Passmed textbook - Obstetrics Flashcards

Question

First dose of anti-D prophylaxis to rhesus -ve women Second dose of anti-D prophylaxis to rhesus -ve women

Answer 1

First dose - 28 weeks Second dose - 34 weeks

Answer 2

- Anaemia - Bacteriuria - Blood group, Rhesus status and anti-red cell antibodies - Down's syndrome - Fetal anomalies - Hepatitis B - HIV - Neural tube defects - Risk factors for pre-eclampsia - Syphilis The following should be offered depending on the history: ``` Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia ```

Answer 3

``` Bacterial vaginosis Chlamydia Cytomegalovirus Fragile X Hepatitis C Group B Streptococcus Toxoplasmosis ```

Answer 4

bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Answer 5

Placental abruption - Shock out of keeping with visible loss (there might be a concealed haemorrhage) - constant pain - tender, tense, woody uterus - normal life + presentation - fetal heart - absent/distressed - coagulation problems - beware of pre-eclampsia, DIC, anuria Placenta praevia - shock in proportion to visible loss - no pain - uterus not tender - lie + presentation may be abnormal - fetal heart usually normal - coagulation problems rare - small bleeds before large Vaginal examination (bimanual) should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Answer 6

first - Miscarriage - Ectopic - Hydatidiform mole second - Miscarriage - Hydatidiform mole - Placental abruption third - Bloody show (labour or pre-term labour) - Placental abruption - Placenta praevia - Vasa praevia other causes - STIs, cervical cancer, fibroids, polyps etc.

Answer 7

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

Answer 8

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

Answer 9

The caudal end of the fetus occupies the lower segment 25% of pregnancies at 28 weeks are breech but it only occurs in 3% of babies near term Frank breech - most common presentation - Hips flexed - Knees fully extended Footling breech - One or both feet come first with the bottom at a higher position - Rare but carries a higher perinatal morbidity

Answer 10

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

Answer 11

Cord prolapse

Answer 12

if < 36 weeks: many fetuses will turn spontaneously if still breech at 36 weeks - External cephalic version (ECV) Success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women 37 weeks in multiparous women if the baby is still breech then delivery options include planned caesarean section or vaginal delivery

Answer 13

* where caesarean delivery is required * APH within the last 7 days * abnormal CTG * major uterine anomaly * ruptured membranes * multiple pregnancy

Answer 14

Lower segment C-section Classical C-section - Longitudinal incision in the upper segment of the uterus

Answer 15

- Cephalopelvic disproportion (absolute indication) - placenta praevia grades 3/4 - pre-eclampsia - post-maturity - IUGR - fetal distress in labour/prolapsed cord - failure of labour to progress - malpresentations: brow https: //els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/51ca00dd-455f-45c6-ba77-b45b242cda95/gr4_lrg.jpg - placental abruption: only if fetal distress; if dead deliver vaginally - vaginal infection e.g. active herpes - cervical cancer (disseminates cancer cells)

Answer 16

Maternal o Persistent wound + abdominal discomfort in the first few months after surgery o increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies o readmission to hospital o haemorrhage o infection (wound, endometritis, UTI) o prolonged ileus o subfertility: due to postoperative adhesions Fetal: o lacerations, one to two babies in every 100

Answer 17

``` Maternal o emergency hysterectomy o need for further surgery at a later date, including curettage (retained placental tissue) o admission to intensive care unit o thromboembolic disease o bladder injury o ureteric injury o death (1 in 12,000) ``` Future pregnancies o increased risk of uterine rupture during subsequent pregnancies/deliveries o increased risk of antepartum stillbirth o increased risk in subsequent pregnancies of placenta praevia and placenta accreta

Answer 18

Success rate = 70-75% Contraindications - Previous uterine rupture - Classical caesarean scar

Answer 19

pressure change in the uterus using internal or external pressure transducers records fetal heart rate + contractions

Answer 20

100-160 bpm

Answer 21

DR C BRAVADO ``` DR - Define risk "low" or "high" C- contractions [frequency, duration] BR - baseline rate [brady/tachy/normal] A- Accelerations [present/absent] V - Variability [5-10 bpm] D - Decelerations [early/variable/late] O - Overall impression + management ```

Answer 22

Heart rate <100bpm - Increased fetal vagal tone - Maternal beta blocker use

Answer 23

Heart rate >160/min - Maternal pyrexia - Chorioamnionitis - Hypoxia - Prematurity

