Obstetrics (Quesmed) Flashcards

Question

How is Congenital Cytomegalovirus Infection diagnosed?

Answer 1

Typically it is diagnosed Post-Natally- by testing the baby's saliva, blood or urine Antenatally, it can be detected on Ultrasound and confirmed by Amniocentesis. Routine screening for CMV antibodies in the mother is NOT recommended

Answer 2

The First Trimester of Pregnancy

Answer 3

Sensorineural Hearing Loss Cataracts Retinopathy Congenital HEART Disease (4 small/low things and 3 extra things) Microcephaly Micrognathia (small LOWER JAW) Low Birth Weight Developmental Delay and Learning Disability HAEMATOLOGICAL abnormalities BLUEBERRY MUFFIN rash Organ Dysfunction

Answer 4

It is caused by Toxoplasma gondii- found in Cat Faeces, Infected Meat and Soil Most people who contract it are ASYMPTOMATIC or have MILD flu-like symptoms It can also spread vertically to babies in the womb- Congenital Toxoplasmosis

Answer 5

CNS Problems (Cerebral Palsy, Epilepsy and Hydrocephalus) Learning Disabilities Visual Impairment Hearing Loss

Answer 6

Antenatal Ultrasound to look for Foetal Abnormalities) Amniocentesis with PCR Testing Maternal IgM testing to check for PREVIOUS exposure Foetal Blood Test SPIRAMYCIN is used to treat toxoplasmosis DURING pregnancy to reduce transmission to the baby

Answer 7

Microcephaly Low Birth Weight Limb Hypoplasia Learning Disabilities Eye Defects Skin Scarring

Answer 8

Diagnosis is clinical Management - if a non-immune pregnant woman comes into contact with someone infected with varicella zoster, Immunoglobulin can be given as prophylaxis - Acyclovir is used as treatment if the maternal infection occurs. This should be given within 24 hours of the onset of the rash - Neonate should be monitored and given IV Acyclovir as soon as they are born

Answer 9

Undiagnosed Vaginal Bleeding- as may be Placenta Praevia and digital examination can provoke a haemorrhage Preterm labour rupture of membranes without clear contractions- to Avoid the infection Ascending into the Uterus

Answer 10

When the umbilical cord exits the cervix prior to the infant LAMP HP - Low Birth Weight - Abnormal Lie - Multiple Pregnancy/ Multiparity - Prematurity - High Head - Polyhydramnios

Answer 11

- Foetus should be delivered asap - While preparing for delivery, further prolapse should be avoided by encouraging a "knees-to-chest" position - Filling the bladder with 500ml warm saline can prevent further prolapse - Avoid exposure and handling of the cord - Tocolytics (Terbutaline)- to stop Uterine Contractions

Answer 12

Foetal Complications - Macrosomia (birthweight>4kg)- due to excess maternal blood glucose crossing the placenta and Increasing Foetal Insulin Production. This can increase the risk of (3) Shoulder Dystocia, Birth Injuries and Emergency Caesarean Section - Pre-term Delivery- which may lead to Respiratory Distress Syndrome - Hypoglycaemia in the baby shortly After Birth due to the high Insulin levels they have. They may have Hypoglycaemic Seizures on birth - Increased risk of developing Type 2 Diabetes later in life Maternal Complications - Increased risk of Hypertension - Increased risk of Pre-Eclampsia - Increased risk of developing Type 2 Diabetes later in life - Increased risk of Gestational Diabetes Mellitus (GDM) in future pregnancies

Answer 13

Coeliac Disease Hypothyroidism Epilepsy Alzheimer's Disease Tumours and Leukaemia Cataracts Hearing Loss

Answer 14

- Brachycephaly with Flat Occiput - Epicanthal Folds and Upslanting Palpebral Fissures - Brushfield Spots on the Iris - Short Nose with a Low Nasal Bridge - Small Ears that may be Low Set - Protruding Tongue - Down-turned Mouth with a Small Oral Cavity - Extra Skin on the back of the baby's Neck - Small Hands with a Single Palmar Transverse Crease - Saddle Toe Gap - Hypotonia (Floppy Baby) - Congenital Heart Disease (50% of Down Syndrome patients have this) - Gross Motor Delay - Language Delay - Hearing Loss - Autism Spectrum Disorder - Constipation

Answer 15

Atrioventricular Septal Defects (AVSD) Ventricular Septal Defects (VSD) Patent Ductus Arteriosus (PDA)

Answer 16

Paediatric Assessment and Specialist Review for conditions associated with Down Syndrome (Congenital Heart Disease is the main risk) General Counselling for Parents Affected Children will require Interventional Treatments Affected Children will need Personalised Education Plans and Social Support

Answer 17

Nuchal Translucency using Ultrasound Scan PAPP-A hormone (Level Reduced in pregnancy affected with Down Syndrome) Beta-hCG (Raised in Pregnancy affected with Down Syndrome) This test is carried out between 11 to 13 weeks of pregnancy in the First Trimester

Answer 18

Triple Test- - Beta HCG - AFP (Reduced in pregnancy affected with Down Syndrome) - uE3 (Reduced in pregnancy affected with Down Syndrome) Additional Test- - Inhibin-A Test (Raised in pregnancy affected with Down Syndrome)

Answer 19

Chorionic Villus Sampling Amniocentesis

Answer 20

Hypertension and Proteinuria Severe Headache Visual Disturbance Drowsiness Epigastric Pain Nausea/ Vomiting Hyperreflexia Peripheral Oedema

Answer 21

Increased Maternal Age Previous or Family History of Pre Eclampsia Existing Disease (Hypertension, Diabetes, Renal Disease, Autoimmune Disease) Multiple Pregnancy Obesity Nulliparity

Answer 22

Maternal Complications - Eclampsia (Seizures due to Cerebrovascular Vasospasm) - Organ Failure - Disseminated Intravascular Coagulation - HELLP Syndrome (Haemolysis, Elevated Liver Enzymes, Low Platelets) Foetal Complications - Intrauterine Growth Restriction - Pre-term Delivery - Placental Abruption - Neonatal Hypoxia

Answer 23

Anti-Hypertensives (LABETALOL is first line) MAGNESIUM SULPHATE can help prevent and treat Eclamptic Seizures

Answer 24

- Pelvic Inflammatory Disease - Genital Infection (like Gonorrhoea) - Pelvic Surgery - Having an Intrauterine Device - Assisted Reproduction - Previous Ectopic Pregnancy - Endometriosis

Answer 25

- Pelvic Pain (Unilateral to the side of the Ectopic) - Shoulder Tip Pain (if the Ectopic bleeds, the blood can Irritate the diaphragm which is felt at the shoulder tip) - Abnormal Vaginal bleeding (missed period or intermenstrual bleeding) - Haemodynamic Instability caused by blood loss if the ectopic ruptures - Abdominal examination may reveal Unilateral Tenderness - Cervical Tenderness (Chandelier Sign) on Bimanual Examination

Answer 26

If the patient has minimal/ no symptoms Do repeat B-hCG tests and if the levels are not falling at a satisfactory rate, then active management is advised

Answer 27

One-off dose of Methotrexate The criteria for Methotrexate treatment (3) (low hCG level, ability to attend follow up, adherence to avoiding pregnancy for a period following treatment) If the initial dose does not work, then a second dose or surgical management may be necessary

Answer 28

4 Criteria for Surgical Management - Significant amount of pain - Adnexal mass of 35mm or more - B-hCG levels are 5000IU or more - Ultrasound identifies a foetal heartbeat Surgical Management- Salpingectomy (fallopian tube containing the Ectopic Pregnancy is removed)- if they only have one Fallopian Tube and wish to remain fertile then a Salpingotomy can be done The risk with Salpingotomy is that sometimes not all of the tissue is removed, so B-hCG measurements are done to make sure no trophoblastic tissue is left

