Obstetrics

Question 1

Define and differentiate between gravidity and parity

Answer 1

• Gravidity: total number of pregnancies, regardless of outcome
• Parity: Total number of pregnancies carried over threshold of viability (24+0 in UK)

Examples

• Patient is currently pregnant; had two previous deliveries = G3 P2
• Patient is not pregnant, had one previous delivery = G1 P1
• Patient is currently pregnant, had one previous delivery and one previous miscarriage = G3 P1+1 (the +1 refers to a pregnancy not carried to 24+0).
• Patient is not currently pregnant, had a live birth and a stillbirth (death of fetus after 24+0) = G2 P2
• Patient is not pregnant, had a twin pregnancy resulting in two live births = G1 P1

Question 2

What is cardiotocography and how does it work

Answer 2

• A way to record fetal heartbeat and uterine contractions during pregnancy
• Does this by measuring tension of the maternal abdominal wall which provides indirect indication of intrauterine pressure

Question 3

What is the normal foetal heart rate

Answer 3

100-160 bpm

Question 4

When is CTG commonly used

Answer 4

If the fetal heart rate pattern (baseline tachycardia or bradycardia or decelerations) is not normal and suggest fetal distress or an increased risk of fetal distress, continuous monitoring with a CTG is indicated if this is available. A CTG will help decide whether fetal distress is present or not. It will also help identify fetal distress if it does develop later in labour. There is no need for routine continuous CTG monitoring in low risk labours if the fetal heart rate pattern is normal when assessed with a fetal monitor.

Question 5

How do you interpret a CTG

Answer 5

DR C BRaVADO

• Define Risk
• Contractions
• Baseline Rate
• Variability
• Acceleration
• Deceleration
• Overall impression

Question 6

What is the relevance of defining risk in a CTG interpretation

Answer 6

• Context to CTG reading
• Threshold for intervention varies as risk is high or low

Question 7

How do you assess contractions on CTG

Answer 7

• Assess number of contrations in 10 minutes
  
  • Square = 1 minute
• Assess:
  
  • Duration of contraction
  • Intensity
    
    • Assessed using palpation
• Eg 2 in 10 minutes (or 2 in 10)

Question 8

What are some factors that define the pregnancy as high risk

Answer 8

Maternal Medical Illness

• Gestational Diabetes
• Hypertension
• Asthma

Obstetric Complications

• Multiple gestation
• Post-date gestation
• Previous C-section
• IUGR
• Premature rupture of membranes
• congenital malformations
• Oxytocin induciton/augmentation of labour
• Pre-eclampsia

Other Risk Factors

• Absence of prenatal care
• Smoking
• Drug abuse

Question 9

How do you assess baseline rate of fetal heart

Answer 9

• Average HR of foetus within 10 minutes
• Ignore decelerations or accelerations

Question 10

Define Fetal tachycardia and name some causes

Answer 10

HR > 160 bpm

• Fetal hypoxia
• Chorioamnionitis
• Hyperthyroidism
• Fetal or maternal anaemia
• Fetal tachyarrhythmia
• Prematurity
• Maternal pyrexia

Question 11

Define fetal bradycardia

Answer 11

HR < 100 bpm

Question 12

It is common to have a baseline HR of 100-120bpm in which two situations

Answer 12

• Post-date gestation
• Occiput posterior or transverse presentations

Question 13

Define severe prolonged bradycardia. What does this indicate

Answer 13

HR < 80 bpm for more than 3 minutes

Severe fetal hypoxia

Question 14

What are some causes of prolonged severe bradycardia

Answer 14

• Prolonged cord compression
• Cord Prolapse
• Epidural and spinal anaesthesia
• MAternal seizures
• Rapid fetal descent

Question 15

How can variability be categorised

Answer 15

• Reassuring: 5-25 bpm
• Non-reassuring
  
  • <5 bmp for 30-50 min
  • >25 bmp for 15-25 min
• Abnormal
  
  • <5 bpm for >50 min
  • >25 bpm for >25 min
  • Sinusoidal

Question 16

What are some causes of reduced variability on a CTG

Answer 16

• Fetal sleeping - no longer then 40 minutes
  
  • Most common
• Fetal acidosis (due to hypoxia)
  
  • More likely if late decelerations also preent
• Fetal tachycardia
• Drugs
  
  • Opiates
  • Benzodiazepines
  • Methyldopa
  • Magnesium sulphate
• Prematurity
  
  • <28 weeks
• Congenital heart abnormalities

Question 17

Define an acceleration on CTG and is this reassuring or not

Answer 17

• Abrupt increase in HR of more than 15 bpm for >15 seconds
• reassuring
• Accelerations alongside uterine contractions is a sign of healthy featus
• Absence of acceleration with an otherwise normal CTG is of uncertain significance

Question 18

Define variability on CTG and what does information does it tell tyou

Answer 18

• Variatioin of fetal HR from one beat to the next
  
  • Variability occurs as a result of interaction between nervous system, chemoreceptors, baroreceptors and cardiac responsiveness,
• Good incicator of how healthy a fetus is at a particular moment in time, as a healthy fetus will be able to adapt its HR in response to environment

Question 19

Normal variability range on CTG

Answer 19

5-25 bmp variability

Question 20

Describe features of early deceleration

Answer 20

• Early decelerations start when uterine contractions begin and recover when contractions stop
• Increased detal intracranial pressure -> increased vagal tone
  
  • So quickly resolves as ICP reduces when contraction ends
• Physiological and NOT pathological

Question 21

Describe features of variable deceleration

Answer 21

• Rapid fall in baseline HR with variable recovery phase
• Variable in duration and may not have any relationship to unterine contractions

Question 22

How does umbilical cord compression lead to variable decelerations

Answer 22

• The umbilical vein is often occluded first causing an acceleration in response.
• Then the umbilical artery is occluded causing a subsequent rapid deceleration.
• When pressure on the cord is reduced another acceleration occurs and then the baseline rate returns.
• Accelerations before and after a variable deceleration are known as the “shoulders of deceleration”.
• Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow.
• Variable decelerations can sometimes resolve if the mother changes position.
• The presence of persistent variable decelerations indicates the need for close monitoring.
• Variable decelerations without the shoulders are more worrying, as it suggests the fetus is becoming hypoxic.

Question 23

Describe features of late deceleration and what does it indicate

Answer 23

• Start at the peak of contraction and recover after it ends
• Indicates insufficient blood flow to uterus and placenta
  
  • Blood flow to fetus sig reduced causing fetal hypoxia and acidosis

Question 24

What are some causes of reduced uteroplacental blood flow (which results in late decelerations)

Answer 24

• Maternal HYPOtension
• Pre-eclampsia
• Uterine hyperstimulation

Question 25

Define prolonged deceleration on CTG

Answer 25

• Prolonged deceleration is a deceleration that lasts more than 3 minutes
  
  • Non-reassuring 2-3 minutes
  • Abnormal > 3 mintues

Question 26

Describe features of sinusoidal patterns on CTG

Answer 26

• RARE but concerning - high fetal morbidity and mortality
  
  • Smooth, regular wave-like pattern
  • Frequency of 2-5 cycles a minute
  • Stable baseline around 120-160 bpm
  • NO beat to beat variability

Question 27

Define a deceleration on a CTG a

Answer 27

• Abrupt decrease in fetal HR of more than 15 bpm for more than 15 sec
• The fetal heart rate is controlled by the autonomic and somatic nervous system. In response to hypoxic stress, the fetus reduces its heart rate to preserve myocardial oxygenation and perfusion. Unlike an adult, a fetus cannot increase its respiration depth and rate. This reduction in heart rate to reduce myocardial demand is referred to as a deceleration.

Question 28

What are the types of deceleration on CTG

Answer 28

• Early deceleration
• Variable deceleration
• Late deceleration
• Prolonged deeleration
• Sinusoidal

Question 29

When are variable decelerations often seen nd usually caused by what

Answer 29

Often seen:

• During labour and in patients with reduced amniotic fluid volume
• Fetus experience stress during labour (reduced fetal perfusion as a result of uterine contractions)
• Stress ie expected during labour but it is challenging to pick up pathological fetal distress
• Caused usually by: umbilical cord compression

Question 30

What does a sinusoidal pattern indicate

Answer 30

• Severe fetal hypoxia
• Severe fetal anaemia
• Fetal/maternal haemorrhage

Question 31

Late decelerations on CTG are a _____ finding and urgent _____ (investigation) is needed to assess for foetal _____ and _____. A pH of >_____ in labour is considered normal. Urgent delivery should be considered if there is foetal _____.

Answer 31

Late decelerations on CTG are a pathological finding and urgent foetal blood sample (investigation) is needed to assess for foetal hypoxia and acidosis. A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is foetal acidosis.

Question 32

NICE 2010: To reduce the risk of hypertensive disroders in pregnancy, what should women who are at high risk of developing HTN disorders (pre-eclampsia) be given (incl dose and duration)

Answer 32

• Aspirin 75mg od from 12 weeks until birth of baby

Question 33

What factors would rank a pregnant woman a high-risk for developing Hypertensive disorders (4)

Answer 33

• Hypertensive disease during previous pregnancies
• Chronic Kidney Disease
• Autoimmune disorders (SLE or Anti-phospholipid syndrome)
• Type 1 or 2 Diabetes Mellitus

Question 34

Describe for blood pressure varies during normal pregnancy

Answer 34

• BP usually falls in first trimester (particularly diastolic)
• Continues to fall until 20-24 weeks
• After this the BP usually increases to pre-pregnancy levels by term

Question 35

How is hypertension defined in pregnancy

Answer 35

• Systolic > 140 mmHg OR Diastolic > 90 mmHg -> Pre-eclampsia
• OR increase above booking readings of:
  
  • >30 mmHg systolic or > 15 mmHg diastolic

Question 36

What is the definitive treatment of pre-eclampsia

Answer 36

Deliver of baby

Question 37

What is used as prophylaxis against seizures in pre-eclampsia and name a side effect

Answer 37

• Magnesium Sulphate
• Crosses placenta freely. Leads to self-limiting hypotonia in the neonate

Question 38

Difference in BP between mild-?moderate and severe pre-eclampsia

Answer 38

• Mild
  
  • >140 Systolic
  • >90 diastolic
• Severe
  
  • >160 systolic
  • >110 diastolic

Question 39

What is the treatment for a pregnant woman with severe pre-eclampsia

Answer 39

1st Line

• IV Hydralazine and/or Labetalol* -> High to Low BP
  
  • HTN
• IV magesium sulfate
  
  • seizure prophylaxis with
• AIM: Get BP to 140-160 systolic and 90-110 diastolic
  
  • Severe systolic HTN leads to loss of cerebral vasculature auto-regulation

2nd line

• Nicardipine and nifedipine PO
  
  • Calcium channel blockers

Short term/Emergency/Others have failed

• IV Nitroglycerin
• IV Sodium Nitroprusside.

* LAbetolol first line in NICE 2010

Question 40

What is the first line treatment for pregnancy-induced hypertension (pre-eclampsia)

Answer 40

Labetolol

Question 41

What are some considerations when considering to use sodium nitroprusside in severe hyeprtension of pregnancy

Answer 41

• carefully monitored and reserved for extreme emergencies due to concerns about cyanide and thiocyanate toxicity in the mother and fetus,
• as well as increased intracranial pressure in the mother

Question 42

Define HELLP Syndrome

Answer 42

Pre-eclampsia with thrombotic microangiopathy involving the liver, characterised by:

• Haemolytic anaemia
  
  • Low Hb, low Hct, high bilirubin, raised LDH, schistocytes on peripheral smear, dark urine
• Elevated Liver Enzymes
  
  • Elevated AST/ALT, Epigastric pain, liver failure, abnormal clotting
• Low Platelets

Warrants immediate delivery. Occurs in 10-20% of patients with pre-eclampsia

Question 43

Clinical features of pre-eclampsia

Answer 43

• Headache
• Visual disturbances (scotoma)
• Vomiting
• Drowsiness
• Epigastric/RUQ pain
• Oedema
• HTN
• Proteinuria ++

Question 44

Complications of pre-eclampsia

Answer 44

Maternal

• Cerebrovascular accident
• Eclampsia
• Haemorrhage
  
  • Placental abruption
  • Intra-abdominal
  • Intra-cerebral
• Multi-organ failure
• Cardiac failure
  
  • Pulmonary oedema
  • Liver Failure
  • Renal Failure

Foetal

• Prematurity
• IUGR, growth retardation
• Increased mortality/morbiditiy

Question 45

Differential diagnoses for hypertension in pregnancy and how would you differentiate between each one

Answer 45

• Chronic, pre-maternal hypertension
• Gestational Hypertension
• Chronic hypertension with superimposed pre-eclampsia
• HELLP Syndrome
• Pre-eclampsia
• Eclampsia

Differentiate using:

• Onset
• Severity of HTN
• Proteinuria
• Oedema
• RUQ pain

Question 46

Define Chronic hypertension with superimposed pre-eclampsia

Answer 46

• characterized by isolated hypertension before 20 weeks’ gestation with development of additional signs of preeclampsia after 20 weeks’ gestation.

Question 47

What are patients with pre-eclampsia at risk of developing in the future

Answer 47

• four-fold increased risk of developing hypertension later in life
• two-fold increased risk of ischemic heart disease, stroke, and venous thromboembolism.

Question 48

What are the features of magnesium toxiity

Answer 48

• Somnolence (hypersomnia)
• Absent deep tendon reflexes
• Hypotension
• Bradycardia
• ECG changes

Question 49

What is the antidote for magneium sulphate toxicity

Answer 49

. Calcium gluconate infusion

Question 50

How is a diagnosis of pre-eclampsia made

Answer 50

Mild preeclampsia

• Two serial blood pressure readings of >140/90 mmHg (either systolic or diastolic) over four hours or more AND
• >0.3 g/24hrs of protein in the urine.

Preeclampsia is considered severe with blood pressure of >160/110 mmHg (either systolic or diastolic), urinary protein of >5g/day, or if there are signs of end-organ damage such as visual disturbance, hepatocellular injury, thrombocytopenia, oliguria (<500mL produced per day), fetal growth restriction, or pulmonary edema.

Question 51

With pre-eclampsia what are the options for timing of birth (i.e. when should you deliver and any considerations)

Answer 51

Before 34 weeks (33+6)

• Continue surveillance unless there are indications for planned early birth.
• Offer intravenous magnesium sulfate and a course of antenatal corticosteroids in planned early birth

34 to 36+6 weeks

• Continue surveillance unless there are indications for planned early birth
• When considering the option of planned early birth, take into account the woman’s and baby’s condition, risk factors (such as maternal comorbidities, multi-fetal pregnancy) and availability of neonatal unit beds. Consider a course of antenatal corticosteroids in line with the NICE guideline on preterm labour and birth.

37 weeks onwards

• Initiate birth within 24–48 hours.

Question 52

What are some indications/thresholds for considering a planned early birth before 37 weeks in women with pre-eclampsia

Answer 52

• Inability to control maternal BP despite using 3 or more classes of anti-hypertensives
• Maternal O2 sats <90%
• Progressive detrioration in liver funciton, renal function, haemolysis or platelet count
• Ongoing neurological features (severe intractable headache, repeated visual scotoma, eclampsia)
• Placental abruption
• Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph pr stillbirth

MDT: Senior obstetrician, anaesthetic team, neonatal team.

