSCS

Monochorionic Monoamniotic: Delivery at 34 weeks via LSCS.

Question 46

Q

If delivering twins vaginally:

what foetal monitoring required?
what required on mother?
what staff required?

Answer

A

Continuous CTG monitoring
Foetal scalp electrode (FSE) for twin 1 once cervix sufficiently dilated
IV access

Experienced staff and neonatologists on call.

Question 47

Q

What things are measured/recorded on a partogram? 8

Answer

A

cervical dilation
descent of the head
position of head
frequency of contractions
strength of contractions
foetal HR
liquor colour
maternal obs (HR, BP, temp etc)

Question 48

Q

What is the definition of ‘slow progress in labour’ in 1st stage of labour?

Answer

A

cervical dilatation of <2cm in 4 hrs (and/or slowing down in progress in multips)

Question 49

Q

What are the three Ps which have to be optimised to ensure labour progresses?

which is the only one which can be adjusted in labour itself?
- what are the two methods of doing this?

what is the only option in 1st stage of labour if these methods fail?

Answer

A

POWER:
- Strength of uterine contractions
= In 1st stage labour, this is the only factor that can be changed

PASSENGER:
- Foetal position and size

PASSAGE:
- Parity and maternal pelvis

TO INCREASE POWER:

Artificial rupture of membranes
Oxytocin – Syntocinon infusion

If failure to progress in 1st stage of labour (and synt etc doesn’t help) then LSCS is only option

Question 50

Q

What are the three types of instrumental delivery?

Answer

A

1) Vacuum extraction aka. Ventouse ( nb cannot manually rotate baby into correct head position for birth)
2) Traction forceps
3) Rotational forceps

Question 51

Q

What are the indications for instrumental delivery? 5

Which stages of labour can instrumental delivery be performed?

Answer

A

Slow progress in 2nd stage of labour
Maternal exhaustion
To avoid raising ICP
To avoid raising BP
Presumed foetal compromise

BASICALLY when need to deliver baby and mother is fully dilated!

instrumental delivery can ONLY be performed in 2nd stage of labour (ie when fully dilated) - if in first stage then need LSCS

Question 52

Q

INSTRUMENTAL DELIVERY:

How to explain to mother? what do you need from her?
what does mother need to do before procedure? 1
what do you (as clinician) need to know about the baby / labour? 3
what medication do you need to give before start?

Answer

A

Explain that the forceps ‘cradle’ the babies head to help guide it out and/or rotate it so it has more space to get out

explain why need to do it
explain maternal and foetal complications
explain that is preferable to LSCS as baby is already far descended and risks with LSCS

mother needs to EMPTY BLADDER before start

NEED TO KNOW:

adequate contractions (add synt if need to)
membranes are ruptured (ARM if needed)
accurate knowledge of foetal postion (palpate and USS if needed)

NEED adequate ANALGESIA before start
= epidural, spinal or pudendal nerve block

Question 53

Q

Potential complications of instrumental delivery:

maternal? 5
foetal (of ventouse)? 2
foetal (of forceps)? 2

Answer

A

MATERNAL

increased blood loss
post-partum pain
psychological distress
perineal trauma (3rd degree tears etc)
weakened pelvic floor

nb always need an episotomy if have forceps delivery (to make space for the forceps)
nb vontouse better for mother as don’t need as much pain relief and less perineal trauma, but can’t rotate baby so forceps used more commonly

FOETAL (VENTOUSE)

cephalohaematoma
retinal haemorrhage

FOETAL (FORCEPS)

facial bruising
facial nerve palsy

Question 54

Q

Aside from instrumental delivery, what other (less invasive) things can speed labour up in 2nd stage? 4

Answer

A

change mother’s postion (can help turn baby)
good hydration of mother
good pain relief (helps relax muscles)
start or increase oxytocin drip

Question 55

Q

SHOULDER DYSTOCIA:

what is it?
how common is it?
risk factors? 6
Main risk to baby? (how common)
risks to mother? 2

Answer

A

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind
the mother’s pubic bone, delaying the birth of the baby’s body (ie when the anterior shoulder impacted behind the pubic bone)

occurs in 0.7% of births

RISK FACTORS

diabetes (gestational or otherwise - induce/delivery early to reduce risk)
BMI >30
previous shoulder dystocia before
long labour
induced labour
instrumental delivery

Main risk to baby is brachial plexus injury (erbs palsy) - occurs in 10% of babies who have shoulder dystocia

increased risks to mother

perineal tears
PPH

Question 56

Q

SHOULDER DYSTOCIA:

what should do as soon as dystocia identified? 2
non-invasive manouveres which can help? 2
more invasive options? 4
final option if nothing else works?

Answer

A

discourage maternal pushing effort
call for help (is obstetric emergency)

1) MCROBERTS MANOUVERE
- flex + externally rotate maternal hips to stretch the symphisis + open pelvic outlet

2) SUPRAPUBIC PRESSURE

MORE INVASIVE OPTIONS:

episiotomy (won’t relieve bony obstruction but will allow for internal vaginal manoeuvres
internal rotational manoeuvres
delivering posterior arm reduces diameter of oetal shoulders (risk of humeral #)
break clavicle

Emergency LSCS if nothing else works

Question 57

Q

When consenting for a section (LSCS), what things do you need to discuss with woman? 5

(eg think about what’s on the consent form)

Answer

A

1) DESCRIBE PROCEDURE – what will be done, AND WHY it is being done
2) Any OTHER anticipated PROCEDURES – e.g. spinal anaesthesia, hysterectomy, blood TRANSFUSION, repair of damage to bowel, bladder or vessels.

3) INTENDED BENEFITS – to secure the safest and quickest route of delivery in the circumstances at time of decision
- –> Because risks to mother and/or baby of an alternative mode of delivery outweigh those of a section

4) RISKS OF PROCEDURE (see other flashcard)

5) ANASTHETIC CONSENT:
- Form of anaesthesia planned (spinal, epidural, GA)
- Benefits
- Risks
- Discussion w anaesthetist before surgery

Question 58

Q

Risks of c-section (LSCS):

common maternal risks? 4
common risk to baby? 1
serious maternal risks? 6
serious risks to future pregnancies? 3

Answer

A

COMMON MATERNAL RISKS:

persistent wound + abdo discomfort
increased risk of section if VBAC attempted in future pregnancies
haemorrhage
infection

COMMON FOETAL RISK:
- scalp laceration (2-3%)

SERIOUS MATERNAL RISKS:

bladder, bowel or ureteric injury
emergency hysterectomy
need for further surgery
VTE
admission to ICU
death (very rare)

SERIOUS RISKS TO FUTURE PREGNANCIES, increased risk of:

uterine rupture
antepartum stillbirth
placenta previa and placenta accreta

Question 59

Q

What’s the difference between PPROM and PROM?

Answer

A

PROM = premature rupture of membranes
- waters break before labour starts but is AT TERM so just wait for labour or induce if not happened within 24hrs

PPROM = preterm premature rupture of membranes
- waters break BEFORE TERM, is trickier to manage - got to think about risks vs benefits of delivering

so basically PROM is at term and PPROM is before term

nb ‘premature’ can also be ‘prelabour’ in some definitions = same thing

Question 60

Q

Risk factors for preterm labour? 4

Answer

A

multiple pregnancy
prev history of preterm delivery
prev hx of late miscarriage (after 14 weeks)
previous cervical surgery (eg LLETZ for dysplasia)

Question 61

Q

Two most common causes / mechanisms of preterm labour?

Answer

A

CERVICAL WEAKNESS / INSUFFICIENCY, shortening in T2
- True cervical insufficiency: painless dilatation and shortening of the cervix in T2, resulting in pregnancy loss or delivery. Caused by cervical anomaly, trauma, or unknown. Diagnosis made in retrospect – uterine activity ruled out. Most women with insufficiency have normal anatomy.

ASCENDING INFECTION
- any cause that triggers an inflammatory process i.e. prostaglandins.