Answer 29

Physiological changes during pregnancy can lower the seizure threshold and increase the frequency of fits. Prolonged fits are dangerous as they can increase the risk of Foetal Hypoxia The mother's use of Anti-Epileptic drugs increases the risk of the foetus developing Congenital Abnormalities such as Neural Tube Defects So you need to find a middle ground between the risk of stopping anti-epileptic medication and the risk of a foetal abnormality although the risk of stopping anti-epileptic medication is generally considered the BIGGER THREAT

Answer 30

Neurology review should be started to assess the current Anti-Epilepsy Medication and they should aim for a Monotherapy, with the Lowest Effective Dose of Medication being used CARBAMAZEPINE and LAMOTRIGINE are the safest anti-epileptic drugs to use in pregnancy. SODIUM VALPROATE should be AVOIDED as it carries the highest risk of congenital abnormalities In general, women with a history of Epilepsy but no high risk of unprovoked seizures can be managed as Low Risk pregnancies. And all medications MAY be stopped if no fits have occurred for at least 2 years Drug compliance must be emphasised and the woman should be advised to continue their medication through pregnancy All of them need to take 5mg/day of Folic Acid pre-conceptually at least until the end of the first trimester. This is to minimise the risk of Neural Tube Defects and Folate Deficiency

Answer 31

All pregnant women with Epilepsy should be under Joint Medical and Obstetric Care Plasma Anti-epileptic Drug Levels should be monitored regularly, as levels are likely to decrease with increasing plasma volume during pregnancy The foetus should be monitored throughout pregnancy for Abnormalities with Serial Growth and Anomaly Scans Anti-epileptic Regimes may inhibit foetal Clotting Factor Production so Vitamin K therapy should be given from 36 weeks gestation Pregnant women with epilepsy should be REASSURED that most will have an uncomplicated labour and delivery and that there are no specific differences in labour management compared to Non-epileptic women If epileptic seizures do occur during labour, they should be terminated as quickly as possible with Benzodiazepines in order to avoid Maternal and Foetal Hypoxia If a pregnant women with no previous diagnosis of epilepsy presents after the first trimester with seizures, the immediate management guidelines for Eclampsia should be followed until a definitive Neurological diagnosis can be made

Answer 32

It is generally safe to take Anti-Epileptic Drugs while Breastfeeding The Anti-Epileptic doses should be reviewed after delivery to prevent post-partum toxicity as plasma levels return to normal

Answer 33

Maternal Factors- - Maternal BMI and Nutrition Status (poor weight gain during pregnancy) - Co-morbidities such as (9) Diabetes, Anaemia, Hypertension, Infection, Sickle Cell Anaemia, Pulmonary or Cardiovascular Disease, Renal Disease and Coeliac Disease - Cigarettes, Alcohol, Drugs - Structural Uterine Malformations Foetal Factors- - Chromosomal Defects - Multiple Pregnancy - Vertically Transmitted Infection (CMV, Rubella, Toxoplasmosis) Placental Factors- - Utero-placental Insufficiency - Pre-Eclampsia

Answer 34

Starts with the Regular Uterine Contractions and ends when there is complete Cervix Dilatation of 10cm - Cervix Dilatation is 1cm every 2 hours in Primiparous Women and 1cm every hour in Multiparous Women (Latent Phase- 0-3cm Cervix Dilatation, Active Phase- 3-10cm Cervical Dilation) - Signs include Regular Painful Contractions, Progressive Cervical Dilatation, Passage of Blood-Stained Mucus known as "show" and Rupture of Membranes - Descent of the Foetal Head into Pelvis

Answer 35

Pregnancy, Antibiotic Use and Immunosuppression

Answer 36

Itching White Curdy or Lumpy Discharge Sour Milk Odour Dysuria Superficial Dyspareunia Pruritus Tenderness Burning Sensation Redness Fissuring Swelling Intertrigo (redness caused by skin to skin rubbing) Thick White Discharge

Answer 37

Soreness Pruritus Redness Dry, Dull, Red, Glazed Plaques and Papules

Answer 38

Investigations are not recommended if the history indicates acute, uncomplicated vulvovaginal candidiasis Microscopy may show the presence of Blastospores, Pseudohyphae and Neutrophils Culture is recommended for recurrent vulvovaginal candidiasis

Answer 39

Managed with Antifungal Treatment- - Oral (-azoles)- Fluconazole (generally FIRST LINE), Itraconazole - Intravaginal- Clotrimazole Pessary - Vulval- Topical Clotrimazole Cream

Answer 40

Middle-Eastern/ South-Asian and Afro-Caribbean Previous Gestational Diabetes Large Babies(>4.5 kg) Previous Stillbirth or Perinatal Death Maternal Obesity (BMI>30) Family History of Diabetes in first degree relatives

Answer 41

Low Glycaemic Index Diet, plus Metformin and Insulin Risk of Future Type 2 Diabetes can be addressed with Diet/ Lifestyle and Metformin GDM tends to disappear as soon as the Placenta is delivered

Answer 42

Signs of Bacterial Infection in the Newborn- Pneumonia, Sepsis, Management

Answer 43

- Positive Group B Streptococcus culture in current or previous pregnancy - Previous birth resulting in Neonatal Group B Streptococcus Infection - Pre-term Labour - Prolonged Rupture of Membranes - Intrapartum Fever (>38 degrees Celsius) - Chorioamnionitis

Answer 44

Intrapartum Antibiotic Prophylaxis to prevent GBS Infection in the newborn Usually Penicillin- given intravenously

Answer 45

It consists of H- Haemolysis, EL- Elevated Liver Enzymes, LP- Low Platelets HELLP manifests during the Third Trimester and is part of a spectrum of Hypertensive Disorders of Pregnancy such as Pre-Eclampsia

Answer 46

Peripheral Oedema Headache RUQ pain due to Liver Distension Epigastric Pain Nausea and Vomiting Blurred Vision

Answer 47

Maternal- - Disseminated Intravascular Coagulation - Organ Failure - Placental Abruption Foetal- - Neonatal Hypoxia - Intrauterine Growth Restriction - Preterm Delivery

Answer 48

The Definitive Treatment is Delivery of the Baby Some mothers may require Blood Transfusions or Steroids during the pregnancy

Answer 49

25-40%, and 90% of these occur during delivery

Answer 50

Start the mother on combination Antiretroviral Therapy (cART) as soon as the diagnosis is confirmed If the mother's viral load is LESS THAN 50, a normal vaginal delivery can be recommended, if it is MORE THAN 50, then elective Caesarean Section is recommended The baby should have Post Exposure Prophylaxis (PEP) with either Zidovudine monotherapy or cART. The duration and type of therapy depends on the risk of transmission In the UK, the safest way to feed these babies is with FORMULA MILK, not the mother's milk However, women with a low viral load on cART who choose not to breastfeed should be informed of the risk of transmission but supported to breastfeed if they wish alongside additional monitoring

Answer 51

It is where a Rhesus Negative Mother becomes sensitised to the Rhesus Positive blood cells of the baby while in the uterus

Answer 52

They are events where the Foetal Blood crosses the placenta into the Maternal Circulation and these are indications for Anti-D Prophylaxis - Antepartum Haemorrhage - External Cephalic Version - Invasive Uterine Procedures like Amniocentesis and Chorionic Villus Sampling - Placental Abruption - Abdominal Trauma - Intrauterine Death, Miscarriage, Termination - Rhesus Positive Blood Transfusion to a Rhesus Negative Mother - Ectopic Pregnancy - Delivery (Normal, Instrumental or Caesarean Section)

Answer 53

- Yellow Coloured Amniotic Fluid due to Excess Bilirubin - Jaundice and Kernicterus in the Neonate - Foetal Anaemia caused by Skin Pallor - Hydrops foetalis appearing as Foetal Oedema in at least 2 compartments- Pericardial Effusion, Pleural Effusion, Ascites) seen on Antenatal Ultrasound - Severe Oedema if Hydrops Foetalis was present in utero - Hepatomegaly or Splenomegaly

Answer 54

- Yellow Coloured Amniotic Fluid due to Excess Bilirubin - Jaundice and Kernicterus in the Neonate - Foetal Anaemia caused by Skin Pallor - Hydrops foetalis appearing as Foetal Oedema in at least 2 compartments- Pericardial Effusion, Pleural Effusion, Ascites) seen on Antenatal Ultrasound - Severe Oedema if Hydrops Foetalis was present in utero - Hepatomegaly or Splenomegaly