OFFER: Magnesium sulfate and course of antenatal corticosteroids if planned early birth

Question 53

Featueres of pre-existing hypertension in pregnancy

Answer 53

• H of HTN before pregnancy
  
  • > 140/90 mmHg before 20 weeks gestation
• No proetinuria
• No oedema
• 3-5% pregnancies and more common in older women

Question 54

Features of pregnancy-induced hypertension (PIH or gestational HTN)

Answer 54

• HTN occuring in second half of pregnancy (>20 weeks gestation)
• No proteinuria
• No oedema
• 5-7% pregnancies
• Resolves following birth (typically after 1 month)
• These women are at increased risk of furute pre-eclampsia or HTN in later life

Question 55

Features of pre-eclampsia

Answer 55

• Pregnancy-induced HTN
• Proteinuria (>0.3g/24hrs)
• Oedema but less commonly used as criteria
• 5% pregnancies

Question 56

What are some moderate and high risk factors of pre-eclampsia

Answer 56

Moderate RF:

• First pregnancy
• Multiple pregnancy
• ≥ 40 years
• Pregnancy interval of >10 years
• BMI ≥ 35 at first visit
• FH

High RF:

• HTN disease in previous pregnancy (PreE, E, HELLP, gHTN)
• Chronic Kidney Disease
• Autoimmune disease (SLE, Anti-phospholipid syndrome
• T1DM, T2DM
• Chronic HTN

Question 57

Features of severe pre-eclampsia

Answer 57

• HTN >160/110 mmHg
• Proteinuria dipstick ++/+++
• Headache
• Visual disturbance
  
  • Scotoma
• Papilloedema
• RUQ/epigastric pain
• Hyperreflexia
• Low Plt, abnormal LFT, HELLP

Question 58

Define eclampsia

Answer 58

• Development of seizures in association with pre-eclampsia:
  
  • symptoms >20 weeks gestation
  • Pregnancy-induced HTN
  • Proteinuria

Question 59

What is the treatment and preventor of eclampsia

Answer 59

• IV Magnesium Sulfate
  
  • Eclampsia: IV bolus 4g over 5-10 minutes, followed by infusion of 1g/hour
• Monitor:
  
  • Urine output, reflexes, respiratory rate and O2 sats
    
    • Respiratory depression as result of Mg toxicity

Question 60

How long should treatment continue after a seizure in eclampsia

Answer 60

• Continue for 24 hours after last seizure or delivery
  
  • 40% seizures occur post-partum

NB: severe pre-eclampsia/eclampsia - fluid restrict to prevent fluid overload

Question 61

Define amniotic fluid embolism

Answer 61

• Foetal cells/amniotic fluid (liqour) enters maternal bloodstream
• Stimulates reaction which results in anaphylaxis - obstetric emergency

Rare complication of pregnancy. High mortality rate. Incidence 2 per 100,000 UK.

Question 62

What are some risk factors for amniotic fluid embolism

Answer 62

• Maternal Age
• Induction of labour

Many associated RF - multiple and prevention is impossible. Aetiology not been proven but widely accepted concept that maternal circulation must be exposed to liqour

Question 63

When does amniotic fluid embolism typically present

Answer 63

• Majority in labour
• Caeserian sections
• Immediate post-partum

Question 64

What ar th signs and suymptoms of amniotic fluid embolsm

Answer 64

Signs

• Cyanosis
• LOW BP
• Bronchospasms
• HIGH HR
• Arrhythmia
• Myocardial infarction

Symptoms

• Chills
• Shivering
• Sweating
• Anxiety
• Coughing

Question 65

How is amniotic fluid embolism diagnosed

Answer 65

• Clinical diagnosis of exclusion
  
  • No definitive diagnostic tests

Question 66

MAnagement of amniotic fluid embolism

Answer 66

• Critical care unit by MDT
• Supportive management iwth resuscitation
  
  • Blood (FBC, clotting, U&E, cross match)
  • Treatment of massive obstetric haemorrhage

Question 67

When should a woman be assessed for her risk of venous thromboembolism (VTE)

Answer 67

• At booking (8-12 weeks)
• Subsequent hospital admission

Question 68

What risk factors are assessed at booking for VTE

Answer 68

• >35 year
• BMI > 30
• Parity > 3
• Smoker
• Gross varicose veins
• Current pre-eclampsia
• Immobility
• FH of unprovoked VTE
• Low risk thrombophilia
• Multiple pregnancy
• IVF pregnancy
• Hospitalisation
• Anaesthesia
• Central venous catheter: Femoral >> Subclavian

Question 69

With risk factors in mind, when would you prophylactically treat someone for VTE

Answer 69

• ≥4 RF warrants immediate treatment with LMWH until 6 weeks post-natal period
• 3 RF LMWH initiated at 28 weeks and continued until 6 weeks post-natal
• If DVT diagnosed shortly before delivery
  
  • continue anti-coagulation treatment for at least 3 months (as in other patients qwith provoked DVTs)

Pregnant woman with previous VTE history is considered high risk immediately and requires immediate LMWH throughout antenatal period

Question 70

What is the prophylactic treatment of VTE in pregnancy

Answer 70

• Low Molecular Weight Heparin (LMWH)
• DO NOT GIVE:
  
  • Direct Oral Antigocaulants (DOACs)
  • Warfarin

Question 71

What are some underlying medical conditions that predisposes VTEs

Answer 71

• Pregnancy
• Malignancy
• Thrombophilia
  
  • Activated protein C Rsistance, Protein C and S deficiency
• Heart failure
• Anti-phospholipid syndrome
• Behcet’s
• Polycythaemia
• Nephrotic syndrome
• Sickle cell disease
• Paroxysmal nocturnal haemoglobinuria
• Hyperviscosity syndrome
• Homocystinuria

Question 72

What are some medications that predisposes you to VTE

Answer 72

• COCP
  
  • 3rd generation >> 2nd generation
• HRT
  
  • O+P >> O only
• Raloxifene
• Tamoxifen
• Antipsychotics (Onlazapine)

Question 73

In obstetric cholestasis, what is there an increased risk of (2)

Answer 73

• Premature birth
• Still birth

Question 74

Features of obstetric cholestasis

Answer 74

• Pruritis
  
  • ​Palms, soles, abdomen
• Raised bile acids
• Bilirubin and LFT may be elevated
  
  • 20% are clinically jaundiced

Question 75

Management of obstetric cholestasis

Answer 75

• Induction of labour at 37 weeks
  
  • Common practice but not really evidence based
• Ursodeoxycholic acid (UDCA)
  
  • Used but not clear
• Vitamin K supplementation

Question 76

Which systems are affected phsyiologically during pregnancy

Answer 76

• Cardiovascular
• Repiratory
• Blood
• Urinary
• Biochemical changes
• Liver
• Uterus

Question 77

What are some cardiovascular changes seen in pregnancy

Answer 77

• Increased:
  
  • SV (130%)
  • HR (115%)
  • CO (140%)
• Diastolic BP reduces in 1st and 2nd trimester
  
  • Returns to non-pregnant levels by term
• Enlarged uterus -> venous return disruption
  
  • Ankle oedema
  • Supine hypotension
  • Varicose veins

Question 78

What are some respiratory changes seen in pregnancy

Answer 78

• Increased
  
  • Ventilation (140%)
  • Tidal volume 500-700mL
    
    • Progesterone on respiratory centre
  • Oxygen requirement (120%)
    
    • Overbreathing leads to reduced pCO2
    • Give rise to ‘dyspnoea’
  • Basal metabolic rate (115%)
    
    • Increased thyroxine and adrenocrotical hormone
    • Find warm conditions uncomfortable

Question 79

What are some haematological changes in pregnancy

Answer 79

• Mild Anaemia
  
  • Increased Red cell mass (120-30%)
  • Plasma volume increase (150%)
    
    • Net dilution
  • Macrocytosis
    
    • Normal
    • Folate or B12 deficiency
• Neutrophilia
• Thrombocytopenia
  
  • Increased platelet size
• Increase fibrinogen and Factors VII, VIII, X
  
  • Low grade increase in coagulant activity
  • Decreased fibrinolysis
    
    • Returns to normal after delivery (?placental disruption)
  • Increased risk VTE

Question 80

What are some changes in the urinary system seen in pregnancy

Answer 80

• Increased
  
  • Perfusion (130%)
  • GFR (130-60%)
  • Salt and water reabsorption
    
    • Elevated sex steroid levels
  • Urinary protein loss
    
    • >300mg/24hrs in pregnant women
    • >150mg/24hrs in non-pregnant
    • Cautious as sign of pre-eclampsia

Question 81

What biochemical changes are seen in pregnancy

Answer 81

• Increased
  
  • Calcium requirements
    
    • Esp 3rd trimester up until lactation
    • Ca transported actively acorss placenta
  • Gut absorption of Ca
    
    • Increased 1,25 Vit D
  • Ionised Ca stable
• Decreased
  
  • Serum Ca and Pi

Question 82

What are some liver changes seen during pregnancy

Answer 82

• NO CHANGE in hepatic blood flow (unlike renal and uterine)
• Raised ALP (150%)
• Decreased albumin
  
  • Dilutational?

Question 83

What changes are seen in the uterus during pregnancy

Answer 83

• Increase
  
  • Mass 100g -> 1100g
  • Hyperplasia THEN hypertrophy
  • Cervical ectropion and discharge
• Braxton-Hicks
  
  • Non-painful practice contractions late pregnancy (>30weeks)
• Retroversion mar lead to retention (12-16weeks) usually self corrects

Question 84

Pathophysiology of Rhesus disease

Answer 84

• Rh -ve mother can develop anti-D igG antibodies if they deliver a Rh +ve child
• Fetal blood may leak and cause above reaction
• In later pregnancies, these IgG can cross placenta and cause haemolysis in the foetus

Question 85

How is Rhesus disease prevented

Answer 85

• Test for D antibodies in Rh -ve mothers at booking
  
  • Test Rhesus status
• NICE (2008): anti-D to non-sensitised Rh -ve mothers at 28 and 24 weeks
• RCOG (2011) - single dose (28wks) or double does (28 and 24 weeks)
• If traumatic event is in 2nd/3rd trimester, give large dose of anti-D and perform Kleihauer test

Question 86

What is the Kleihauer test

Answer 86

• Determines proportion of fetal RBCs present if traumatic event happens 2nd/3rd trimester
• Would also give big dose of anti-D

Question 87

Anti-D Immunoglobulin should be given (ALWAYS within 72 hours) in what situations

Answer 87

• Delivery of Rh +ve infant, live or stillborn
• Termination of pregnancy
• Miscarriage (if gestation > 12 weeks)
• Ectopic pregnancy surgical management
  
  • Not required if managed with methotrexate
• External cephalic version
• Antepartum haemorrhage
• Amniocentesis, chorionic villus sampling, fetal blood sampling
• Abdominal trauma

Question 88

What tests are done in rhesus disease and what are their functions

Answer 88

• FBC, blood group, Coomb’s test
  
  • All babies born to Rh -ve mothers - cord blood at delivery
• Kleihauer test
  
  • Add acid to maternal blood, fetal cellls are resistant

Question 89

What can happen to the fetus if they are affected in Rhesus disease

Answer 89

• Oedematus
  
  • Hydrops fetalis
  • As liver devoted to RBC production, albumin falls
• Jaundice, anaemia, hepatosplenomegaly
• Heart failure
• Kernicterus

Question 90

Treatment of affected fetus in rhesus disease

Answer 90

• Transfusions
• UV phototherapy

Question 91

Define placenta praevia

Answer 91

• When the placenta implants in the lower uterus close to or covering the internal cervical os.
• 5% will have low lying placenta when scanned at 16-20 weeks gestation
• Incidence at delivery is 0.5% therefore most placentas rise away from cervix

IMPORTANT CAUSE OF ANTEPARTUM HAEMORRHAGE

DEATH NOW EXTREMELY RARE. Major cause of death in women with placenta praevia is now PPH

Question 92

List and describe the different types of placenta praevia

Answer 92

• Complete
  
  • Completely covers cervical os
• Partial
  
  • Partially covers cervical os
• Marginal
  
  • Edge of placenta extends to within 2cm of cervical os

Question 93

Define the classical grading for placenta praevia

Answer 93

• I - placenta reaches lower segment but not the internal os, extends within 2cm of 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

Question 94

What are some risk factors for placenta praevia

Answer 94

Anything that has damaged endometrium and decrease vascularisation

• Previous C-section
• Abortion
• Uterine surgery
• Multiparity
• Multiple pregnancies

Other

• Multiple placentas
• Placenta with larger than normal SA
  
  • Twins or triplets
• Maternal age > 35
• Intrauterine fibroids
• Maternal smoking

Question 95

Clinical features of placenta praevia

Answer 95

• NO pain and uterus NOT tender
• Lie and presentation may be abnormal
• Fetal heart usually normal
• Small bleeds before large
• Shock proportional to visible loss
• Coagulation problems rare

Question 96

Investigations for placenta praevia

Answer 96

• Often picked up at routine check up >20 weeks on abdominal US
• RCOG = transvaginal ultrasound to localise placenta
  
  • If placenta praevia is possible diagnosis, digital vaginal examination should not be performed until placenta praevia has been excluded -> cause bleed

Could also speculum to check for polyps/ectropion

Question 97

What are the two contexts which would change how you manage placenta praevia

Answer 97

• If low-lying placenta at 16-20 week scan OR
• Placenta praevia with bleeding

Question 98

In patient who has a low lying placenta in their 16-20 week scan, what would your management be

Answer 98

• Rescan at 34 weeks
  
  • No need to limit activity or intercourse UNLESS THEY BLEED
• If still present at 34 weeks and grade I or II:
  
  • Scan every 2 weeks
• If high presenting part or abnormal lie at 37 weeks
  
  • C-section deliverr

Question 99

In patient who has placenta praevia with bleeding, what would your management be

Answer 99

• Admit
• Treat shock
• Cross match blood
• Find ultrasound at 36-37 weeks to determine method of delivery:
  
  • C-section: Grade II or IV at 37-38 weeks
  • Vaginal delivery: Grade I

Question 100

What are the two causes of jaundice in pregnancy

Answer 100

• Intrahepatic cholestasis of pregnancy (Obstetric cholestasis)
• Acute fatty liver of pregnancy

Question 101

What is the most common liver disease of pregnancy

Answer 101

Obstetric cholestasis

Question 102

When does obstetric cholestasis typically present

Answer 102

Third trimester

Occurs in 1% pregnancies

Question 103

Features of obstetric cholestasis

Answer 103

• Pruritis (severe), in palms and soles
• No rash (skin changes due to scratching may be present)
• Raised bilirubin

Question 104

Management of obstetric cholestasis

Answer 104

• Ursodeoxycholic acid
  
  • Symptomatic relief
• Weekly LFTs
• Induction of labour at 37 weeks

Question 105

Comp[lications of obstetric cholestasis

Answer 105

• Increased rate of stillbirth
• Not generally associated with increased maternal morbidity

Question 106

When does acute fatty liver of pregnancy usually present

Answer 106

• Third trimester OR
• Period immediatelty following delivery

Question 107

Features of acute fatty liver of pregnancy

Answer 107

Non-specific presenting symptoms

• Abdominal pain
• Nausea and vomitting
• Headache
• Jaundice
• Mild pyrexia
• Hyupoglycaemia
• Severe disease may result in pre-eclampsia

OBSTETRIC EMERGENCY

Question 108

Investigations for acute fatty liver of pregnancy (AFLP)

Answer 108

• Elevetaed transaminases (ALT >500 u/L)
• Investigate synthetic function of liver (clotting studies)

Question 109

Management of acute fatty liver of pregnancy

Answer 109

• Supportive care
• Once established delivery is definitive management

Question 110

Name the three conditions under the spectrum Gestational trophoblastic disorders

Answer 110

Disorder originating from placental trophoblast

• Complete hydatidiform mole
• Partial hydatidiform mole
• Choriocarcinoma

Question 111

What is the underlying pathology in complete hydatidiform mole

Answer 111

• Benign tumour of trophoblastic material
• When empty egg is fertilised by single sperm
• Sperm DNA replicated so all 46 chromsomes are paternal origin

Question 112

Features of complete hydatidiform mole

Answer 112

• Bleeding in first or early second trimester
• Exaggerated symptoms of pregnancy (Hyperemesis)
• Uterus large for dates
• Very high levels of hCG
• Hypertension and hyperthyroidism may be seen

Question 113

Why could hypertension and hyperthyroidism be seen in complete hydatidiform mole pregnancies

Answer 113

• Beta hCG similar in structure to LH, FSH and TSH
• so B-hCG can stimulate thyroid production of thyroxine (T4) and triiodothyronine (T3)
• T4 and T3 have negative feedback on pituitary gland leading to fall in TSH levels

Question 114

In complete hydatidiform molar pregnancy, what would you expect the B-hCG, TSH and thyroxine levels to be

Answer 114

• High B-hCG
• High thyroxine
• Low TSH

Question 115

Management of complete hydatidiform molar pregnancy

Answer 115

• URGENT referal to specialist centre
  
  • Evacuation of uterus is performed
• Contraception is recommended to avoid pregnancy in the next 12 months

around 2-3% develop choriocarcinoma

Question 116

What is the underlying pathology in partial mole

Answer 116

• Normal haploid egg may be fertilised by two sperms or by one sperm with duplication of paternal chromosomes
• DNA is maternal and paternal in origin
• Usually triploid 69 XXX or 69 XXY
• Feotal parts may be seen

Question 117

Describe the stages of labour with some details on timing

Answer 117

• Initiation and diagnosis of labour
  
  • Braxton Hicks contractyions in third trimester which develop into contraction
  • Labour diagnosed when there are painful regular contractions which lead to effacement and dilatation of cervix
• First Stage
  
  • From diagnosis of labour to full dilation of cervix (10cm)
  • Membranes rupture now normally, if not already
  • Latent phase: Cervix dilates slowly for first 4 cm - takes several hours
  • active phase: 1cm/h dilatation nulliparous women or 2cm/hr in multiparous
  • Active first stage should NOT last more tha 16 hours

Question 118

How is labour diagnosed

Answer 118

• Initiation and diagnosis of labour
  
  • Braxton Hicks contractyions in third trimester which develop into contraction
  • Labour diagnosed when there are painful regular contractions which lead to effacement and dilatation of cervix

Question 119

What happens in the first stage of labour (description and baby movement) and how long should this last

Answer 119

From diagnosis of labour to full dilation of cervix (10cm)

• Descent, flexion and internal rotation occur to varying degrees
• Membranes rupture now normally, if not already
• Latent phase: Cervix dilates slowly for first 4 cm - takes several hours
• active phase: 1 cm/hr dilatation nulliparous women or 2 cm/hr in multiparous
• Active first stage should NOT last more than 16 hours

Question 120

What happens in the second stage of labour and how long does this usually last

Answer 120

From full dilatation of cervix to delivery of baby

• Descent flexion and rotation are copmleted and followed by extension as head delivers
• Passive stage: Full dilatation until head reaches pelvic floor and mother has desire to push.
  