Answer 24

<5 beats/min - Prematurity - Hypoxia

Answer 25

Deceleration of the heart rate which commences with the onset of a contraction + returns to normal on completion of the contraction - Usually an innocuous feature - Indicates head compression

Answer 26

Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction - Indicates fetal distress - e.g. asphyxia or placental insufficiency

Answer 27

Independent of contractions - May indicate cord compression

Answer 28

Chickenpox - Caused by primary infection with the varicella-zoster virus Shingles - caused by reactivation of dormant virus in dorsal root ganglion Pregnancy - fetal varicalla syndrome - risk to both the mother + the fetus

Answer 29

Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation Very small number of cases occurring between 20-28 weeks gestation None following 28 weeks ``` features Skin scarring Eye defects (microphthalmia) Limb hypoplasia Microcephaly Learning disabilities ```

Answer 30

risk to mother and fetus - fetal varicella syndrome risk to mother - 5 times greater risk of pneumonitis risk to fetus - shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester - severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 31

Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP) - Maternal blood should be urgently checked for varicella antibodies (if in doubt about the mother previously having chickenpox) - if the pregnant woman less than or 20 weeks gestation is not immune to varicella --> give varicella-zoster immunoglobulin (VZIG) asap VZIG is effective up to 10 days post exposure - if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Answer 32

Specialist advice should be sought Increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy Oral aciclovir - if the woman is < 20 weeks the aciclovir should be 'considered with caution' - given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash

Answer 33

- bacteria infect the chorion and amnion (the membranes that surround the fetus) and the amniotic fluid (in which the fetus floats) - potentially life-threatening condition to both mother and foetus - Considered a medical emergency - Can affect up to 5% of all pregnancies - Usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta Major risk factor --> is the preterm premature rupture of membranes --> exposure of the normally sterile environment of the uterus to potential pathogens It can still occur when the membranes are still intact Prompt delivery of the foetus (via cesarean section if necessary) + administration of IV abx

Answer 34

Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus Occurs in 1/500 deliveries Left untreated, this can lead to - Compression of the cord or cord spasm --> fetal hypoxia --> irreversible damage or death

Answer 35

* prematurity * multiparity * polyhydramnios * twin pregnancy * cephalopelvic disproportion * abnormal presentations e.g. Breech, transverse lie * placenta praevia * long umbilical cord * high fetal station

Answer 36

The majority of cord prolapses occur at artificial rupture of the membranes The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus

Answer 37

* Presenting part of the fetus may be pushed back into the uterus to avoid compression * Tocolytics ro reduce compression and allow CS If the cord is past the level of the introitus • Should be kept warm + moist • Should not be pushed back inside • Patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out • Immediate C-section Usual first-line method of delivery Instrumental vaginal delivery is possible if the cervx is fully dilated + the head is low

Answer 38

Standard: combined test * nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A) * should be done between 11 - 13+6 weeks * Down's syndrome = ↑ HCG, ↓ PAPP-A, thickened nuchal translucency * Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower For women who book later in pregnancy: • Triple or quadruple test should be offered between 15 - 20 weeks • triple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin • quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A

Answer 39

Pre-eclampsia - a condition seen after 20 weeks gestation pregnancy-induced hypertension proteinuria Eclampsia - The development of seizures in association pre-eclampsia

Answer 40

* Used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop * Should be given once a decision to deliver has been made Eclampsia • IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour • Treatment should continue for 24h after last seizure or delivery • Monitor UO, reflexes, RR, O2 sat during treatment Respiratory depression can occur Management of magnesium sulphate induced respiratory depression • Calcium gluconate Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload

Answer 41

* Folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects * Aim for monotherapy * No indication to monitor antiepileptic drug levels * Pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn sodium valproate - NTD carbamazepine - the least teratogenic of the older antiepileptics phenytoin - cleft palate lamotrigine - rate of congenital malformations may be low Dose of lamotrigine may need to be increased in pregnancy

Answer 42

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

Answer 43

Significant risk of neurodevelopmental delay in children Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary Women of childbearing age should not start treatment without specialist neurological or psychiatric advice

Answer 44

* 400mcg of folic acid until the 12th week of pregnancy * women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy ``` women are considered higher risk if any of the following apply: • either partner has a NTD • previous pregnancy affected by a NTD • family history of a NTD • antiepileptic drugs • coeliac disease • diabetes • thalassaemia trait • obesity ( [BMI] of 30 kg/m2 or more). ```