Answer 55

95% chance The newborn should be given HBV IgG and HBV vaccination within 24 hours of delivery to reduce the risk- this procedure is 95% effective

Answer 56

Severe vomiting with onset before 20 weeks of gestation It is severe enough to require admission into hospital and is a diagnosis of Exclusion

Answer 57

- Infections such as (5) Gastroenteritis, Urinary Tract Infection, Hepatitis and Meningitis - Gastrointestinal Problems- Appendicitis, Cholecystitis and Bowel Obstruction - Metabolic Conditions- Diabetic Ketoacidosis and Thyrotoxicosis - Drug Toxicity - Molar Pregnancy- abnormally high levels of beta-hCG due to Gestational Trophoblastic Disease can cause severe nausea and vomiting

Answer 58

- Fluid Replacement Therapy - Potassium Chloride (excessive vomiting causes Hypokalaemia) - Antiemetic medication like CYCLIZINE (first line), Metoclopramide or Prochlorperazine. Ondansetron or Dompheridone may be used in severe cases - Thiamine and Folic Acid to prevent development of Wernicke's Encephalopathy - Antacids to relieve Epigastric Pain - Thromboembolic (TED) stockings and LMWH as there is an increased risk of VTE due to Pregnancy, Immobilisation and Dehydration

Answer 59

Psychological Sequelae- Depression, PTSD and Resentment towards the pregnancy Gastrointestinal Problems- Mallory-Weiss Tear, Malnutrition and Anorexia Dehydration related to Ketosis and VTE Metabolic Disturbances such as Hyponatraemia, Wernicke's Encephalopathy, Kidney Failure, Hypoglycaemia If the condition is severe- the foetus may be affected by the Metabolic Disturbance Foetal Complications include Low Birth Weight, Intrauterine Growth Restrictions and Premature Labour

Answer 60

Chronic Hypertension - Stop all Antihypertensives and switch to pregnancy-safe alternatives such as Labetalol Gestational Hypertension - After 20 weeks of gestation and BP>150/100mmHg- give ORAL LABETALOL first line - Mild Hypertension (140/90- 149/99) during pregnancy, then regular blood pressure monitoring should be carried out and no treatment is recommended - If Labetalol is not tolerated then alternative medications can be used such as Methyldopa and Nifedipine - For ALL WOMEN- regular blood pressure monitoring and URINALYSIS should be carrie dout

Answer 61

Peripheral Features (Snorlax is hairless with Thick Hide as an ability and probably doesn't have sex much) - Dry, thick skin - Brittle hair - Scanty secondary sexual hair Head and Neck Features (Snorlax with small eyebrows) - Macroglossia - Puffy face - Loss of lateral third of the eyebrow - Goitre (depending on cause) Cardiac Features (a Big Slow Heart- Snorlax) - Bradycardia - Cardiomegaly Neurological Features (Snorlax is slow and imagine a Snorlax walking like a Spinda cos of the ataxia- plus with Carpal Tunnel) - Carpal tunnel syndrome - Slow relaxing reflexes - Cerebellar ataxia - Peripheral neuropathy Auto-immune Causes (Remember Anti-TPO) - Hashimoto's thyroiditis - Anti-TPO (thyroperoxidase): 90-95% of patients - Anti-thyroglobulin: 35-60% of patients - Anti-TSH receptor (blocking): 10% of patients - Atrophic thyroiditis - Autoimmune polyendocrine syndromes Iatrogenic Causes - Surgical - Radioablation - Radiation Congenital Causes (TIP SHIP) - Thyroid aplasia - Infiltrative - Pendred syndrome (defect in thyroxine synthesis) - Sarcoid - Haemochromatosis - Iodine deficiency/Excess Related Causes - Primary Autoimmune Hypothyroidism Types of autoimmune thyroiditis include: - Hashimoto's thyroiditis - Atrophic thyroiditis - Autoimmune polyendocrine syndromes

Answer 62

Levothyroxine is First Line (If patient is already on Levothyroxine, increase by 25mcg when they have a confirmed pregnancy even if they are in a Euthyroid State, as Free Thyroxine Increases in normal pregnancy until 12th week so this should be mimiced)- otherwise baby will have Neurodevelopmental Delay 2 main risks include Cardiac Arrhythmias and Osteoporosis

Answer 63

Indications- - Post-dates= >41 weeks Gestation - Preterm prelabour Rupture of Membranes - Intrauterine Foetal Death - Abnormal CTG - Maternal Conditions such as (3) Pre-Eclampsia, Diabetes and Cholestasis Contraindications- - Previous classical/ vertical incision during Caesarean Section - Multiple Lower Uterine Segment Caesarean Sections - Transmissible Infections (Herpes Simplex) - Vasa Praevia - Placenta Praevia - Severe Foetal Compromise - Malpresentations - Cord Prolapse

Answer 64

Membrane Sweep (Gloved finger into os and separating the membranes from the cervix) Vaginal Prostaglandins (PGE2) Amniotomy- Artificial rupture of membranes Balloon catheter

Answer 65

How favourable the patient is as a candidate for induction of labour A score of 9 or more means that the patient is likely to achieve a successful vaginal delivery and is a favourable candidate for labour induction A lower score means they are less favourable

Answer 66

Indicated when there is a suspicious Cardiotocograph. It is used to confirm Foetal Hypoxia The procedure involves making a small incision of the foetus scalp transvaginally. Blood is then collected and analysed for ACIDAEMIA

Answer 67

Prolonged DECELERATIONS on cardiotocography Maternal Infection (HIV, Herpes Simplex) Prematurity (<34 weeks)

Answer 68

pH- 7.21- 7.24 Lactate- 4.2-4.8

Answer 69

Inform a senior obstetrician and the neonatal team Talk to the woman and her birth companions about what is happening and take her preferences into account Expedite the birth (speed it up)

Answer 70

Borderline + no accelerations in response to foetal scalp stimulation- take a second foetal blood sample no more than 30 minutes later Normal + no accelerations in response to foetal scalp stimulation- take a second foetal blood sample no more than 1 hour later

Answer 71

Immediate Replacement of the Uterus is the best first step as the GREATER the DELAY in attempting this, the greater the likelihood of the manouevre failing General Resuscitation should also be taken and Tocolytic drugs can be used to aid the Replacement of the Uterus process if a first attempt fails

Answer 72

Increased Loss (Menorrhagia, GI Bleeding, Hookworm) Reduced Intake (Poor Diet) Malabsorption (Coeliac Disease and Inflammatory Bowel Disease)

Answer 73

Symptoms (such as lethargy, tiredness, weakness, jaundice, heavy periods, change in bowel habits) and Hypochromic, Microcytic Red Cells Total Iron Binding Capacity (TIBC)- high as the body mobilises Iron Stores to make up for the Iron Deficiency Ferritin- low as available Iron Stores in the body are mobilised to counteract the Iron Deficiency

Answer 74

Iron Deficiency can be treated with Ferrous Sulphate Unexplained Iron Deficiency may require urgent investigation to rule out a new diagnosis of cancer

Answer 75

It is used to measure the amount of Foetal Haemoglobin in the mother's bloodstream In Significant Sensitisation events, it can be used to determine the quantity of Rh-D antigen in the maternal circulation and guide the quantity of Anti-D needed to be given to prevent Sensitisation - in mothers who are RhD negative with foetuses who are RhD positive- as they produce antibodies against RhD antigens

Answer 76

Anti-D antibodies can result in incompatibility and haemolysis in future pregnancies. To attenuate this risk, Anti-D antibodies are given to patients who have experienced a Sensitisation event

Answer 77

Contracted from Contaminated Foods (commonly UNPASTEURISED DAIRY PRODUCTS and SOFT CHEESES) When a pregnant mother is infected, the bacterium may be transmitted through the placenta or during delivery into the foetus