  • Rotation and flexion are commonly completed here
  • May last a few minutes but can last longer
• Active stage: When mother is pushing
  
  • Pressure of head on pelvic floor produces irresistable desire to bear down (epidural may prevent this)
  • bBaby deliveres after 40 minutes (nulliparous) or 20 minutes (multiparous)
  • Can be quicker but if it takes >1 hours, SVD becomees increasingly unlikely

Question 121

Describe the movements involved at delivery (ie as babies head extends out of poerineum)

Answer 121

• Head extends out through perineum and out of the pelvis
• Perineum stretches and often tears (episiotomy)
• Head restitues and rotates 90o to adopt transvere position (same position as it entered the pelvic inlet)
• Shoulders deliver in the next contraction
  
  • Anterior shoulder comes under symphysis pubis first, then posterior shoulder then rest of body (see pg 285 for more detail)

Question 122

What happens in the third stage of labour

Answer 122

Time of delivery to delivery of placenta

• Uterine muscle fibres contract to compress blood vessels supplying placenta
• This hears away from uterine wall and is delivered
• Lasts 15 minutes
• Normal blood loss up to 500 mL

Question 123

Describe the pathology in placenta accreta

Answer 123

• Attachment of the placenta to the myometrium due to defective decidua basalis.
• Placenta does not properly separate in third stage of labour -> risk of PPH

Question 124

Risk factors for placenta accreta

Answer 124

• Previous c-section
• Placenta praevia
• PID

Question 125

Describe the three types of placent accreta

Answer 125

• accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
• increta: chorionic villi invade into the myometrium
• percreta: chorionic villi invade through the perimetrium

Question 126

Define shoulder dystocia

Answer 126

• Complication of vaginal cephalic delivery
• Inability to deliver the body of the foetus using gentle traction, the head already being delivered
• Usually due to anterior foetal shoulder impacting on maternal symphysis pubis

Question 127

What are some risk factors for shoulder dystocia

Answer 127

Fetal

• Macrosomia

Maternal

• High BMI
• Diabetes Mellitus
• Prolonged labour (second stage?)

Question 128

What are some maneouvres used in shoulder dystocia

Answer 128

• ASK FOR HELP as soon as shoulder dystocia identified
• McRobert’s maneouvre performed, if unsuccessful:
  
  • Can use the woodscrew maneouvre
  • Rubin maneouvre
  • Mother on all fours on all fours
• If nothing works Push head back and do emergency c-section

Question 129

What is McRoberts Position

Answer 129

• Hyperflexion and abduction of mother’s hips, with her thighs towards her abdomen
• Apply suprapubic pressure
• This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery

Question 130

What is Rubin maneouvre

Answer 130

Question 131

What is woodscrew maneouvre

Answer 131

• Putting hand in the vagina to attempt to rotate baby 180 degrees

Question 132

What is the Zavanelli maneuver

Answer 132

Cephalic replacement via reversal of the cardinal movements of labour

Not first-line option

Question 133

Folic acid supplementation is important in preventing what

Answer 133

Formation of neural tube defects

Question 134

How does folic acid function in foetal development

Answer 134

• Folic acid converted to tetrahydrofolate (THF).
• Role in transfer of 1-carbon unite (methyl etc) to essential substrates involved in DNA and RNA synthesis

Question 135

Source of folic acid

Answer 135

Supplementation

Green leafy vegetables

Question 136

Causes of folic acid deficiency

Answer 136

• Phenytoin
• Methotrexate
• Pregnancy
• EtOH excess

Question 137

Consequences of folic acid deficiency

Answer 137

• Macrocytic , megaloblastic anaemia
• Neural tube defects

Question 138

What is the recommendation with preventing neural tube defects during pregnancy

Answer 138

• ALL women should take 0.4mg (400mcg) folic acid/day pre-conception and continue until 13 weeks
  
  • Started pre-conception as neural tube forms within first 28d of embryo development
• Women at high risk of conceiving a child with NTD should take 5 mg/day pre conception until 12th week pregnancy

Question 139

What factors would make a mother at high risk of conceiving a baby with NTD

Answer 139

• Previous child with NTD (or FH)
• Diabetes mellitus
• Anti-epileptic
• Obese (BMI >30)
• HIV +ve taking co-trimoxazole
• Sickle cell (thalassamie trait)
• Coeliac disease (malabsorption)

Question 140

Define lochia

Answer 140

• Vaginal discharge containing blood, mucous and uterine tissue during puerperium
  
  • Period of 6 weeks after birth in which mother;s reproductive organs return to normal
  • L:ochia is normal part of this process

Question 141

When would you start investigating lochia and how would you investigate

Answer 141

Ultrasound if lochia persists beyond 6 weeks

Question 142

How would you counsel and safety net a mother about their lochia

Answer 142

Counsel

• Lochia is normal bleeding post partum
• Consists of blood, mucous and uterine tissue
• Can pressit up to 6 weeks
• Bright red first and then changes colour before finally stopping

Safety net to seek medical help if:

• Offensive smell
• Increase in volume
• Or persists past 6 weeks

Question 143

Define preterm prelabour rupture of the membranes (PPROMs)

Answer 143

• Membranes rupture < 37 weeks
• Aetiology often unknown but all causes of pre-term labour may be implicated
• Occurs in 2% pregnancies but make up around 40% of preterm deliveries

Question 144

What are some causes of preterm deliveries

Answer 144

Too much inside

• Multiple pregnancy
• Antepartum haemorrhage
• Polyhydramnios

Defenders escape (foetal survival repsponse)

• Antepartum haemorrhage
• IUGR
• Pre-eclampsia
• Foetal distress (?)

Weak wall

• Cervical incompetence
• Uterine abnormalities

Other (Enemy)

• Infection
• Diabetes
• Idiopathic
• Iatrogenic

Question 145

Complications of PPROM

Answer 145

Foteal

• Preterm delivery (within 48hrs in 50% cases)
• Infection
  
  • Funisitis (cord infeciton)
• Pulmonary hypoplasia
• Umbilical cord prolapse (rare)

Maternal

• Chorioamnionitis

Question 146

Clinical feature of PPROM (history)

Answer 146

History

• Gush of clear fluid is normal
• Followed by further leaking
• <37 weeks gestation

Question 147

Clinical featuers of PPROM (examination)

Answer 147

• Sterile Speculum examination
  
  • Pool of fluid in posterior fornix is diagnostic - variable
• AVOID DRE
  
  • Could cause infection
• Features of chorioamnionitis
  
  • Contractions or abdominal pain
  • Fever or hypothermia
  • Tachycardia
  • Uterine tenderness
  • Coloured offensive liqour
    
    • Clinical signs often appear late

Question 148

What investigations would you do in PPROM

Answer 148

• Actim Partus
  
  • helps decide whether to send mother home or admit
• USS
  
  • Reduced liqour (oligohydramnios) but can be normal as foetus produces urine
• Look for infectyion
  
  • High vaginal swab
  • FBC
  • CRP
  • Lactate
• CTG
  
  • Foetal well-being
  • Persistent tachycardia suggestive of infection

Question 149

Management of PPROM

Answer 149

• Admission
• Regular observations to ensure chorioamnionitis is not developing
• Oral erythromycin for 10 days
• Antenatal corticosteroids
  
  • Reduce risk of RDS
  • Delivery considered at 34 weeks gestation
    
    • Trade off between risk of maternal chorioamnionitis with decrease risk of RDS in baby as pregnancy progresses
• Co-amoxiclav CONTRAINDICATED as neonate prone to NEC

Question 150

What are three mental health problems a mother might face post-partum

Answer 150

• Baby blues
• Postnatal depression
• Peuperal psychosis

Question 151

What are the differences in onset between babyblues, postnatal depression and peurperal psychosis

Answer 151

• Baby Blues = 3-7d following birth, common in primimaprous mothers
• Postnatl depression = month post-partum and peaks at 3 months
• Peurperal psychosis = first 2-3 weeks following birth

Question 152

Describe the differences in the clinical features of babyblues, postnatal depression and peurperal psychosis

Answer 152

• Baby blues
  
  • Anxious, tearful and irritable
• Postnatal depression
  
  • Similar to depression in other contexts (low mood, energy and anhedonia)
• Peurperal psychosis
  
  • Severe mood swings (similar to bipolar disorder)
  • Disordered perception (auditory hallucinations)

Question 153

Management of baby blues

Answer 153

• Reassurance and provide support
• Health visitor plays key role

Question 154

Managment of postnatal depression

Answer 154

• Reassurance and support as with baby blues
• CBT first line!
• Severe symptoms: SSRI (sertraline or paroxetine)
  
  • Secreted in breast milk but not harmful to babay

Question 155

Managmeent of peurperal psychosis

Answer 155

• Admission to hospital
• 20% risk of recurrence following future pregnancies

Question 156

When does the second screen for anaemia and atypical red cell alloantibodies occur in the entental care

Answer 156

28 weeks

Question 157

When does nuchal scan occur in antenatal care

Answer 157

11 - 13 +6 weeks

Question 158

When do you collect urine culture to detect asymptomatic bacteriuria

Answer 158

8-12 weeks (booking visit)

Question 159

Describe the RCOG guidelines on grading perineal tears

Answer 159

• 1st degree = Superficial damage with no muscle invovlement (not past fourchette)
• 2nd degree = injury to perineal muscle but not involving anal sphincter
• 3rd degree = injury to perineum involving anal sphincter complex
  
  • 3a = <50% of external anal sphincter thickenss torn
  • 3b = >50% EAS thickness torn
  • 3c = IAS torn
• 4th degree = involves EAS and IAS AND rectal mucosa

Question 160

Risk factors for perineal tears

Answer 160

• Primigravida
• Large baby (macrosomia)
• Precipitant labour (very rapid childbirth 1st and 2nd stage labour < 2hours)
• Shoulder dystocia
• Forceps delivery

Question 161

How do you differentiate between placenta praevia, placental abruption and vasa praevia

Answer 161

• Placenta praevia = painless and bright red bleeding (usually small bleeds then large, with shock proportional to loss)
• Placental abruption = associated with pain and dark red bleed
• Vasa praevia = painless PV bleed + fetal bradycardia and membrane rupture

Question 162

Define post-partum haemorrhage

Answer 162

• Blood loss of >500mL
• Primary = within 24hrs of delivery
• Secondary = more than 24 hours -12 weeks post birth
  
  • Apparently changed from 6 weeks

Question 163

What is the most common cause of PPH

Answer 163

• Uterine atony (90% of cases)
• Other causes:
  
  • Genital trauma
  • Clotting disorders (DIC or deficiencies)

Question 164

Risk factors for primary PPH

Answer 164

Basically anything that causes distension of uterus or anything that stops it contracting

• Previous PPH
• Prolonged labour
• Pre-eclampsia
• Increased maternal age
• Polyhydramnios
• Emergency C-section
• Placenta praevia
• Placenta accreta
• MAcrosomia
• Ritodrine
  
  • B2 adrenergic receptor aghonist used for tocolysis

Previously thought multiparity was RF but recent modern studies show nulliparity is RF

Question 165

Managment of PPH

Answer 165

• Seek senior help! 222 call
• ABC (+14G cannulae)
• Medical
  
  • IV syntocinon 10 IU or IV ergomwetrine 500mcg
    
    • RCOG says 5 IU double check
  • IM carboprost
• Surgical
  
  • Intrauterine balloon tamponade first line
    
    • Where uterine atony is only or main cause of haemorrhage
  • Others
    
    • B-Lynch suture
    • Ligation of uterine arteries orinternal iliac arteries
• Severe haemorrhage
  
  • Hysterectomy = life-saving procedure

Question 166

What is secondary PPH caused by

Answer 166

• Retained placental tissue
• Endometritis

Question 167

What triad do women with preterm-PROM present with when they have chorioamnionitis

Answer 167

• Maternal pyrexia
• Maternal tachycardia
• Fetal tachycardia

Reasonable differentials: PID, UTI (maybe STI)

Question 168

What is the underlying pathology in chorioamnionitis

Answer 168

• Ascending bacterial infection of amniotic fluid/membranes/placenta
• Preterm premature rupture of membrane (however can still occur when membranes are intact) exposes sterile uterus to patohgens

Question 169

Management of chorioamnionitis

Answer 169

• Obstetric emergency
• Prompt delivery of foetus (via c-section if necessary)
• IV antibiotics initial treatment

Question 170

Define placental abruption

Answer 170

• Separation of normally sited placenta form uterine wall
• results in maternal haemorrhage into intervening space

Occurs in ~1/200 pregnancies

Question 171

What are some risk factors for placental abruption

Answer 171

• Proteinuric hypertension
• Multiparity
• Maternal trauma
• Increasing maternal age

Question 172

What are some clinical features of placental abruption

Answer 172

• Constant abdominal pain
• Shock disproportionate to blood loss
  
  • 20% of placental abruptions are concealed - trapped behind placenta and doses not drain
• Uterus may be in spasm and feel firm or woody
• Fetal heart: absent or distressed
• coagulation problems
• Beware pre-eclampsia, DIC, anuria

Question 173

Risk factors for Group B Streptococcus (GBS) infection inneonate

Answer 173

• Prematurity
• Prolonged rupture of membranes
• Previous sibling with GBS infection
• Maternal pyrexia (secondary to chorioamnionitis)

Question 174

Management of GBS (RCOG 2017)

Answer 174

• Universal screening for GBS should NOT be offered to all women
  
  • Maternal request is also NOT an indication for screening
• Mothers who have had GBS detected in previous pregnancy should be informed of their risk of maternal GBS carriage (50%)
  
  • Offer maternal IV antibiotic prophylaxis (IAP)
  • OR testing in late pregnancy and then antibiotics if still positive
• IAP

Question 175

What are the indications for IV antibiotic prophylaxis (IAP)

Answer 175

• Mother has GBS in previous pregnancy
• Positive test in late pregnancy
• Mothers with previous baby with earl- or late-onset GBS disease
• Women in preterm labour - regardless of GBS status
• Women with pyrexia during labour (>38)

Question 176

What is the antibiotic of choice in GBS prophylaxis

Answer 176

Benzylpenicillin

Question 177

What is the organism in GBS

Answer 177

Streptococcus agalactiae

Gram positive, coccus in chains, facilitative anaerobe

Question 178

When should women have GBS swabs if they were to have swabs (ie if their previous pregnancy was GBS +ve)

Answer 178

• 35-37 weeks OR
• 3-5 weeks prior to anticipated delivery date

Question 179

What organism causes ophthalmia neonatorum

Answer 179

• Neisseria gonorrhoea
• Gram negative diplococcus
• Obligate anaerobe
• Conjunctivites

Question 180

Define oligohydramnios

Answer 180

Varied definitions

• <500mL at 32-36 weeks AND
• Amniotic Fluid Index (AFI) < 5th percentile

Question 181

Causes of oligohydramnios

Answer 181

• Premature rupture of membranes
• Foetal renal problems (e.g. renal agenesis)
• IUGR
• Post-term gestation
• Pre-eclampsia

Question 182

What are three major causees of bleeding during pregnancy in the first trimester

Answer 182

• Spontaneous abortion
• Ectopic pregnancy
• Hydatidiform mole

Exclude STIs and cervical polyps

Question 183

What are three major causees of bleeding during pregnancy in the second trimester

Answer 183

• Spontaneous abortion
• Hydatidiform mole
• Placental abruption

Exclude STIs and cervical polyps

Question 184

What are four major causees of bleeding during pregnancy in the third trimester

Answer 184

• Bloody show
• Placental abruption
• Placenta praevia
• Vasa praevia

Exclude STIs and cervical polyps

Question 185

Define antepartum haemorrhage

Answer 185

Bleeding after 24 weeks

Question 186

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

Diagnosis?

