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Passmedicine - Obstetrics Flashcards

1
Q

What are the risks associated with prematurity?

A

Increased mortality (depends on gestation)
IRDS
Intraventricular hemorrhage
Necrotising enterocolitis
Chronic lung disease, hypothermia, feeding problems, infection, jaundice
Retinopathy of newborn, hearing problems

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2
Q

If a women is in premature labour but at an early stage what two medications should you give her?

A

Steroids - helps foetal lung maturation

Tocolytics - may stop premature labour

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3
Q

What is a first degree perineal tear?

A

Superficial damage with no muscle involvement (vaginal mucosa only)

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4
Q

What is a second degree perineal tear?

A

Injury to the perineal muscle but not involving the anal sphincter

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5
Q

What is a third degree perineal tear?

A

Injury to perineum involving the anal sphincter complex (external and internal anal sphincter)

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6
Q

What is a 3a degree perineal tear?

A

<50% of EAS thickness torn

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7
Q

What is a 3b degree perineal tear?

A

> 50% EAS thickness torn

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8
Q

What is a 3c degree perineal tear?

A

IAS torn

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9
Q

What is a fourth degree perineal tear?

A

Injury to perineum involving the anal sphincter complex + rectal mucosa

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10
Q

What are risk factors for perineal tears?

A 
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
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11
Q

What are the three stages of post-partum thyroiditis?

A
  1. Thyrotoxicosis
  2. Hypothyroidism
  3. Normal thyroid function (recurrence rate high in future pregnancies)
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12
Q

What kind of antibodies are found in 90% of patients with post-partum thyroiditis?

A

TPO

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13
Q

How is post-partum thyroiditis managed?

A

Thyrotoxic phase - don’t use ATD as thyroid is not overaction, propanolol for symptom control
Hypothyroid phase - thyroxine

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14
Q

Post-partum thyroiditis is based upon clinical manifestations and ____ alone?

A

Thyroid function tests

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15
Q

What 3 criteria is post-partum thyroiditis definitively diagnosed using?

A
  1. Patient is within 12 m of giving birth
  2. Clinical manifestations are suggestive of hypothyroidism
  3. Thyroid function tests support diagnosis
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16
Q

Define pre-eclampsia

A

Condition after 20 wees gestation characterised by pregnancy induced hypertension + proteinuria (>0.3g/24h)

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17
Q

What is the classic triad of pre-eclampsia?

A

Pregnancy induced:
HTN
Proteinuria
Oedema (not included in definition)

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18
Q

What does pre-eclampsia predispose to?

A

Foetal: prematurity, intrauterine growth retardation
Eclampsia
Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
Cardiac organ failure
Multi-organ failure

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19
Q

What are high risk factors for pre-eclampsia?

A

Hypertensive disease is another pregnancy
CKD
Autoimmune disease, e.g. SLE, antiphospholipid syndrome
T1/T2DM
Chronic HTN

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20
Q

What are moderate risk factors for pre-eclampsia?

A 
First pregnancy 
Age 40+
Pregnancy interval of >10 years
BMI of 35+ at first visit
FH pre-eclampsia
Multiple pregnancy
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21
Q

What are the features of severe pre-eclampsia?

A 
HTN: >170/110mmHg
Proteinuria: dipstick ++/+++
Headache
Visual disturbances
Papilloedema
RUQ/epigastric pain 
Hyperreflexia
Platelet count <100x10^6/l, abnormal liver enzymes or HELLP syndrome
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22
Q

When should you treat someone’s BP in pre-eclampsia?

A

BP >160/110mmHg recommended but many treat when it is under this

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23
Q

What is used to treat pre-eclampsia?

A

1st line: oral labetaolol

Alts: nifedipine, hydralazine

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24
Q

What is the definitive management of pre-eclampsia?

A

Delivery of the baby

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25
Q

What may help reduced BP during labour if a women has pre-eclampsia?

A

Epidural anaesthesia

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26
Q

Should women continue to take their anti-epileptic medication throughout their pregnancy?

A

Usually as the risks of uncontrolled epilepsy during pregnancy generally outweigh risks of meds to the foetus

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27
Q

What drug should women with epilepsy who are trying for a baby be advised to take?

A

Folic acid 5mg per day

minimise risk of neural tube defects

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28
Q

What are the key points for women taking anti-epileptics whilst pregnant?

A

Aim for monotherapy

No need to monitor AED levels

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29
Q

What congenital malformation is sodium valproate associated with?

A

Neural tube defects

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30
Q

What congenital malformation is carbamazepine associated with?

A

Actually considered one of the least teratogenic

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31
Q

What congenital malformation is phenytoin associated with?

A

Cleft palate

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32
Q

What congenital malformation is lamotrigine associated with?

A

Also considered to have low rates of congenital malformations

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33
Q

Can you breastfeed whilst on AEDs?

A

Yes, apart from barbituates

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34
Q

Pregnant women taking phenytoin should be given what drug in the last month of pregnancy and why?

A

Vitamin K to prevent clotting disorders in the newborn

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35
Q

In which group of people should sodium valproate not be used?

A

Pregnant women or women of childbearing age

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36
Q

What should be the first line AED for a women of child bearing age?

A

Lamotrigine

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37
Q

How is the SV affected by pregnancy?

A

Goes up by 30%

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38
Q

How is the HR affected by pregnancy?

A

Goes up by 15%

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39
Q

How is the CO affected by pregnancy?

A

Goes up by 40%

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40
Q

How is BP affected by pregnancy?

A

Systolic unchanged

Diastolic reduced in 1st and 2nd trimester, returns to normal by term

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41
Q

Apart from those already mentioned, what other physiological changes occur to the CV system during pregnancy?

A

Enlarged uterus may interfere with venous return –> ankle oedema, supine hypotension, varicose veins

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42
Q

What physiological changes occur to the respiratory system during pregnancy?

A

Pulmonary ventilation and tidal volume increases

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43
Q

Why might pregnant women find warm conditions uncomfortable?

A

BMR increases (due to increased thyroxine and adrenocortical hormones)

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44
Q

Why might pregnant women find themselves being more breathless?

A

Oxygen requirements increase by 20% so over breathing can lead to fall in pCO2
Elevation of diaphragm

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45
Q

How is the maternal blood volume affected by pregnancy?

A

Goes up by 30%

NB - red cells increased by 20% but plasma increases by 50% so Hb falls

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46
Q

How is coagulation affected by pregnancy?

A

Low grade increase in coagulant activity
Rise in fibrinogen and factors VII, VIII, X
Fibrinolytic activity is decreased

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47
Q

How is coagulation activity increased in pregnancy?

A

To prepare for delivery

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48
Q

Changes in maternal coagulation put a pregnant mother at risk of what?

A

TE

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49
Q

How is platelet count affected by pregnant?

A

Falls

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50
Q

What happens to ESR, WCC and CRP in pregnancy?

A

ESR and WCC is raised

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51
Q

Why is GFR increased in pregnancy?

A

As blood flow increases

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52
Q

What elevates salt and water resorption in pregnancy?

A

Elevated sex steroid levels

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53
Q

What is excreted more in urine when you are pregnant?

A

Protein

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54
Q

What element is needed more during pregnancy?

A

Ca (esp. 3rd trimester and continues into lactation)

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55
Q

How is more calcium absorbed?

A

Increased 1, 25 dihydroxy vit D

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56
Q

How is hepatic blood flow affected by pregnancy?

A

Remains unchanged

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57
Q

What liver enzyme is raised in pregnancy?

A

ALP

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58
Q

How is albumin level affected by pregnancy?

A

Falls

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59
Q

How does the uterus change in pregnancy?

A

100g –> 1100g
Hyperplasia –> hypertrophy later
Increase in cervical ectropion + discharge

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60
Q

What may a retroverted uterus lead to in pregnancy?

A

Retention (at 12-16w) this usually self corrects

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61
Q

What are Braxton-Hicks contractions?

A

Non-painful practice contractions in late pregnancy (>30w)

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62
Q

What signs are features of increased CO and blood volume in pregnancy?