Answer 78

Neonatal Sepsis Meningitis Respiratory Distress Management- - Antibiotic treatment involves AMPICILLIN and an AMINOGLYCOSIDE - Pregnant women should be advised to avoid potentially contaminated food products - And if there is a Febrile Illness, then Cultures for Listeria should be carried out

Answer 79

Lithium should be avoided- specifically in the first Trimester of Pregnancy as it is Teratogenic It can lead to Ebstein's Anomaly and Miscarriage

Answer 80

There is a higher risk of complications at high gestational ages At 41 weeks- a membrane sweep should be offered to the mother. A midwife or doctor inserts their finger into the cervical opening and SWEEPING to separate the amniotic membranes from the cervix This separation causes the RELEASE OF PROSTAGLANDINS which may stimulate spontaneous labour If this is unsuccessful, then the INDUCTION of LABOUR is offered. This involves the administration of PROSTAGLANDINS to stimulate contractions If this is refused then FOETAL MONITORING is NEEDED

Answer 81

There is a higher risk of complications at high gestational ages At 41 weeks- a membrane sweep should be offered to the mother. A midwife or doctor inserts their finger into the cervical opening and SWEEPING to separate the amniotic membranes from the cervix This separation causes the RELEASE OF PROSTAGLANDINS which may stimulate spontaneous labour If this is unsuccessful, then the INDUCTION of LABOUR is offered. This involves the administration of PROSTAGLANDINS to stimulate contractions If this is refused then FOETAL MONITORING is NEEDED

Answer 82

It is the first faeces that is passed by the newborn- this is usually thick and dark green in colour It may be expelled before birth in the amniotic fluid- which is known as "meconium stained liquor" It is important that this is recognised as it may be a sign of Foetal Distress and Hypoxia (which causes Intestinal and Sphincter Relaxation However this may be a NON-PATHOLOGICAL FINDING beyond 40 weeks of Gestation The presence of Meconium in in the Amniotic Fluid may develop to Meconium Aspiration Syndrome MAS is caused by the passage of meconium from the amniotic fluid into the lungs This can cause blockage and inflammation in the airways and is associated with significant morbidity and mortality

Answer 83

The Meconium is thickened and causes obstruction of the bowel in the neonate. This is most commonly the early presentation of Cystic Fibrosis It presents as Bilious Vomiting, a Distended Abdomen and a Failure to pass Meconium within the first 12-24 hours This obstruction may Lead to- - Bowel Perforation - Peritonitis - Mal-Rotation of the Bowel - Intestinal Atresia (it didn't develop properly)

Answer 84

Meconium-stained liquor during Rupture of Membranes or at birth (greenish or yellowish appearance of amniotic fluid) Green staining of infant's skin, nail beds or umbilical cord Signs of respiratory distress in the newborn (Increased Respiratory Rate, Grunting, Cyanosis, Noisy Breathing, Use of Accessory Muscles) LIMP INFANT or low APGAR Score (done on infants after birth) Crackles on Auscultation of Foetal Lungs

Answer 85

Postdate Pregnancies (>40 weeks gestation) Prolonged or Difficult Labour Chorioamnionitis Problems during pregnancy- Pre-Eclampsia, Hypertension, Oligohydramnios, Maternal Infection, Placental Insufficiency, Intrauterine Growth Restriction

Answer 86

Gentle Suctioning of mouth and nose should be carried out to remove any visible Meconium Antibiotics should be given to reduce the Risk of Infection and the baby should be transferred to a Neonatal Intensive Care Unit for Oxygen Administration and Careful Monitoring In SEVERE CASES- Artificial Ventilation may be required

Answer 87

Methotrexate always has a Once Weekly Dosing Regimen and only comes in the form of 2.5mg tablets Generally patients start at a low dose and go up by 2.5mg every week until the disease is controlled or a maximum dose is reached

Answer 88

- Cytopenia- monitor their Full Blood Count and advice them to report suspected Infections and Bruising - Hepatotoxicity- monitor Liver Function Tests. Mild Elevation is normal but discontinue Methotrexate if it rises to more than 3x the normal limit - Renal Impairment- monitor Renal Function Tests - Pulmonary Fibrosis- Take a baseline CXR- advice patient to report any Respiratory Symptoms- Dyspnoea and Dry Cough - Teratogenicity- Advice use of contraception while on Methotrexate and 3 MONTHS AFTER USE- this is how long it takes Methotrexate to wash out (otherwise can lead to Cleft-Palate)- Low dose steroids can be given if a disease flare-up is experienced during this period of trying for a baby. (O) METHOTREXATE impairs FOLATE METABOLISM so other ANTI-FOLATE DRUGS must be avoided, such as- - Trimethoprim - Permetrexed - Proguan (Anti-malarial) FOLIC ACID (5mg) has to be prescribed with METHOTREXATE and should be taken on a DIFFERENT DAY. Depending on the toxicity, Folic Acid should be taken 1-6 times a week Remember "Methotrexate Mondays and Folate Fridays" to help remember to take them on different days and once a week!

Answer 89

Folinic Acid (not Folic Acid) Also can give (2)- Thymidine and Glucarpidase

Answer 90

Those under 16 years old and over 45 years old

Answer 91

Complete- - One Sperm and an Empty Egg with no genetic material - The sperm then replicates to give a normal number of chromosomes- so all the chromosomes are from the dad - There is no foetal tissue present- just a proliferation of Swollen Chorionic Villi Partial- - Two Sperms and a Normal Egg - Both paternal and maternal content is present - There is variable evidence of foetal tissue present

Answer 92

Vaginal bleeding Uterus is larger than expected for Gestational age- due to excessive growth of trophoblasts and retained blood Nausea Thyrotoxicosis (because hCG is closely related to TSH and can therefore activate its receptors) Hyperemesis Gravidarum

Answer 93

B-hCG levels are often much higher than would be expected in a Normal Pregnancy Trans-vaginal Ultrasound is used which may show a SNOWSTORM APPEARANCE in a Complete Pregnancy

Answer 94

Urgent referral to a specialist centre for treatment to reduce the timeframe for Potential Complications such as Choriocarcinoma or Invasion from developing Molar pregnancies can not survive- so are managed with Suction Curettage to remove them from the Uterus When fertility doesn't need to be preserved, then a Hysterectomy can be performed Surveillance is recommended - Two weekly Serum and Urine hCG until the levels are Normal - If a Partial Mole, a repeat hCG is done 4 weeks later- if normal, then the patient is discharged from surveillance - In a Complete Mole, monthly repeat hCG samples are sent for at least 6 months

Answer 95

It is used to calculate the Estimated Due Date (EDD)- based on the first day of the woman's Last Menstrual Period You (Add One Year and Seven Days) to the first day of the Last Menstrual Period and (Subtract Three Months) This may not be accurate with women with irregular or long cycles or those who have been using the Combined Oral Contraceptive Pill This is an ESTIMATE

Answer 96

It can occur during delivery when the baby comes into contact with Primary Vesicles in the Maternal Genital Tract Signs- - Vesicular Lesions in the Eyes - Vesicular Lesions in the Skin - Vesicular Lesions in the Oral Mucosa - Seizures - Encephalitis - Hepatitis - Sepsis Symptoms usually occur within the first 4 weeks of birth

Answer 97

Parenteral Acyclovir and Intensive Supportive Therapy for severe cases An Elective Caesarean Section or Intrapartum IV Acyclovir may be advised if Active Primary Herpes Lesions are present in the mother at term or there has been a primary outbreak within 6 weeks of labour

Answer 98

Non Pharmacological Methods (TENS Stimulation, Hypnosis, Acupuncture, Massage, Heat, Exercise and Movement) Nitrous Oxide (Entonox or "gas and air") Simple Analgesia (Paracetamol) Opiate Analgesia (Oral Codeine Phosphate/ IV or IM Diamorphine) Epidural Analgesia Pudendal Nerve Block Generally- NSAIDs are AVOIDED!!