Answer 186

Ectopic pregnancy

Question 187

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

Diagnosis?

Answer 187

Hydatidiform mole

Question 188

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

Diagnosis?

Answer 188

Placental abruption

Question 189

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

Diagnosis?

Answer 189

Placenta praevia

Question 190

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

Diagnosis?

Answer 190

Vasa praevia

Question 191

Should a vaginal exmination be performed (in primary care) for suspected antepartum haemorrhae

Answer 191

No

Can cause haemorrahge esp placenta praevia

Question 192

In a woman with epilepsey, risk of uncontrolled epilepsey during pregnancy generally outweigh risk of medication to the foetus. 2% risk of congenital defects in non-epileptic mothers and 4% in epileptic mothers. For each of the following AED, what congenital defects are they associated with:

• Sodium valproate
• Carbamazepine
• Phenytoin
• Lamotrigine

Answer 192

• Sodium valproate - Neural tube defects and teratogenic
• Carbamazepine - teratogenic (least of older AED)
• Phenytoin - cleft palate
• Lamotrigine -low rate of ocngenital malformations

Question 193

Is breastfeeding safe for mothers taking antiepileptics?

Answer 193

Yes

Question 194

Which AED is considered not safe when breastfeeding

Answer 194

barbiturates

Question 195

If a pregnant woman is taking phenytoin, what must be given in the last month of pregnancy to prevent clotting disorders in the newborn

Answer 195

Vitamin K

Question 196

What are some general diseases/disorders found in pregnancy

Answer 196

• Pre-eclampsia/Eclampsia
• Hypertension
• Diabetes and GDM
• Cardiac Disease
• Respiratory disease
• Epilepsy
• Thyroid disease
• Liver disease
• Renal Disease
• Thrombophilia
• VTE
• Obesity
• Psychiatric
• Reacreational Drug use
• Anaemia
• Haemoglobinopathies
• Foetal Genital mutilation

Question 197

What types of diabetes are seen in pregnancy

Answer 197

• Pre-existing
  
  • Type I
  • Type II
• Gestational diabetes

Question 198

Define gestational diabetes

Answer 198

• Carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy (NICE 2015)
• Becoming more prevalent due toobesity and varying diagnostic thresholds
• Pregnancy is a pro-diabetic state, therefore women with impaired glucose tolerance can deteriorate and be classified as diabetic in pregnancy

Question 199

How does NICE define gestational diabetes mellitues (GDM)

Answer 199

• Fasting glucose ≥ 5.6 mmol/L OR
• >7.8 mmol 2 hours after a 75g glucose load (Glucose tolerance test GTT)

Question 200

What are some feotal complications of GDM?

Answer 200

Complications due to elevated glucose levels

• Cognenital abnormalities (NTD and cardiac) 3-4x
• Preterm labour
  
  • Immature lungs compared to non-DM pregnancies
• Macrosomia
• Polyhydramnios
  
  • Polyuria, increased liqour
• Dystocia and birth trauma
• Foetal compromise, distress and sudden foetal death
  
  • Poor third trimester glucose control

Question 201

What are some maternal complications of GDM

Answer 201

Complications are related to glucose levels, so women with GDM (and better control) are less affected

• Increased insulin requirements (300%)
  
  • Hypoglycaemias
  • Ketoacidosis (rare)
• Infection
  
  • UTI
  • delivery wound or endometrial infection
• Hypertension
• Pre-eclampsia
• Caeserean or instrumental delivery
  
  • Foetal compromise and macrosomia
• Diabetic nephropathy
  
  • Proteinuria and renal deterioration
• Diabetic retinopathy
  
  • Due to rapid control of blood glucose

Question 202

In a woman with pre-existing diabetes, what pre-conceptual care needs to be considered

Answer 202

• Glucose control
  
  • Monthly HbA1c <6.5%
  • Preganancy not adviced it >10%
• Fasting glucose 4-7 mmol/L
  
  • Metformin and insulin are appropriate, stop other hypoglycaemic drugs
• Other
  
  • 5mg Folic acid
  • Stop statins
  • Switch to pregnancy safe anti-HTN (labeteolol, methyldopa)
  • Renal function; creatinine < 120 umol/L
  • Blood pressure
  • Retina assessment

Question 203

How do you monitor diabetes in preghnancy (when to test and test result aims)

Answer 203

• HbA1c checked at booking
• Glucose checked at home:
  
  • Fasted in the morning
  • Before meals
  • 1 hour after meals
  • Bedtime
• Result aims: without hypoglycaemia
  
  • Fasting < 5.3 mmol/L AND
  • 1hour glucose < 7.8 mmol/L
• Contact with healthcare professional should be no less than 2 weekly

• NICE GDM =*
• Fasting glucose ≥ 5.6 mmol/L OR*
• >7.8 mmol 2 hours after a 75g glucose load (Glucose tolerance test GTT)*

Question 204

What are ttreatment options for glucose control for diabetes in pregnancy

Answer 204

• Metformin OR Insulin
  
  • MEtformin dose will usually need to be increased as pregnancy advances and may need to be supplemented with insulin in type II
  • Insulin: combo of :
    
    • once or twice daily long-intermmediate acting AND 3 preprandial short-acting insulin injuections
  • Insulin pumps for poor control
  • Advise exercise and diet!

Question 205

In addition to the usual pregnancy scans, fetal echocardiography is indicated. Ultrasound is used to monitor _____ _____ and _____ _____ at _____ and _____ weeks. Even where glucose control has been good, macrosomia and polyhydramnios can occur (Fig. 21.5). Umbilical artery Doppler is not useful unless pre-eclampsia or intrauterine growth restriction (IUGR) develops.

Answer 205

In addition to the usual pregnancy scans, fetal echocardiography is indicated. Ultrasound is used to monitor fetal growth and liquor volume at 32 and 36 weeks. Even where glucose control has been good, macrosomia and polyhydramnios can occur (Fig. 21.5). Umbilical artery Doppler is not useful unless pre-eclampsia or intrauterine growth restriction (IUGR) develops.

Question 206

When is delivery advised in pregnancy with diabetes and what mode of delivery is recommended

Answer 206

• Delivery 37-39 weeks
• Elective C-section
  
  • Likely birth trauma if US (though unprecise) estimates fetal weight > 4kg

Question 207

What is used to control glucose levels during labour

Answer 207

Sliding scale of insulin and dextrose infusion

Question 208

What is the management overview/aim for diabetes in pregnancy

Answer 208

• Preconceptual glucose control
• Assess maternal diabetic complications
• PAtient education and MDT]
• Glucose monitoring and insulin adjustment
• Anomaly and cardiac USS and foetal surveillance
• Delivery 37-39 weeks

Question 209

How is GDM screened for

Answer 209

Risk-based screening; if +1 risk factors

• Oral Glucose Tolerance Test (OGTT) at 24-28 weeks OR
• If previous GDM, OGTT at 16-18 weeks. If normal repeat OGTT at 24-28 weeks

Question 210

What are some risk factors for GDM

Answer 210

• Previous large baby (>4.5 kg) or Unexplained still birth
• Previous history of GDM
• First-degree relative (parents or siblings) with diabetes
• BMI > 30
• Minority ethnicity (S. asian, black Caribbean, Middle Eastyern)
• Polyhydramnios

Question 211

What OGTT results would diagfnose GDM and therefore requires treatment

Answer 211

• Fasting > 5.6 mmol/L OR
• 2h glucose > 7.8 mmol/L

Question 212

What is the general management/overview of GDM

Answer 212

• Explain Implications of GDM to mother and foetus
• Blood glucose monitoring
• Diet and exercise
• Pharmacological management of glucose

Question 213

Outline the pharmacological management of gestational diabetes

Answer 213

Question 214

What AED are safe to use in pregnancy

Answer 214

• Carbamezapine
• Lamotrigine

Question 215

As well as switching to appropriate AEDs, what else needs to be done to manage epilepsy in pregnancy

Answer 215

• 5mg Folic acid throughout pregnancy
• 10mg Vit K po from 36 weeks
• 20 week scan and feotal echocardiography to exclude foetal abnormalities

Question 216

What are maternal risks associated with obesity in pregnancy

Answer 216

• Thromboembolism
• Pre eclampsia
• Diabetes
• C-section
• Wound infections
• Difficult surgery
• Postpartum haemorrhage
• Maternal death

Question 217

What are foetal risks associated with obesity in pregnancy

Answer 217

• Congenital abnormalities (NTD)
• Diabetes
• Perinatal mortality (pre-eclampsia)

Question 218

How is obesity managed in pregnancy

Answer 218

• Preconceptual weight loss
• Preconceptual 5mg Folic acid + Vitmain D
• Weight is best maintained during pregnancy
  
  • Loss may lead to malnutrition
• BMI > 35 = high risk pregnancy
• BMI > 40 = formal anaesthetic risk assessment and antenatal thromboprophylaxis

Question 219

What are the two types of PROM

Answer 219

• Premature rupture of membranes (PROM)
• Pre-term premature rupture of membranes (PPROM)

Question 220

Define PROM

Answer 220

• Rupture of foetal membranes at least 1 hour prior to onset of labour at ≥37 weeks gestation
• 10-15% term pregnancies, minimal risk to mother and foetus due to advanced gestation

Question 221

Define PPROM

Answer 221

• Rupture of foetal membranes occuring at <37 weeks gestation
• Complicates 2% pregnancies and has high rate of maternal and foetal complications
• Associated with 40% preterm deliveries

Question 222

Aetiology and pathophysiology or PROM/PPROM

• The fetal membranes consist of the _____ and the _____. They are strengthened by _____, and under normal circumstances, become weaker at term in preparation for labour.
• The physiological processes underlying this weakening include apoptosis and collagen breakdown by _____.
• In cases of premature rupture of membranes and P-PROM, a combination of factors can lead to the early weakening and rupture of fetal membranes:
• _____ – higher than normal levels of apoptotic markers and MMPs in the amniotic fluid.
• _____ – inflammatory markers e.g. cytokines contribute to the weakening of fetal membranes. Approximately 1/3 of women with P-PROM have positive amniotic fluid cultures.
• _____ _____

Answer 222

• The fetal membranes consist of the chorion and the amnion. They are strengthened by collagen, and under normal circumstances, become weaker at term in preparation for labour.
• The physiological processes underlying this weakening include apoptosis and collagen breakdown by enzymes.
• In cases of premature rupture of membranes and P-PROM, a combination of factors can lead to the early weakening and rupture of fetal membranes:
  
  • Early activation of normal physiological processes – higher than normal levels of apoptotic markers and MMPs in the amniotic fluid.
  • Infection – inflammatory markers e.g. cytokines contribute to the weakening of fetal membranes. Approximately 1/3 of women with P-PROM have positive amniotic fluid cultures.
  • Genetic predisposition

Question 223

What are some risk factors for PROM/PPROM

Answer 223

• Smoking (esp <28 wk gest)
• Previous PROM/pre-term delivery
• Vaginal bleeding during pregnancy
• Lower genital tract infecition
• Iatrogenic (amniocentesis)
• Polyhydramnios
• Multiplpe pregnancy
• Cervical insufficiency

In many cases of PROM/PPROM, there are no identifiable risk factors

Question 224

What are some clinical features of PROMS

Answer 224

• Typical history of broken water
  
  • Painless popping senstion followed by gush of watery fluid from the vagina
• Can be non-specific - gradual leak
• Speculum - may see pooling in posterior vaginal fornix
  
  • Speculum not needed if amniotic fluid is seen draining from vagina
• Lack of normal vaginal discharge (washed clean)

Question 225

Differential diagnosis for PROMS

Answer 225

• Urinary incontinence
• Normal vaginal secretions in pregnancy
• Cervical infection
• Loss of mucus plug

Question 226

What are some investigations for PROMs/PPROMs

Answer 226

Diagnosis usually made by i) maternal history of membrane rupture and ii) positive examination findigns

• High vaginal swab in ALL cases
  
  • May grow GBS, which would indicate intrapartum Abx
• ferning test
  
  • Leting cervical secretions dry from a glass slide - forms fern-pattern
• Ultra sound
  
  • Not routinely used but can be used if diagnosis unclear
    *

Question 227

With regards to management of PROMs, what factors are considered to guide management

Answer 227

• Rupture of membrane will stimulate uterus - therefore majority of women go into labour withing 24-48 hours
• If women do not go into labour, induction of labour may be considered:
  
  • Balancing gestational age (dont induce so foetus can develop more)
  • Risk of infection

Summary: IOL and delivery if >34 weeks

Expectant management if < 34 weeks

Question 228

What is the management of PROM if it occure >36 weeks gestation

Answer 228

Expectant management

• wait 24hr as 60% go into labour naturally
• IOL recommended if >24hr
• Monitor signs of clinical chorioamnionitis
• High vaginal swab
  
  • Clindamycin/penicillin intrapartum if +ve

Question 229

What is the management of PROM if it occure 34-36 weeks gestation

Answer 229

• IOL and delivery recommended
• Monitor signs of chorioamnionitis
  
  • Avoid sexual intercourse
  • Prophylactic erythromycin 250mg QDS for 10 days
• high vaginal swab
  
  • Clindamycin/penicillin intrapartum
• Corticosteroids

Question 230

What is the management of PROM if it occure 24-33 weeks gestation

Answer 230

• Aim expectant management until 34 weeks
• Monitor signs of chorioaminonitis
  
  • Avoid sexual intercourse
  • Prophylactic erythromycin 250mg QDS 10days
• Corticosteroids

Historically the aim was to get the pregnancy to 36 weeks if there was no evidence of infection. However, with improvements in neonatal care (and evidence for poorer outcomes in babies if there is maternal infection), management has shifted towards 34 weeks and induction of labour once there has been a course of steroids.