Answer 45

``` Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess ``` Consequences of folic acid deficiency: macrocytic, megaloblastic anaemia neural tube defects

Answer 46

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid. Functions THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Answer 47

* fetal distress in the second stage of labour * maternal distress in the second stage of labour * failure to progress in the second stage of labour * control of head in breech deliver

Answer 48

Typically occurs in women who have recently stopped breastfeeding Due to occlusion of a lactiferous duct --> build up of milk creates a cystic lesion in the breast The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Answer 49

* BMI of > 30 kg/m² * previous macrosomic baby weighing 4.5 kg or above * previous gestational diabetes * first-degree relative with diabetes * family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 50

Women who've previously had gestational diabetes: • • OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal • Early self-monitoring of blood glucose is an alternative to the OGTTs women with any of the other risk factors should be offered an OGTT at 24-28 weeks

Answer 51

Gestational diabetes is diagnosed if either: fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L

Answer 52

Management of gestational diabetes • newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week • women should be taught about self-monitoring of blood glucose • advice about diet (including eating foods with a low glycaemic index) and exercise should be given • Fasting plasma glucose level is < 7 mmol/l o Trial of diet and exercise - 1st line o Start metformin - 2nd line If glucose targets are not met within 1-2 weeks of altering diet/exercise o Add insulin - 3rd line If glucose targets are still not met Gestational diabetes is treated with short-acting, not long-acting, insulin • Fasting glucose level is >= 7 mmol/l o Start insulin • Plasma glucose level is between 6-6.9 mmol/l + evidence of complications (e.g. macrosomia, hydramnios) Insulin should be offered o Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 53

Fasting - 5.3 mmol/l 1 hour after meals - 7.8 mmol/l 2 hour after meals - 6.4 mmol/l

Answer 54

* Weight loss for women with BMI of > 27 kg/m^2 * Folic acid 5 mg/day from pre-conception to 12 weeks gestation * Stop oral hypoglycaemic agents, apart from metformin * Commence insulin * Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts * tight glycaemic control reduces complication rates * treat retinopathy as can worsen during pregnancy

Answer 55

-Common condition in pregnancy Resuls from - Dilution - Decreased production of platelets - Increased destruction of platelets (increased work of maternal spleen --> mild sequestration)

Answer 56

- Autoimmune condition - Associated with acute purpuric episodes in children - Chronic relapsing course may be seen more frequently in women

Answer 57

Gestational thrombocytopenia - Platelet count continues to fall as the pregnancy progresses (not a reliable sign) - Does not affect neonates ITP - If the patient becomes dangerously thrombocytopenic - treat with steroids + dx ITP - Pregnant women found to have low plt during booking vist or those with a previous dx of ITP --> tested for serum antiplatelet antibodies for confirmation - Can affect neonates if maternal antibodies cross the placenta Depending on the degree of thrombocytopenia in the newborn - plt transfusions may be indicated Serial plt counts performed to see whether there is an inherited thrombocytopenia

Answer 58

Describes a spectrum of disorders originating from the placental trophoblast: complete hydatidiform mole partial hydatidiform mole choriocarcinoma

Answer 59

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin Less commonly an empty ovum is fertilised by 2 sperms

Answer 60

In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

Answer 61

Features - bleeding in first or early second trimester - exaggerated symptoms of pregnancy e.g. hyperemesis - uterus large for dates - very high serum hCG - hyperthyroidism (hGC can mimic TSH) - hypertension

Answer 62

- urgent referral to specialist centre - evacuation of the uterus is performed - effective contraception is recommended to avoid pregnancy in the next 12 months Around 2-3% go on to develop choriocarcinoma

Answer 63

- most common cause of early-onset severe infection in the neonatal period - around 20-40% of mothers have GBS present in their bowel flora --> 'carriers' of GBS - Infants may be exposed to maternal GBS during labour --> can develop potentially serious infections

Answer 64

- prematurity - prolonged rupture of the membranes - previous sibling GBS - infection - maternal pyrexia e.g. secondary to chorioamnionitis

Answer 65

* universal screening for GBS should not be offered to all women * maternal request is not an indication for screening Swabs for GBS o Should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date • women who've had GBS detected in a previous pregnancy o risk of maternal GBS carriage in this pregnancy is 50% o Should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive IAP o Women with a previous baby with early- or late-onset GBS disease o Women in preterm labour regardless of their GBS status o Women with a pyrexia during labour (>38ºC) o Benzylpenicillin is the antibiotic of choice for GBS prophylaxis If it is isolated during the antenatal period, it does not require treatment immediately, as it will not reduce the likelihood of colonisation at delivery.

Answer 66

o Women with a previous baby with early- or late-onset GBS disease o Women in preterm labour regardless of their GBS status o Women with a pyrexia during labour (>38ºC) o Benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Answer 67

Features nausea & vomiting right upper quadrant pain lethargy Investigations bloods: Hemolysis Low Platelet Treatment delivery of the baby

Answer 68

Late stages of pregnancy

Answer 69

Significant overlap with severe pre-eclampsia in terms of the features Some patients present with no prior history so many specialists consider it a separate entity in its own right Around 10-20% of patients with severe preeclampsia will go on to develop HELLP

Answer 70

1) all pregnant women are offered screening for hepatitis B 2) Babies should receive a complete course of vaccination + hepatitis B immunoglobulin 3) hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 71

- Screening o HIV screening should be offered to all pregnant women - Maternal antiretroviral therapy o all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously - Mode of delivery o Vaginal delivery <50copies/ml at 36w o C-section - zidovudine infusion should be started 4h before beginning the C-section - Neonatal antiretroviral therapy o Zidovudine - administered orally to neonate if maternal viral load is <50copies/ml o Triple ART - 4-6/52 - Bottle feeding instead of breastfeeding

Answer 72

- produced by the embryo and later by the placental trophoblast - Its main role is to prevent the disintegration of the corpus luteum - hCG levels double approximately every 48 hours in the first few weeks of pregnancy - levels peak at around 8-10 weeks gestation

Answer 73

o hypertensive disease during previous pregnancies o CKD o AI disorders e.g. SLE, APL o T1DM/T2DM Management aspirin 75mg od from 12 weeks until the birth of the baby

Answer 74

o blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks o after this time the blood pressure usually increases to pre-pregnancy levels by term

Answer 75

systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Answer 76