Question 62

Q

How do you screen for likelihood of preterm labour? 2

who is offered screening? 3

Answer

A

1) cervical length measurement (norm via TV USS?**)

2) foetal fibronectin test
- protein involved in connection between placenta and uterus. Positive finding indicates preparation for labour.

if evidence of cervical shortening or positive fibronectin then offer treatment

Offered if:

Hx of preterm delivery
Hx late miscarriage
Hx cervical treatment/ surgery

Question 63

Q

Treatment options for people at high risk / likelihood of preterm labour? 2

Answer

A

Cervical Stitch - Can be placed pre-conception in those with poor history.

Progesterone treatment (pessaries from wk16-24 to wk 34)

Question 64

Q

What medication should be offered if:

24-29wks in preterm labour? 1
35wks or less in preterm labour? 1
if membranes ruptured prelabour? (regardless of gestation)? 1
you want to delay the onset of labour? 1 (2 instances you would use)

Answer

A

24-29wks preterm labour
= magnesium sulphate (prevent cerebral palsy)
- may also give at later gestations

34wks or less in preterm labour
= IM steroids (betamethasone) 12 hours apart (use tocolytics until 24hrs after last dose)

if membranes ruptured
= prophylactic erythromycin for up to 10 days or until labour starts (whichever is sooner)
- if at term (over 37wks) then induce 24hrs after waters break if still no labour

if want to delay labour
= tocolytics
only use:
1) to allow steroids to work (take until 24hrs after 2nd steroid dose)
2) to allow transfer to unit with a neonatal cot

nb tocolytics are useless if membranes have broken or any bleeding or signs of infection

Answer 65

A

pre-term delivery: follows within 48hrs in >50% of cases
infection (chorioamnionitis, also can have of foetus, placenta or cord)
prolapse of umbilical cord

nb infection is sometimes the cause of PPROM

Answer 66

A

vaginal loss - gush of clear fluid, followed by trickle or dampness

STERILE speculum
- pool of fluid visible in posterior fornix

Abdo exam
- check lie and presentation

(can do digital exam to check for cord prolapse if presentation not cephalic - but do with caution as high risk of introducing infection)

ALSO DO MATERNAL OBS AND CTG

Answer 67

A

Fever/ malaise
Tachycardia (foetal and maternal)
Abdominal pain +/- contractions
Uterine tenderness
Purulent/ offensive vaginal discharge/ liquor

Answer 68

A

Swabs (do during sterile speculum)

HVS
VVS
MSU
CTG

(plus obvs maternal obs)

bloods:

FBC
CRP
Group + save (only last 72hrs in obstetrics)

USS
- for foetal presentation, weight and liquor volume (will go down once waters broken)

Answer 69

A

CHORIOAMNIONITIS

Steroids (betamethasone 12mg IM)
broad spectrum abx (benpen)
deliver baby

NO CHORIOAMNIONITIS

Steroids = betamethasone 12mg IM, 2x 12 hrs apart
Prophylactic Antibiotics = erythromycin QDS for 10 days
liaise with neonatal team
Outpatient monitoring until 34 weeks delivery

Answer 70

A

PV bleeding after 24wks gestation (before 24wks = threatened miscarriage)

minor bleed = <50mls
major bleeds = >50mls

UTERINE CAUSES

placental abruption
placental previa
vasa previa
marginal bleed

CERVICAL CAUSES

“show” = loss of mucus plug from cervix
cervical cancer
cervical polyp
ectropian

VAGINAL CAUSES

trauma
infection

DON’T DO VAGINAL EXAMINATION (until after a scan) - AS MAY BE PREVIA!!

Answer 71

A

Premature separation of a normally situated placenta from the uterine wall – resulting in maternal haemorrhage into the intervening space

RISK FACTORS

Previous abruption
Hypertensive disorders
Thrombophilias
Smoking
Cocaine
Abdo trauma

Answer 72

A

SYMPTOMS

Vaginal bleeding (not always present! - blood usually dark red)
Abdominal pain
Uterine contractions

SIGNS

uterine tenderness +++
Tense, ‘woody’ abdomen
Shock (disproportionate to visible blood loss)
Normal lie and presentation
Foetal heart absent or distressed on CTG

BEWARE of pre-eclampsia, DIC, anuria

Answer 73

A

Placenta is wholly or partially implanted in the lower segment of the uterus (nb doesn’t necessarily have to be covering os to be called previa)

GRADING

I = placenta reaches lower segment but not internal os
II = placenta reaches internal os but doesn't cover it
III = placenta covers internal os before dilation, but not when dilated
IV = placenta completely covers the internal os

RISK FACTORS

multiparity
previous LSCS
multiple pregnancy

Answer 74

A

SYMPTOMS

painless, bright red vaginal bleeding
- small bleeds before large

SIGNS

shock (proportionate to visible blood loss)
non-tender uterus
lie and presentation may be abnormal
foetal heart normally normal

Answer 75

A

5% at 20wk scan
0.5% at delivery

If see at 20wks, rescan at 34wks

no need to limit activity or intercourse, unless bleeding

If still present at 34 wks and grade I or II, scan every 2wks

If abnormal lie (or grade III or IV) at 37 wks then LSCS

vaginal delivery for grade I

Answer 76

A

CROSS MATCH
FBC
U+E
clotting
admit to hospital
treat shock
deliver by LSCS betwen 37-38wks

Answer 77

A

BLOOD LOSS

previa = bright red, small then large
abruption = may be absent, dark red if present

SHOCK

previa = proportionate to visible blood loss
abruption = more severe in proportion to visible blood loss

UTERUS

previa = non-tender
abruption = tender,. hard, woody

PRESENTATION / LIE

previa = may be abnormal
abruption = normal

CTG FINDINGS

previa = normally normal
abruption = absent or distressed FHR

Answer 78

A

A-E approach

get IV access (grey in both)
call for help
left lateral position

bloods

crossmatch 4 units
FBC
clotting

replace fluid / clotting factors (also blood if need)

put catheter in (and monitor fluid balance)

anti-D to all rh neg women

do USS to assess position of placenta

if stable:

monitor baby with CTG
consider elective LSCS at 37wks

if unstable:
- emergency section immediately (mother’s life takes priority)

Answer 79

A

sometimes no signs!

tachycardia
hypotension
reduced O2 sats
pleuritic chest pain
SOB
collapse
reduced air entry

nb women of all gestation and post-partum are at higher risk! - though most common in 3rd trimester

Answer 80

A

A-E approach

facial oxygen - 15L nrbm

get ABG
ECG
CXR (exclude other causes)
V/Q scan (spiral CT if can’t)

if clinically suspicious anti-coagulate while awaiting results

nb don’t do d-dimer in pregnancy (as always raised)

Answer 81

A

LMWH (warfarin CI in pregnancy)

use for remainder of pregnancy and till at-least 6wks post-partum

high-risk in future pregnancies - consider prophylactic dose

Answer 82

A

X-RAYS

CXR is fine in all trimesters (protect abdo with shield)
Abdo / pelvic xray is fine in 2nd and 3rd trimester

CT scans much higher risk (but still do if benefit outweighs risk)

Answer 83

A

1st DEGREE
- injury to skin only

2nd DEGREE

injury to perineum, involving perineal muscle
includes episiotomy

3rd DEGREE

injury to perineum involving external anal sphincter (EAS)
3a = <50% of EAS torn
3b = >50% of EAS torn
3c = internal anal sphincter torn

4th DEGREE
- tear through anal mucosa (ie through perineum, EAS, IAS and rectal mucosa)

1% of vaginal deliveries result in 3rd or 4th degree tears

Answer 84

A

nulliparity
birthweight >4kg
shoulder dystocia
persistent occiput-posterior position
2nd stage > 1 hour
induction of labour
epidural
forceps delivery
midline episiotomy

Answer 85

A

suture asap (difficult ones repair in theatre)
rectal exam before and after (to ensure no injury to anal sphincter)
adequate analgesia (spinal, epidural, caudal block)
broad spectrum abx
stool softener
review 6wks afterwards
physio input

warn risk of faecal, fluid and flatal incontinence (also dyspareunia)
- 60-80% will have good result and be symptom-free at 12 months