Question 231

Complications of PROM

Answer 231

Outcome or PROM correlates with gestational age of foetus. Majority women go into labour after PROM but there is a greater latency period the younger the gestational age. Pre-disposes greater risk of maternal and foetal complications

• Chorioamnionitis
  
  • Infection of foetal membrane
  • Risk increases longer membranes remained ruptured and baby undelivered
• Oligohydramnios
  
  • Sig in <24 weeks gestation, increases risk of lung hypoplasia
• Neonatal death
  
  • Prematurity, sepsis, pulmonary hypoplasia
• Placental abruption
• Umbilical cord prolapse

Question 232

Define induction of labour (IOL)

Answer 232

• Process of starting labour artificially
• Most women go into labour sponataneously by 42 weeks of gestation, roughly 1 in 5 will require an induction
• IOL performed when its though that the baby will be safer delivered than remaining in utero. Also could be due to concerns for maternal health

Question 233

What is the general indication for IOL and name 5 specific contexts where IOL is indicated

Answer 233

IOL indicated when delivering baby is safer for the baby and or mother thanfor baby to remain in utero

• Prolonged gestation
• PROM/PPROM
• Maternal health problems
• Foetal growth restriction
• Intrauterine foetal death

Question 234

In women with prolonged gestation, when should they be offered IOL

Answer 234

• If uncomplicated, offer between 41⁺⁰ to 42⁺⁰ weeks’ gestation.

Question 235

In women with prolonged gestation, what is the aim of IOL

Answer 235

• Avoid risk of foetal compromise and still birht (thought to be secondary to placental ageing)

Question 236

If a patient with prolonged gestation declines an IOL, how should she be managed

Answer 236

• Increased frequency of monitoring from 42 weeksa onwards
• at least twice‑weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth

Question 237

What is the management of PROM in terms of delivery

Answer 237

>37 week gestation

• Offer IOL
• OR expectant management for a maximum 24 hours
  
  • Any longer increases risk of ascending infection -chorioamnionitis
  • 84% women will spontaneously go into labour withitn first 24 hours
• ​High vaginal swab
• Clindamycin/penicillin intrapartum if +ve

Question 238

What is the management of P-PROM in terms of delivery

Answer 238

Dependent on stage of gestation:

<34 weeks gestation

• Delay IOL unless obstetric factors indicate otherwise (foetal distress) - Aim for 34 weeks gestation
• Monitor signs of chorioaminonitis
  
  • Avoid sexual intercourse
  • Prophylactic erythromycin 250mg QDS 10days
• Corticosteroids

>34 weeks gestation

• IOL and delivery recommended
  
  • Timing depends on risk v benefits of delaying pregnancy further (increased risk of infection)
• Monitor signs of chorioamnionitis
  
  • Avoid sexual intercourse
  • Prophylactic erythromycin 250mg QDS for 10 days
• high vaginal swab
  
  • Clindamycin/penicillin intrapartum
• Corticosteroids

Question 239

What are some examples of maternal health problems which would indicate IOL

Answer 239

• Hypertension
• Pre-eclampsia
• Diabetes
• Obstetric Cholestasis

Decision will depend on health of mother and foetus

Question 240

What is the second most common indication for IOL and what is the aim of IOL in this context

Answer 240

• Foetal growth restriction
• Aim: Deliver baby prior to foetal compromise

Question 241

When can you offer IOL in a woman with intrauterine foetal death

Answer 241

• MOther physically well with intat membranes

Question 242

What are some absolute contraindications for IOL

Answer 242

• Ceophalopelvic disproportion
• Major placenta praevia
• Vasa praevia
• Cord prolapse
• Transverse lie
• Active primary genital herpes
• Previous classical C-Section

Question 243

What are some relative contraindications to IOL

Answer 243

• Breech presentation
• Triplet or higher order pregnancy
• Two or more previous low transverse C-section

Question 244

What does IOL increase the risk of with a women who has had a previous c-section

Answer 244

Increased risk of:

• Emergency caeseran
• Uterine rupture

Question 245

What are the three types of breech presentation

Answer 245

• Frank breech
• Complete breech
• Incomplete breech
  
  • Footling breech
  • Kneeling breech

Question 246

What are the three main methods of induction

Answer 246

• Vaginal prostaglandins
• Amniotomy
• Membrane Sweep

Question 247

What is the mainstay method of IOL (1st line NICE 2008) and describe how it works

Answer 247

• Vaginal prostaglandins
• Prostaglandins
  
  • act to prepare the cervix by ripening it
  • have a role in contraction of smooth muscle of uterus

Question 248

What are the two regimens for vaginal prostaglandin induction and describe how they are taken/differences

Answer 248

• Tablet/gel regimen
  
  • 1 cycle = 1st dose, plus 2nd dose if labour has not started within 6 hours
• Pessary regimen
  
  • 1 cycle = 1 dose over 24 hours

Recommended maximum of one cycle in 24 hours (IOL can sometimes take multiple days)

Question 249

Describe how amniotomy can be used in IOL

Answer 249

• Membranes are ruptured artificially using an amniohook
• Like in membrane sweep, this process releases prostaglandins in an attempt to expedite labour
• Often given with Syntocinon infusion

Question 250

How does a Syntocinon infusion help in amniotomy?

The aim is to start _____ and titrate _____ until there are _____ (number) _____ every _____ minutes

Answer 250

• Increases strength and frequemncey of contractions

The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes

Question 251

The aim of amniotomy + syntocinon infusion is to start _____ and titrate _____ until there are _____ (number) _____ every _____ minutes

Answer 251

The aim of amniotomy + syntocinon infusion is to start low and titrate upwards until there are 4 contractions every 10 minutes

Question 252

What is the indication for amniotomy +/- syntocinon

Answer 252

• NOT FIRST LINE for IOL
• Only when cervis is ripe (Bishop Score ≥ 7)
• OR Prostaglandin use is contraindicated (high risk of uterine hyperstimulation)

Question 253

Describe the process involved in membrane sweep and how it helps in IOL

Answer 253

• Inserting gloved finger through cervix and rotating against foetal membranes
• Aims to separate chorionic membrane from the decidua
• Separation helps release natural prostaglandins to attemtp to kick-start labour

Question 254

When would you offer membrane sweep for IOL

Answer 254

Used as an adjunct of IOL. Perfomring it increases likelihood of spontaneous delivery reducing need for formal induction

• 40-41 weeks nulliparous women
• At 41 weeks multiparous women

Question 255

How is IOL monitored

Answer 255

• Bishop Score
• CTG

Question 256

What does the Bishop score measure

Answer 256

• Assessment of cervical ripeness based on factors taken during vaginal examination
• Checked prior to induction and during induction to assess progress (6 hours post-tablet/gel, 24 hours post-pessary)

Question 257

What are the factors that make up Bishop Scoring

Answer 257

• Dilation (cm) of cervix
• Length of cervix (cm)
• Station (relative to ischeal spines)
• Consistency of cervix
• Position of cervix

Question 258

What are the scoring thresholds for the Bishop Score

Answer 258

• ≥ 7 = cervix is ripe or favourable
  
  • High cance of responsiveness to interventions made to induce labour (ie IOL possible)
• <4
  
  • Labour unlikely to progress naturally
  • therefore prostaglandin therpay required

Question 259

If the cervix fails to ripen despite prostaglandin use, what may you need to consider

Answer 259

Caeserian section

Question 260

When and what things should you be looking out for on CTG during IOL

Answer 260

• CTG prior to IOL to confirm reassuring foetal HR
• After IOL initiation, when contraction begins, assess foetal HR until normal rate is confirmed (use continuous CTG)
  
  • Subsequently assess using intermittent auscultation
• If oxytocin infusion is stated, mointor using continuous CTG throughout labour

Question 261

Complications of IOL and briefly describe how you would manage them

Answer 261

• Failure of induction (15%)
  
  • Offer further cycle of prostaglandins or C-section
• Uterine hyperstimulation (1-5)
  
  • Contractions too long or too frequent leading to foetal distress
  • Manage with tocolytics (terbutaline)
• Cord prolapse
  
  • Can occur at amniotomy, esp when presentation of foetal head is high
• Infection
  
  • Fewer veginal examinations
• Pain
  
  • IOL more painful than spontaneous labour
  • Epidural analgesia
• Uterine rupture (rare)
• Increased rate of further intervention vs spontaneous labour

Question 262

Define caeserian section

Answer 262

Delivery of baby through surgical incision in the abdomen and uterus

Question 263

What are the classifications of caeserian section

Answer 263

• Category 1
  
  • Immediate threat to life of woman or foetus
  • Deliver in 30 minutes (some 20 min)
• Category 2
  
  • Maternal or foetal compromise that is not immediately life-threatening
  • Deliver in 60-75 minutes
• category 3
  
  • No maternal or foetal compromise but needs early delivery
• Category 4
  
  • Elective

Question 264

What are the two most common reasons for an emergency C0-section

Answer 264

• Failure to progress in labour
• Suspected/confirmed foetal compromise

Question 265

What are some indications for an elective C-section

Answer 265

• Breech presentation at term
• Other malpresentations
  
  • Unstable, Transverse, Oblique lie
• Twin pregnancy
  
  • When first twin is NOT cephalic presentation
• Maternal medical conditions
  
  • Cardiomyopathy
• Foetal compromise
• Transmissable disease
  
  • Poorly controlled HIV
• Primary genital herpes
  
  • in third trimester
• Placenta praevia
• Maternal diabetes
  
  • Foetal weight > 4.5 kg
• Previous major shoulder dystocia
• Previous 3rd/4th perineal tear
• Maternal request

Question 266

At what gestational week are elective C-sections planned for and why is this

Answer 266

• After 39 weeks
  
  • Reduce respiratory distress in neonate (TTN)
• If before 39 weeks consider corticosteroid administration
  
  • Developmoent of foetal lungs

Question 267

What are some pre-operative investigations and management for elective C-section

Answer 267

• FBC and G&S
  
  • blood loss 500-1000mL
• H2-receptor antagonist
  
  • Ranitidine +/- ?metoclopramide
• VTE risk score
  
  • TED stockings +/- LMWH
• Type of anaesthesia
  
  • Regional anaesthetis (epidural or spinal)
  • General anaesthetic

Question 268

What is Mendelson’s Syndrome

Answer 268

• Aspiration of gastric contents into the lung leading to chemical pneumonitis
• Caused by pressure from gravid uterus on gastric ocntents

Question 269

Layers the needle goes through for a spinal anaesthesia

Answer 269

• Skin
• Fat
• Muscle
• Suprspinous ligaments
• Interspinous ligaments
• Ligamentum flavum
• Dura
• Subdural space
• Arachnoid mater
• Subarachnoid space

Question 270

Roughly outline the operative procedure in C-setions

Answer 270

• Pre-incision
  
  • Left lateral tilt of 15⁰ - reduce risk of supine hypotension due to aortocaval compression
  • Foley’s catheter - drain bladder and reduce risk of injury
  • Skin cleaned and antibiotics administered
• Skin incision
• Sharp or blunt dissection into abdomen
• Incision of visceral peritoneum
• Uterine incision
• Oxytocin 5IU
• Closure

Question 271

Name two types of transverse lower abdominal skin incisions for c-sections

Answer 271

• Pfannenstiel
• Joel-Cohen

Question 272

Compare and contrast transverse low incisions and midline incisions for c-section

Answer 272

Question 273

What are the layers of the abdomen that are cut through during shapr/blunt dissection

Answer 273

• Skin
• Camper’s fascia - superficial layer of SC tissue
• Scarpa’s fascia - deep membranous layer of SC tissue
• Rectus sheath - anterior and posterior
• rectus muscle
• Parietal peritoneum (abdominal)
• Uterus/bladder

Question 274

When reaching the visceral peritoneum, what is used to retract the bladder

Answer 274

Doyen retractor

Question 275

What types of uterine incisions are used in c-section

Answer 275

• Transverse curvilinear incision
  
  • Digitally extended
• De Lee’s incision
  
  • Lower vertical - required if lower uterine incision is poorl;y formed(rare

Question 276

Why is oxytocin given once baby delivered by c-section

Answer 276

• given IV by anaesthetist to aid delivery of placenta by controlled cord traction by surgeon

Question 277

What observations are measured post-operatively c-section

Answer 277

• Early warning chart
• Lochia
  
  • PV bleed loss

Question 278

What are encouraged pos-c section to enhance recovery

Answer 278

Early mobilisation

Eating and drinking

removal of catheter

Question 279

A primary c-section reduces the risk of what

Answer 279

• Perineal trauma and pain
• Urinary incontinence
• Anal incontinence
• Uterovaginal prolapse
• Late stillbirth
• Early neonatal infection

Question 280

What are some immediate complications of c-section

Answer 280

• PPH >1000mL
• Wound haematoma (high BMI, diabetes, immunosup.)
• Intra-abdo haemorrhage
• Bladder/bowel trauma (esp in those with previous abdo surgery)
• Neonatal
  
  • TTN
  • Foetal lacerations

Question 281

What are some intermediate complications of c-section

Answer 281

• Infection
  
  • UTI
  • Endometritis
  • Respiratory (in GA)
• VTE

Question 282

What are some late complications of C-section

Answer 282

• Urinary tract trauma (fistula)
• Subfertility
• Psyhcological sequelae
• VBAC - Vaginal birth after c-section
• Placenta Praevia/accrete
• Caeserean scar ectopic pregnancy

Question 283

What are the two delivery options in a patient with previous C-section

Answer 283

• Vaginal birth after C-section (VBAC)
• Planned elective repeat C-section

Question 284

VBAC is clinically safe for the majority of women who have had one prior lower segment c-section (NICE, RCOG, ACOG). More complex circumstances requires caution and senior obstetrician care. What are some examples of these complex circumstances

Answer 284

• Multiple pregnancy
• Macrosomia
• Maternal age > 40 y

Question 285

For each of the following, identify whether each one is referring to VBAC or elective repeat C-Section (ERCS)

• Shorter hospital stay and recovery
• Greater risk of uterine rupture
• No risk of anal sphincter injury
• Higher risk of maternal death
• Likely to require future C-Section
• Higher risk of neonatal respiratory morbidity
• Higher risk of hypoxic ischaemic encephalopathy (HIE)
• Increased risk of placental problems and adhesion formation

Answer 285

• Shorter hospital stay and recovery - VBAC
• Greater risk of uterine rupture - VBAC
• No risk of anal sphincter injury - ERCS
• Higher risk of maternal death - ERCS
• Likely to require future C-Section - ERCS
• Higher risk of neonatal respiratory morbidity - ERCS
• Higher risk of hypoxic ischaemic encephalopathy (HIE) - VBAC
• Increased risk of placental problems and adhesion formation - ERCS

Question 286

What are some considerations/management of VBAC

Answer 286

• Deliver in hospital setting (emergency c-section and advanced neonatal resuscitation)
• Continuous CTG monitoring
• Additional analgesic requirements
• Avoid induction where possible
  
  • risk of rupture is less with mechanical tehcniques (amniotomy) vs with prostaglandins
• Augmentation can increase risk of uterine scar rupture
• Senior obstetrician input
• >39 weeks = recommended elective repeat C-section
  *

Question 287

What are the absolute contraindications to VBAC

Answer 287

• Classical caeserean scar
• Previous uterine rupture
• Other contraindications for vaginal birth that apply to the clinical scenario (eg placenta praevia)

Question 288

What are the relative contraindications for VBAC

Made on case-by-case basis by senior obstetrician

Answer 288

• Complex uterine scars
• >2 prior lower segment C-sections

Question 289

Define uterine rupture

Answer 289

• Full thickness disruption of uterine muscle and overlying serosa
• Foetus can be extruded from uterus resulting in foetal hypoxia and large internal haemorrhage

RARE but significant maternal and foeatl morbidity nad mortality

Question 290

Describe the two types of uterine rupture

Answer 290

• Incomplete
  
  • Peritoneum overlying uterus is intact
  • Uterine contents remain in the uterus
• Complete
  
  • Peritoneum is also torn
  • Uterine contants can escape into the petioneal cavity

Question 291

What are the risk factors of uterine rupture

Answer 291

• Previous C-section
• Previous uterine surgery (myomectomy)
• Induction (prostaglandins or augmentation of labour)
• Obstruction of labour
  
  • Developing countries
• Multiple pregnancy
• Multiparity

Question 292

Clinical features (symptoms) of uterine rupture

Answer 292

Non-specific

• Abdominal pain
  
  • Persists between contractions
• Shoulder tip pain
• Vaginal bleeding

Question 293

Signs of uterine rupture (on examination)