``` - Pre-existing HTN o Hx of HTN before pregnancy or elevated BP >140/90mmHg before 20 weeks gestation o No proteinuria, no oedema o Occurs in 3-5% of pregnancies o More common in older women ``` - Gestational HTN/Pregnancy induced HTN (PIH) o elevated BP >140/90mmHg after 20 weeks gestation o No proteinuria, no oedema o Occurs in 5-7% of pregnancies o Resolves following birth - typically after 1 month o Women with PIH --> increased risk of future pre-eclampsia or HTN later in life - Pre-eclampsia o PIH in association with proteinuria (>0.3g/24h) or Other maternal organ dysfunction  Renal insufficiency (Cr > 90micromol/L, >1.02mg/100ml)  Liver involvement ( transaminases – ALT or AST > 40IU/L) with or without RUQ or epigastric abdominal pain  Neurological complications (eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata)  Haematological complications (thrombocytopenia (plt < 150.000/microleter), DIC, or haemolysis)  Uteroplacental dysfunction e.g. IUGR, abnormal umbilical artery doppler waveform analysis, stillbirth o Occurs in around 5% of pregnancies

Answer 77

o prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery o prelabour premature rupture of the membranes, where labour does not start o diabetic mother > 38 weeks o pre-eclampsia o rhesus incompatibility

Answer 78

Bishop score Cervical position 0 - Posterior 1 - Intermediate 2 - Anterior Cervical consistency 0 - Firm 1 - intermediate 2 - Soft ``` Cervical effacement 0 - 0-30% 1 - 40-50% 2 - 60-70% 3 - 80% ``` ``` Cervical dilation 0 - <1cm 1 - 1-2cm 2 - 3-4cm 3 - >5cm ``` ``` Fetal station 0 - -3 1 - -2 2 - -1,0 3 - +1, +2 ``` <5 - labour is unlikely to start without induction ≥ 8 - cervix is ripe or favourable - high chance of spontaneous labour, or response to interventions made to induce labour