If symptom-free by next pregnancy, risk of recurrence is 10%

if symptomatic at time of next pregnancy, risk is higher, offer elective LSCS

nb suturing is done in lithotomy position (ie legs in stirrups)

Answer 86

A

woman can do perineal massage antenatally

warm compress on perineum as head is crowning
episiotomy if looks like tear may occur

Answer 87

A

blood loss of 500ml or more from genital tract

primary = within 24hrs of delivery

secondary = 24hrs of delivery to 6wks post-partum

Answer 88

A

The 4 T’s

TONE (most common)
= uterine atony = failure to contract fully after delivery

TISSUE

large placenta
abnormal placental site (eg pervia or accretia)
retained placenta

TRAUMA

genital tract trauma (pernieal tears, episiotomy, lacerations to cervix)
uterine rupture or inversion

THROMBIN
- coagulation disorders (see other flashcard)

Answer 89

A

over distended uterus (eg multiparity)
foetal macrosomia
placental abruption
prolonged labour (2nd stage failure)
failure to actively manage 3rd stage
general anaesthetic
retained tissue
infection
previous PPH

Answer 90

A

severe pre-eclampsia (PET)
placental abruption
sepsis
autoimmune disease
liver disease
inherited/acquired coagulation disorders

Answer 91

A

ANTENATAL

Previous PPH
Previous retained placenta
Maternal Hb <8.5 at onset of labour
High BMI
Para 4+
Maternal age >35
Antepartum haemorrhage
Placenta praevia
Over-distension of the uterus
Uterine abnormalities

INTRAPARTUM

Induction of labour
Use of oxytocin
Prolonged labour
Precipitate labour (ie unusually rapid)
Vaginal operative delivery
LSCS

Answer 92

A

investigate and treat any maternal anaemia

also look for position of placenta

Answer 93

A

A-E approach

IV access (grey)
bimanual compression to stop bleeding
position patient flat
warmed crystalloid infusion
warm patient
blood transfusion (if required)
urgent group + save OR crossmatch
FBC
coagulation

also do repeat maternal obs every 15 mins

UTERINE ATONY

ergometrine IV bolus
syntocinon infusion
consider prostaglandins (misoprostol PR) if no response
may need examination under anaesthesia +/- laparotomy

nb ergometrine often causes N+V and is contraindicated in HTN

RETAINED PLACENTA

manual removal under GA or spinal (depending on condition)

GENITAL TRACT TRAUMA

repair surgically

ALL PPH are at increased risk of VTE
- so should be given prophylactic LMWH

Answer 94

A

when uterus literally inverts on itself

presents as vaso-vagal shock (pale, clammy, hypotensive & bradycardic) and a mass at the introitus
significant haemorrhage, clotting abnormalities and renal dysfunction can occur if not corrected promptly
shock corrects itself when uterus is replaced
O’Sullivan’s method - reduce inversion by hydrostatic technique

associated with grand multips and incorrect management of the third stage

nb this is RARE - just be aware it exists!

Answer 95

A

commonest cause = retained products +/- endometritis

check for evidence of infection
- ie bloods, swabs, purulent discharge, other sites of infection, maternal obs

TV USS to look for retained products

management

at least 24hr antibiotics
evacuation of retained products

Answer 96

A

Eclampsia: one or more generalised convulsions or coma in the setting of pre-eclampsia and absence of other neurologic conditions

often get epigastric pain alongside the seizures

40% of seizures occur post-partum

Answer 97

A

A-E approach

IV magnesium suplhate or diazepam to stop fits
prevent further fits with IV magnesium sulphate infusion (continue until 24hrs after last seizure)

antihypertensives (labetalol 1st line)

deliver baby (regardless of gestation)

MONITOR fluid balance (at risk of fluid overload - don’t give fluid if hypertensive)

nb magnesium sulphate can cause resp depression (reverse with calcium gluconate)
- can also affect reflexes, urine output and o2 sats

Answer 98

A

1st line: labetalol

2nd line: nifedipine

3rd line: hydralazine (rarely used)

Answer 99

A

Maternal = strep A

Neonatal = strep B

“A comes before B, the mother cam before the child”

Answer 100

A

aetiology obscure but 70% maternal mortality

signs + symptoms include:

collapse
DIC
unaccountable bleeding

diagnosis of exclusion or at post-mortem

MANAGEMENT

conservative
early transfer to ITU (as likely to need renal + inotrope support)
correct clotting

Answer 101

A

1 in 200 women in labour after one previous c-section (risk goes up if multiple sections)

risk in multiparous women on oxytocin infusion

risk very low in primigravid

Answer 102

A

EARLY SIGNS

raised maternal HR
localised scar pain (breaks through epidural)
abnormal CTG / foetal distress

LATER SIGNS

fresh vaginal bleeding
haematuria
constant severe abdo pain (breaks through epidural)
shock

Answer 103

A

A-E approach
- IV access and basic resus (incl oxygen)

Immediate laparotomy to salvage baby - repair damage or hysterectomy

Answer 104

A

Haemolysis
Elevated Liver enzymes
Low Platelet

it is a complication of severe pre-eclampsia (though can rarely occur with no prior history of PET)

nausea + vomiting
RUQ pain
lethargy

(nb also symptoms of pre-eclampsia)

FBC (haemolysis + low platelets)
LFT (elevated liver enzymes - esp ALT + GGT - ALP less useful)
clotting
group + save OR crossmatch

deliver the baby!!!

Answer 105

A

6 weeks post-delivery

UTERUS SIZE

Immediately: uterus shrinks down to level of umbilicus
2 weeks postpartum: no longer palpable above symphysis
6 weeks: uterus returned to non-pregnant size

Lochia: decidual sloughing after delivery, should gradually get less (if increases or more purulent/blood then likely infection)

sex safe as soon as ready, norm after 2-3 weeks

return of menstruation within 6-8wks

Answer 106

A

Colostrum = thick yellow fluid produced from ~20weeks gestation

High level of secretory IgA + rich in protein
Important part in gut maturation and immunity in infant
Produced in small quantities following birth of baby

Answer 107

A

Produced rapidly post-delivery – feed within first 2 hrs increases volume
- Increasing to around 500ml for 5 days postpartum

More energy efficient than formula milk

Cabergoline is given to supress lactation (dopamine receptor agonist)

Answer 108

A

ADVANTAGES FOR BABY:
lower incidence of:
- allergies
- GI infections
- otitis media
- resp infections

ADVANTAGES FOR MOTHER:

reduce risk of breast ca, ovarian ca + osteoporosis
bonding experience
lactational amenorrhoea
helps uterine involution

Answer 109

A

approx 8 times a day
- ‘Demand’ feeding encouraged: results in less weight loss in immediate postpartum period and increased duration of feeding. Reduced risk of hyperbilirubinemia and prevents breast engorgement

Recommend exclusive breast feeding for 4-6 months

decreases milk production:

COCP
smoking

women with Sheehan syndrome (pituitary gland damaged during childbirth) do not lactate

Answer 110

A

HIV (possible if undetectable viral load but still discouraged!)
varicella

(also some meds - see other flashcards)

Answer 111

A

AVOID

chloramphenicol
ciprofloxacin
erythromycin
tetracyclines
sulphonamides

PERMITTED

cephalosporins
penicillin
clarithromycin
trimethoprim

Answer 112

A

AVOID

amiodarone
ACE inhibitors
aspirin

PERMITTED

beta-blockers (labetalol)
digoxin
hydralazine
warfarin
heparin

Answer 113

A

AVOID

lithium
benzodiazepines
??? fluoxetine (*check)

PERMITTED

carbamazepine
sodium valproate
SSRIs
tricyclic antidepressants

Answer 114

A

Carbimazole = unsafe
Cytotoxic drugs = unsafe
glucocorticoids = safe
Iodines = unsafe
Levothyroxine = safe
Methotrexate = unsafe
NSAIDs = safe
Paracetamol = safe
Salbutamol = safe
Sulphonylureas = unsafe
Theophyllines = safe