Answer 99

It is the build up of bile acids occuring after 24 weeks of pregnancy - Fatigue or Malaise - Nausea/ Loss of Appetite - Abdominal Pain- typically in the RUQ - Rarely- Mild Maternal Jaundice- Dark Urine and Pale Stools - Pruritus- Worse on Hands and Feet

Answer 100

Chlorphenamine to reduce the Itch Vitamin K to reduce the risk of Haemorrhage Early delivery to avoid Intrauterine Death

Answer 101

Lower than normal volume of amniotic fluid in the uterus - Chromosomal Anomalies - Uteroplacental Insufficiencies leading to Intrauterine Growth Restriction- could be due to maternal disease such as Hypertension, Pre Eclampsia, Maternal Smoking and Placental Abruption - Premature Rupture of Membranes - Maternal use of certain drugs (Prostaglandin Inhibitors or ACE Inhibitors) - Abnormalities with the Foetal Urinary System (Amniotic Fluid is derived mainly from the the Foetal Urine). Examples include Renal Agenesis, Polycystic Kidneys or Urethral Obstruction - Post-term Gestation

Answer 102

Reduced space around the foetus- Reduced Amniotic fluid for foetal lung growth and development - Clubbed Feet - Facial Deformity - Congenital Hip Dysplasia - Pulmonary Hypoplasia (due to underdeveloped lungs) - Combination of all these symptoms is known as Potter Syndrome

Answer 103

a combination of Iatrogenic Induction of Ovulation and is an Exaggerated response to Hormonal Therapy This can occur in IVF due to multiple follicles maturing and enlarging and becoming Corpus Luteums This results in an excessive production of Oestrogen, Progesterone and local Cytokines (Vascular Endothelial Growth Factor)

Answer 104

Large Ovaries (Bloating and Abdominal Discomfort) Vascular Endothelial Growth Factor causes blood vessels to leak- - Weight Gain - Oedema - Ascites - Pleural Effusion

Answer 105

Bloods- Haemoconcentration and Organ Dysfunction Chest Xray for Pleural Effusion

Answer 106

Largely supportive- so things like Analgesia, Fluid Replacement, Drainage of Fluids (Ascites/ Pleural Effusion) but depends on severity so can be ITU Admission These patients are at risk of VTE so make sure to give them Thromboprophylaxis

Answer 107

Bilateral Abdominal Pain Discharge Post Coital Bleeding Adnexal Tenderness Cervical Motion Tenderness on Bi-Manual Examination Fever (Fitz Hugh Curtiz Syndrome- RUQ pain secondary to Inflammation of the Liver Capsule- but LFTs are normal)

Answer 108

Pelvic Examination Pregnancy Test Swabs for Gonorrhoea and Chlamydia Bloods Transvaginal Ultrasound

Answer 109

Ofloxacin and Metronidazole (or Ceftriaxone and Doxycycline and Metronidazole), and maybe Analgesia if needed Patient should be reviewed within 4 weeks as well ALL YOUNG, SEXUALLY ACTIVE women presenting with bilateral abdominal pain should be given treatment for Pelvic Inflammatory Disease

Answer 110

First Degree Tear- Limited to SUPERFICIAL Perineal Skin or Vaginal Mucosa only Second Degree Tear- Tear extends to Perineal MUSCLES AND FASCIA, but the Anal Sphincter is Intact (an Episiotomy is a Second Degree Tear) Third Degree Tear- (if the Sphincter is Torn but Mucosa is fine) 3a- Less than 50% of the thickness of the External Anal Sphincter is torn 3b- more than 50% of the thickness of the External Anal Sphincter is torn- but the INTERNAL ANAL SPHINCTER is Intact 3c- External and Internal Anal Sphincters are torn, but the ANAL MUCOSA is Intact Fourth Degree Tear- Perineal Skin, Muscle and Anal Mucosa are torn

Answer 111

First Degree- likely to heal on their own as long as minimal blood loss Second Degree- Suturing is needed as the muscle is torn Third and Fourth Degree- Surgical Repair needed under Local or General Anaesthetic- Patients should be given LAXATIVES to avoid Constipation BROAD SPECTRUM ANTIBIOTICS should be given Post-Operatively

Answer 112

Abnormalities of Placental Abruption into the Uterine Wall - Previous Caesarean Section - Advanced Maternal Age - Previous Termination of Pregnancy - Dilatation and Curettage - Uterine Structural Defects - Placenta Praevia

Answer 113

Spectrum of Abnormalities of Placental Implantation into the Uterine Wall - Previous Caesarean Section (as it can go into the cut) - Advanced Maternal Age - Previous Terminated Pregnancy - Dilatation and Curettage - Uterine Structural Defects - Placenta Praevia

Answer 114

THEY PRESENT WITH PAINLESS VAGINAL BLEEDING Placenta Accreta- Adherence of the placenta directly to Superficial Myometrium but DOES NOT penetrate the thickness of the muscle Placenta Increta- When the Villi invades INTO but NOT THROUGH the Myometrium Placenta Percreta- When the Villi invades THROUGH the full thickness of the Myometrium into the Serosa. There is an increased risk of Uterine Rupture and risk of the placenta attaching onto other Abdominal Organs such as the Bladder or the Rectum

Answer 115

It is diagnosed through Doppler Ultrasound and MRI- but can be difficult to diagnose Antenatally There will also be High Levels of Fetoprotein and Beta- HCG If Abnormal Placental Implantation is suspected, the safest management plan is a Caesarean Section and Hysterectomy

Answer 116

Abnormal implantation of the Placenta can lead to an increased risk of Severe Post-partum Bleeding, Preterm Delivery and Uterine Rupture

Answer 117

When the Placenta is covering the Cervical OS Painless Vaginal Bleeding- if this occurs after 24 weeks of pregnancy then Placenta Praevia should be Suspected Mother may present with Shock if there is significant blood loss and Malpresentation of the foetus may be found on examination

Answer 118

- If there is painless bleeding occurring after 13 weeks of Pregnancy or if there is Previous History of Uterine Incision, then Transvaginal Ultrasound should be used to exclude Placenta Praevia - Further Ultrasound should be carried out at 37 weeks to reassess Placental Position

Answer 119

Bleeding with UNKNOWN PLACENTA POSITION- - ABC Approach, Resuscitation and Stabilisation - If they are stable, then Urgent Ultrasound - If the bleeding is not controlled, then Emergency Caesarean Section Bleeding with KNOWN PLACENTA PRAEVIA- - ABC Approach, Resuscitation and Stabilisation. If stabilisation is NOT ACHIEVED- then Emergency Caesarean Section - Corticosteroids should be considered if 24-34 weeks of gestation and there is Risk of Preterm Labour (Corticosteroids and Tocolytics DELAY LABOUR) In Labour- then Caesarean Section Placenta Praevia with NO BLEEDING and NOT IN LABOUR- - Monitor with Ultrasound Scans - Give advice about Pelvic Rest (No Penetrative Sexual Intercourse) and advice to go to the hospital if there is significant Vaginal Bleeding At TERM- - If there is any degree of Placental Overlap at 35 weeks- aim for Elective C. Section at 37-38 weeks. Urgent C. Section if she goes into Labour - When the Placental Edge is greater than 20mm from the Internal Cervical OS, women can be offered a Trial of Labour (if no bleeding and with Careful Intrapartum Monitoring). If Significant haemorrhage or foetal distress develops during trialled vaginal delivery, immediately take to the theatre for IMMEDIATE C SECTION

Answer 120

It is the premature separation of the placenta from the uterine wall in pregnancy- this leads to a MATERNAL HAEMORRHAGE Vaginal Bleeding (however in some cases the haemorrhage may be confined to the uterus) "Woody" Hard Uterus Abdominal Pain (Often Sudden and Severe) Reduced Foetal Movement and Abnormal CTG Contractions Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding

Answer 121

Maternal Trauma (Assault, RTC) Multiparity or Increased Maternal Ages Pre Eclampsia or Hypertension Polhydramnios Previous History of Abruption Substance Abuse during pregnancy (Smoking or Cocaine) Existing Coagulation Disorders Risk factors for ABRUPTION: Abruption before, Blood pressure high, Ruptured membranes, Uterine injury, Polyhydramnios, Twins/ multiple pregnancy, Infection, Older age (>35), Narcotics eg cocaine use