Answer 79

o Membrane sweep Examining finger passing through the cervix to rotate against the wall of the uterus --> separates the chorionic membrane form the decidua Can be done by the midwife in the AN clinic Nulliparous women - offered this at 40 - 41 weeks Parous women - offered this at 41 weeks Regarded as an adjunct to IOL rather than an actual method of induction --> prior to formal IOL women should be offered a vaginal examination for membrane sweeping o Vaginal prostaglandin E2 (PGE2) Preferred method of IOL unless there are specific clinical reasons for not using it o Maternal oxytocin infusion o Amniotomy (breaking of waters) o Cervical ripening balloon Passed through the endocervical canal - gently inflated to dilate the cervix

Answer 80

Main complication of IOL --> uterine hyperstimulation Uterine hyperstimulation --> prolonged + frequent uterine contractions - sometimes called tachysystole potential consequences - intermittent interruption of blood flow to the intervillous space over time --> fetal hypoxemia and acidemia - uterine rupture (rare) management - removing the vaginal prostaglandins if possible - stopping the oxytocin infusion - tocolysis with terbutaline

Answer 81

Features ``` o pruritus - may be intense - typical worse palms, soles and abdomen clinically detectable o jaundice (20% of patients) o raised bilirubin (> 90% of cases) ```

Answer 82

Associated with an increased risk of premature birth recurrence - 45-90% in subsequent pregnancies

Answer 83

o IOL 37-38 weeks (common practice but may not be evidence based) o ursodeoxycholic acid - widely used but evidence base not clear o vitamin K supplementation

Answer 84

the onset of regular and painful contractions associated with cervical dilation + descent of the presenting part

Answer 85

o regular and painful uterine contractions o a show (shedding of mucous plug) o shortening and dilation of the cervix o rupture of the membranes (not always)

Answer 86

stage 1: from the onset of true labour to when the cervix is fully dilated stage 2: from full dilation to delivery of the fetus stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Answer 87

o FHR monitored every 15min (or continuously via CTG) o Contractions assessed every 30min o Maternal pulse rate assessed every 60min Every 4 hours o Maternal BP and temp o Vaginal examination to check progression of labour o Maternal urine should be checked for ketones and protein

Answer 88

Latent phase - 0-3 cm dilation - Normally takes 6 hours (0.5cm/hr) Active phase - 3-10 cm dilation - Normally 1cm/hr

Answer 89

Head enters pelvis in occipito-lateral position The head normally delivers in an occipito-anterior position

Answer 90

Passive second stage - 2nd stage but in the absence of pushing Active second stage - active process of maternal pushing

Answer 91

- less painful than 1st (pushing masks pain) - lasts approximately 1 hours - if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section - episiotomy may be necessary following crowning - associated with transient fetal bradycardia

Answer 92

Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth

Answer 93

o Reduced amniotic fluid o <500ml at 32-36 weeks o AFI (amniotic fluid index) <5th percentile o Maximum vertical pocket (MVP) <2 cm from late mid-trimester Causes - PROM - Fetal renal problems e.g. renal agenesis - IUGR - PET - Post-term gestation

Answer 94

o first degree: superficial damage with no muscle involvement o second degree: injury to the perineal muscle, but not involving the anal sphincter o third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS): o 3a: less than 50% of EAS thickness torn o 3b: more than 50% of EAS thickness torn o 3c: IAS torn o fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Answer 95

``` o primigravida o large babies o precipitant labour o shoulder dystocia o forceps delivery ```

Answer 96

Depend on the degree of invasion 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

Answer 97

previous caesarean section | placenta praevia

Answer 98

As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage

Answer 99

Attachment of the placenta to the myometrium, due to a defective decidua basalis

Answer 100

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

Answer 101

Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section 5% will have low-lying placenta when scanned at 16-20 weeks gestation incidence at delivery is only 0.5%, therefore most placentas rise away from cervix

Answer 102

``` o shock in proportion to visible loss o no pain o uterus not tender o lie and presentation may be abnormal o fetal heart usually normal o coagulation problems rare o small bleeds before large ```

Answer 103

o often picked up on the routine 20 week abdominal ultrasound o use of transvaginal ultrasound improves the accuracy of placental localisation and is considered safe

Answer 104

o rescan at 34 weeks o if present at 34w + grade I/II scan every 2 w o final US at 36-37w to determine the mode of delivery I - trial of vaginal delivery may be offered III/IV - ELCS at 37-38 w o if woman with known placenta praevia goes into labour prior to ELCS --> EMCS to reduce risk of PPH