Answer 115

A

May occur 2-4 days postpartum in women who are not breast-feeding, or at any time if breast-feeding is interrupted

MANAGEMENT

tight bra
ice packs
analgesia

Answer 116

A

regional infection of breast parenchyma
- norm staph aureus

nb more common in primips

focal unilateral breast erythema, oedema, tenderness

overcome ductal obstruction by continuing to breastfeed or pump
- analgesia also

Abx indications:

systemically unwell (fever, chills)
nipple fissure present
symptoms don’t improve after 12-24hrs of effective milk removal
culture indicates infection

fluoxetine (10-14 days)

breast abscess

palpable lump
needs incision + drainage (and abx)

nb mastitis occurs in 10% of breastfeeding women

Answer 117

A

immediate mother

maternal obs
uterine fundus palpated
vaginal bleeding recorded

immediate baby

apgar score
given vit K injection

hours and days for mother

early ambulation (+ hydration)
adequate pain management

6 week check for both

do babies get a TORCH screen too?? ***

Answer 118

A

need contraception from 21 days (ie 3wks) after delivery

2 in 100 will get pregnant in a year using lactational amenorrhoea
- ONLY effective if exclusively breastfeeding (ie not mixed)

discussed at 6 week check (if not before as well)

Answer 119

A

IMMEDIATELY

condoms
any progesterone only (POP, implant, injection)

FROM 21 DAYS
- emergency contraceptive pill (don’t need before this!)

3-6 WEEKS (depending on breastfeeding + VTE risk factors)
- combined (pill, patch, ring)

4 WEEKS (or within 48hrs)
- IUD/IUS

6 WEEKS
- Diaphragm (check it fits first!)

Answer 120

A

mild transient depression, occurs in >50% of women

begins around day 3 post-birth, resolves within 10 days (so by 2 weeks in total from birth)

tearfullness
irritability
anxiety
poor sleep

provide support and reassurance

Answer 121

A

10-15% get postnatal depression

symptoms from 2 months, resolve slowly over 6-12 months

screened at:

antenatal appointments
4-6wks check
3-4 months post-birth

risk factors

previous postpartum depression (70%)
history of depression (30%)

Answer 122

A

general symptoms of depression
PLUS:
- fears about baby's health
- feelings of maternal deficiencies
- marital tensions (incl loss of libido)

Edinburgh Postnatal Depression Scale

Answer 123

A

CBT (and self help)

SSRIs
- fluoxetine should be avoided if breastfeeding as long half life (others are safe)

Answer 124

A

a range of psychotic conditions presenting in immediate postnatal period

presents within 2-3 weeks of birth

1 in 500 deliveries

suicide risk = 5%
infanticide risk = 4%

Answer 125

A

Personal hx of mental illness

Bipolar Affective Disorder
Previous puerperal psychosis

Family Hx of mental illness

1st degree relative with hx of BAD
1st degree relative with hx puerperal psychosis
young age
primiparity
traumatic birth or pregnancy

Answer 126

A

hallucinations
delusions
mania
low mood
loss of inhibitions
feeling suspicious or fearful
restlessness
feeling very confused
behaving in a way that’s out of character

Answer 127

A

IF HIGH RISK

refer to specialist perinatal mental health service in antenatal period
can use prophylactic medication

IMMEDIATE

risk assessment (harm to self + others, incl baby)
urgent psychiatric assessment + treatment
admit to hospital (ideally specialist mother + baby unit - MBU)

TREATMENT OPTIONS

antidepressant or antipsychotic medication
mood stabilisers
ECT (rare)

most patient make a full recovery
- although high rate of recurrence in future pregnancies

Answer 128

A

ASK ABOUT

urine normal
bowels normal
eating and drinking?
mobilising well?
enough analgesia?

DIRECTLY OBSERVE

lochia
involution (uterus shrinking)
wounds (section scars or perineum)
signs of VTE
neonatal feeding + care

FORMALLY ASSESS

VTE risk
mental health risk assessment
signs of anaemia - check Hb

give anti-D to women (if they’re negative and baby positive)

Answer 129

A

MATERNAL FACTORS

Age >40 (at EDD)
Age <16 (at booking)
BMI >30 at booking
grand multiparity (G6)
IVF pregnancy
Tocophobia (pathological fear of childbirth
late booking

PREV OBS Hx

recurrent miscarriage
molar pregnancy
stillbirth / neonatal death / T2 loss
preterm delivery (<37wks)
large for gestational age (LGA >90th centile)
small for gestational age (SGA <10th centile)
congenital abnormality
pre-eclampsia
gestational diabetes
puerperal psychosis
red cell antibodies (ie rh -ve)
prev traumatic delivery
shoulder dystocia
3rd/4th degree tear
LSCS (or other uterine scarring)
significant antepartum or post-partum haemorrhage
retained placenta with PPH
prev placenta accretia

Answer 130

A

PAST GYNAE Hx

pelvic fracture
pelvic mass
uterine abnormalities
endometrial resection
hx of subfertility
cone biopsy or >1 LLETZ
Female genital mutilation

PAST MED HX

Psychiatric disorder (prev admission, suicide attempt or meds)
neurological disorder (incl epilepsy)
Cardiac disease / murmur
hypertension
haematological disorder (incl prev VTE)
cystic fibrosis
severe asthma (or other resp prob)
GI disease
endocrine disease (incl DM)
renal disease

Answer 131

A

FHx

1st deg relative pre-eclampsia
1st deg relative gestational DM
1st degree relative VTE <50yo
foetus at risk of inherited disease / abnormality

SHx

mother smoking during pregnancy
mother taking recreational drugs during preg
mother drinking excessive alcohol during pregnancy

Answer 132

A

MATERNAL CONDITIONS

hypertension / proteinuria / pre-eclampsia
gestational DM

MATERNAL INFECTIONS

newly diagnosed STI
2 or more UTIs
confirmed exposure to Zika virus

MATERNAL SYMPTOMS

PV bleeding after 1st trimester
persistent haematuria

BLOOD RESULTS

low Hb not responding to treatment
deranged LFTs (HELLP or obs chole)

PLACENTA

abnormal umbilical artery doppler
placenta previa

FOETUS

multiple pregnancy
RFM (>1 episode)
abnormal foetal growth / SGA
abnormal amniotic fluid volume (high or low)
foetal abnormality
incorrect presentation / orientation at 36 wks

Answer 133

A

basically if have any risk factor - either at booking or discovered later in pregnancy then see consultant!

(nb if consultant-led care, still see community midwifes, just have ANC appts as well)

Answer 134

A

direct = VTE

Indirect = cardiac

Answer 135

A

8-10 weeks with midwife (takes about an hour)

obstetric hx
medical hx (incl LMP)

(basically fill in a massive form covering all potential risks to see if woman high or low risk)

BP (baseline for comparison)
urineanalysis (protein, blood, infection)
BMI

bloods

FBC
Group + save (rh status)
blood infection screen (can opt out)
haemoglobinopathies (SSA, thalassaemia)

offer / discuss antenatal screening:

combined screening
chlamydia test (if <25)

meds to take

flu vaccine
folic acid (400mg for first 3 months, 5g if risk factors like obesity, DM, epilepsy)
vit D

FOODS TO AVOID

soft cheese (camembert, brie, stilton) AND pate + contact w live lambs (listeria)
cat faeces, gardening (toxoplasmosis)
raw or partially cooked eggs and meat, esp poultry (salmonella)
liver (vit A)

nb nuts, eggs, salad + honey are fine

OTHER LIFESTYLE

stop smoking (incl education re stillbirths)
stop alcohol
be aware of carbon monoxide risk (test CO levels!)