A

Ejection systolic murmur

Third heart sound

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63
Q

What organism is responsible for most early-onset severe infection in the neonatal period?

A

Group B strep

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64
Q

Why might mothers be described as carriers of GBS?

A

They have GBS in their bowel/vaginal flora and can expose their newborn to it during labour

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65
Q

What are risk factors for GBS infection?

A

Prematurity
PROM
Prev. sibling GBS infection
Maternal pyrexia, e.g. secondary to chorioamniotiis

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66
Q

Is universal screening for GBS offered to all women?

A

No

And mothers cannot request it

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67
Q

What is the risk of maternal carriage of GBS of someone who has had GBS detected in a previous pregnancy?

A

50%

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68
Q

For those who’ve had GBS in a previous pregnancy, what action should be taken when having another child?

A

Intra-partum antibiotics
OR
Testing in late pregnancy

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69
Q

If women are being offered swabs for GBS when should this be done?

A

35-37 weeks or 3-5w prior to anticipated delivery date

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70
Q

Who should be offered GBS prophylaxis?

A

A women with a previous baby with GBS disease
OR
Any women in preterm labour
OR
Women with pyrexia (>38) during pregnancy

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71
Q

What antibiotic is used for intra-partum prophylaxis for GBS? When should it be givne?

A

Benzylpenicillin

At start of labour and 4hrly intervals thereafter

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72
Q

What infections are GBS associated with?

A

Chorioamnionitis

Neonatal sepsis

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73
Q

Define foetal lie

A

Long axis of foetus relative to the longitudinal axis of the uterus

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74
Q

What are the three types of lie?

A

Longitudinal (99.7% foetuses at term)
Transverse lie
Oblique lie

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75
Q

What has a higher incidence: oblique or transverse lie?

A

Transverse

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76
Q

How does the management for oblique and transverse lie differ?

A

Same management for both

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77
Q

Define transverse lie

A

Foetal longitudinal axis lies peripendicular to the long axis of the uterus

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78
Q

What are the two types of transverse lie?

A

Scapulo-anterior: foetus faces mother’s back

Scapulo-posterior: foetus faces mother’s front

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79
Q

When is transverse lie actually quite common?

A

Early gestation (most have moved to longitudinal lie bby 32w)

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80
Q

What are risk factors for transverse lie?

A 
Those who have had previous pregnancies
Fibroids/other pelvic tumours
Pregnant with twins/triplets
Prematurity
Polyhydramnios
Foetal abnormalities
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81
Q

When is abnormal foetal lie picked up?

A

Routine antenatal appointments by abdominal ex

US will show foetal lie

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82
Q

What are complications of transverse lie?

A

PROM
Cord-prolapse
Compound presentation

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83
Q

How is transverse lie managed?

A

<36w: nothing, most will move into longitudinal lie spontaneously
36w: appt to discuss options

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84
Q

What are the two options for managing transverse lie >36w?

A

External cephalic version

elective c-section (if pt opts for it or failed ECV)

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85
Q

When can ECV be done up until?

A

Early labour (before rupture of membranes)

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86
Q

What are contraindications to doing ECV?

A 
Maternal rupture within last 7 days
Multiple pregnancy
Major uterine abnormality 
Abnormal CTG
Where c-section is required
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87
Q

What is the success rate of ECV?

A

50%

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88
Q

What is the decision to perform C-section over ECV based on?

A 
Risks to mother/foetus
Preference of pt
Pts previous pregnancies
Co-morbidities
Pts ability to access obstetric care rapidly
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89
Q

How many antenatal visits is required for a first pregnancy if uncomplicated?

A

10

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90
Q

How many antenatal visits is required for a subsequent pregnancy if uncomplicated?

A

7

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91
Q

When is the booking visit? What happens here?

A

8-12 weeks
General info re diet, alcohol, smoking, folic acid, vit D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine

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92
Q

What tests are done as part of the booking bloods/urine?

A

FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Hep B, syphillis, rubella
HIV
Urine culture to detect asymptomatic bacteriuria

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93
Q

What is done as part of antenatal care at 10-13+6 weeks?

A

Early scan to confirm dates, exclude multiple pregnancy

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94
Q

What is done as part of antenatal care at 11-13+6 weeks?

A

Down’s syndrome screening, incl. nuchal scan

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95
Q

What is done as part of antenatal care at 16 weeks?

A

Info on the anomaly + blood results
If Hb <11g/dl consider iron
Routine care - BP + urine dipstick

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96
Q

What is done as part of antenatal care at 18-20+6 weeks?

A

Anomaly scan

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97
Q

What is done as part of the antenatal care at 25 weeks (if primip)?

A

BP, urine dipstick, symphysis-fundal height

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98
Q

What is done as part of antenatal care at 28 weeks?

A

BP, urine dipstick, SFH
Second screen for anaemia, atypical red cell alloantibodies
If Hb <10.5g/dl, consider iron
First dose anti-D to rh-ve women

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99
Q

What is done as part of the antenatal care at 31 weeks (if primip)?

A

Routine care - BP, dipstick…

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100
Q

What is done as part of the antenatal care at 34 weeks?

A

Routine care
Second dose anti-D
Info on labour and birth plan

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101
Q

What is done as part of the antenatal care at 36 weeks?

A

Routine care
Check presentation + offer ECV if indicated
Info on breast feeding, vit K, baby blues

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102
Q

What is done as part of the antenatal care at 38 weeks?

A

Routine care

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103
Q

What is done as part of the antenatal care at 40 weeks (if primip)?

A

Routine care

Discussion about prolonged pregnancy

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104
Q

What is done as part of the antenatal care at 41 weeks?

A

Routine care

Discuss labour plans, possibility of induction

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105
Q

Define placenta praevia

A

A placenta lying wholly/partly in the lower uterine segment

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106
Q

What factors are associated with placenta praevia?

A

Multiparity
Multiple pregnancy
Embyros are more likely to implant on a lower segment scar from a previous c-section

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107
Q

What are the clinical features of placenta praevia?

A 
Shock in proportion to visible loss
No pain
Uterus not tender
Lie + presentation may be abnormal (e.g. high presenting part)
Small bleeds before large
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108
Q

Where is placenta praevia often picked up?

A

20w scan

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109
Q

What is the best imaging technique to see placenta praevia?

A

TVUS

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110
Q

What is a grade I placenta praevia?

A

Placenta reaches lower segment but not the internal os

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111
Q

What is a grade II placenta praevia?

A

Placenta reaches internal os but doesn’t cover it

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112
Q

What is a grade III placenta praevia?

A

Placenta covers internal os before dilatation but not when dilated

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113
Q

What is a grade IV placenta praevia?

A

Placenta completely covers the internal os

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114
Q

What is the key clinical feature in placenta praevia?

A

Painless PV bleeding after 24 weeks

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115
Q

What tool is used to screen for PND?

A

Edinbrugh postnatal depression scale

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116
Q

What is the max score on the edinbrugh scale?

A

30

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117
Q

What does the edinbrugh scale indicate?

A

How the mother has felt over the last week

Includes a q about self harm

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118
Q

What score on the edinbrugh scale would indicate a ‘depressive illness of varying severity’?

A

> 13

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119
Q

How common is baby blues?

A

Affects 60-70% women

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120
Q

When does baby blues tend to happen?

A

Usually 3-7 days after birth

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121
Q

In who is baby blues most common?

A

Primps

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122
Q

What are features of baby blues?

A

Anxiety, tearfulness, irritability

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123
Q

How common is PND?

A

10%

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124
Q

When do most cases of PND start?

A

Within a month but typically peaks at 3 months

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125
Q

What are the features of PND?

A

Similar to depression

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126
Q

How common is puerperal psychosis?

A

0.2% of women

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127
Q

When does puerperal psychosis tend to occur?

A

2-3w after birth

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128
Q

What are features of puerperal psychosis?

A 
Severe swings in mood (similar to bipolar) 
Disordered perception (eg. auditory hallucinations)
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129
Q

How is baby blues managed?