Answer 105

o admit o ABC approach to stabilise the woman o if not able to stabilise → emergency caesarean section o if in labour or term reached → emergency caesarean section

Answer 106

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space occurs in approximately 1/200 pregnancies

Answer 107

``` o shock out of keeping with visible loss o pain constant o tender, tense uterus o normal lie and presentation o fetal heart: absent/distressed coagulation problems o beware pre-eclampsia, DIC, anuria ```

Answer 108

``` o proteinuric hypertension o cocaine use o multiparity o maternal trauma o increasing maternal age ```

Answer 109

Fetus alive and < 36 weeks o fetal distress: immediate caesarean o no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks o fetal distress: immediate caesarean o no fetal distress: deliver vaginally Fetus dead o induce vaginal delivery

Answer 110

``` Maternal o shock o DIC o renal failure o PPH ``` Fetal o IUGR o hypoxia o death Prognosis o associated with high perinatal mortality rate o responsible for 15% of perinatal deaths

Answer 111

Edinburgh Postnatal depression scale - 10 item questionnaire - Max score of 30 - Indicates how the mother has felt over the previous week - >13 - depressive illness of varying severity - >90% sensitivity +specificity - incl. qs about self-harm PHQ-9 score - Nine item depression scale of the patient health questionnaire - Items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV ``` 0-4 - none 5-9 - mild 10-14 - moderate 15-19 - moderately severe 20-27 - severe ```

Answer 112

Baby blues o Seen in around 60-70% of women o Typically seen on day 3, peak at 5th day, subside within 10 days o more common in primips o Mothers are characteristically anxious, tearful and irritable, poor concentration o Reassurance and support, the health visitor has a key role Postnatal depression o Affects around 10% of women o Most cases start within a month and typically peaks at 3 months o Features are similar to depression seen in other circumstances o Fears about baby's health, maternal deficiencies, martial tensions incl. loss of sexual interest o As with the baby blues reassurance and support are important o CBT may be beneficial o SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant o paroxetine - the low milk/plasma ratio o fluoxetine is best avoided - long half-life Puerperal psychosis o Affects approximately 0.2% of women o Onset usually within the first 2-3 weeks following birth o Can take form of manic depression or schizophrenia o Severe swings in mood (similar to bipolar disorder) o Disordered perception (e.g. auditory hallucinations) o There might be high suicidal drive o Admission to hospital is usually required o There is around a 25-50% risk of recurrence following future pregnancies

Answer 113

1. Thyrotoxicosis 2. Hypothyroidism 3. Normal thyroid function (but high recurrence rate in future pregnancies) Thyroid peroxidase antibodies are found in 90% of patients

Answer 114

Thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive o Propylthiouracil Present in breast milk but this does not preclude breast-feeding as long as neonatal development is closely monitored and the lowest effective dose is used. Amount in milk probably too small to affect infant; high doses may affect neonatal thyroid function Carbimazole (CMZ) Present in breast milk but this does not preclude breast-feeding as long as neonatal development is closely monitored and the lowest effective dose is used. Amount in milk may be sufficient to affect neonatal thyroid function therefore lowest effective dose should be used. Propranolol used for symptom control Hypothyroid phase is usually treated with thyroxine

Answer 115

pregnancy extended to or beyond 42 weeks

Answer 116

Neonatal - Reduced placental perfusion - Oligohydramnios Maternal - Increased rates of intervention incl. forceps + C-section - Increased rates of IOL

Answer 117

Early onset (within 72h) GBS, Streptococcus agalactiae Late onset Staphylococcus epidermis

Answer 118

o Gestational diabetes is treated wish short-acting + not long-acting insulin  Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.

Answer 119

Day 28 post party,

Answer 120

Contraception is not required before day 21 postpartum. As sperm can survive in the vagina for up to 7 days, and the earliest date of ovulation after giving birth is 28 days postpartum, no contraception is needed until day 21

Answer 121

Sertraline Fluoxetine To resent in tiny amounts in breast milk

Answer 122

Falls in first half of pregnancy Continues to fall until 20-24 weeks After this time the bop usually increases to prepregnancy levels by term

Answer 123

30% rises in GFR because of the increase CO (5L/min before pregnancy, 6.5L/min during pregnancyj. Therefore a normal creatinine in pregnancy is a sign of kidney failure

Answer 124

Infected nipple fissure Symptoms do not improve or worsen after 12-24h despite effective milk removal Positive bacterial culture Flucloxacillin 500mcg 14/7 Erythromycin if penicillin allergic

Answer 125

PAPP-A low | Bhcg raised

Answer 126

AFP low Unconjugated oestradiol low Bhcg raised Inhibit A raised

Answer 127

Associated with congenital anomalies

Answer 128

Low alpha fetoprotein (AFP) Low oestriol High human chorionic gonadotrophin beta-subunit (-HCG) Low pregnancy-associated plasma protein A (PAPP-A) Thickened nuchal translucency High inhibin A “All serum tests are low inDS excpet thenones that are HIM(hcg, inhibin A)”

Answer 129