Answer 122

Any woman presenting with Antepartum Haemorrhage should be RESUSCITATED using an ABCDE approach. Do NOT Delay this The management depends on the health of the foetus otherwise - Emergency Delivery- Indicated in the presence of maternal or foetal compromise and this is usually done through CAESAREAN SECTION unless spontaneous delivery is IMMINENT or OPERATIVE VAGINAL BIRTH is achievable - Even if an IN-UTERO foetal death has been diagnosed, a CAESAREAN SECTION may be needed if there is maternal compromise - Induction of Labour- for HAEMORRHAGE at TERM and there is NO COMPROMISE - Conservative Management- for some partial or marginal abruptions which are not associated with maternal or foetal compromise (depending on the gestation and the amount of bleeding) - In ALL CASES- give Anti-D within 72 hours within the onset of bleeding if the woman is Rhesus Negative

Answer 123

Excess Production due to Excess Foetal Urination - Maternal Diabetes Mellitus - Foetal Renal Disorders - Foetal Anaemia - Twin-to-Twin Transfusion Syndrome Insufficient Removal- - Diaphragmatic hernia - Oesophageal or Duodenal Atresia - Anencephaly - Chromosomal Disorders

Answer 124

Uterus which feels tense or large for gestational date and it is difficult to feel the foetal parts on Palpation It is managed by treating the cause (such as Maternal Diabetes Mellitus) and in severe cases- Amnio-Reduction

Answer 125

Maternal Complications- - Maternal Respiratory Compromise due to pressure on Diaphragm - Increased risk of UTIs due to increased pressure on Urinary System - Worsening of other symptoms generally associated with Pregnancy- such as (4) Gastro-Oesophageal Reflux, Constipation, Peripheral Oedema and Stretch Marks - Increased incidence of Caesarean Section Deliveries - Increased risk of Amniotic Fluid Embolism (although this is rare) Foetal Complications- - Pre-term Labour and Delivery - Premature Rupture of Membranes - Placental Abruption - Malpresentation of Foetus (foetus has more space to move within the uterus) - Umbilical Cord Prolapse- Polyhydramnios can prevent the foetus from engaging with the pelvis so there will be more room for the Umbilical Cord to Prolapse

Answer 126

The first 3 weeks

Answer 127

Male and Female Condoms- Can be used anytime after delivery Female Sterilisation- Can be performed at the time of CAESAREAN SECTION Diaphragm- Women are advised to wait 6 WEEKS after delivery before relying on a DIAPHRAGM Intrauterine Contraception (Copper Intrauterine Device and Levonorgestrel-releasing Intrauterine System) - Can be inserted IMMEDIATELY AFTER delivery, up to 48 hours after delivery - After 48 hours, insertion should be delayed until 28 days after childbirth Progesterone-only Contraception- Can be started anytime after delivery Combined Hormone Contraception- (like COCP, Patch or Vaginal Ring) - Women who are not breastfeeding and have no additional risk factors for VTE should wait until 21 DAYS AFTER (Pre-Eclampsia and Post Partum Haemorrhage count as risk factors as well) - Women who are breastfeeding should wait until 6 WEEKS AFTER childbirth before initiating CHC Lactational Amenorrhoea- can be used if the woman is less than 6 months Post-Partum, Amenorrhoeic and Fully Breastfeeding

Answer 128

Previous VTE Thrombophilia Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions) Age >35 BMI >30 Parity >3 Smoking Multiple pregnancy Pre-eclampsia Caesarean section Prolonged labour Operative delivery Preterm birth Stillbirth Postpartum haemorrhage >1000mL Other surgical procedure carried out Immobility Systemic infection

Answer 129

Lowering of Mood/ Reduced Enjoyment in Activities and Reduced Energy Levels Biological Symptoms of Depression may also be present- Poor appetite and Poor sleep- and it is important to differentiate between sleep that is disrupted due to the Baby Waking and sleep that is poor for other reasons In Postpartum Depression, there may also be concerns from the mother about Bonding or Caring for her baby, and even Harming Herself or the Baby in Extreme cases Unlike Baby Blues, which presents in the first TWO WEEKS and resolves on its own- Postpartum Depression rarely resolves on its own and needs to be treated to prevent Long-Term Depressive Disorder

Answer 130

CBT or Interpersonal Therapy should be offered First Line- unless the Severity of the Depressive Episodes is High or there is a Risk, at which point the mother should be admitted to an Inpatient Mental Health Unit

Answer 131

It is the lost of at least 500ml of blood within the first 24 hours after delivery (>1000ml is a MAJOR PPH) - Tone- Most common cause of PPH is Uterine Atony- which is the failure of the uterus to contract after surgery - Trauma- PPH may come after a birth canal injury or tear. This risk is increased in Instrumental Deliveries - Tissue- Retained Placental or Foetal Tissue can lead to continued bleeding - Thrombin- Coagulopathies can lead to continued bleeding due to failure of clotting

Answer 132

Resuscitation (Cannulation and cross-matched blood) and then treatment to encourage uterine contraction- IV Oxytocin and Bimanual Uterine Compression

Answer 133

It is a placental condition affecting pregnant women commonly from 20 weeks of gestation HYPERTENSION and PROTEINURIA Other signs include- Peripheral Oedema, Severe Headache, Drowsiness, Visual Disturbances, Epigastric Pain, Nausea and Vomiting and Hyperreflexia

Answer 134

Increasing Maternal Age Nulliparity Multiple Pregnancy Obesity Previous History or Family History of pre-Eclampsia Existing Disease (Hypertension, Diabetes- HIGH RISK FACTOR, Renal Disease, Autoimmune Disease)

Answer 135

Maternal- - HELLP Syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) - Organ Failure - Disseminated Intravascular Coagulation - Eclampsia (Seizure due to Cerebrovascular Vasospasm) Foetal- - Intrauterine Growth Restriction - Pre-term Delivery - Placental Abruption - Neonatal Hypoxia

Answer 136

Labetalol is the first-line antihypertensive Magnesium Sulphate is used as to prevent and treat Eclamptic Seizures The delivery of the placenta is the only curative treatment choice

Answer 137

U&Es, FBC, Transaminase and Bilirubin 3 times a week

Answer 138

It is when the amniotic membranes rupture before the onset of labour after 37 weeks gestation Most women with PROM at term will start spontaneous labour within the 24 hours after this occurs The two main risks of PROM is Chorioamnionitis and Neonatal Infection

Answer 139

Women with PROM at Term should be assessed for any signs of Infection (Foul-smelling or Green Liquor, Maternal Fever and Reduced Foetal Movements) The Foetal Heart should be monitored. Digital Vaginal Examination should be avoided in the absence of labour as the membranes are ruptured so there is a risk of infecting

Answer 140

Women with PROM at Term should be assessed for any signs of Infection (Foul-smelling or Green Liquor, Maternal Fever and Reduced Foetal Movements) The Foetal Heart should be monitored. Digital Vaginal Examination should be avoided in the absence of labour

Answer 141

If labour does not commence within 24 hours, Induction of Labour should be offered. If a woman does not choose to go through an induction, she should be MONITORED for her Temperature, Foetal Movements, Foetal Heart Rate and Vaginal Discharge and return if there are any abnormalities If there are any signs of Infection- After taking bloods to CULTURE, immediate Induction of Labour should be commenced under consultant guidance and a BROAD SPECTRUM ANTIBIOTIC should be given If there are any signs of Foetal Compromise, senior review is required to make a decision about whether Immediate Caesarean Section is needed Following delivery, even if both mother and baby are Asymptomatic, the should be closely observed in hospital for 12 hours post-birth If this Occurs earlier with no issues, give 2 doses of BETAMETHASONE 12mg IM 24 hours apart- Steroids are given to ADVANCE FOETAL LUNG MATURITY as they are likely to deliver Preterm