A

Reassurance
Support
Health visitor has a key role

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130
Q

How is PND managed?

A

Reassurance, support
CBT
SSRIs, e.g. sertraline, paroxetine if symptoms severe

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131
Q

Why are sertraline + paroxetine used for PND?

A

They are secreted in breastmilk but are not thought to be harmful to the infant

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132
Q

How is puerperal psychosis managed?

A

Admission

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133
Q

What is the risk of recurrence of puerperal psychosis in future pregnancies?

A

20%

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134
Q

Define post partum haemorrhage

A

Loss of 500ml + blood from genital tract

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135
Q

What are the two types of PPH

A

Primary

Secondary

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136
Q

What is a primary PPH

A

PPH occuring in first 24h after birth

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137
Q

What accounts for 90% cases of PPH?

A

Uterine atony

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138
Q

What are other causes of PPH?

A 
4Ts - 
Tissue
Trauma
Tone
Thrombin

(e.g. genital trauma, clotting factor problems)

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139
Q

What are risk factors for a primary PPH?

A 
Previous PPH
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydramnios
Emergency C-section 
Placenta praevia, placenta accreta
Macrosomnia
Ritodrine
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140
Q

What is ritodrine?

A

A beta-2 adrenergic receptor agonist used for tocolysis

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141
Q

How is primary PPH managed?

A

ABC, incl. 2 peripheral cannulae (14G)
1. Bimanual uterien compression to manually stimulate contractions
2. IV syntocinon (oxytocin) 10 units or IV ergometrine 500microg
3. IM carboprost
4. intramyometrial carboprost
5. Rectal misoprostol
If these fail - consider surgical options

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142
Q

What are surgical options for managing primary PPH?

A

1st line: intrauterine balloon tamponade (if uterine atony)
Other options: B-lynch suture, ligation of the uterine arteries or internal iliac arteries
V. severe, uncontrolled: hysterectomy may be lifesaving

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143
Q

Define secondary PPH

A

PPH occuring 24h-12w after birth

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144
Q

What tends to be the cause of secondary PPH?

A

Retained placental tissue or endometritis

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145
Q

What things are associated with uterine atony?

A

Overdistension (e.g. due to multiple gestation, macrosomnia, polyhydramnios)

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146
Q

What virus is responsible for chicken pox?

A

Varicella zoster virus

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147
Q

What causes shingles?

A

Reactivation of dormant VZV in the dorsal root ganglion

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148
Q

If a mother is exposed to VZV during pregnancy for the first time what is the foetus at risk of?

A

Foetal varicella syndrome
Shingles in infancy (if exposed in third trimester)
Severe neonatal varicella which may be fatal

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149
Q

If a mother is exposed to VZV during pregnancy for the first time what she more at risk of?

A

5x greater risk of pneumonitis

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150
Q

What are features of foetal varicella syndrome?

A

Skin scarring, eye defects (microphthalmia, limb hypoplasia, microcephaly, learning disabilities

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151
Q

How should pregnant lady exposure to varicella be managed?

A

If any doubt about VZV status - check maternal blood for varicella Abs
If not immune give VZIG ASAP

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152
Q

How should you manage a pregnant lady with chicken pox?

A

Oral aciclovir if they present within 24h of rash onset

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153
Q

Up to how many days post-exposure if VZIG effective?

A

10 days

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154
Q

Can the varicella vaccine be given during pregnancy?

A

No as it is a live vaccine

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155
Q

What can cause nipple pain whilst breast feeding?

A

A poor latch
Blocked duct - nipple pain when breast feeding, continue breastfeeding, seek advice re positioning of baby, breast massage
nipple candidiasis

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156
Q

How should nipple candidiasis while breastfeeding be managed?

A

Miconazole cream for mother

Nystatin suspension for baby

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157
Q

How common is mastitis?

A

Affects 1 in 10 breastfeeding women

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158
Q

When should you treat mastitis?

A

If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24h of effective milk removal or if culture indicates infection

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159
Q

What is the first line antibiotic for mastitis?

A

Flucloxacillin 10-14 days

erythromycin if penicillin allergic

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160
Q

Should you continue to breastfeeding if you have mastitis?

A

Yes

Continue through treated

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161
Q

What may develop as a result of untreated mastitis?

A

Breast abscess

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162
Q

How are breast abscesses managed?

A

Incision and drainage

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163
Q

What are the feature of breast engorgement?

A

Breast pain a few days after birth affecting both breasts
Usually worse just before a feed
Milk doesn’t flow well and infant may find it hard to attach and suckle
Fever may be present but tends to settle after 24h
Breasts may appear red

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164
Q

What are complications of breast engorgement?

A

Blocked milk ducts
Masitis
Difficulties breastfeeding

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165
Q

What may help the discomfort of engorgement?

A

Although initially painful hand expression of milk may help

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166
Q

What happens in Raynaud’s disease of the nipple?

A

Intermittent nipple pain, usually present during + immediately after feeding
Blanching of nipple may –> cyanosis +/or erythema

Nipple pain resolves when nipples return to normal colour

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167
Q

What is the management of Raynaud’s disease of the nipple?

A 
Advice re minimising cold
Use heat packs following breastfeeding
Avoid caffeine
Stop smoking
If persistent - refer to specialist to try oral nifedipine
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168
Q

What are contraindications to breast feeding?

A

Galactosaemia
Viral infections (e.g. HIV)
Drugs

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169
Q

List drugs that should be avoided when breastfeeding

A 
Antibiotics (ciprofloxacin, tetracycline, chloramphenicol, sulphonamides)
Psychiatric drugs: lithium, benzos, clozapine
Aspirin
Carbimazole
Methotrexate
SUs
Cytotoxic drugs
Amiodarone
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170
Q

Define olgiohydramnios

A

Reduced amniotic fluid (less than 500ml at 32-36 weeks + an amniotic fluid index <5th percentile)

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171
Q

What are causes of olgiohydramnios?

A 
PROM
Foetal renal problems, e.g. renal agenesis
IUGR
Post-term gestation 
Pre-eclampsia
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172
Q

How can pre-eclampsia cause oligohydamnios?

A

Hypoperfusion of placenta

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173
Q

What factors would mean a pregnant lady is at high risk of VTE?

A

Previous VTE

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174
Q

What should be done if a pregnant lady is considered at high risk of VTE?

A

LMWH prophylaxis throughout antenatal period

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175
Q

What factors would mean a pregnant lady is at intermediate risk of VTE?

A

Hopsitalisation or surgery
Co-morbidities
Thrombophilia

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176
Q

What should be done if a pregnant lady is considered at intermediate risk of VTE?

A

Consider antenatal prophylactic LMWH

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177
Q

What are risk factors for VTE during pregnancy?

A 
Age >35
BMI >30
Parity >3
Smoker
Gross varicose veins 
Current pre-eclampsia
Immobility
FH of unprovoked VTE
Low risk thrombophilia 
Multiple pregnancy 
IVF pregnancy
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178
Q

How many risk factors for VTE in pregnancy warrants treatment with LMWH?

A

4+

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179
Q

How long should women be given LMWH for if they are pregnant and at risk of VTE?

A

Until 6 weeks postnatal

Unless diagnosis of DVT is made before shortly before delivery then continue for at least 3 months

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180
Q

What is shoulder dystocia?

A

Inability to delivery the body of the foetus using genital traction after delivery of the head

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181
Q

What are complications of shoulder dsytocia?

A

PPH
Perineal tears
Brachial plexus injury
Neonatal death

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182
Q

What are risk factors for shoulder dystocia?

A

Foetal macrosomnia
High maternal BMI
DM
Prolonged labour

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183
Q

What tends to cause shoulder dystocia?

A

Impaction of the anterior foetal shoulder on the maternal pubic symphysis

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184
Q

How is shoulder dystocia managed?

A

Call additional help

McRobert’s manoeuvre

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185
Q

What does McRobert’s manoeuvre entail?