``` Congenital cataracts Sensorineural deafness (indicated by the milky opacities and lack of response to the hearing screen respectively) ``` The risk of damage to the foetus increases the earlier in the pregnancy infection occurs, with 90% being affected if infected in the first 8-10 weeks ``` Miscarriage Congenital heart defects (usually a patent ductus arteriosus) Purpuric 'blueberry muffin' skin lesions Intellectual disability Hepatosplenomegaly ```

Answer 130

Congenital toxoplasmosis tends to be asymptomatic, and pregnant women are classically exposed to the parasite through cat litter rather than person-to-person transmission When signs and symptoms are present, they typically include cerebral calcification, chorioretinitis hydrocephalus Toxoplasmosis- remembers by the 4Cs: - Convulsions - Chorioretinitis - Calcifications - Cephaly (anencephaly, hydrocephalus)

Answer 131

Treponema pallidum is the bacterium that causes syphilis Congenital syphilis tends to present 2-6 weeks after birth Blunted upper incisor teeth (Hutchinson's teeth), rhagades saber shins saddle nose keratitis deafness It does not tend to cause cataracts in neonates

Answer 132

microcephaly | central nervous system abnormalities

Answer 133

skin scarring microphthalmia limb hypoplasia intellectual disability

Answer 134

Streptococcus agalactiae = group B streptococcus (GBS) This woman should receive oral antibiotics immediately to treat her urine infection She would then be offered IV benzylpenicillin as soon as she presents in labour Following the first dose, she would receive further IV benzylpenicillin doses 4 hourly until delivery Women who test positive for GBS on urine cultures or vaginal swabs in pregnancy are offered intrapartum IV antibiotics due to the high risk of neonatal sepsis. If positive urine culture this also requires antenatal antibiotics. Vaginal swabs positive for GBS do not require antenatal treatment, only intrapartum.

Answer 135

Associated with taking lithium during pregnancy pan-systolic murmur Cardiac echocardiogram - low insertion of the tricuspid valve - large right atrium - small right ventricle - associated tricuspid incompetence Ebstein's anomaly - 'atrialisation' of the right ventricle Ebstein's anomaly results in low insertion of the tricuspid valve resulting in a large right atrium and small right ventricle causing tricuspid incompetence.

Answer 136

1 - Truncus Arteriosus (pulm + aorta connect into 1) 2 - Transposition (2 great arteries are swapped) 3 - Tricuspid atresia (3 cusps) 4 - Tet Fal (4 aspects) 5 - Total Anomalous Pulmonary Venous Return (5 words) CoA becomes cyanotic if the PDA closes

Answer 137

Risk factor (RF) for GBS = either offer intrapartum IV penicillin OR offer swab test @ 35-37 weeks or 3-5 weeks before expected delivery date GBS + Urine = intrapartum IV penecillin & tx immediately GBS -urine +RF = intrapartum IV penecillin

Answer 138

An ultrasound detecting fetal heart rate, breathing, movement, tone; and amniotic fluid volume It is an evaluation of fetal wellbeing at a given point in time and is often used to assess the need for rapid induction of labor

Answer 139

Combined screening is now standard and comprises an ultrasound scan to assess nuchal translucency; and serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A). α-fetoprotein, unconjugated oestriol and β-hCG comprises the triple test conducted between 15-20 weeks gestation to assess for Down's syndrome. Either the triple test or the quadruple test (see below) are often offered when women have missed the window for combined antenatal screening. α-fetoprotein, unconjugated oestriol, β-hCG and inhibin-A comprise the quadruple test, which maybe conducted between 15-20 weeks gestation to assess for Down's syndrome.