Answer 142

The Rupture of Amniotic Membranes can allow bacteria into the uterus- this can lead to Chorioamnionitis due to Ascending Infection Increased risk of Preterm Birth and the Associated Complications of Preterm Birth (Respiratory Distress Syndrome, Necrotising Enterocolitis, Foetal Death) Low levels of Amniotic Fluid due to PPROM can lead to Developmental Problems such as Pulmonary Hypoplasia, Facial and Limb Deformities (due to compression in the uterus) and Cord Prolapse

Answer 143

Early Viable/ Failing Intrauterine Pregnancy Complete Miscarriage Ectopic Pregnancy

Answer 144

Serial serum Beta-hCGs 48 hours apart to give an indication of the Location and Prognosis of the Pregnancy - If the levels fall, then it is suggested that the foetus will not develop or there has been a miscarriage - If there is only a slight increase or a plateau in B-hCG, there may be an Ectopic Pregnancy - A Normal Increase in B-hCG suggests the foetus is growing Normally but does not Exclude an Ectopic Pregnancy (in NORMAL PREGNANCY BETA hCG doubles every 48 hours and peaks at 8-10 weeks) Transvaginal Ultrasound may show the location- but you may not see it in the early days of pregnancy- so it may be worth repeating this at a later date

Answer 145

The onset of regular uterine contractions and cervical changes before 37 weeks gestation Preterm Birth- is the delivery of a baby after 20 weeks gestation but BEFORE 37 weeks gestation Prolonged Premature Rupture of Membranes is when the membranes rupture over 24 hours before the onset of labour Pre-term Premature Rupture of Membranes is the rupture of membranes which occurs before 37 weeks

Answer 146

Foetal Fibronectin Test- assesses risk of Preterm Delivery after the onset of Preterm Labour A negative Foetal Fibronectin Test means there is likely to be a low risk of delivery occurring within the next 1-2 weeks

Answer 147

Conditions which may cause "Overstretching of the Uterus"- Multiple Pregnancy (commonly due to Assisted Conception) and Polyhydramnios Conditions where Foetus is at risk- Pre-Eclampsia, Intrauterine Growth, Placental Abruption etc. Problems with the Uterus or Cervix- Fibroids, Congenital Uterine Malformation, Short or Weak Cervix, Previous Uterine or Cervical Surgery Infections such as Chorioamnionitis, Maternal or Neonatal Sepsis, Bacterial Vaginosis, Trichomoniasis, Group B Streptococcus, STI and UTI Maternal Comorbidity (Hypertension, Diabetes, Renal Failure and Thyroid Disease)

Answer 148

Corticosteroids should be given to Accelerate Foetal Lung Maturation (Betamethasone or Dexamethasone) Intravenous Antibiotics should be given if there is an increased risk of Infection (Group B Streptococcus in current or previous pregnancy, presence of Maternal fever) Penicillin is the ANTIBIOTIC of CHOICE if there is no allergy Tocolytic agents may be considered to buy time for Administration of Corticosteroids, but risk of side effects and benefits should be weighed up NIFEDIPINE is the recommended First Line Tocolytic- but can only buy a few days of time- not weeks

Answer 149

Delayed Gastric Emptying Relaxed Gastro-oesophageal Sphincter due to INCREASING CIRCULATING PROGESTERONE LEVELS Increased Intragastric Pressure due to Gravid Uterus Vigorous Abdominal Palpation or Disturbance during Examination, Labour or Caesarean Section

Answer 150

They are routinely given before a Caesarean Section to reduce Maternal Gastric Volume and Acidity This reduces the risk of Aspiration of Gastric Contents during Surgery and Subsequent Aspiration Pneumonia

Answer 151

Polymorphic Eruption of Pregnancy- This occurs most frequently in the THIRD TRIMESTER and presents with Itchy Papules, typically first appearing on Striae Gravidarum, but may spread to the entire Abdomen, Thighs and Buttocks. It may progress to a Widespread Eczematous Rash with Fluid-filled Vesicles. PEP may be treated with Emollients and Topical Corticosteroids Obstetric Cholestasis- Caused by Elevated Bile Acids. It can cause Pruritus which can develop into a rash. It is treated with URSODEOXYCHOLIC ACID, Emollients and Antihistamines Atopic Eruption of Pregnancy- Presents similar to Eczema. Typical sites include the Face, Neck, Chest and Flexor Surfaces of the Upper Limbs. Treatment is with Emollients and Topical Corticosteroids Pemphigoid Gestationis- Rare, Itchy Rash which forms around the UMBILICUS and can progress into Blisters. Management is with Emollients and Topical Corticosteroids. This condition is likely to flare up during pregnancy

Answer 152

Placental Abruption Antepartum Haemorrhage Intrauterine Death, Miscarriage or Termination Rhesus Positive Blood Transfusion Ectopic Pregnancy Delivery (Normal, Instrumental or Caesarean Section) Abdominal Trauma Invasive Uterine Procedures (Amniocentesis, Chorionic Villus Sampling) External Cephalic Version

Answer 153

PPH in Previous Pregnancy BMI>35 Multiple Pregnancy Parity>4 Placental Praevia/ Accreta Placental Abruption Pre-Eclampsia or Gestational Hypertension or Anaemia Delivery via Caesarean Section Induction of Labour Instrumental Delivery Prolonged Labour (>12 hours) Macrosomia (>4kg baby) Advanced Maternal Age

Answer 154

FULL DILATATION- Then Foetus head is Flexed and Descends and Engages with the Pelvis Foetus Internally rotates to face Outwards towards the Maternal Block Foetus head Extends to deliver the head Foetus Externally Rotates (Restitution) after delivery of the head so that Shoulders are in AP Position The Anterior Shoulder is delivered first and the rest of the Foetus is Expelled

Answer 155

The Maternal Desire to Push Can last between 20 minutes to 2 hours

Answer 156

In Nulliparous Women- >3 hours with Epidural, >2 hours without Epidural In Multiparous Women- >2 hours with Epidural, >1 hour without Epidural

Answer 157

Instrumental Delivery Caesarean Section in a Prolonged Second Stage increases Maternal Morbidity

Answer 158

Excessive Vaginal Bleeding occurring between 24 hours and 12 weeks after Delivery - Poor healing of Perineal Tear or Genital Tract Trauma - Abnormal Involution of the Placental Site - Choriocarcinoma - Endometritis (bleeding occurs 2-10 days after delivery)- Often accompanied with OFFENSIVE DISCHARGE and may be due to RETAINED PLACENTAL TISSUE which leads to Uterus Atony - Displacement of a Retained Blood Clot

Answer 159

After the head is delivered, the Anterior Shoulder becomes impacted behind the Maternal Pubic Symphysis

Answer 160

- Fat, Short, Old, Diabetic Mother Maternal Gestational Diabetes Maternal Short Stature or Small Pelvis Maternal Obesity Advanced Maternal Age - Big, Fat, Delayed Baby Macrosomia Birthweight>4kg Post-dates Pregnancy ALSO PROLOGED SECOND STAGE of LABOUR and AUGMENTATION of LABOUR with OXYTOCIN

Answer 161

RETRACTION of Foetal Head (Turtle-Neck Sign) Difficult Delivery of Foetal Face or Chin Failure of Restitution Failure of Descent of the Foetal Shoulders following Delivery of Head

Answer 162

Immediately Call for Help Do NOT APPLY FUNDAL PRESSURE as this may lead to Uterine Rupture and discourage maternal pushing as this may Exacerbate the Shoulder Impaction - 5 APPROACHES in Order 1) McRoberts Manouevre- = Hyperflexion and Abduction of Mother's legs tightly to the Abdomen = This may be accompanied with applied Suprapubic Pressure = Routine Traction (as applied during normal delivery) in an Axial Direction- NOT Downward- should be applied to assess whether the shoulders have been released 2) All Fours Position (Gaskin's Manoeuvre) 3) Internal Rotational Manoeuvres = Rubin Manoeuvre II- Rotation of the Anterior Shoulder towards the Foetal Chest = Woods' Screw Manoeuvre- Anterior Shoulder is pushed towards the Foetal Chest and the Posterior Shoulder is pushed towards the Foetal Back = Episiotomy will NOT RELIEVE Shoulder Dystocia as it is a Bony Obstruction, but may be indicated to allow space for the Internal Rotational Manoeuvres 4) Cleidotomy or Symphysiotomy (Division of the Foetal Clavicle or Maternal Symphysial Ligament) 5) Zavanelli Manoeuvre- Putting the Head back into the Canal and then Subsequent delivery Via Caesarean Section Following Delivery- - Mother should be examined and monitored for Postpartum Haemorrhage, Severe Perineal Tears and other Genital Tract Trauma - Baby should be examined by Neonatologist for Injury- including Brachial Plexus Injury, Hypoxic Brain Damage, Humeral or Clavicular Fractures