A

Flexion + abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

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186
Q

What is intrahepatic cholestasis of pregnancy associated with?

A

Increased risk of premature birth and still birth

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187
Q

What are features of intrahepatic cholestasis of pregnancy?

A

Pruritus (typically worse on palms, soles + abdomen)
Jaundice in 20%
Raised bilirubin, GGT, ALP
RUQ pain, steathorrhoea

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188
Q

How is intrahepatic cholestasis of pregnancy managed?

A

Induction of labour at 37w
Ursodeoxycholic acid
Wkly LFTs
Vit K supplementation

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189
Q

What should be given to babies born to mothers who are chronically infected with Hep B or have had an acute Hep B infection during pregnancy?

A

Complete course of vaccination + hep B Ig

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190
Q

Can hep B be transmitted via breastfeeding?

A

No

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191
Q

Define antepartum haemorrhage

A

Bleeding after 24 weeks

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192
Q

What are reasons for 1st trimester bleeding?

A

Spontaneous abortion
Ectopic pregnancy
Hydatidform mole

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193
Q

What are reasons for 2nd trimester bleeding?

A

Spontaneous abortion
Hydatidiform mole
Placental abruption

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194
Q

What are reasons for 3rd trimester bleeding?

A

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

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195
Q

Along with pregnancy related causes of bleeding during pregnancy what other things should you rule out?

A

STIs

Cervical polyps etc.

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196
Q

How does hydatidiform mole tend to present?

A

Bleeding in 1st/2nd trimester associated with exaggerated symptoms of pregnancy, e.g. hyperemesis
Uterus large for dates
Serum bHCG v. high

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197
Q

How does vasa praevia tend to present?

A

Rupture of membranes followed by immediate vaginal bleeding

Foetal bradycardia

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198
Q

What is vasa praevia?

A

Foetal blood vessels cross or run near the internal orifice of the uterus
Vessels can become compromised when the membranes rupture

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199
Q

What are foetal complications of premature rupture of the membranes?

A

Prematurity
Infection
Pulmonary hypoplasia

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200
Q

What are maternal comlications of PROM?

A

Chorioamnionitis

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201
Q

What investigations may be useful in PROM? What investigation should be avoided?

A

Sterile speculum examination
Nitrazine sticks (detect changes in pH)
US to show oligohydramnios

DO NOT do digital ex due to infection risk

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202
Q

What is the management of PROM?

A 
Admission
Regular obs to ensure chorioamnionitis doesn't develop
Oral erythromycin 10d
Antenatal corticosteroids to reduce IRDS
Delivery considered at 34w
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203
Q

Up until what week of gestation can catching VZV for the first time lead to foetal varicella syndrome?

A

20

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204
Q

Define labour

A

Onset of regular + painful contractions associated with cervical dilatation + descent of the presenting part

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205
Q

What are signs of labour?

A

Regular + painful uterine contractions
A show
Rupture of the membranes
Shortening + dilatation of the cervix

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206
Q

What is a show?

A

Shedding of the mucous plug

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207
Q

How stages of labour are there?

A

3

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208
Q

What is the first stage of labour?

A

Onset of true labour to when cervix is fully dilated

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209
Q

What is the second stage of labour?

A

From full dilatation to delivery of the foetus

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210
Q

What is the third stage of labour?

A

From delivery of foetus to when the placenta membranes have been completely delivered

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211
Q

What monitoring is done during labour?

A 
FHR
Contractions
Maternal pulse rate
Maternal BP and temp
VE
Maternal uterine
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212
Q

How often should FHR be assessed during labour?

A

Every 15m
OR
Continuously via CTG

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213
Q

How often should contractions be assessed during labour?

A

Every 30 minutes

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214
Q

How often should maternal pulse rate be assessed during labour?

A

Every hour

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215
Q

How often should maternal BP and temperature be checked during labour?

A

Every 4h

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216
Q

How often should VE be done during labour?

A

Every 4h to check progression of labour

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217
Q

How often should maternal urine be checked for ketones and protein during labour?

A

Every 4h

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218
Q

What are the cons of having an epidural during labour?

A

It is associated with a prolonged labour + increased operative vaginal delivery

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219
Q

What would CI an epidural?

A

Coagulopathy

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220
Q

What is folic acid converted to the in the body?

A

Tetrahydrofolate

221
Q

What are good dietary sources of folate?

A

Green, leafy vegetables

222
Q

What is the function of tetrahydrofolate (THF)?

A

Plays key role in transfer of 1-carbon units (e.g. methyl, methylene + formyl groups) to the essential substrates involved in the synthesis of DNA and RNA

223
Q

What can cause folate deficiency?

A

Phenytoin
Methotrexate
Pregnancy
Alcohol xs

224
Q

What kind of anaemia do you get with a folate deficiency?

A

Macrocytic, megaloblastic

225
Q

What are consequences to the foetus during pregnancy if the mother has a folate deficiency?

A

Neural tube defects

226
Q

What is the recommendation for pregnant women taking folate when they are not deemed to be at risk of their child having a NTD?

A

400mg of folic acid until 12th week of pregnancy

227
Q

What is the recommendation for pregnant women taking folate when they are deemed to be at higher risk of their child having a NTD?

A

5mg folic acid from before conception until 12th week of pregnancy

228
Q

What factors would make a women high risk of having a child with a NTD?

A

Partner has NTD, they have had prev. pregnancy affected by a NTD, FH NTD
She is on AEDs or has coeliac disease, diabetes, thalassaemia trait
BM 30+

229
Q

What are the two types of twins?

A

Dizygotic

Monozygotic

230
Q

What is a dizygotic twin?

A

Non-identical, develop from two separate ova that were fertilised at the same time

231
Q

What is a monozygotic twin?

A

Identical, developed from single ovum which has divided to form two embyros

232
Q

What type of twin is more common?

A

Dizygotic (80% of twins)

233
Q

What are monoamniotic monozygotic twins more at risk of?

A

Increased spontaneous miscarriage and perinatal mortality
Increased malformations, IUGR, prematurity
Twin to twin transfusions

234
Q

What factors predispose to having dizygotic twins?

A 
Previous twins
FH
Increasing maternal age
Multigravida
Induced ovulation, IVF
Race, e.g. afrocaribbean
235
Q

What antenatal complications are associated with twins?

A

Polyhydramnios
Pregnancy induced HTN
Anaemia
Antepartum haemorrhage

236
Q

What are foetal complications associated with twins?

A

Prematurity
Light for date babies
Malformation

237
Q

What labour complications are associated with twins?

A

PPH (x2 increased risk)
Malpresentation
Cord prolapse, entanglement

238
Q

What additional things should be done during a twin pregnancy?

A

Additional iron + folate

Precautions at labour, e.. 2 obstetricians present

239
Q

What is twin to twin transfusion syndrome?

A

Two foetuses share the same placenta, so blood can flow between the twins
One foetus (donor) recieves a lesser share of the blood flow than the other twin (recipient)
Recipient may become fluid overloaded and the donor becomes anaemia
(one has polyhydramnios + the other oligohydramnios etc.)
Can be fatal to one or both foetuses

240
Q

What causes twin to twin transfusion syndrome?

A

Abnormalities in the network of placental blood vessels

241
Q

What factors will reduce the vertical transmission of HIV?

A

Maternal ART
C-section
Neonatal ART
Bottle feeding

242
Q

When might you do a vaginal delivery in an HIV positive woman?

A

If viral load <50 copies/ml at 36w

243
Q

What medication is given prior to having a c-section in HIV +ve women?

A

Zidovudine infusion (start 4h before c-section)

244
Q

What ART is given to the neonates of HIV +ve women?

A

If maternal viral load <50copies/ml - oral zidovudine

Otherwise triple ART for 4-6 wees

245
Q

What are the two types of C-section?

A

Lower segment C-section

Classic C-section (longitudinal incision upper segment of uterus)

246
Q

What type of c-section is most commonly done?

A

Lower segment c-section (99%)

247
Q

What are indications for c-section?