Answer 136

A

BMI >30

OGTT at 26 wks
growth scans at 30 + 36 wks

BMI > 40
- same as above PLUS an OGTT at 16wks

Answer 137

A

screens for:

downs
edwards
patau

between 10-14 wks

at same time as dating scan
blood test in addition to scan
nuchal translucency (high is bad, want <3.5mm)
PAPP-A (low is bad)
HCG (High is bad)

^ these are taken together with maternal age!

If risk is >1 in 150 then result is ‘high risk’

if high risk, woman offered chorionic villus sampling or amniocentesis (1 in 100 risk of miscarriage)

CVS 11-14wks
amniocentesis wk 15

^these tests will be able to say if have or not but not to what severity

If too late (or can’t obtain nuchal translucency) then can have quadruple blood testing between 14-20 wks

only screens for downs
not as accurate as combined
measures bHCG, inhibin-A, AFP, estriol

nb can have NIPT (non-invasive prenatal testing) IONA tests in private sector - get foetal DNA from mothers blood

Answer 138

A

HIV
Hep B
syphilis

nb these are all opt-out

Answer 139

A

1) what do they know about test already?
2) what conditions is it screening for?
3) can’t tell you whether they do or don’t have conditions, just gives a chance as a number, if high risk, can do other test to confirm
4) think about what you are going to do with the results? would you get further tests? would you terminate?

whenever discussing downs etc - always talk about the ‘chance’ or ‘likelihood’ of foetus having it, not ‘risk’

Answer 140

A

11+2-14+1 weeks

crown rump length (CRL)
- approximate gestational age in weeks (get EDD from this)

presence of gestational sac
yolk sac and embryo
foetal cardiac activity
single or multiple foetus?
evaluate uterus + adnexal structures

part of combined screening
- measure nuchal translucency (want <3.5mm)

Answer 141

A

18 - 20+6 weeks

ANATOMY SURVEY

face (excl cleft palate)
brain
spine
limbs
heart (incl activity)
stomach bubble
umbilical cord insertion
kidneys
bladder
gentalia

OTHER

assess growth / age
amniotic fluid volume
umbilical cord + number of vessels
placental location
cervical length
evaluate uterus + adnexa

also exclude multiple pregnancies again

Answer 142

A

WHO NEEDS

any risk / concerns around foetal growth (eg DM, small/large on SFH measurements, prev small/large baby, smoker etc)
> 1 episode of RFM (1st episode do CTG)

1) ESTIMATED FOETAL WEIGHT (EFW)
- combination of:
= head circum (HC)
= abdo circum (AC)
= femur length (FL)

2) LIQUOR VOLUME
- measure deepest pool, if this is high or low then measure all

3) DOPPLER STUDIES
- foetal heart beat
- uterine artery pulsitility index, indicator of resistance (PI or UAPI - want low)
- umbilical artery end-diastolic flow (EDF - want positive)
- middle cerebral artery (MCA - may be proportionally higher if foetus compensating)

4) FOETAL MOVEMENTS
- see if move, turn mum on side and back to try and stimulate

5) PRESENTATION AND LIE
- also placental position if low-lying at 20wks

Answer 143

A

FOR ALL

28wks gestation (?at 34wks aswell)
following birth (but only if baby is rh positive)

ALSO GIVE IF:

any TOP (medical or surgical)
any miscarriage over 12wks
any surgical management of miscarriage
any surgical management of ectopic
antepartum haemorrhage (bleeding >24wks)
external cephalic version (ECV)
amniocentesis / chorionic villus sampling
foetal blood sampling (FBS)
abdominal trauma (during preg)

nb these are all for rh negative women only (never need to give anti-D if mother rh positive)

Answer 144

A

take cord blood for:

FBC
blood group
coombs test

if baby is rh positive, give mother another dose of anti-D

Answer 145

A

1 in 4 women experience domestic abuse / violence in lifetime
- 30% of this begins in pregnancy

existing abuse may also get worse during pregnancy or after birth

increases risk of:

miscarriage
infection
premature birth
injury or IUD

Answer 146

A

20-30% of smokers continue to smoke during pregnancy
- very difficult group to teach, cultural beliefs that labour will be easier if it’s a smaller baby etc

increases risk of:

miscarriage
stillbirth / IUD
premature birth
low birth weight
perinatal mortality

also:

sub-fertility
menopause 3-5 years earlier than otherwise

Answer 147

A

FOETAL ALCOHOL SYNDROME

facial abnormalities (short palpebral fissure, hypoplastic upper lip, smooth/absent filtrum)
microcephaly
learning difficulties
growth retardation
cardiac malformations

May show signs of withdrawal at birth:

irritable
hypotonic
tremors

Answer 148

A

FOETUS

IUGR
cerebral infarction
placental abruption
congenital abnormalities (dt cocaine-induced vasospasm during preg)

MOTHER

Uterine rupture
HTN
seizures
death

Answer 149

A

1) NAUSEA + VOMITING
- ‘morning sickness’
- mainly in 1st trimester, norm resolves by 16-20wks
- caused by bHCG levels
MANAGEMENT
= increase fluids
= smaller meals
= antiemetics (metoclopramide)

REFLUX
- throughout pregnancy (esp T3)
- affects 70%
- caused by progesterone -> relaxation of oesophageal sphincter (plus incressed abdo pressure)
MANAGEMENT
= use extra pillows (worse if supine)
= avoid spicy foods
= antacids
= ranitidine (if bad)

CONSTIPATION
- caused by progesterone -> reduces smooth muscle tone
- often made worse by iron supplements
- very common, can improve with gestation
MANAGEMENT
= increase fibre
= drink more water
= fibre supplements
= stool softeners (ispaghula husk)
= osmotic laxatives (lactulose)

HAEMORRHOIDS
- mainly in T3
- dt constipation + increased abdo pressure
MANAGEMENT
= avoid constipation
= ice packs
= digital reduction
= suppositries
= topical haemorrhoid preparations licensed in pregnancy (eg corticosteroids, local anaesthetic etc)
= surgical removal if thrombosed

Answer 150

A

1) Increased urgency (throughout)
- avoid caffeine + late-night fluids

2) stress incontinence (esp in T3)
- may need pads

3) UTIs

nb creatinine and urea are low in pregnancy due to increased glomerular filtration rate

Answer 151

A

all women get dipstick at booking

TREAT ASYMPTOMATIC BACTERURIA!

If symptomatic, ALWAYS take cultures (ie MSU)

Nitrofurantoin
= 1st + 2nd trimester only
- neonatal haemolysis if in T3

Trimethoprim
= 3rd trimester only
- teratogenic in T1 + 2

2ND LINE
- cephalosporins and penicillins are safe (but avoid co-amoxiclav!!)

Answer 152

A

pre-eclampsia - can present with epigastric pain

though MUCH more likely to just be reflux

do BP and dip urine for protein

Answer 153

A

need to exclude ruptured membranes!!
- watery, profuse discharge

candida is very common
- treat with clotrimazole pessary (NOT oral anti-fungals!)

Exclude STIs too!!

basically if woman presents with change in discharge in pregnancy, do a speculum to look for ROM and swab for candida and other infections, incl STIs

Answer 154

A

SYMPHISIS PUBIS DYSFUNCTION (SPD)
- pelvic pain in pubic + sacroilliac joints
MANAGEMENT
- physio
- care with leg abduction
- corsets
- analgesia

BACKACHE +/- SCIATICA
- almost universal
- caused by altered posture, pressure on sciatic nerves
MANAGEMENT
- physio
- massage
- postural advice
- corset

CARPAL TUNNEL SYNDROME
- caused by oedema compressing median nerve
- usually resolves after pregnancy
MANAGEMENT
- splints
- positional advice while sleeping

Answer 155

A

common, normally self limiting
- can use emollients and refer to derm if bad

Exclude:

obstetric cholestasis
infectious causes (eg varicella)

OBS CHOLE
- check sclera for jaundice
- do LFTs
(this is 1% of pregnancies!!)