Answer 293

• Regression of presenting part
• Scar tenderness on palpation
• Palpable foetal parts
• Hypovolaemic shock
  
  • Significant haemorrhage
• Foetal distress or absent heart sounds

Question 294

Differentials for uterine rupture

Answer 294

• Placental abruption
  
  • Abdo pain +/- vaginal bleeding
  • Uterus often described as tense on palpation and woody
• Placenta praevia
  
  • Painless vaginal bleeding
• Vasa praevia
  
  • Triad:
    
    • Ruptured membranes
    • Painless vaginal bleeding
    • Foetal bradycardia

Question 295

Vasa praevia triad

Answer 295

• Painless vaginal bleeding
• Rupture of membranes
• Foetal bradycardia

Question 296

Investigations for uterine rupture

Answer 296

• Intrapartum CTG (in women at risk of rupture)
  
  • Recurrent or late decelerations
  • Proloinged foetal bradycardia
• Maternal haematuria
  
  • Catheter
• Ultrasound
  
  • Suspicion of uterine rupture in pre-labour setting
  • Abnormal foetal lie or presentation
  • Haemoperitoneum
  • Abesnt uterine wall

Question 297

Management of uterine rupture

Answer 297

OBSTETRIC EMERGENCY

• Call for senior help and appropriate staff
• A-E approach
• 222 call
• Resuscitation
• Surgical management

Question 298

Surgical management of uterine rupture

Answer 298

• Deliver by C-section
• Uterus repair or hysterectomy
• Decision-incision interval in operative intervention should be <30 minutes

Question 299

Define operative vaginal delivery (OVD)

Answer 299

Use of an instrument to aid delivery of foetus

Question 300

What are the two instrument types used in operative deliveries

Answer 300

• Ventouse
• Forceps

Question 301

Which of the two instruments used in OVDs tend to have a lower risk of ofetal complications and higher risk of maternal complicatiosn

Answer 301

• Forcep delivery

Question 302

When using instruments in an OVD, when should the attempt be abandoned

Answer 302

• Abandon if after three contractions and pulls with any instrument, there is no reasonable progress

Question 303

What are some ventouse types

Answer 303

• Silastic cup attached to electric pump
  
  • Only if foetus in occipital-anterior position
• Kiwi - handheld disposable device
  
  • Omni-cup, used for all foetal positions and rotational deliveries
• Bird cup
  
  • Occipital-posterior positions

Question 304

Where should the cup in ventouse be placed

Answer 304

• Cup with centre over the flexion point of the foetal skull
  
  • Midline, 3cm anterior to the posterior fontanelle

During contractions, traction is applied perpendicular to the cup

Question 305

Ventouse deliveries are associated with:

• Lower/higher success rate
• Less/more maternal perineal injuries
• Less/more pain
• Less/more cephalhaematoma
• Less/more Subgaleal haematoma
• Less/more foetal retinal haemorrhage

Answer 305

• Lower success rate
• Less maternal perineal injuries
• Less pain
• More cephalhaematoma
• More Subgaleal haematoma
• More foetal retinal haemorrhage

Question 306

Forceps are double bladed instruments. Name some different types

Answer 306

• Rhodes, Neville-Barnes or Simpsons
  
  • OA positions
• Wrigley’s
  
  • C-section
• Kielland’s
  
  • Rotational deliveries

Question 307

How are forceps used in OVD

Answer 307

• Blades introduced to pelvis (taking care not to cause trauma to maternal tissue)
• Applied around sides of foetal head
• Blades lock together
• Gentle traction during uterine contractions, following the J shape of the maternal pelvis

Question 308

Use of forceps is associated with:

• Lower/Higher rate of 3rd/4th degree tears
• Used less/more often to rotate
• Requires/Does not require maternal effort

Answer 308

• Higher rate of 3rd/4th degree tears
• Used less often to rotate
• Does not require maternal effort

Question 309

Indications of OVD

Answer 309

Considered in 2nd stage of labour. Is there a valid clinical indication to intervene? Is the patient a suitable case for an intrumental delivery?

Maternal:

• Inadequate progress
  
  • Nulliparous women - general rule to expect delivery after two hours of active pushing
  • Multiparous women - expect delivery within one hour of active pushing
• Maternal exhaustion
• Maternal medical conditions that means active pushing or prolonged exertions should be avoidied
  
  • Intracranial patholgies
  • Maternal congenital heart disease
  • Severe hypertension

Foetal

• Suspected foetal compromise in 2nd stage of labour
  
  • CTG monitoring
  • Abnormal foetal blood sample
• Clinical concerns
  
  • Significant antepartum haemorrhage

Question 310

What are some pre-requisites for instrumental delivery

Answer 310

• Fully dilated
• Ruptured membranes
• Cephalic presentation
• Defined foetal position
• Foetal head at least at the level of ischial spines and no more than 1/5 palpable per abdomen
• Empty bladder
• Adequate pain relief
• adequate maternal pelvis

Question 311

What are the absolute contraindications of OVD

Answer 311

• Unengaged foetal head in singletone pregnancies
• Incompletely dilated cervix in singleton pregnancies
• True cephalo-pelvic disproportion (foetal head too large to pass through maternal pelvis)
• Breech and face presentation
• Preterm gestation (<34 weeks) for ventouse
• High likelihood of fetal coagulation disorder for ventouse

Question 312

What are some relative contraindications to OVD

Answer 312

• Severe non-reassuring foetal status, with station of the head above the level of pelvic floor (foetal scalp not visible)
• Delivery of second twin when the head is not quite engaged or the cervix has reformed
• Prolapse of the umbilical cord with foetal compromise when the cervix is completely dilated and the station is mid cavity

Question 313

How is OVD classified (no descriptiuon)

Answer 313

Classified by degree of foetal descent. The lower the classification, the less the risk of complications

Question 314

Describe the three classifications of OVD

Answer 314

Outlet

• Foetal scalp visible with labie parted
• Foetal skull reached pelvic floor
• Foetal head on perineum

Low

• Lowest presenting part (not caput) is +2, or further below the ischial spines. subdivided to:
  
  • >45 degrees - rotation needed
  • <45 degrees - no rotation needed

Midline

• 1/5 palpable abdominally. Lowest part is above +2 but is lower than ischial spines. Subdivided to:
  
  • >45 degrees - rotation needed
  • <45 degrees - no rotation needed

Question 315

Complications of OVD

Answer 315

Foetal

• Neonatatl jaundice
• Scalp lacerations
• Cephalhaematoma
• Subgaleal haematoma
• Facial bruising
• Facial nerve damage
• Skull fractures
• Retinal haemorrhage

Maternal

• Vaginal tears (3rd/4th degree)
  
  • Forceps >> ventouse > vaginal delivery
• VTE
• Incontinence
• PPH
• Shoulder dystocia
• Infection

Question 316

Define small for gestational age (SGA)

Answer 316

• Infant birth weight <10th centile for gestational age
• Severe SGA = birth weight <3rd centile

Question 317

Define foteal small for gestational age

Answer 317

• Estimated foetal weight (EFW) or adbominal circumference (AC) <10th centile
• Severe = EFW or AC < 3rd centile

Question 318

Define foetal growth restriction (FGR)

Answer 318

• When genetic growth is restricted by a pathological process
• This can present with features of foetal compromise:
  
  • Reduced liqour volume
  • Abnormal doppler studies
• Likelihood of FGR is higher in severe SGA foetus

Question 319

Define the boundary of a low birth weight

Answer 319

• Birth weight <2.5kg (2500g)

Question 320

What are the 3 aetiologies/pathophysiologies of a small for gestational age baby

Answer 320

• Normal (constitutionally) small
• Placenta mediated growth restriction
• Non-placenta mediated growth restriction

Question 321

Describe what is meant by a normal (constitutionally) small baby

Answer 321

• Small size at all stages but follows growth centiles
• No pathology is present
• Conrtibuting factors include ethnicity, sex, parental height

50-70% SGA foetus/infants are consitutionally small

Question 322

Describe the pathophysiology of placenta mediated growth restriction

Answer 322

• Growth normal initially but slows in utero
• Leads to placental insufficiency
• Common cause of FGR and can be due to maternal factors

Question 323

Describe some maternal factors that can lead to placenta-mediated growth restriction (placental insufficiency)

Answer 323

• Low-pregnancy weight
• Substance abuse
• Autoimmune disease
• Renal disease
• Diabetes
• Chronic HTN

Question 324

Describe the pathophysiology under non-placenta mediated growth restriction

Answer 324

• Growth affected by foetal factors
  
  • Chromosomal or structural anomaly
  • Error in metabolism
  • Foetal infection

Question 325

When are women assessed for risk factors of SGA

Answer 325

• Booking visit AND
• 20 weeks gestation

Question 326

What are some minor risk factors for SGA

Answer 326

• Maternal age ≥35
• Smoker 1-10/day
• Nulliparity
• BMI < 20 or 25-34.9
• IVF singleton
• Previous pre-eclampsia
• Pregnancy interval <6 or ≥60 months (5 years)
• Low fruit-intake pre-pregnancy

Question 327

What are some major risk factors for SGA

Answer 327

• Maternal age >40
• Smoker ≥ 11/day
• Previous SGA baby
• Maternal/paternal SGA
• Previous stillbirth
• Cocaine use
• Daily vigorous exercise
• MAternal disease (Chronic HTN, renal impariment, diabetes w/ vascular disease, APS)
• Heavy bleeding
• Low PAPP-A

Question 328

When would you refer someone for UAD surveillance in SGA

Answer 328

• 3 minor risk factors present -> UAD
• Major risk factor present -> serial ultrasound and UAD

Question 329

How is SGA investigated/diagnosed

Answer 329

• Ultrasound
  
  • Diagnosis and surveillance of SGA
• Foetal anatomical survey
• Uterine artery doppler (UAD)
• Karyotyping
• Infection screen
  
  • Congenitcal CMV
  • Congenital toxoplasmosis
  • Congenital syphilis
  • Congenital malaria

Question 330

What features are you looking for on ultrasound scan for SGA

Answer 330

• Biometrics - plotted on centil charts (take into account maternal height, weight, ethnicity, parity)
  
  • EFW (estimated foetal weight)
  • Abdominal circumference (AC)
• Head circumferenc (HC):AC ratio
  
  • Symmetrically small foetus likely to be constitutionally small
  • Asymmetrically small foetus more likely due to placental insufficiency
  • Brain sparing effect
• Reduced amniotic fluid
  
  • Impaired foetal kidney function as a result of placental insufficiency

Question 331

Overview of the management of SGA

Answer 331

• Prevention
• Surveillance
• Delivery

Question 332

In the management of SGA, describe the details of prevention

Answer 332

• MAnage modifieable risk factors for SGA
  
  • Smoking cessation
  • Optimise maternal disease
• 75mgaspirin 16 weeks gestation until delivery
  
  • For women at high risk of pre-eclampsia

Question 333

In the management of SGA, describe surveillance

Answer 333

• Uterine artery doppler (AUD) primary surveillance tool in SGA foetus
  
  • If normal, repeat every 14d
  • If abnormal, repeat more frequently and consider delivery
• Other surveillance tests:
  
  • Symphysis fundal height (SFH)
  • Middle Cerebral artery (MCA) doppler
  • Ductus venous (DV) doppler
  • CTG
  • Amniotic fluid volume

Question 334

In the manfemetn of SGA, outline the features of devliery

Answer 334

• If considering delivery 24 to 35+6 weeks gestation = single course antenatal steroids

Question 335

What is a maternal complciation of SGA

Answer 335

Increased risk of still-birth

Question 336

What are some neonatal complications of SGA

Answer 336

• Birth asphyxia
• Meconium aspiration
• Hypothermia
• Hypo/Hyperglycaemia
• Polycythaemia
• Retinopathy of prematurity
• Persistent pulmonary hypertension
• Pulmonary haemorrhage
• Necrotising enterocolitis

Question 337

What are the long term neonatla complications of SGA

Answer 337

• Cerebral palsy
• T2DM
• Obesity
• Hypertension
• Precocious puberty
• Behavioural problems
• Depression
• Alzheimer’s disease
• Cancer (breast, ovarian, colon, lung, blood)

Question 338

Define prolonged pregnancy

Answer 338

• Pregnancies which persist up to and beyond 42 weeks gestation
• AKA Post-term or post-dates pregnancy
• 5-10% pregnancies

Question 339

What are some risk factors of prolonged pregnancies

Answer 339

Unlcear but:

• Nulliparity
• Maternal age >40
• Previous prolonged pregnancy
• High BMI
• FH of prolonged pregnancies

Question 340

What are some clinical features of prolonged pregnancy

Answer 340

• Static growth
• Maybe macrosomia
• Oligohydramnios
• Reduced foetal movements
• Presence of meconium
  
  • Meconium staining (on nails)
• Dry/flaky skin with reduced vernix
  
  • Vernix is white, waxy substance on skin of newborn babies

Question 341

Investigations for prolonged pregnancy

Answer 341

• Diagnosis based on gestational age
• Dating between 11+0 and 13+6 weeks in first trimester is most reliable as foetus rarely shows signs of being consitutionally large or small until later gestational stage
• Ultrasound scanning to check growth, liqour volume, dopplers performed in women with prolonged pregnancy

Question 342

Management of prolonged pregnancy

Answer 342

NICE/RCOG:

Deliver by 42 weeks gestation to reduce risk of stillbirth

• Membrane sweep (offer from 40+0 in nulliparous and 41+0 in parous women)
• IOL (offer 41+0 and 42+0)

Women who decline IOL should be offereed twice weekly CTG monitoring and USS with amniotic fluid measurement to identify foetal distress, in which case emergency c-section might be indicated

Question 343

complication of prolonged pregnancy

Answer 343

• Increased risk of still birth
  
  • Rate exponentially rises after 37 weeks gestation
• Foetal acidaemia and meconium aspiration in labour
  
  • Due to placental insufficiency
• Neonatal hypoglycaemia
  
  • Placental degradataion/insufficiency, so reduced O2 and nutrient transfer
  • Can deplete foetal glycogen stores

Question 344

Define placental abruption

Answer 344

• when part of or all of placenta separates from the wall of the uterus prematurely
• Important cause of antepartum haemorrhage (pv bleed from week 24 until delivery)

Question 345

Describe the pathophysiology of placental abruption

Answer 345

• Occus following a rupture of materna lvessels within basal layer of endometrium
• Blood accumulates and splits the placental attachment form the basal layer
• Detached portion of placenta is unable to function leading to foetal compromise

Question 346

What are the two types of placental abruption and describe themAttach Images

Answer 346

• Revealed
  
  • Bleeding tracks down from the site of placental separation and drains through the cervix
  • Results in vaginal bleeding
• Concealed
  
  • Bleeding remains in the uterus and typically forms a clot retroplacentally
  • Bleeding is not visible but can be severe enought to cause systemic shock

Question 347

Risk factors for placental abruption

Answer 347

• Previous placental abruption (most predictive factor)
• Pre-eclampsia and HTN disorders
• Abnormal lie of baby (transverse)
• Polyhydramnios
• Abdominal trauma
• Smoking or drug use (cocaine)
• Bleeding in first trimester
  
  • Haematoma is seen inside uterus on first trimester scan
• Underlying thrombophilias
• Multiple pregnancy

Question 348

Clinical features of placental abruption

Answer 348

• Painful vaginal bleeding
  
  • Bleedig may be concealed
  • Inquire about pain during contraction if in labour
• O/E, uterus may be woody (tense all the time) and painful on palpation

Question 349

Differential diagnosis for antenatal haemorrhape

Answer 349

• Placental abruption (not most common)
• Placenta praevia
• Marginal placental bleed
  
  • Small placental abruption large enough to cause revealed bleeding but small enough not to cause maternal or foetal compromise
• Vasa praevia
• Uterine rupture
• Local genital cause
  
  • Benign or malignant
    
    • Polyps, carcinoma, cervical ectropion (common)
  • Infection
    
    • Candida, bacterial vaginosis, chlamydia

Question 350

Investigations for placental abrutpion

Answer 350

• Haematology
  
  • FBC
  • Clotting profile
  • Kleihauer test
    
    • if woman is Rh negative, to determine amount of foeto-maternal haemorrhage and this the dose of Anti-D required
  • Group and save
  • Cross match
• Biochemistry
  
  • U&E
  • LFT
  • exclude hypertensive disroders (pre-eclampsia, HELLP)
• Foetal wellbeing - CTG
• Imaging
  
  • Ultrasound scan
    
    • Whwen patient is stable
    • retroplacental haematoma might be seen
    • Good positive predictive value but poor negative predictive value
    • Therefore should not be used to exclude abruption

Question 351

Management of placental abruption

Answer 351

• ABCDE approach

Ongoing management of placental abruption is dependent of foetal health

• Emergency delivery
  
  • C-section if there is maternal or foetal compromise
• IOL
  
  • Haemorrhage at term without maternal/foetal compromise
  • Recommende to avoid further bleeding
• Conservative
  
  • Some partial or marginal abruptions without maternal or foetal compromise

All cases give anti-D within 72 hours on the onset of bleeding if woman is Rh -ve

Question 352

Describe the different types of multiple pregnancy

Answer 352

• Dizygotic twins (DZ)
  
  • Results from fertilisation of different oocytes by different sperm
  • Foetuses can be different sexes and are no more genetically similar than siblings from different pregnancies
• Monozygotic twins (MZ)
  
  • Results from mitotic division of a single zygote into identical twins.
  • Whether they share the same amnion or placenta depends on the time at which division into separate zygotes occured

Question 353

In monozygotic twins (MZ), what determines wherther they share the same placenta or same amnion

Answer 353

The time at which the zygote divides to form separate zygotes

Question 354

Describe the different types of placenta- / amnion- sharing seen in monozygotic twin pregnancies

Answer 354

• Dichorionic diamniotic (DCDA)
  
  • Division before day 3
• Monochorionic diamniotic (MCDA)
  
  • Division 4-8 day
• Monochorionic monoamniotic (MCMA)
  
  • Division 9-13 days
• Conjoined twins
  
  • Incomplete division

Placenta basically established earlier than amnion.