A

Absolute - placenta praevia (grade 3/4)/cephalopelvic disproportion

Relative - 
Pre-eclampsia
Post-maturity
IUGR
Foetal distress in labour/prolapse cord
Failure of labour to progress
Malpresentations (brow)
Placental abruption (only if foetal distress, if dead, delivery vaginally)
Vaginal infection, e.g. active herpes
Cervical cancer
248
Q

Why should a women with cervical cancer deliver via c-section?

A

Vaginal delivery disseminates cancer cells

249
Q

What are some serious maternal complications of c-section?

A 
Emergency hysterectomy
Need for further surgery at later date (incl. curettage)
Admission to ITU
TE dx
Bladder injury
Ureteric injury
Prolonged ileus
Death
250
Q

What are some serious complications for future pregnancies of c-section?

A

Increased risk of uterine rupture in subsequent pregnancies/deliveries
Increased risk of antepartum stillbirth
Increased risk in subsequent pregnancies of placenta praevia + accreta
Subfertility

251
Q

What are some common complications of c-section for the mother?

A

Persistent wound + abdominal discomfort in 1st few months after
Increased risk of repeat c-section when vaginal delivery attempted in subsequent pregnancies
Readmission to hospital
Haemorrhage
Infection (wound, endometritis, UTI)

252
Q

What is a common complication of c-section to the foetus?

A

Lacerations

253
Q

What are contraindications to having a vaginal birth after caesarean?

A

Previous uterine rupture

Classical caesarean scar

254
Q

What layers do you go through when performing a lower segment C-section?

A 
Skin
Superficial fascia
Deep fascia
Anterior rectus sheath 
Rectus abdominis muscle (incision of linea alba and muscle pushed aside)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
255
Q

What happens the serum urea and creatinine and the urinary protein loss in pregnancy normally?

A

Decreased serum urea and creatinine (increased perfusion to kidneys in pregnancy)

Increased urine protein loss

256
Q

What is the bishop score used for?

A

To help assess whether induction of labour will be required

257
Q

What are the 5 components of the bishop score?

A 
Cervical position 
Cervical consistency 
Cervical effacement 
Cervical dilatation 
Foetal station
258
Q

How do you score 0-2 on the bishop score for cervical position?

A

0 - posterior
1 - intermediate
2 - anterior

259
Q

How do you score 0-2 on the bishop score for cervical consistency?

A

0 - firm
1 - intermediate
2 - soft

260
Q

How do you score 0-3 on the bishop score for cervical effacement?

A

0 - 0-30%
1 - 40-50%
2 - 60-70%
3 - 80%

261
Q

How do you score 0-3 on the bishop score for cervical dilatation?

A

0 - <1cm
1 - 1-2cm
2 - 3-4cm
3 - >5cm

262
Q

How do you score 0-2 on the bishop score for foetal station?

A

0 - -3
1 - -2
2 - -1, 0
3 - +1, +2

263
Q

What score on the bishop score indicates that labour is unlikely to start without induction?

A

<5

264
Q

What score on the bishop score indicates that labour is likely to start spontaneously?

A

> 9

265
Q

What techniques can be used to suppress lactation?

A

Stop lactation reflex - stop suckling/expressing
Supportive measures - analgesia, well supported bra
Cabergoline

266
Q

What is cabergoline? How does it work to suppress lactation?

A

Dopamine receptor agonist which inhibits prolactin production –> suppression of lactation

267
Q

Define lochia

A

Vaginal discharge containing blood, mucous and uterine tissue

268
Q

How long can lochia continue for after birth?

A

6 weeks

269
Q

What advice can you give to people re lochia?

A

If it begins to smell badly, its volume increases or it doesn’t stop seek medical attention

270
Q

Where is hCG produced?

A

By embyro then later by placental trophoblast

271
Q

What is the main action of hCG?

A

Prevent disintegration of the corpus luteum to maintain the production of progesterone

272
Q

How often do hCG levels double in the first few weeks of pregnancy?

A

Double every 48h

273
Q

When do levels of hCG peak?

A

Around 8-10 weeks gestation

274
Q

What hormone forms the basis of many of the pregnancy home testing kits?

A

bhCG

275
Q

When can hCG be detected in the maternal blood after conception?

A

8 days

276
Q

Define breech presentation

A

Caudal end of foetus occupies the lower segment

277
Q

What is the most common type of breech presentation?

A

Frank breech (hips flexed + knees fully extended)

278
Q

What is the other type of breech (not frank)?

A

Footling breech (1 or both feet come first with the bottom at a higher position)

This is rarer with higher perinatal morbidity

279
Q

What are RFs for breech presentation?

A

Uterine malformations, fibroids
Placental praevia
Polyhydramnios or oligohydramnios
Foetal abnormality (e.g. CNS malformation, chromosomal disorders)
Prematurity (due to increased incidence earlier in gestation)

280
Q

What complication is more common in breech presentations?

A

Cord prolapse

281
Q

How do you manage breech presentation <36w?

A

Many will turn spontaneously

282
Q

How do you manage breech presentation at 36w?

A

ECV

offer at 36w in nulliparous women and 37w in multiparous

283
Q

If ECV fails to fix a breech presentation what are the options?

A

Planned c-section or vaginal delivery

must inform women that planned c-section carried reduced perinatal mortality

284
Q

How can non-infectious mastitis become infected?

A

Accumulation of milk in breast tissue –> inflammatory response (non-infectious mastitis) with inadequate milk removal predisposes to bacterial growth (infectious mastitis)

285
Q

How does infectious mastitis tend to present?

A 
Painful breast
Fever
Malaise
Tender, red, swollen and hard area
Usually in wedge shaped distribution
286
Q

How do you define a major PPH and a minor PPH?

A

Minor 500-1000ml

Major >1000ml

287
Q

If you find a low lying placenta at the 16-20w scan what should you do?

A

Rescan at 34 weeks

No need to limit activity/intercourse unless they bleed

288
Q

If you rescan someone who had a low lying placenta at 16-20w scan at 34 weeks and it is still low lying what should you do?

A

If grade I/II then scan every 2 weeks

If high presenting part/abnormal lie at 37w –> c-section

289
Q

How should you manage a placenta praevia with bleeding?

A

Admit
Treat shock
Cross match blood
Final US 36-37w to determine method of selivery
C-section for grades III/IV between 37-38 weeks
If grade I - vaginal delivery

290
Q

What is the normal foetal heart rate?

A

Varies between 100-160bpm

291
Q

With regards to CTG:

Define baseline bradycardia

A

HR <100bpm

292
Q

With regards to CTG:

Define baseline tachycardia

A

HR >160bpm

293
Q

With regards to CTG:

What can cause baseline bradycardia?

A

Increased foetal vagal tone

Maternal Bblocker use

294
Q

With regards to CTG:

What can cause baseline tachycardia?

A

Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity

295
Q

With regards to CTG:

Define loss of baseline variability

A

<5 beats/min variation

296
Q

With regards to CTG:

What can cause loss of baseline variability?

A 
Foetus is asleep (most common reason for short episodes (<40m))
Prematurity
Hypoxia (foetal acidosis)
Use of maternal drugs, e.g. benzos, opioids, methyldopa
297
Q

With regards to CTG:

Define early deceleration

A

Deceleration of HR which commences with the onset of contraction + returns to normal on completion of contraction

298
Q

With regards to CTG:

What does an early deceleration usually mean?

A

Usually harmless feature

Indicates head compression

299
Q

With regards to CTG:

Define late deceleration

A

Deceleration of HR which lags the onset of a contraction + does not return to normal until 30s following the end of the contraction

300
Q

With regards to CTG:

What does a late deceleration indicate?

A

Foetal distress, e.g. asphyxia or placental insufficiency

Want to delivery asap

301
Q

With regards to CTG:

Define variable decelerations

A

Independent of contractions

302
Q

With regards to CTG:

What can variable deceleration indicate?

A

Cord compression

303
Q

Supplementation of which vitamin may be teratogenic in pregnancy?