INFECTIOUS CAUSES

inspect rash
ask about any contact with other people with rashes

Answer 156

A

Where excessive nausea and vomiting in early pregnancy (NVP) is so severe as to cause severe dehydration, weight loss, or electrolyte disturbance

About 1 in 100 - 1 in 700 pregnancies

most common 8-12wks (though can go up to 20wks)

RISK FACTORS / ASSOCIATIONS:

nulliparity
IVF or assisted reproduction
Trophoblastic disease (eg molar)
multpile pregnancies
obesity
hyperthyroidism

Answer 157

A

SYMPTOMS

nausea + vomiting
epigastric pain
excessive salivation
reduced urine output

SIGNS

dehydration
epigastric tenderness
ketonuria

Answer 158

A

urine dipstick
- to look for ketones (also exclude infection)

FBC
U+E
LFT
TFT (rule out thyroid probs)

TV USS
- to exclude molar pregnancy

Answer 159

A

encourage oral fluid intake
antiemetics (eg cyclizine, metoclopramide)

WHEN TO ADMIT

1) Continued N+V, unable to keep down oral fluids + oral antiemetics
2) ketonuria despite oral antiemetics
3) weight loss >5% body mass
4) co-existing condition (eg DM) which may be affected by continued N+V

MANAGEMENT IN HOSP

IV fluids
IV antiemetics

= NG feeding
= thiamine to prevent deficiencies (also correct other electrolytes)
= corticosteroids if really severe

Answer 160

A

MOTHER

Wernicke’s encephalopathy (prevent with thiamine)
mallory-weiss tear
acute tubular necrosis

FOETUS

growth restriction
pre-term birth

Answer 161

A

LOW BIRTH WEIGHT
= < 2.5kg, regardless of gestational age

SMALL FOR GESTATIONAL AGE (SGA)
= weight of foetus or newborn is <10th centile for gestational age

INTRA-UTERINE GROWTH RESTRICTION (IUGR)
= foetus that has failed to achieve its growth potential due to genetic or environmental factors

AGA
= 10th to 90th centile for gestational age (ie normal

FOETAL MACROSOMIA
= estimated weight (not birth weight) >4.5kg

LARGE FOR GESTATIONAL AGE
= > 90th centile (incidence is 5%)

Answer 162

A

Symmetric: foetus is proportionally small, suggesting long term compromise

Asymmetric: foetal head is proportionally larger than body – short term compromise with sparing of the brain.

Answer 163

A

FOETAL GENETIUC FACTORS (5-15%)

Chromosomal anomalies e.g. trisomy’s and sex chromosome abnormalities
Single gene defects e.g. dwarfism, phenylketonuria

FOETAL STRUCTURAL ABNORMALITIES

Cardiovascular anomalies
Bilateral renal agenesis

MULTIPLE PREGNANCY

Risk of IUGR increases with foetal number
Worse in MCDA + MCMA (twin-twin transfusion syndrome)

UTEROPLACENTAL INSUFFICIENCY (25-30%)

Chronic hypertension, pre-eclampsia
Antiphospholipid antibody syndrome
Chronic placental abruption
Velamentous (ie abnormal) insertion of umbilical cord.

DRUG / TOXIIN EXPOSURE

Illicit drugs e.g. cocaine
Heavy cigarette smoking, esp. in older mothers

MATERNAL MALNUTRITION
gestational malnutrition superimposed on poor pregnancy nutritional status

MATERNAL MEDICAL CONDITIONS

Poorly controlled hyperthyroidism
Haemoglobinopathies
Chronic pulmonary disease
Cyanotic heart disease
Anaemia
Diabetes (though more commonly causes big baby)

MATERNAL INFECTION 
 (5-10%)
- Malaria (single biggest cause of IUGR worldwide)
- Rubella
- Cytomegalovirus 
- Varicella

Answer 164

A

multiple pregnancy
previous IUGR (recurrence 20%)
pre-eclampsia (40% have IUGR)
maternal smoking
other maternal medical conditions (ie high risk pregnancies)

Answer 165

A

based on estimates foetal weight for gestation

other evidence of foetal compromise

oligohydramnious
abnormal dopplers

(ie diagnose on scan,. but can also get scan if SFH are not increasing like they should)

Answer 166

A

Perinatal mortality: commonest cause of stillbirth (50%)
Preterm birth
Birth asphyxia
Neonatal hypoglycaemia
Neonatal polycythaemia due to chronic hypoxia

Answer 167

A

determine aetiology

USS for anomalies
check karyotype
exclude infection
regular foetal scans (twice weekly if need)
repeat CTG

consider delivery after 34wks if deterioration or once foetal lung maturation is documented (ie 24hrs after 2nd steroid dose)

50-80% IUGR babies will develop foetal distress in labour so may try for vaginal but many end up having LSCS

Send placenta for pathology to look for evidence of vasculopathy

Answer 168

A

MOST COMMON:

1) Maternal diabetes (35-40%)
2) Post-term pregnancy, ie after 42wks (10-20%)
3) Maternal obesity (10-20%)

OTHER RISK FACTORS

multiparity
prev macrosomic infant
male infant
increased maternal height
advanced maternal age
beckwith-wiederman syndrome (chromosomal abnormality)

Answer 169

A

FOETUS:

increased incidence of IUD + neonatal death
shoulder dystocia + brachial plexus palsy
hypoglycaemia
polycythaemia
jaundice

MOTHER

Increased maternal morbidity (increased incidence of LSCS)
PPH
perineal trauma / forceps
puerpral infection

Answer 170

A

antenatal growth scans

induce or elective section before 40wks (exactly when depends on cause)
- vaginal delivery under high risk supervision

Answer 171

A

ASTHMA!!! It’s a beta blocker!

use nifedipine instead!

Answer 172

A

duration?
how active were they before?
have movements come back now?
ever had this before
vaginal loss (incl waters) / PV bleeding?
abdo pain?
well in yourself? any fever?
any problems in this pregnancy so far?
any problems ion prev pregnancies? (incl SGA)

Answer 173

A

SFH
uterine tenderness
maternal obs (incl temp)
CTG

do bloods if suspect infection

do USS if:

abnormal CTG
more than one episode of RFM

consider early delivery (+/- steroids) if:

evidence of IUGR / foetal distress
recurrent RFM

can always do repeat dopplers

Answer 174

A

any pregnancy exceeding 42wks from first day of LMP

3-10% incidence (depending on whether EDD or LMP used)

common in primips

if prev prolonged pregnancy , recurrence = 30%

Answer 175

A

DIZYGOTIC

ie non-identical twins
2 eggs, 2 sperms

MONOZYGOTIC (identical)

= dichorionic diamniotic (DCDA)

split day 0-4
lamda sign

= monochorionic diamniotic (MCDA)

split day 4-8
T sign

= monochorionic monoamniotic (MCMA)

split day 8-12
risk of cords tangling around each other

nb all dizygotic twins are DCDA, as well as a 1/3rd of monozygotic twins)

CHORIONCITY = the number of placentas

Answer 176

A

FHx of twins / multiple pregnancy
IVF
older maternal age

incidence = 1 in 80

Answer 177

A

FOETAL

miscarriage
IUD / vanishing twin
perinatal mortality
IUGR
pre-term delivery
polyhydramnios
malpresentation
cord prolapse

MATERNAL

hyperemesis
anaemia
pre-eclampsia
gestational DM
acute fatty liver
placenta previa
placental abruption
PPROM (10-20%)
high chance of operative delivery
PPH

Answer 178

A

MCDA and MCMA at risk

as share placenta
risk is 20%

nb DCDA don’t get TTT as don’t share same placenta

vary severity, perinatal mortality is 40-80%

RECIPIENT TWIN

polycythaemia
HTN
cardiac hypertrophy
oedema (hydrops)
polyhydramnios

DONOR TWIN

anaemia
IUGR
hypotension
oligohydramnios
TEND TO FAIR WORSE!