Question 355

_____ twins have a higher foetal loss rate, particularlty before _____ weeks

Answer 355

Monochorionic twins have a higher foetal loss rate, particularlty before 24 weeks

Question 356

What are some factors associated with multiple pregnancy

Answer 356

• Increasing maternal age - DZ twinning
• Increasing parity - DZ twinning
• Assisted conception
  
  • 20% IVF conceptions
  • 5-10% clomiphene-assisted conceptions
• Genetic factors

Question 357

What are some clinical features of multiple pregnancies

Answer 357

• More marked vomiting in early pregnancy
• Uterus larger than expected from dates
• Palpable before 12 weeks
• Three or more poles felt later in pregnancy

Question 358

Diagnosis of multiple pregnancy

Answer 358

Ultrasound

Question 359

What are some maternal complications of multiple pregnancy

Answer 359

All obstetric risks are exaggerated in multiple pregnancies

• Gestational diabetes
• Pre-eclampsia
• Miscarriage and preterm delivery
• IUGR
• Anaemia
  
  • Greater increase in blood volume and more demeand for iron and folic aicd
• Congenital abnormalities
• Antepartum and postpartum haemorrhage
• Malpresentation
• TTTS in MC twins only

Question 360

What are some foetal antenatal compliocations in all multiple pregnancies

Answer 360

Complications are due to preterm delivery, IUGR, and monochorionicity

• Mortatlity (6x)
• Long-term handicap (5x)
  
  • Triplets 18x
• Miscarriage
  
  • 1st trimester death and late miscarriages
• Preterm delivery
• IUGR
• Congenital abnormalities

Question 361

What are the complications of monochorionicity in multiple pregnancies

Answer 361

Result from shared blood supply in the single placenta

• Twin-Twin Transfusion Syndrome (TTTS)
• Twin anaemia polycythaemia sequence (TAPS)
• Twin Reversed arterial perfusion (TRAP)
• IUGR
• Co-twin death

Question 362

Describe the pathophysiology ot twin-twin transfusion syndrome (TTTS). What types of twins can this only occur in

Answer 362

Occurs only in MCDA twins

• Unequal blood distribution through vascular anastomoses of the shared placenta
• The donor twin is volume depleted and develops anaemia, IUGR and oligohydramnios.
• The recipient twin becomes volume overloaded and may develop polycythaemia, cardiac failure, massive polyhydramnios (in extremis, causes massive distension of uterus)

Question 363

What does the donor twin in TTTS develop?

Answer 363

• Anaemia
• IUGR
• Oligohydramnios

Question 364

What does the recipient twin in TTTS develop

Answer 364

• Volume overloaded
• Polycythaemia
• Cardiac failure
• Polyhydramnios

Question 365

How is TTTS staged

Answer 365

Quintero staging (1-5)

III - absent or reversed end-diastolic flow in the umbilical artery, pulsatile uymbilical venous flow, reverse ductus venosus flow

Question 366

In TTTS, both twins are ate very high risk of what two complications

Answer 366

• In utero death
• Severely pre-term delivery

Question 367

Define the features of Twin Anaemia Polycythaemia Sequence (TAPS)

Answer 367

• Occurs when there is marked Hb differences between MC twins but in the absence of liqour volume changes characterisitic of TTTS
• These occur due to small placental anastomoses, following incomplete laser ablation for TTTS

Question 368

Describe the pathophysiology of Twin Reversed Arterial Perfusion (TRAP)

Answer 368

Rare abnormality in MC twins

• Abnormal, acardiac foetus, perfused by a normal ‘pump’ twin
• Oxygenated blood comes in from UV into fRV. Deoxygenated blood come out of the pump twins UA into the acardiac foetus UA through anastomoses in placental bed.
• This blood then leaves acardiac foetus through its UV back into the placenta

Question 369

In TRAP, the pump twin is a t risk of what

Answer 369

cardiac failure

Question 370

• Intrauterine growth restriction is more common in MC twins, in the absence of clear blood volume discordancy.
• A particular problem is where the umbilical arterywaveform of the smaller twin is very erratic (selective IUGR with intermittent absent or reversed end-diastolic flow, abbreviated to sIUGR with iAREDF).
• This may be the result of the superficial artery–artery anastomoses, shown in Fig. 27.4; an ultrasound of these is shown inFig. 27.5.
• Sudden in utero death occurs in up to 20%, handicap in 8%.

Answer 370

• Intrauterine growth restriction is more common in MC twins, in the absence of clear blood volume discordancy.
• A particular problem is where the umbilical artery waveform of the smaller twin is very erratic (selective IUGR with intermittent absent or reversed end-diastolic flow, abbreviated to sIUGR with iAREDF).
• This may be the result of the superficial artery–artery anastomoses, shown in Fig. 27.4; an ultrasound of these is shown inFig. 27.5.
• Sudden in utero death occurs in up to 20%, handicap in 8%.

Question 371

Co-twin death: If one of an MC twin pair dies, due to TTTS or any other cause, the drop in its _____ _____ allows acute transfusion of blood from the other twin. This rapidly leads to _____ and, in about 30% of cases, death or _____ damage. The survivor of a dichorionic twin pregnancy is not at risk, except of _____ _____, because the circulation is not shared.

Answer 371

Co-twin death: If one of an MC twin pair dies, due to TTTS or any other cause, the drop in its Bloood pressure allows acute transfusion of blood from the other twin. This rapidly leads to hypovolaemia and, in about 30% of cases, death or neurological damage. The survivor of a dichorionic twin pregnancy is not at risk, except of preterm delivery, because the circulation is not shared.

Question 372

In monochorionic monoamniotic twins, the _____ are always _____. In utero _____ is common, probably because of this and/or sudden acute _____ of blood between the two babies in anastomoses between the close cord insertions

Answer 372

In monochorionic monoamniotic twins, the cords are always tangled. In utero demise is common, probably because of this and/or sudden acute shuinting of blood between the two babies in anastomoses between the close cord insertions

Question 373

In ultrasound of dichorionic twins, what sign can be seen

Answer 373

• Lambda sign
• Dividing membrane is thicker as it meeths the placentas.
• Remembe dichorionic twins form when fertilised egg divides early

Question 374

In monochorionic twins, what sign is seen on ultrasound

Answer 374

• T sign
• The dividing membrane is thinner as it meets the placentas
• Remember monochorionic twins form when fertilised egg divides later

Question 375

Are multiple pregnancies high or low risk pregnancies

Answer 375

High risk pregnancies, consultant-led

• Iron and folic acid supplementation
• Low dose aspirin if other RF for pre-eclampsia

Question 376

Twins of _____ gender are always _____

Answer 376

Twins of opposite gender are always Dizygotic

Question 377

Identification of risk of preterm delivery: Transvaginal
ultrasound of _____ length is not advised in the UK
but may identify those at most risk. In contrast to singletons, neither progesterone nor cervical _____ prevents _____ _____ in multiple pregnancies.

Answer 377

Identification of risk of preterm delivery: Transvaginal
ultrasound of cervical length is not advised in the UK but may identify those at most risk. In contrast to singletons, neither progesterone nor cervical cerclage prevents preterm** **birth in multiple pregnancies.

Question 378

How is IUGR monitored in multiple pregnancy

Answer 378

• More difficult to identify vs singleton pregnancies
• Serial ultrasound examinations performed at 28, 32, 36 weeks and more often with monochorionic twins

Question 379

When is devliery recommended for multiple pregnanciees

Answer 379

• 37 weeks
  
  • Dichorionic twins
• 36 weeks
  
  • Uncomplicated monochorionic twins

Question 380

In monochorionic twins, when does ultrasound surveillance start and what features are we looking out for

Answer 380

• Start 12 weeks and scan every 2 weeks until 24 weeks, at which it should be 2-3 weekly
• Features:
  
  • TTTS (16-24 weeks)
    
    • growth
    • liqour volume discordances
    • Polyhydramnios
    • Tricuspid reguritation (overload)

Question 381

How can mild TTTS be managed

Answer 381

• Laser ablation of the entire placental interfacce in a foetal medicine centre using ultrasound and foetoscopy

Survival both twins 50%, one twin 80%

Question 382

How is high order multiple pregnancy managed

Answer 382

• Selective reduction to twin pregnancy at 12 weeks
  
  • Needs discussion
  • Balance between increased early miscarriage rates and reduced preterm birth (therefore cerebral palsy)
  • Safest before 14 weeks
• Surveillance according to chorionicitiy
• Deliver by 36 weeks

Question 383

What are the indications for the different modes of delivery in multiple pregnancies

Answer 383

• Vaginal delivery - if first foetus is cephalic, regardless of second’s lie or presentation
• C-section - if first foetus is breech or transverse lie. With high order multiple pregnancies. If there have been antepartum complications. (some places - all monochorionic twins)

Question 384

What considerations need to be had when delivering multiple pregnancies

Answer 384

• When to deliver 37 weeks (DC) or 36 weeks (MC)
• continious CTG
• Contractions diminish after first baby delivered - can give oxyitocin if contractions dont start again
• ECV of second twin can pe performed if not longiutuidinal
• If foetal distress or cord prolapse, delivery can be expedited with ventouse or breech extraction
• Prophylactic oxytocin to prevent PPH

Question 385

What are some pitfalls of delivering twins

Answer 385

• Scaring the mother (too mamny people present)
• Failure to monitor second twin properly
• Overstimulation of uterus with oxytocin
• Early rupture of membranes
• PPH

Question 386

Define a breech presentation

Answer 386

• Foetus presents buttocks or feet first (rather than cephalic presentation - head)
• Breech delivery has higher perinatal mortality and morbidity (due to birth asphyxia/trauma, prematurity, congenital malformations)

Question 387

Name and describe the types of breech presentation

Answer 387

• Complete (flexed) breech
  
  • Both legs are flexed at hips and knees
  • Foetus sitting cross-legged
• Frank (extended) breech
  
  • Both legs are flexed at the hip and extended at the knee
  • Most common type of breech presentation
• Footling breech
  
  • Onr or both legs are extended at the hip
  • foot is presenting part

Question 388

What are some uterine risk factors for breech presentation

Answer 388

• Multiparity
• Uterine malformation (septate uterus)
• Fibroids
• Placenta praevia

Question 389

What are some foetal risks of breech presentation

Answer 389

• Prematuritty
• Macrosomia
• Polyhydramnios
• Twin pregnancy (or higher order)
• Abnormality (anencephaly)

Question 390

At what gestational age does a breech presentation have limited and important significance

Answer 390

• Limited = 32- 35 weeks
  
  • Likely to revert to cephalic presentation before delivery
• Important = >37 weeks

Question 391

How is breech presentation identified and describe features

Answer 391

• Clinical examination
  
  • Palpation of abdoman - round foetal head in upper part of uterus and irregular mass (foetal buttock and legs) in pelvis
  • Foetal heart auscultated higher on maternal abdomen
• 20% not diagnosed until labour
  
  • Vaginal examination - sacrum or foot may be felt through the cervical opening

Question 392

What sign of foetal distress is seen on breech presentation during labour

Answer 392

Meconium stained liqour

Question 393

Differential diagnosis for breech presentation

Answer 393

• Oblique lie
• Transverse lie
• Unstable lie

Question 394

Investigations for breech presentation

Answer 394

• Ultrasound scan
  
  • Reveal type of breech
  • Identify foetal or uterine abnormalities that predisposes the breech presentaiton

Question 395

Management options for breech presentation

Answer 395

• External cephalic version
• Caeserian section
• Vaginal breech birth

Question 396

Describe how external cephalic version is used to manage breech presentation

Answer 396

• Manipulation of ofetus to cephalic presentation through maternal abdomen
  
  • If successful -> vaginal delivery
  • 40% success in primiparous, 60% in multiparous

Question 397

Complications of ECV in breech presentations

Answer 397

• Transient foetal hear abnormalities (revert ot onrmal)
• Persistent hear rate abnormalities (fetal bradycardia) -rarer
• Placental abruption -rARE

Question 398

Contraindications of ECV in breech presentation

Answer 398

• Recent antepartum haemorrhage
• Ruptured membranes
• Uterine abnormalities
• Previous C-Section

Question 399

When is C-section indicated in breech presentation

Answer 399

• If ECV is unsuccessful, contraindicated or declined by woman
• Based on evidence that higher perinatal mortality and morbidity in planned vaginal breech biorths vs c-section in term babies

Question 400

Contraindications to vaginal breech birth

Answer 400

• Footling breech
  
  • Shoulders or head can become trapped in non-fully dilated cervix

Question 401

What is the most important thing to remember in a vaginal breech delivery

Answer 401

• Hand off the breech
• Traction on baby during delivery can cause feotal head to extend, getting trapped in delivery
• Foetal sacrum needs to be maintained anteriorly, which is done by holding foetal pelvis
• If baby does not deliver spontaneously, maneouvres may be required

Question 402

If spontanoues vaginal devliery does not occur in vaginal breech delivery, what maneouvres can be used and describe them

Answer 402

• Flexing foetal knees
  
  • enables delivery of legs
• Loovsett’s maneouvre
  
  • Rotate the body and deliver shoulders
• Mauriceau-Smellie-Veit (MSV) maneouvre
  
  • Delivery of head by flexion
  • if MSV fails, forceps can be used

Question 403

Complications of breech presentation

Answer 403

• Cord prolapse
  
  • Cord drops down below presenting part of baby and becomes compressed
• Foetal head entrapment
• PROMs
• Birth asphyxia
  
  • Secondary to delay in delivery
• Intracranial haemorrhage
  
  • Rapid compression of head during delivery

Question 404

Define foetal lie and name examples

Answer 404

• Relationship between the long axis of of foetus and the mother
  
  • Longitudinal
  • Transverse
  • Oblique

Question 405

Define foetal presentation and examples

Answer 405

• The foetal part that first enters the maternal pelvis
  
  • Cephalix vertex = most common and safest
  • Breech
  • Shoulder
  • Face
  • Brow

Question 406

Define foetal position and describe examples

Answer 406

• Position of foetal head as it exits the birth canal
  
  • Usually head angages in the occipito-anterior position (foetal occiput facting anteriorly)
    