A

Vit A

Should avoid foods rich in this too, e.g. liver

304
Q

What vitamin should pregnant women be advised to supplement?

A

Vit D

305
Q

What is the alcohol limit during pregnancy?

A

Avoid all together

306
Q

What are the risks of smoking during pregnancy?

A 
Low birthweight
Preterm birth 
Increased risk miscarriage
IUGR
Increased risk of sudden unexpected death in infancy
307
Q

What can be offered to pregnant women to help them stop smoking?

A

NRT

DO NOT offer varenicline or bupropion to pregnant/breastfeeding woman

308
Q

What two food acquired infections should pregnant women be advised to take extra care to avoid?

A

Listeriosis

Salmonella

309
Q

What kinds of products might you catch listeriosis from?

A

Unpasteurised milk
Ripened soft cheeses (e.g. Brie, Camembert)
Pate
Undercooked meat

310
Q

What kinds of products might you catch salmonella from?

A

Raw/partially cooked eggs and meat (esp poultry)

311
Q

At what gestation should women be advised to avoid air travel?

A

> 37w if uncomplicated singleton pregnancy

>32 if uncomplicated multiple pregnancy

312
Q

Why are pregnant women advised not to fly after a certain gestation?

A

Risk of VTE

313
Q

How may women who have to travel by air while pregnant reduce their risk of getting a VTE?

A

Compression stockings

314
Q

What advice should you give to pregnant women re. taking prescribed medications?

A

Avoid unless benefits outweigh risks

315
Q

What advice should you give to pregnant women re. taking OTC medications?

A

Use as little as possible

316
Q

What advice should you give to pregnant women re. using complimentary therpies?

A

Avoid as much as possible

No evidence of their safety/effectiveness during pregnancy

317
Q

Should women be advised to continue/begin exercise during pregnancy?

A

Yes - moderate exercise is not associated with adverse outcomes

318
Q

What spots should be avoided in pregnancy?

A

High impact sports where there is a risk of abdominal trauma

Scuba diving

319
Q

Should you advise women to stop having sex during pregnancy?

A

Sex is not associated with adverse outcomes

320
Q

What factors put someone at risk of getting gestational HTN?

A

HTN dx during prev. pregnancies
CKD
Autoimmune dx, e.g. SLE, antiphospholipid syndrome
T1/T2 DM

321
Q

Define HTN in pregnancy

A

Systolic >140 OR diastolic >90mmHg

Or increase above booking readings of >30mmHg systolic or >15mmHg diastolic

322
Q

What are the 3 groups of hypertensive diseases in pregnancy?

A

Pre-existing HTN
Gestational HTN
Pre-eclampsia

323
Q

How can you tell if a pregnant women has pre-existing HTN?

A

Hx HTN before pregnancy/before 20 weeks gestation + BP >140/90
No proteinuria/oedema

324
Q

Define gestational HTN

A

HTN (>140/90) occurring after 20 weeks gestation

With NO oedema/proteinuria

325
Q

Does gestational HTN tend to resolve after giving birth?

A

Yes

326
Q

What are women with gestational HTN more at risk of in later life?

A

Future pre-eclampsia/HTN

327
Q

Define pre-eclampsia

A

Pregnancy induced HTN with proteinuria (>0.3g/24h)

328
Q

In what % of pregnancies does pre-eclampsia occur?

A

5%

329
Q

Define mild gestational HTN

A

140-149/90-99mmHg

330
Q

Define moderate gestational HTN

A

150-159/100-109mmHg

331
Q

Define severe gestational HTN

A

> 160/110mmHg

332
Q

How is gestational HTN managed?

A

Oral labetalol

Alts: nifedipine, methylopa

333
Q

What condition CIs the use of methyldopa?

A

Depression

334
Q

What is a first degree perineal tear?

A

Superficial damage with no muscle involvement

335
Q

What is a second degree perineal tear?

A

Injury to the perineal muscle but not involving the anal sphincter

336
Q

What is a third degree perineal tear?

A

Injury to perineum involving the anal sphincter complex

337
Q

What is a 3a perineal tear?

A

Less than 50% EAS thickness torn

338
Q

What is a 3b perineal tear?

A

More than 50% EAS thickness torn

339
Q

What is a 3c perineal tear?

A

IAS torn

340
Q

What is a fourth degree perineal tear?

A

Injury to perineum involving anal sphincter complex and rectal mucosa

341
Q

What are RFs for perineal tears?

A 
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
342
Q

What are the three types of diabetes that can be present during pregnancy?

A

T1
T2
Gestational DM

343
Q

What are RFs for gestational DM?

A 
BMI >30
Previous macrosomic baby weighing 4.5kg+
Prev. gestational DM
1st degree relative with DM
FH with high prevalence DM (e.g. South Asian, black caribbean)
344
Q

What screening should be done for gestational DM in those who have previously had gestational DM?

A

OGTT after booking and at 24-28w if first test is normal

OR can do early self-monitoring of blood glucose

345
Q

What screening should be done for gestational DM in those with any other RF for gestational DM?

A

OFTT at 24-28w

346
Q

How can you diagnose gestational DM?

A

If either:
Fasting BG >=5.6mmol/l
2h BG >=7.8mmol/l

347
Q

Women who are newly diagnosed with gestational diabetes should be seen within what clinic within 1 week?

A

Joint diabetes + antenatal clinic

348
Q

What should advice should women receive when they are diagnosed with gestational DM?

A

How to self monitor BG
Diet
Exercise

349
Q

How is gestational DM managed?

A

If fasting G <7: trial diet + exercise
If glucose targets not met within 1-2w - start metformin
If glucose targets still not met - add insulin

If fasting GB >= 7 at time of diagnosis - start insulin

350
Q

In which situations might you give insulin to treat gestational DM if fasting BG is not >=7?

A

If fasting BG 6-6.9 + evidence of complications (e.g. macrosomia, hydramnios)

351
Q

What drug can be offered for women who cannot tolerate metformin/fail to meet glucose targets with metformin but refuse insulin?

A

Glibenclamide

352
Q

How do you manage pr-existing DM in pregnancy?

A

Wt loss if BMI >27
Stop oral hypoglycaemics, apart from metformin + start insulin
Folic acid 5mg from before conception till 12w
Aspirin 75mg/d from 12w to birth
Detailed anomaly scan at 20w (4 chamber view of heart + outflow tracts)
Tight glycaemic control

353
Q

What can worsen for diabetics during pregnancy?

A

Retinopathy

354
Q

Why do you give aspirin to pregnant diabetics?

A

Reduce risk of getting pre-eclampsia

355
Q

What are the targets for fasting BG for those with gestational DM/pre-existing DM?

A

5.3mmol/l

356
Q

What are the targets for 1 hour post meal BG for those with gestational DM/pre-existing DM?

A

7.8mmol/

357
Q

What are the targets for 2 hour post meal BG for those with gestational DM/pre-existing DM?

A

6.4mmol/l

358
Q

What is the only oral hypoglycaemic that should be used whilst breastfeeding?

A

Metformin

359
Q

During what part of the pregnancy is it most common to get acute fatty liver of pregnancy?

A

3rd trimester or period following delivery

360
Q

What are the clinical features of acute fatty liver of pregnancy?

A 
Abdominal pain 
NV
Headache
Jaundice
Hypoglycaemia
Severe disease may --> pre-eclampsia
Raised ALT
361
Q

How do you manage acute fatty liver of pregnancy?

A

Supportive care

Delivery once stabilised is definitive management

362
Q

What are the features of HELLP syndrome?

A

Haemolysis
Elevated liver enzymes
Low platelets

363
Q

What is the WHO definition of a post-term pregnancy?

A

Pregnancy extending to or beyond 42 weeks

364
Q

What are potential complications of a post-term pregnancy to the unborn child?

A

Reduced placental perfusion

Oligohydramnios

365
Q

What are potential complications/consequences of a post-term pregnancy to the mother?

A

Increased rates of intervention incl. forceps + c-section

Increased rate of labour induction

366
Q

What causes gestational thrombocytopenia?