MANAGEMENT

expectant management
serial amniocentesis
laser obliteration of placental vascular communications

Answer 179

A

high dose folic acid (5mg)
iron
also aspirin (if indicated for another reason)

DCDA

growth scans = 28, 32, 36wks
delivery at 38wks (induction if baby 1 is cephalic, or LSCS if breech or transverse)

MCDA + MCMA

USS every 2 wks from 16-24 wks (to look for TTTS)
growth scans same as DCDA

MCDA
= deliver 36-37wks
- induce if twin 1 is cephalic, LSCSC if not or TTTS

MCMA
= deliver at 32wks by LSCS (high risk of cord entanglement after this)

Answer 180

A

PRE-EXISTING HTN

HTN (>140/90 prior to 20wks)
different mechanism, though is a risk factor for gestational HTN / pre-eclampsia

GESTATIONAL HTN

new-onset, persistent BP >140/90 after 20wks WITHOUT proteinuria OR symptoms of PET
or an increase above booking readings of >30 systolic or >15 diastolic

PRE-ECLAMPSIA (PET)
- new-onset, persistent BP >140/90 after 20wks PLUS significant proteinuria (>300mg/24hrs or >1+ on urine dip) OR symptoms of PET

(nb exclude UTI before diagnosing PET)

ECLAMPSIA
= one or more generalised convulsions or coma in the setting of pre-eclampsia and absence of other neurologic conditions

HELLP syndrome
- a complication of severe pre-eclampsia
= Haemolysis
= Elevated Liver enzymes
= Low Platelets

Answer 181

A

= prev Hx of pre-eclampsia

= chronic HTN
= pre-existing diabetes

= chronic renal disease
= anti-phospholipid syndrome (or lupus)

FHx of pre-eclampsia
BMI >35
black ethnicity
extremes of maternal age (high + low)
multiple pregnancy

nb nulliparity may also slightly increase risk, risk resets if new partner

ASPIRIN 150mg
- taken from 12th wk (ideally, useless if started after 20wks) until delivery

Answer 182

A

PRE-EXISTING HTN

continue antihypertensives (stop any ACEi or diuretics and switch to labetalol, nifedipine)
give aspirin from 12wks
foetal growth scans

GESTATIONAL HTN

Give labetalol (nifedipine 2nd line, hydralazine 3rd line)
continue to monitor for PET and make mother aware of symptoms to look out for

Answer 183

A

6-8% of pregnancies in UK

can only make diagnosis after 20wks!!!

SYMPTOMS

persistent severe headache
visual disturbances
facial swelling
epigastric / RUQ pain (liver capsule stretch)

can also get SOB if got ARDS as a complication

SIGNS

peri-orbital oedema
hyper-reflexia
clonus

Answer 184

A

BP
protein dipstick (always exclude UTI if protein)

24hr urine collection (looking for >300mg in 24hrs)
^ now mainly do PCR?? **

FBC
LFTs
U+Es
Group + save

Answer 185

A

Features of severe pre-eclampsia
hypertension:

typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

PRE-ECLAMPSIA COMPLICATIONS:

Eclampsia
Stroke
HELLP Syndrome
DIC
Multi system organ failure: Renal, Hepatic, Pulmonary oedema, ARDS

Answer 186

A

antihypertensives to reduce stroke risk
- labetalol 1st line (then nifedipine and hydralazine)

STEROIDS
= 24-34 weeks, IM betamethasone 24hrs apart
= 34-36 wks, CONSIDER giving the above

MAGNESIUM SULPHATE
= if severe pre-eclampsia or foetus before ?*28wks??
= if severe pre-eclampsia, give during labour and 24hrs postpartum to prevent eclampsia

MILD PET
= deliver once >36wks
- also repeat USS to look for IUGR

SEVERE PET
= weigh up risk, close monitoring, norm deliver by 32wks

OBSERVE

blood pressure
renal function
hepatic function
foetal distress (repeat CTGs)

Answer 187

A

previous gestational DM
previous macrosomic baby (>4.5kg)
BMI >30
1st degree relative with DM (of any kind)
Black, south asian or middle eastern ethnicity

IF RISK FACTORS:
- OGTT at 26wks

nb if previous gestational DM then do OGTT at 16wks and then again at 26 wks (if first is normal)

GESTATIONAL DIABETES if, either
- fasting glucose >= 5.6mmol
OR
- 2-hour glucose >= 7.8

“remember 5 6 7 8”

Answer 188

A

MOTHER

DKA
pre-eclampsia / PIH
Obstetric cholestasis
instrumental delivery
higher risk of needing a LSCS

nb women with gestational DM are more likely to get type 2 DM later in life

FOETUS

miscarriage / still birth
birth defects (incl spinal bifida, renal, cardiac, GI probs)
macrosomia +/- shoulder dystocia (nb can also get IUGR though)
preterm birth
respiratory distress syndrome
neonatal hypoglycaemia
neonatal jaundice
increased risk of diabetes later in life

Answer 189

A

nb give pre-conceptual advice to improve control and reduce weight if possible!

under care of joint diabetic and obstetric team: consultant-led care

STOP

oral hypoglycaemics (except metformin)
ACE inhibitors
Statins

switch oral meds to insulin

SAFE TO USE:

metformin
insulin

EXTRA TO TAKE

5mg (ie high dose) folic acid
150mg aspirin (from 12wks)

LIFESTYLE

loose weight if BMI >27
tight glycaemic control will drastically reduce complication risk (though beware of DKA + hypos)

also monitor eyes as retinopathy can worsen during pregnancy

detailed anatomy scan at 20wks (incl 4 chamber view of heart)
- also additional growth scans in 3rd trimester

Answer 190

A

pre-existing (ie type 1 or 2)
= deliver at 37-39weeks

gestational
= deliver 39-40weeks

nb these both assume no maternal or foetal complications secondary to the diabetes - if these are present, cionsider earlier delivery

planned delivery can be done by induction or LSCS - depending on other comorbidities etc

Answer 191

A

5% of pregnancies

1st line:
- diet

2nd line:
- metformin

3rd line:
- insulin

POST-BIRTH

warn mother of risk of type 2 DM later in life (give dietary/exercise advice)
do fasting glucose test at 6 week check

Answer 192

A

monitopr blood glucose every HOUR during labour
- should be between 4 and 7

SLIDING SCALE FOR:

all type 1 DM
anyone who’s BMs are not between 4 and 7

Answer 193

A

nb pregnancy in itself is a risk factor

PREGNANCY-RELATED RISKS

hyperemesis / dehydration
pre-eclampsia
excessive blood loss
prolonged labour
trauma to pelvic veins during delivery
parity >4
multiple pregnancy
IVF / ART

OTHER RISKS

Previous VTE
FHx of VTE in 1st degree relative <50
BMI >30
> 35 years
immobility
travel
surgery
gross varicose vein
severe infection
sickle cell anaemia (SCA)
inflammatory disorders
thrombophilia (eg anti-phospholipid)

PROPHYLACTIC LMWH

prev VTE of FH, give LMWH antenatally + 6wks post-partum
3+ risk factors = LMWH from 28wks - 6wks postpartum
4+ risk factors = LMWH immediately - 6wks post-partum

nb in women at extremes of body weight or other high-risk factors, routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy recommended

Answer 194

A

DVTs

90% left leg
70% above the knee (above knee = increased embolic risk)
nb Mostly occur below the knee in non-pregnancy state

DVT - leg USS / doppler

PE

VQ scan (increases risk of leukaemia for baby)
CTPA (if essential)

also do:

ABG
ECG

D-DIMER IS USELESS during pregnancy (as pregnancy raises it)

Give treatment-dose LMWH if high clinical suspision of VTE in pregnancy (even if can’t do imaging)

ie have a low index of suspision
give for 3 months

can giv ethrombolysis (alteplase etc) only if life-threatening

DON’T USE WARFARIN OR DOACS DURING PREGNANCY!

Answer 195

A

The woman’s!!