    • Ideal for birth
  • Occipito-posterior
  • Occipito-transverse

Right is vertex presentation

Question 407

What are some risk factors for abnormal foetal lie, malpresentation and malposition

Answer 407

• Prematurity
• Multiple Pregnancy
• Uterine abnormalities (fibroids, partial septate uterus)
• Foetal abnormalities
• Placenta praevia
• Primiparity

Question 408

How is foetal lie identified

Answer 408

abdominal examination

Question 409

How is foetal presentation identified

Answer 409

abdominal examination

Question 410

How is foetal position ascertained

Answer 410

Vaginal examination

Question 411

When identifying foetal lie and presentation, what facotrs might prevent you from identifying either features

Answer 411

• High maternal BMI
• Full bladder
• Small foetus
• Polyhydramnios

Question 412

In terms of lie, presentation and position, what is most favourable

Answer 412

• Longitudinal
• Cephalic vertex
• Occipito-anterior position

Question 413

How are abnormal lies or malpresentation invesitigated

Answer 413

Confirmed by ultrasound scan

Could demonstrate predisposing uterine or foetal abnormalities

Question 414

Management of abnormal foetal lie

Answer 414

• External cephalic version between 36-38 weeks

Question 415

Management of malpresentation

Answer 415

Dependent on the presentation

• Breech - attempt ECV, vaginal breech delivery or C-Section
• Brow - C-section
• Face
  
  • Chin anterior (mento-anterior) normal labour possible
    
    • Likley prolonged and risk of C-section being required
  • Chin posterior (mento-posterior) C-section
• Shoulder - C-section

Bascially C-section except for breech (ECV then C-section/Breech vaginal delivery) or Mento-anterior face presentation

Question 416

Management of malposition

Answer 416

• 90% spontaneously rotate to occipito-anterior as labour progresses
• If foteal head does not rotate -> rotation and operative vaginal delivery can be attempted
• C-section is alternative

Question 417

What is amniotic fluid comprised of

Answer 417

• Foetal urine output
• Small contributions from placenta
• Small contributions from foetal secretions (respiratory)

Question 418

Describe the normal evolution of amniotic fluid volumes

Answer 418

• Amniotic fluid volume increases steadily until 33 weeks gestation
• Plateaus 33-38 weeks and then declines
• Volume at term ~ 500mL

Question 419

Describe the physiology involved in the changing amniotic fluid volumes

Answer 419

• Foetus breathes and swallows amniotic fluid
• Gets processed, fills bladder and voided
• Cycle repeats
• Problems with any structures on this pathway can lead to too much or too little fluid

Question 420

Define oligohydramnios

Answer 420

• Low level of amniotic fluid during pregnancy
• Amniotic fluid index < 5th centile for gestational age
• 4.5% term pregnancies

Question 421

Causes of oligohydramnios

Answer 421

Anything that reduces foetal urine production, output blockade or rupture of membranes

• P-PROM
• Placental insufficiency
  
  • Blood flow redistribution to foetal brain rather than abdomen and kidneys. Poor urine output
• Renal agenesis (Potter’s Syndrome)
• Non-functioning foetal kidneys
  
  • Bilateral multicystic dysplastic kidneys
• Obstructive uropathy
• Genetic/chromosomal anomalies
• Viral infections
  
  • Can also cause polyhydramnios

Question 422

How is oligohydramnios diagnosed and what two measurements can be made - describe them

Answer 422

Ultrasound examination

• Amniotic fluid index
  
  • Measuring cord-free vertical pocket of fluid in four quadratns of uterus and adding them together
• Maximum pool depth
  
  • Vertical measurement in any area

Both have similar diagnostic accuracy but AFI is more commonly used

Question 423

Oligohydramnios is diagnosed by ultrasound examination. Therefore, clinical assessment of patyient is directed at establishing the underlying cause. What features in your assessment could point you towards the cause

Answer 423

• History
  
  • Symptoms of leaking fluid
  • Feeling damp all the time
  • New urinary inctontinence
• Examination
  
  • Symphysis fundal height
  • Speculum examination - pooling of liqour
• Ultrasound
  
  • Liqour volume, structural abnormalities, renal agenesis, obstructive uropathy
  • Foetal size
    
    • Small babies result from placental insufficiency which causes oligohydramnios
    • Rise in pulsatility index of umbilical artery doppler in placental insuffieicney
• Karytopying
  
  • Early and unexplained oligohydramnios
• IGFBP-1 in vagina
  
  • If suspecting ruyptrued membrane
  • Found in amniotic fluid, if positive = strongly suggestive of membrane rupture

Question 424

Management of oligohydramnios is dependent on what

Answer 424

Dependent on the underlying cause. Most common two causes are:

• Rupture of membranes
• Placental insufficiency

Question 425

Management of oligohydramnios (2o to ruptured membranes)

Answer 425

• Labour likely to comence in 24-48 hours
• in P-PROM (<37 weeks) IOL considered 34-36 weeks in absence of infection
  
  • Course of steroids fro foetal lung development
  • Antibiotics to reduce ascending infection

Question 426

Managmenet of oligohydramnios (2o to placental insufficiency)

Answer 426

• Deliver, which is dependent on:
  
  • Rate of foetal growth
  • Umbilical artery and middle cerebral artery doppler scans
  • CTG
• Likely delivered <36-37 weeks

Question 427

• Oligohydramnios in the _____ trimester carries poor prognosis. In these cases, there is PROM+/- infection, with subsequent _____ delivery and pulmonary _____ (lead to respiratory distress at birth
• Oligohydramnios associated with _____ _____ carries higher rate of preterm deliveries (usually through planned IOL). These have _____ prognosis than that of normal growing foetus
• Amniotic fluid allows foetus to move its limbs in utero (exercise). Without this, the foetus can develop severe _____ _____- which may lead to _____ despite physiotherapy after birth

Answer 427

• Oligohydramnios in the second trimester carries poor prognosis. In these cases, there is PROM+/- infection, with subsequent premature delivery and pulmonary hypoplasia (lead to respiratory distress at birth
• Oligohydramnios associated with placental** **insufficiency** carries higher rate of preterm deliveries (usually through planned IOL). These have **poorer prognosis than that of normal growing foetus
• Amniotic fluid allows foetus to move its limbs in utero (exercise). Without this, the foetus can develop severe muscle** **contractures** - which may lead to **disability despite physiotherapy after birth

Question 428

Most common cause of oligohydramnios

Answer 428

Premature rupture of membranes (PROMs)

Treatment is by optimising gestation of delivery

Question 429

Define polyhydramnios

Answer 429

• Abnormally large level of amniotic fluid during pregnancy
• Amniotic fluid index > 95th centile for gestational age

Question 430

Causes of polyhydramnios

Answer 430

• Idiopathic 50-60%
• Any condition that prevents foetus from swallowing
  
  • Oesophageal atresia, CNS abnormalities, muscular dystrophy, congenital diaphragmatic hernia obstructing oesophagus
• Duodenal atresia
  
  • Double bubble sign on USS
• Anaemia
  
  • Alloimmune disorders, viral infection
• Foetal hydrops
• TTTS
• Increased lung secretions
  
  • Cystic adenomatoid malformation of lung
• Genetic or chromosomal abnormalities
• Maternal diabetes
• MAterna lithium
  
  • Foetal diabetes insipidus
• Macrosomia
  
  • Large babies produce more urine

Question 431

How is polyhydramnios diagnosed

Answer 431

Ultrasound scan (with amniotic fluid index and/or maximum depth pool)

Question 432

Polyhydramnios is diagnosed by ultrasound scan. The clinical assessment is directed at establishing the underlying cause. What are some features of the assessment that may identify the cause

Answer 432

• Examination
  
  • Tense uterus on palpation
• Ultrasound scan
  
  • Measurement of liqour volume
  • Assess foetal size
  • Assess foetal anatomy (structural causes)
  • Doppler - foetal anaemia
• Maternal GTT
  
  • GDM or maternal DM
• Karyotypiung
• Viral infections (TORCH)
• Maternal red cell antibodies
  
  • at 28 weeks

Question 433

Management of polyhydramnios

Answer 433

No medicla intervention in majortiy of women

• Maternal symptoms (breathlessness)
  
  • Amnioreduction
    
    • Associated with infection and placental abruption
    • Not performed routinely
• Indomethacin
  
  • Enhance water retnetion and reduces foetal urine output
  • Premature closure of ductus arteriosus. DO NOT use beyond 32 weeks
• Idiopathic polyhydramnios
  
  • Baby must be examined before first feed to ensure no fistulas or oesophageal atresias

Question 434

Prognosis in pregnancies with polyhydramnios

Answer 434

• Severe and persistently unexplained polyhydramnios = increased perinatal mortality, due to:
  
  • Presence of underlying abnomralitiy or congenital malformation
  • Increased incidence of preterm labour (due to over-distension of uterus)

Question 435

Complications of polyhydramnios

Answer 435

• Perinatal mortality
• Malpresentation
  
  • Transverse lie or breech presentation
  • foetus has more room to move
• High risk of cord prolapse at rupture of membranes
• PPH
  
  • Uteurs has to contract further to achieve haemostasis

Question 436

Urinary tract infections in pregnancy is associated with what complications

Answer 436

• Preterm labour
• Anaemia
• Perinatal mortality and morbidity

Question 437

Asymptomatic bacteriuria affects 5% of women but in pregnancy is more likely to lead to what

Answer 437

Pyelonephritis (20%)

Question 438

What are some investigations for bacteruria

Answer 438

• Urine culture at booking visit
• Treat asymptomatic bacteruria at booking
• Culture if nitrites found on urinalysios

Question 439

Clinical features of pyelonpehritis

Answer 439

• Fever
• Loin tenderness and abdominal pain
• Dysuria
• Rigors
• Tachycardia
• Vomitting

Question 440

Management of pyelonephritis

Answer 440

IV antibiotics

• ?Erythromycin/?cephalosporin

Question 441

What is the usual causative organism for pyelonephritis in 75% of cases

Answer 441

• E coli
• Resistant to amoxiciillin

Question 442

Thyroid status does not alter in pregnancy, although _____ clearance is increased. Goitre is more common. Fetal thyroxine production starts at _____ weeks; before, it is dependent on maternal thyroxine. Maternal thyroid-stimulating hormone (TSH) is _____ in early pregnancy.

Answer 442

Thyroid status does not alter in pregnancy, although iodine clearance is increased. Goitre is more common. Fetal thyroxine production starts at 12 weeks; before, it is dependent on maternal thyroxine. Maternal thyroid-stimulating hormone (TSH) is increased in early pregnancy.

Question 443

Most common causes of hypothyroidism in UK

Answer 443

• Hashimoto’s thyroiditis
• Thyroid surgery (iatrogenic)
• Iodine defieicny (developing countries)

Question 444

Hypothyroidisim associated with increased risks in

Answer 444

• Perinatal mortality
• Miscarriage
• Preterm delivery
• Intellectual impariemtn in childhoof
• Pre-eclampsia (esp if anti-thyroid Ab present)

Question 445

Management of hypothyroidism in pregnancy

Answer 445

• Replacement of thyroxine
• Monitor TSH 6-weekly

Question 446

Common cause of hyperthyroidism

Answer 446

Graves disease

Question 447

Untreated hyperthyroidism increases what

Answer 447

perinatal mortality

Question 448

Graves disease in pregnancy: Antithyroid antibodies also cross the _____; rarely, this causes neonatal _____ and goitre. For the mother, thyrotoxicosis may improve in late pregnancy but poorly controlled disease risks a ‘_____ storm’ whereby the mother gets acute symptoms and _____ failure. Symptoms may be confused with those of pregnancy.

Answer 448

Antithyroid antibodies also cross the placenta; rarely, this causes neonatal thyrotoxicosis and goitre. For the mother, thyrotoxicosis may improve in late pregnancy but poorly controlled disease risks a ‘thyroid storm’ whereby the mother gets acute symptoms and heart failure. Symptoms may be confused with those of pregnancy.

Question 449

Hyperthyroidism in pregnancy treated with?

Answer 449

• Propylthiouracil (PTU) in 1st trimester
  
  • Instead of carbimazole
  • PTU crosses placenta
  • Can sometimes cause neonatal hypothyroidism
  • Lowest possible dose used
  • TFT tested monthly
• Grtaves worsens post-partum

Question 450

What is a common cause of postnatal depression

Answer 450

Postpartum thyroiditis

common 5-10%

Question 451

Risk factors for postpartum thyroiditis

Answer 451

• Antithyroid antibodies
• Type 1 diabetes

Question 452

Describe the evolution of postpartum thyroiditis

• Transient and usually subclinicaly _____(hyper/hypo)thyroidism, usually about _____ months post-partum
• this is followed by _____ months of _____(hyper/hypo)thyroidism
• Permanent in 20%

Answer 452

• Transient and usually subclinical hyperthyroidism, usually about 3 months post-partum
• this is followed by 4 months of hypothyroidism
• Permanent in 20%

Question 453

What is the most important route of transmission of HIV in pregnant women

Answer 453

Heterosexual intercourse

Question 454

What are some maternal effects of HIV in pregnancy

Answer 454

• Pre-eclampsoa
• GDM

Question 455

What are some neonatal/foetal effects of HIV in pregnancy

Answer 455

• Stillbirth
• pre eclampsia
• Growth restriction
• Prematurity

Question 456

When is the risk of HIV transmission highest in pregnancy

Answer 456

• Beyond 36 weeks
• Intrapartum
• Breastfeeding

Question 457

What are some factors that increase the risk of transmission of HIV

Answer 457

• Low CD4 counts
• High viral load
• Coexistent infection
• Premature delivery
• Intrapartum
• Prolonged rupture of membranes >4 hours

Question 458

Management of HIV in pregnancy

Answer 458

Screening and prophylaxis

• Screened at booking
• STI and PCP surveillance
• LFTs and renal function (drug toxicity)
• Hb and glucose monitoring

Preventing transmisison

• Control viral load with HAART
  
  • Continued throughout pregnancy and delivery
• Neonate treated with PeP for first 6 weeks
• If woman was not on treatment pre-pregnancy, then start therapy at 28 weeks
• C-section ig viral load >50 copies/mL and co-existing Hep C infection
• Avoid breastfeedging

Question 459

Define female genital mutiltaion

Answer 459

• Female circumcision
• Partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons
• Practised in Africa and Middle East, Malaysia and Indonesia for different reasons, including ideas of preservation of virginity, promoting hygeine, adherence to cultural norms and religion - FGM is not condoned in the Bible or the Koran
• Violation of human rights, child abuse and has no health benefits

Question 460

What are the classifications of FGM

Answer 460

Type 1

• Clitoridectomy
• Partial or total removal of the clitoris, or of the prepuce

Type 2

• Excision
• Partial or total removal of the clitoris and the labia minora ± the labia majora

Type 3

• Infibulation
• Narrowing of the vaginal opening by cutting and repositioning the labia, with or without removal of the clitoris

Type 4

• Other
• All other non-medical procedures to female genitalia for non-medical purposes (?peircings)

Question 461

Complications of FGM

Answer 461

• Short term
  
  • Pain, bleeding, infection, urinary retention, damage to pelvic organs, death
• Longer term
  
  • Failure to heal, UTI, difficulty urinating/menstruating, chronic pelvic infection, vulval pain (cysts and neuromas), dyspareunia, infertility, fistula, severe perineal trauma during childbirth
  • Psychological

Question 462

FGM and the law: True or false

• In the UK it is illegal to perform FGM, including reinstatement after vaginal birth, or to arrange for FGM to happen.
• It is illegal to take or arrange for a girl to be taken to another country for FGM, even if it is legal in that country.
• Female children may be at risk of FGM and healthcare workers have a statutory duty to safeguard them.

Answer 462

• In the UK it is illegal to perform FGM, including reinstatement after vaginal birth, or to arrange for FGM to happen. - TRUE
• It is illegal to take or arrange for a girl to be taken to another country for FGM, even if it is legal in that country. -TRUE
• Female children may be at risk of FGM and healthcare workers have a statutory duty to safeguard them. - TRUE