A

Dilution, decreased production + increased destruction of platelets

367
Q

Why is there increased destruction of platelets in gestational thrombocytopenia?

A

Increased work of the maternal spleen leading to mild sequestration

368
Q

How can you distinguish between ITP and gestational thrombocytopenia?

A

If platelets continue to fall during pregnancy - more likely GT
If dangerously thrombocytopenia assumed ITP and given steroids
At booking if platelets low/prev. ITP diagnosis -> test serum antiplatelet antibodies to confirm

369
Q

Which of gestational thrombocytopenia and ITP affect the newborn?

A

ITP - as maternal antibodies cross the placenta

370
Q

How should a neonate born to a mother with ITP be treated differently?

A

Depends on degree of thrombocytopenia but may req. platelet transfusion
Serial platelet counts should be done to see if it is an inherited thrombocytopenia

371
Q

What sort of delivery should be avoided in a mother with ITP as it may provoked a haemorrhage/cephalohaematoma in the newborn?

A

Prolonged ventouse delivery

372
Q

What may be given to help with the itch in intrahepatic cholestasis of pregnancy but does not improve outcomes?

A

Antihistamines

Topical menthol emollients

373
Q

What drug should be used first line for nausea and vomiting during pregnancy?

A

Antihistamines, promethazine is first line

374
Q

What natural remedies are recommended by NICE for nausea and vomiting during pregnancy?

A

Ginger and acupuncture on the p6 point

375
Q

How much vitamin D should pregnant/breast feeding women take every day?

A

10 microg

376
Q

Which steroid is given in PROM to reduce risk of IRDS?

A

Dexamethasone (corticosteroid)

377
Q

Define cord prolapse

A

Umbilical cord descends ahead of the presenting part of the foetus

378
Q

What does untreated cord prolapse lead to?

A

Compression of cord
Cord spasm
–> foetal hypoxia and eventually death

379
Q

What are risk factors for cord prolapse?

A 
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Cephalopelvic disporpotion
Abnormal presentations, e.g. Breech, transverse lie
Placenta praevia
Long umbilical cord
High foetal station
380
Q

When do the majority of cord prolapses occur?

A

At artificial rupture of the membranes

381
Q

How do you manage cord prolapse?

A

Push presenting part of foetus back in to avoid compression
Tocolytics
If cord is passed level of introitus keep warm + moist but do not push back inside
Pt on all 4s
Immediate c-section (although instrumental vaginal delivery may be possible if cervix fully dilated)

382
Q

What is an amniotic fluid embolism?

A

Foetal cells/amniotic fluid enters the mothers bloodstream + stimulates a reaction

383
Q

What are RFs for amniotic fluid embolism?

A

Maternal age

Induction of labour

384
Q

When do the majority of cases of amniotic fluid embolism occur?

A

In labour

385
Q

What are symptoms of amniotic fluid embolism?

A

Chills, shivering, sweating, anxiety, coughing

386
Q

What are signs of amniotic fluid embolism?

A

Cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, MI

387
Q

How do you diagnose amniotic fluid embolism?

A

Diagnosis of exclusion - no specific tests

388
Q

How is amniotic fluid embolism managed?

A

Supportively (in critical care unit)

389
Q

Define placental abruption

A

Separation of a normally sited placenta from the uterine wall –> maternal haemorrhage into the intervening space

390
Q

What are associated factors with placental abruption?

A

Proteinuric hypertension
Multiparity
Maternal trauma
Increasing maternal age

391
Q

What are clinical features of placental abruption?

A 
Shock out of keeping with visible loss
Constant pain 
Tender, tense uterus
Normal lie and presentation 
Absent/distress foetal heart
392
Q

How often should patients with T1DM measure their BG?

A

Daily fasting, pre-meal, 1h post meal, bed times

393
Q

What is drinking alcohol in pregnancy associated with?

A

Foetal alcohol syndrome

394
Q

What are the features of foetal alcohol syndrome?

A

Learning difficulties
Characteristic facies - smooth philtrum, thin vermilion, small palpebral fissures
IUGR + post-natal restricted growth
Microcephaly

395
Q

What is one of the biggest risk factors for foetal alcohol syndrome?

A

Binge drinking

396
Q

What are risks to the mother if she uses cocaine during pregnancy?

A

HTN in pregnancy, incl. pre-eclampsia

Placental abruption

397
Q

What are risks to the foetus is the mother is using cocaine during the pregnancy?

A

Prematurity

Neonatal abstinence syndrome

398
Q

What are the consequences of maternal heroine use during pregnancy?

A

Neonatal abstinence syndrome

399
Q

What antibiotic should be avoided for treating UTIs in the first trimester?

A 
Avoid trimethoprim (teratogenic) 
Use nitrofuratoin (avoid in full term due to risk of neonatal haemolysis)
400
Q

List ALL (18) of the conditions that should be offered to be screened for during pregnancy

A 
Anaemia
Bacteriuria
Blood group, Rh status, anti-red cell Abs
Down's
Fetal anomalies
Hep B 
HIV
NTDs
Risk factors for pre-eclampsia
Rubella immunity
Syphillis
\+ depending on if hx is suggestive - 
Placenta praevia
Psychiatric illness
Sickle cell disease
Tay-Sachs disease
Thalassaemia
401
Q

What can occur if a Rh-ve women has a Rh +ve child?

A

Foetal RBCs may leak into maternal blood flow during birth
–> anti-D IgG antibodies to form in mother
In later pregnancies can cross placenta + cause haemolysis in foetus

402
Q

When is anti-D given to non-sensitised Rh-ve pregnancy women?

A

28 and 34 weeks

403
Q

If a women who is Rh -ve has a sensitising event in the 2nd or 3rd trimester what action should be taken?

A

Give large dose anti-D and perform Kleihauer test

404
Q

What does Kleihauer test determine?

A

Proportion of foetal RBCs present

405
Q

In which situations does anti-D Ig need to be given ASAP (and what is the time window it must be given in?)?

A

Within 72h

  • Delivery of Rh+ve infant (live or stillborn)
  • Any TOP
  • Miscarriage >12w
  • Ectopic pregnancy (only if surgical management)
  • ECV
  • Antepartum haemorrhage
  • Amniocentesis, CVS, foetal blood sampling
  • Abdominal trauma
406
Q

What should all babies born to Rh-ve mothers have done at birth?

A

Have blood taken from cord for FBC, blood group and direct coombs test

407
Q

What does coombs test do?

A

Direct antiglobulin test - will demonstrate Abs on the surface of the RBCs of the baby

408
Q

How does Kleihauers test work?

A

Add acid to maternal blood, foetal cells are resistant

409
Q

How might a foetus in a Rh -ve sensitised women be affected?

A

Oedematous (hydrops fetalis as liver devoted to RBC production, albumin falls)
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus

410
Q

How can you treat a foetus in a Rh -ve sensitised women that has been affected?

A

Transfusions

UV phototherapy

411
Q

How might you distinguish between intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy clinically?

A

Cholestasis: severe pruritus

Fatty liver: non-specific symptoms (e.g. fever, malaise, jaundice)

412
Q

When does baby blues tend to subside by?

A

10 days

413
Q

What are symptoms women get with baby blues?

A

Tearfulness, irritability, anxiety about the baby, poor concentration

414
Q

What are symptoms women get with PND?

A

Usual features of depression, fears about baby’s health, maternal deficiencies, martial tensions incl. loss of sexual interest

415
Q

When does puerperal psychosis tend to occur?

A

Within first 2 weeks

416
Q

What are the two forms of puerperal psychosis?

A

Manic depression

Schizophrenia

417
Q

Who does galactocele tend to occur in?

A

Women who have recently stopped breastfeeding

418
Q

What is a galactocele caused by?

A

Blocked lactiferous duct

419
Q

What is a galactocele?

A

Build up of milk creating a cystic lesion in the breast

420
Q

How can you differentiate a galactocele from an abscess?

A

Galactocele usually painless with no local/systemic features of infection

421
Q

What causes rubella?