Answer 163

To Assess- - Cervical Dilatation (should not happen until around 38 weeks) - Rupture of Membranes - Antepartum Haemorrhage - Vaginal Discharge

Answer 164

To Assess- - Cervical Dilatation (should not happen until around 38 weeks) - Rupture of Membranes - Antepartum Haemorrhage - Vaginal Discharge

Answer 165

Spina Bifida Occulta- Incomplete fusion of the vertebrae, but with No Herniation of the Spinal Cord- may only be visible as a SMALL TUFT OF HAIR Meningocele- Incomplete fusion of the vertebrae, with Herniation of a Meningeal Sac filled with CSF, visible prominence usually covered in skin Myelomeningocele- Incomplete fusion of the vertebrae with herniation of herniation of a Meningeal Sac containing CSF and Spinal Cord - Usually accompanied by other defects such as Hydrocephaly or Chiari Malformation. Visible prominence at skin with Exposed Meninges

Answer 166

All pregnant women, and those trying to conceive are recommended to take Folic Acid to decrease the risk of NTDs - 400mcg/day from 3 months prior to Conception, until 12 weeks of gestation - in women at higher risk (5) (like those with a child with an NTD, or mothers with Coeliac disease, Diabetes, Thalassaemia, Obesity or those on Antiepileptics) are recommended a higher dose of 5mg/day

Answer 167

Prenatal scans or Ultrasound

Answer 168

Neurological- - Motor Deficits - Sensory Deficits - Neurogenic Bladder or Bowel - Hydrocephalus - Seizures Musculoskeletal- - Increased risk of Hip Subluxation - Scoliosis - Contractures (shortening and hardening of bones) Management- - Primary Neurosurgical Repair - Orthopaedic Surgery

Answer 169

All pregnant women, and those trying to conceive are recommended to take Folic Acid to decrease the risk of NTDs - 400mcg/day from 3 months prior to Conception, until 12 weeks of gestation - in women at higher risk (5) (like those with a child with an NTD, or mothers with Coeliac disease, Diabetes, Thalassaemia, Obesity or those on Antiepileptics) are recommended a higher dose of 5mg/day Also Vitamin D- 10mcg (400IU) per day- shown to be beneficial in Foetal Bone Formation. Recommended in Pregnancy and Breastfeeding (1000IU recommended for obese women/ women who get reduced sunlight levels)

Answer 170

A The pregnancy has not exceeded its 24th week of pregnancy and the continuation of the pregnancy would have greater risks that benefits to the physical and mental healths of the mother and her existing children B The termination of the pregnancy is necessary to prevent permanent injury to the physical or mental health of the mother C The continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy was terminated D There is a substantial risk that the baby would suffer from mental and physical abnormalities to be seriously handicapped

Answer 171

Medical Termination of Pregnancy - Mifepristone, a Progesterone Antagonist blocks PROGESTERONE required for the continuation of pregnancy - Misoprostol, a Prostaglandin Analogue. Causes SMOOTH MUSCLE CONTRACTIONs of Myometrium, resulting in expulsion of uterus contents (800mcg between 10+1 and 23+6 weeks of Pregnancy- 100mcg if after this as uterus becomes more sensitive)- followed by 400mcg every 3 hours Surgical Termination of Pregnancy - Suction Termination - Dilatation and Evacuation/ Curettage (D&Cs)

Answer 172

Fraser Guidelines

Answer 173

Retained products of Conception +/- Pelvic Inflammatory Disease Check Inflammatory Markers, FBC and CRP and give INTRAVENOUS ANTIBIOTICS if high If she is Pyrexial, she will need urgent Invasive Management- such as a Transvaginal Ultrasound

Answer 174

Beta HCG- to make sure the termination was complete it should decrease over time

Answer 175

Delivery of Foetus- beginning Delivery of Placenta and Foetal Membranes- end Last 30 minutes to 1 hour, or 5-10 minutes with Oxytocin - Gush of Blood - Lengthening of Umbilical Cord - Ascension of Uterus in the Abdomen

Answer 176

Controlled Cord Traction This must be gentle or else there is an increased risk of causing complications such as Uterine Inversion or Postpartum Haemorrhage

Answer 177

They are indicated in Preterm Labour to delay delivery by a few days- usually to buy time for Maternal Steroids to work or to allow the mother to be transferred to the appropriate unit - Nifedipine (Calcium Channel Antagonist) - Atosiban (Oxytocin Receptor Antagonist) - Indomethacin (NSAID) - Terbutaline (Beta-2-Antagonist) - Magnesium Sulphate administered for its Neuroprotective Effects ORAL NIFEDIPINE is FIRST LINE It can only suppress by a FEW DAYS

Answer 178

Chorioamnionitis Cervical Dilatation greater than 4cm Maternal Factors- Pre-Eclampsia, Ante-Partum Haemorrhage, Haemodynamic Instability Intrauterine Growth Restriction or Placental Insufficiency Non-reassuring Cardiotocograph, Fatal Foetal Anomaly or Intrauterine Death Greater than 34 weeks Gestation

Answer 179

Monozygotic Twins (One Egg and One Sperm) - Dichorionic and Diamniotic (Two Different Sacs) - Monochorionic and Diamniotic (One Outer Sac and Two Inner Sacs) - Monochorionic and Monoamniotic (Same Sac) - Monozygotic Twins are at risk of certain complications (like Twin-to-twin Transfusion Syndrome) and must be monitored more carefully Dizygotic Twins (Two Different Eggs and Two Different Sperms) - All of these are Dichorionic and Diamniotic and have Separate Placentas -offer Elective Birth from 37 weeks onwards if Dichorionic Twins - offer Elective Birth from 36 weeks onwards if Monochorionic Twins 2/3s of all twins are Dizygotic and 1/3 are Monozygotic

Answer 180

It occurs due to the anastomoses of Umbilical Vessels between the two foetuses in the Placenta of Monochorionic Twins Both Foetuses are at risk of developing Heart Failure and Hydrops (severe oedema in babies) - Donor suffers High Output Cardiac Failure due to Anaemia - Recipient suffers from Fluid Overload Management- If Untreated, the mortality rate is high and the Donor is More Likely to Survive. Management is Laser Transection of the Blood Vessels in-utero

Answer 181

Cephalic - Vertex (most common presentation) - Brow - Face - Chin Breech Presentations - Frank- the Legs are extended up to the head, the Buttocks are the presenting part - Complete- the Hips and Knees are Flexed- the Buttocks is presenting - Incomplete- One or both Hips are extended and the Knee or Foot is the presenting part - Footling (single/ double)- One or both Legs are extended and a Foot/Feet is the presenting part Shoulder Presentations - Arm is the leading Part - Shoulder is the leading Part - Trunk is the leading Part

Answer 182

Risks- - Increased risk of Uterine Rupture (Scar Rupture) (Sudden Onset of Abdominal Pain and Loss of Contractions suggests this- Emergency surgery (C. Section/ Laparotomy) if this happens) - Increased risk of requiring Caesarean Section (failed VBAC) Contraindications- - Classical (Vertical) Caesarean Section scar - Previous history of Uterine Rupture - usual contraindications to Vaginal Delivery- such as a Major Placenta Praevia

Answer 183

It is used to achieve Contractions of a Normal Rate, Duration and Intensity to facilitate labour In the first stage of labour, they should be 3-5 per 10 minute period and should last 30-60 seconds

Answer 184

Cabergoline