Obstetrics

Question 1

Congenital Rubella Syndeome
When at risk?
Features (9)

Answer 1

Risk
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks

sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
'salt and pepper' chorioretinitis
microphthalmia
cerebral palsy

Question 2

Management of Rubella exposure in pregnancy (4)

Answer 2

suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit

if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella

non-immune mothers should be offered the MMR vaccination in the post-natal period

MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

Question 3

Hypertension in pregnancy - causes (3)

Answer 3

Pre-existing hypertension - A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

Pregnancy-induced hypertension - hypertension occurring after 20 weeks of pregnancy. no proteinuria or oedema. increased risk of pre-eclampsia in future pregnancies.

Pre-eclampsia - hypertension with proteinuria at 20 weeks of pregnancy or later.

Question 4

Types of breech presentation

Answer 4

Frank breech - most common, hips flexed and knees fully extended.
Footling breech - one or both feet come first with the bottom at a higher position, rare but higher perinatal morbidity

Question 5

Risk factors for breech presentation (5)

Answer 5

uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)

Question 6

Mx of Breech presentation

Answer 6

if still breech at 36 weeks = external cephalic version (ECV) at 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery

Question 7

contraindications to ECV (6)

Answer 7

where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy

Question 8

Suppressing lactation

Answer 8

stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline is the medication of choice if required

Question 9

Management of HIV in pregnancy

Answer 9

All mothers:
- ARVT, advise against breastfeeding.
Viral load less than 50:
- vaginal delivery
- treat infant with zidovudine for 4 to 6 weeks
Viral load over 50
- C-section with zidovudine infusion prior
- treat infant with ARVT for 4 to 6 weeks

Question 10

Resus negative women Mx

Answer 10

anti-D at 28 + 34 weeks

Question 11

What is HELPP Syndrome?

Answer 11

A severe form of pre-eclampsia whose features include: Haemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP). Present with malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.

Question 12

Shoulder dystocia manoueveures and Mx

Answer 12

1: McRoberts position - hyperflex the mother’s legs onto her abdomen and apply suprapubic pressure
2: Rubin manoeuvre - press on the fetal posterior shoulder
3: Woodscrew manoeuvre - putting a hand in the vagina and rotating the foetus 180 degrees
repeat these manoeuvres with the mother on all-fours
failing this, push the head back in and emergency c-section

Question 13

What is Sheehan’s syndrome?

Answer 13

Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery.

Question 14

What is cord prolapse

Answer 14

umbilical cord descending ahead of the presenting part of the fetus

Question 15

Mx of cord prolapse

Answer 15

The presenting part of the fetus may be pushed back into the uterus to avoid compression.
Tocolytics may be used.
If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.
The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out.

Question 16

VTE Risk factors in pregnancy

Answer 16

Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy

Question 17

VTE prophylaxis in pregnancy

Answer 17

Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.

Question 18

VTE Mx in pregnancy

Answer 18

LMWH

In women with extremes of body weight or complicating factors e.g. renal impairment monitor anti-Xa activity

Question 19

Drugs to avoid during breast feeding

Answer 19

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone

Question 20

Mx of PPROM

Answer 20

• admission
• regular observations to ensure chorioamnionitis is not developing
• oral erythromycin should be given for 10 days
• antenatal corticosteroids to reduce the risk of respiratory distress syndrome
• delivery should be considered from 34 weeks of gestation

Question 21

Presentation of amniotic fluid embolisation

Answer 21

majority occur in labour , though they can occur in caesarean section and after delivery in the immediate postpartum.
Sudden deterioration
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Question 22

Mx of Amniotic fluid embolisation

Answer 22

Critical care unit by a multidisciplinary team, management is predominantly supportive

Question 23

tool for assessing PND

Answer 23

Edinburgh Postnatal Depression Scale

Question 24

Mx of chicken-pox exposure in pregnancy

Answer 24

check immunity with Varicellar Zoster Antibody

if not immune give VZ immunoglobulin

Question 25

Stages of post-partum thyroiditis

Answer 25

Three stages

1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (but high recurrence rate in future pregnancies)

Question 26

Mx of post-partum thyroiditis

Answer 26

the thyrotoxic phase is not usually treated with anti-thyroid drugs but Propranolol is typically used for symptom control
the hypothyroid phase is usually treated with thyroxine

Question 27

Antenatal Care timetable

Answer 27

8-12 - booking visit and bloods
10-13+6 - early scan - confirm dates, exclude multiple pregnancies, nuchal scan if past 11 weeks
18-20+6 - anomaly scan
25 primip routine care
28 routine care +anti D
31 routine care
34 routine care +anti D
38 routine care
40 primip/ 41 if not routine care and discuss options for prolonged pregnancy

Question 28

Mx of Eclampsia

Answer 28

magnesium sulphate first-line

Question 29

What is Lochia?

When and how to investigate?

Answer 29

Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium*. This should be expected to cease after 4-6 weeks.
Continued vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.