Answer 140

- The Kleihauer is used after a sensitising event to see if fetomaternal haemorrhage has occurred add acid to maternal blood which removes adult hemoglobin, fetal cells are resistant so % of fetal to maternal cells can be calculated'.

Answer 141

Direct Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby An indirect Coombs is a screening test that is carried out at booking/28/34 weeks to establish if the mother already has Rh Abs present.

Answer 142

Maternal circulation volume and cardiac output is increased in pregnancy, and this is NORMAL. The resulting signs include ejection systolic murmur (due to increased cardiac output), a forceful apex beat (increased cardiac output), peripheral oedema (due to increased venous volume and backpressure), and a third heart sound (due to increased vascular volume). Despite all these changes, a physiological pregnancy should never result in enough pulmonary oedema, as this would be detrimental to the health of the mother and foetus.

Answer 143

Women who develop chickenpox during pregnancy should be treated with oral aciclovir 800mg 5 times a day for 7 days if >20 weeks pregnant. The RCOG advises that only women who develop severe infection and are at high risk of complicated chickenpox should be referred to hospital for IV aciclovir. Patients should be hospitalised if they develop chest or CNS symptoms, a dense hemorrhagic rash, or are immunocompromised.

Answer 144

Small first degree tears can be Left to heal on their own Trained midwife can repair deep first second degree tears and episiotomies in labour suite Third and fourth degree tears need to be repaired in an operating theatre by a doctor eithe uner local or generalised anaesthesia

Answer 145

Lamotrigine Carbamazepine Levetiracetam

Answer 146

Tocolytics - terbutaline

Answer 147

300,000 mIU/ml is approximately the upper limit of expected βhCG in an intrauterine pregnancy during weeks 9-12.

Answer 148

Footling presentation at delivery

Answer 149

is worth noting that, unlike the combined screen, the quadruple screen only screens for Down's syndrome and is less accurate.

Answer 150

abnormal findings at the time of the 12-week scan high-risk trisomy screening test results a previous pregnancy/baby with a genetic condition maternal/paternal family history of another genetic condition (e.g. sickle cell disease, thalassaemia major or cystic fibrosis)

Answer 151

Changing metformin to modified-release metformin can be helpful in patients who do not tolerate metformin due to side-effects such as gastrointestinal upset, but would not have a role in improving glycaemic control in this patient. Infants with cystic fibrosis at 1 to 2 weeks of age show increased levels of IRT in the plasma in the neonatal heal-prick test

Answer 152

Nitrofurantoin should not be used near term due to the risk of neonatal haemolysis.

Answer 153

can start cocp from D21 post partum if not breastfeeding first 21 days - increased risk of DVT COCP might slightly reduce breast milk production

Answer 154

Dx o Fasting plasma glucose level >5.6 mmol/L o 2-h plasma glucose level (OGTT) >7.8 mmol/L ``` Targets CBG o Fasting glucose <5.3 mmol/L o 1h after meal <7.8 mmol/L o 2h after meal <6.4mmol/L ```

Answer 155

Nitrofurantoin can safely be prescribed in the first and second trimester, though is contraindicated in the third trimester due to increased risk of neonatal haemolysis

Answer 156

Treatment should be offered to all pregnant woman who are symptomatic. This consists of oral metronidazole 400mg twice daily for 5-7 days (2grams stat dose is not recommended in pregnancy). Treatment is considered on a individual basis for pregnant woman with BV who are asymptomatic. This is because evidence suggests that identification and treatment of asymptomatic pregnant women does not lower the risk of preterm births.

Answer 157

he correct answer is trace glycosuria. Glomerular filtration rate (GFR) increases during pregnancy, which causes a physiological reduction in creatinine levels. In accordance with this, trace glycosuria is often seen due to reduced levels of tubular reabsorption of freely filtered glucose due to greater flow rate through the tubules.

Answer 158

4 3 2 1 4 blood (FBC, rhesus, blood group, alloantibodies) 3 virus (hepB, HIV, syphilis) *rubella no more* 2 UTI (dipstick, culture) 1 full physical examination (breast, BMI, BP)

Answer 159

Indomethacin and salbutamol can be used as tocolytics.

Answer 160

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen- C-section); P for Polyhydramnios; T for Twins or multiple gestation/multiparity; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 161

115 for non-pregnant women, 110 in early pregnancy, 105 in later pregnancy, and 100 after childbirth.