She should be given written information about repeated section vs VBAC and also have a chance to discuss both options with a dr in antenatal clinic

elective sections norm booked around 36wks
- take place at 39wks

Answer 196

A

ADVANTAGES:

A vaginal birth (better for mother + baby - less likely to have resp problems)
greater chance of an uncomplicated normal birth in future pregnancies
shorter recovery (can drive/lift asap) and shorter stay in hospital
less abdo pain after birth
not having surgery

75% who have VBAC will be successful (ie won’t need an emergency section)

Will need CTG monitoring during labour

risk of scar rupture:

0.5% if natural
3% if induced/augmented (ie if have oxytocin)

ABSOLUTE CI

3 or more previous sections
prev uterine rupture
high uterine incision (classical c-section scar)
other pregnancy complications that require a section (eg previa)

Answer 197

A

ADVANTAGES

virtually no risk of scar rupture
knowledge of date of delivery (though 10% of women will go into labour before this)

nb discuss with women what their wishes would be if they went into spontaneous labour before elective - want emergency section or try VBAC

DISADVANTAGES OF REPEAT SECTIONS

longer (+ potentially more difficult) operation
need for elective section in future pregnancies
all major risks (placenta accretia, large PPH etc) increase with number of sections performed

DISADVANTAGES OF SECTIONS GENERALLY

damage to other organs (bladder, bowel, ureter)
VTE risk (5x increased risk)
increased risk of bleeding
increased risk of infection
anaesthetic risks (say anaesthetist will discuss)
longer recovery (can’t drive or lift for 6 weeks)
transient neonatal respiratory problems more common than if vaginal birth
2% risk of scalp laceration to baby

FUTURE PREGNANCY RISKS

higher risk of rupture
placenta accretia
still birth

Answer 198

A

5mg folic acid
- take as long before conception as possible

aim for monotherapy

Although most anti-epileptic medications are teratogenic to greater or lesser degrees, the risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the foetus

risk reduction through

5mg folic acid
aiming for monotherapy with least teratogenic medication which is still effective in keeping woman seizure-free

Answer 199

A

nb all anti-epileptics are considered teratogenic to some level but the risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the foetus

SODIUM VALPROATE

very teratogenic - only use if it’s definitely the only thing which maintains seizure-free
neural tube defects
neurodevelopmental delay in children

CARBAMAZEPINE
- often considered the least teratogenic of the older antiepileptics

PHENYTOIN

associated with cleft palate
give oral vit K in last month of pregnancy to reduce clotting disorders in newborn

LAMOTRIGINE
- studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

LAMOTRIGINE + CARBAMAZEPINE + LEVITERACETAM are the safest!!

nb breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 200

A

fatigue
fainting
chest pain
palpitations
SOB
orthopnoea

may also pick up a murmur on auscultation (nb some are normal in pregnancy - check which one**)

Answer 201

A

mitral stenosis

less common in british women, consider in immigrant women
norm associated with rheumatic heart disease

do 12-lead ECG (24hr if nothing found) if any symptoms

involve cardiology and MDT team early if congenital or acquired

consider early delivery if mother has cardiac problems
- monitor mother closely during labour/section

Answer 202

A

HTN increases risk of:

pre-eclampsia
placental abruption
IUGR
preterm delivery
maternal morbidity + mortality (eg stroke, retinopathy)
neonatal morbidity/mortality

SWITCH TO:

labetalol
nifedipine
methyldopa

give aspirin from 12wks

Answer 203

A

death from 6wks to a year post-natally from a cause related to pregnancy or birth

biggest cause = suicide

suicide within a year of birth is classed as a DIRECT maternal cause of death

nb overall 1 in 7 maternal deaths is from suicide

Answer 204

A

maternal death from overdose
IUGR
preterm delivery
stillbirth
placental abruption (esp w cocaine)
neonatal withdrawal syndrome

Answer 205

A

check antibodies

if immune, no action needed
if not immune, give IV Ig immediately

if patient presents within 24hrs of rash onset, give oral acyclovir

Answer 206

A

T1 = Hb >110

T2/3 = Hb >105

post-partum = HB >100

Give oral iron 1st line if anaemic during pregnancy

advise re constipation and co-prescribe laxatives if need
also recommend have on empty stomach with orange juice to increase absorption

Answer 207

A

FGM = “All procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons”

REMOVAL of ALL or PART of:

type 1 = clitoris + clitoral hood (clitoridectomy)
type 2 = clitoris + labia minora +/- excision of labia majora (excision)
type 3 = closure of the vagina, narrowing of the vaginal opening (infibulation)
type 4 = other harmful procedures to genetalia (eg burning clitoris, piercing, cutting or scarring vaginal opening, stretching labia

In Africa, around 50% girls undergo FGM between birth and 5 years. Remainder at risk between 5 and 15 years.

Answer 208

A

IMMEDIATE

Severe pain
urinary retention
haemorrhage
damage to adjacent organs
fractures from forcible restraint
wound infection (-> sepsis)
tetanus + gangrene
BBV infection (HIV, hep B)
death

LONG-TERM

recurrent UTI
difficulty voiding urine + faeces
painful menstruation
keloid scarring + cysts, infibulation cysts
sexual difficulties
psychological problems
infertility

PREGNANCY

delay in final stage of childbirth = high rates of LSCS, instrumental delivery, PPH + death
high rates of foetal asphyxia + perinatal death

Answer 209

A

FGM or arranging FGM overseas for a UK resident is illegal (can go to prison for 14 years for organising the trip)

if woman has a vaginal birth then will perform a vertical episiotomy (ie cut through what’s been sewn up) and won’t stitch it back up again

must document in notes if someone has had FGM

If a child has had FGM, call the polic (and notify safeguarding lead)

If child is at risk of having it, contact safeguarding lead + refer to social services

Answer 210

A

A family which belongs to a community in which FGM is practised
A family making preparations to take a child on holiday to an area where FGM is practised, for example arranging vaccinations. If the family is from a community known to practise FGM, travel to any country (not just their country or origin) should raise suspicions
A child from an FGM-practising community that is talking about a ‘special procedure or ceremony’ that is going to take place
You become aware of a mother who has already undergone FGM. This might prompt concern for any daughters, girls or young women in the family
A school nurse may notice a girl from an FGM-practising community avoiding specific classes or activities such as PE or sports, perhaps giving reasons of bladder, menstrual or abdominal problems

Answer 211

A

paracetamol = safe

NSAIDs = AVOID

causes miscarriage + malformation in T1, premature closure of ductus arteriosus in T3
are safe in breastfeeding though
aspirin is okay (but lower doses)

Answer 212

A

nitrofurantoin
= yes in T1 +T2, no in T3 (neonatal haemolysis)

trimethoprim
= no in T1 + T2, yes in T3
(anti-folate, teratogenic)

cephalosporins + penicillins
= safe
except co-amoxiclav!! (relative CI - risk of necrotising enterocolitis in baby)

Tetracyclines = absolute CI (neonatal tooth discolouration)

Macrolides (erythromycin etc) = safe!

clindamycin = safe

metronidazole = safe

Answer 213

A

FIRST LINE

T1 + T2
= Nitrofurantoin (DO NOT USE in 3rd trimester (neonatal haemolysis))

T3
= Trimethoprim ((anti folate drug) DO NOT use in 1st trimester (teratogenic))

SECOND LINE
= Cephalosporins and penicillins safe (but avoid co-amoxiclav in pregnancy due to risk of necrotising enterocolitis (NEC) in baby)

nb DO NOT USE Tetracyclines – neonatal tooth discolouration

Answer 214

A

use penicillins and macrolides (eg erythromycin)

co-amoxiclav is NOT safe!

Answer 215

A

Erythromycin for 7 days to prevent chorioamnionitis

Chorioamnionitis 
 treatment
= IV Cefuroxime 
AND
= IV Metronidazole

Answer 216

A

co-amoxiclav = 1st line

if pen allergic
= clindamycin AND metronidazole

nb can give co-amoxiclav for endometritis as baby is no longer in uterus!

Answer 217

A

Do not use ACE inhibitors ARBs in pregnancy - fetal renal damage in 2nd and 3rd trimester and possibly malformation in 1st trimester

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obstetrics Flashcards

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