A

Togavirus

422
Q

If a women contracts rubella whilst pregnant what is the risk to the foetus?

A

Congenital rubella syndrome

423
Q

How long are people with rubella infectious?

A

From 7 days before symptoms appear to 4 days after onset of rash

424
Q

At what gestation is there the highest risk of the foetus getting congenital rubella syndrome if the mother contracts rubella?

A

First 8-10 weeks

Rare after 16w

425
Q

What are the features of congenital rubella syndrome?

A 
Sensorineural deafness
Congenital cataracts
Congenital heart disease, e.g. PDA
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
Salt and pepper chorioretinitis
Microphthalmia
Cerebral palsy
426
Q

What infection is very similar to rubella and you must check the serology for if a pregnant women presents with this? Why must you do this?

A

Parovirus B19

Risk of transplacental infection and foetal loss

427
Q

Suspected cases of rubella in pregnancy should be discussed with who?

A

The local health protection unit

428
Q

Is rubella immunity checked at booking?

A

No

429
Q

Can you give the MMR vaccine to a non-immune woman during pregnancy?

A

No!!

Offer in postnatal period

430
Q

What is the management of a non-immune to rubella pregnant woman?

A

Just have to advise to keep away from infected people

431
Q

After ____ weeks gestation, the fundal height should increase by __cm per week.

A

24

1

432
Q

What may be a reason for the fundal height increasing by more than expected per week after 24w?

A

Unknown multipregnancy

Baby is big for dates

433
Q

Define induction of labour

A

Process of labour is started artifically

434
Q

What are indications for induction of labour?

A

Prolonged pregnancy (>12d after EDD)
Prelabour PROM where labour does not start
Diabetic mother >38w
Rh incompatability

435
Q

What are methods of inducing labour?

A

Membrane sweep
Intravaginal prostaglandins
Breaking of waters
Oxytocin

436
Q

What do intravaginal prostaglandins do?

A

Ripen the cervix and induce labour

437
Q

What produces alpha feto-protein?

A

The developing uterus

438
Q

What things may cause increased AFP in a pregnant lady?

A

NTDs (meningocele, myelomeingocele, anencephaly)
Abdominal wall defects (omphalocele, gastroschisis)
Multiple pregnancy

439
Q

What things may cause decreased AFP in a pregnant lady?

A

Down’s syndrome
Trisomy 18
Maternal DM or obesity

440
Q

Define placenta accreta

A

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

441
Q

What is the big risk with placenta accreta and why?

A

PPH as the placenta does not separately properly during labour

442
Q

What are RFs for placenta accreta?

A

Prev. c-section

Placenta praevia

443
Q

What are the 3 types of placenta accreta?

A

Accreta: choronic villi attach to myometrium rather than being restricted within the decidua basalis

Increta: choronic villi invade into myometrium

Percreta: choronic villi invade through perimetrium

444
Q

What are gestational trophoblastic disorders?

A

Spectrum of disorders originating from the placental trophoblast

445
Q

What are the gestational trophoblastic disorders?

A

Complete hydatidiform mole
Partial hyatidiform mole
Choriocarcinoma

446
Q

What is a complete hydatidiform mole?

A

Benign tumour of trophoblastic material

447
Q

What causes a complete hydatidiform mole?

A

Empty egg is fertilised by single sperm that duplicates its own DNA –> 46 paternal chromosomes

448
Q

What are the clinical features of a complete hydatidiform mole?

A 
Bleeding in 1st/2nd trimester
Exaggerated symptosm of pregnancy, e.g. hyperemesis
Uterus large for dates
V. high levels bHCG
HTN and hyperthyroidism may be seen
449
Q

How is a complete hydatidiform mole managed?

A

Evacuation of uterus

450
Q

What recommendation should be given to women who have had evacuation of the uterus for a complete hydatidiform mole?

A

Use contraception to avoid pregnancy in the next year

451
Q

2-3% of complete hydatidiform moles go on to develop what?

A

Choriocarcinoma

452
Q

What happens to cause a partial mole?

A

Normal haploid egg fertilised by two sperms/one sperm with duplication of parental chromosomes

DNA is maternal + paternal
Usually triploid

Foetal parts may be seen

453
Q

Why is hyperthyroidism seen in a complete hydatidiform mole?

A

hCG can mimic TSH

454
Q

What should women at moderate/high risk from pre-eclampsia take?

A

75mg aspirin daily from 12w gestation until birth

455
Q

What are indications for a forceps delivery?

A

Foetal or maternal distress in the 2nd stage of labour
Failure to progress in 2nd stage of labour
Control of head in breech delivery
Prophylactic use in medical conditions, e.g. CV dx, HTN

456
Q

What are the requirements for a forceps delivery?

A 
FORCEPS =
Fully dilated cervix
OA position preferable
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty - usually req. catheterisation
457
Q

Define engaged

A

Head at or below ischial spines

458
Q

What are the 2 second stages of labour?

A

Passive second stage - 2nd stage in absence of pushing

Active second stage - active process of maternal pushing

459
Q

Which of the two stages of the second stage of labour is more painful?

A

1st (pushing masks pain)

460
Q

How long does the second stage of labour usually take? What can you do it if it is taking longer?

A

1h

Consider ventouse extraction, forceps delivery or c-section

461
Q

What is a typical history of retained products post-c-section?

A

Pain, heavy vaginal bleeding
Boggy poorly contracted uterus
Offensive discharge may indicate products have become infected

462
Q

How do you manage retained products?

A

Urgent ex under anaesthesia to remoe products

463
Q

Define eclampsia

A

Development of seizures in associated with pre-eclampsia

464
Q

What drug is used to prevent seizures in those with severe pre-eclampsia and treat seizures once they occur?

A

Magnesium sulphate

465
Q

When should mg sulphate be given for severe pre-eclampsia?

A

Once a decision to delivery ahs been made

466
Q

How should mg sulphate be given for eclampsia?

A

IV bolus 4g over 5-10m then infusion of 1g/h

467
Q

What parameters should be measured during treatment with mg sulphate?

A

Urine output
Reflexes
RR
O2 sats

as resp. depression can occur

468
Q

How do you treat resp. depression due to mg sulphate treatment?

A

Calcium gluconate

469
Q

When should treatment with mg sulphate be continued until?

A

Until 24h after last seizure or delivery

470
Q

What are features of eclampsia?

A

Seizures

Abdominal pain
NV
Visual disturbance
Hyperreflexia

471
Q

Define puerperal pyrexia

A

Temperature >38C in the first 14d after delivery

472
Q

What is the most common cause of puerperal pyrexia?

A

Endometritis

473
Q

What are other causes of puerperal pyrexia?

A

UTI
Wound infections (perineal tears, c-section)
Mastitis
VTE

474
Q

How should endometritis be managed?

A

Refer to hospital for IV antibiotics (clindamycin + gentamicin until afebrile for >24h)

475
Q

What tests are done for Down’s syndrome in antenatal screening?

A

Combined test: nuchal translucency measurement (USS), serial bHCG (raised)+ pregnancy associated plasma protein A (low)

476
Q

When should the combined test for Down’s screenig be done?

A

Between 11 - 13 + 6 weeks

NB if women book later in pregnancy either triple/quadruple test should be offered between 15 and 20weeks

477
Q

What is involved in the triple assessment?

A

AFP (low), unconjugated oestriol (low), hCG (high)

478
Q

What is involved in the quadruple assessment?

A

AFP, unconjugated oestriol, hCG, inhibin A (high)

479
Q

What women are at increased risk of NTDs and should be advised to take 5mg dose of folic acid?

A 
Prev. child with NTD
DM
Women on antiepileptic
Obese (BMI >30)
HIV +ve taking co-trimoxazole
Sickle cell
Coeliac disease
Thalassaemia trait
480
Q

When is the neural tube formed during the embyro’s development?

A

In the first 28 days

481
Q

What is foetal fibronectin?

A

Protein released from the gestational sac

High levels related with early labour

482
Q

Is active management of the third stage of labour recommended? Why or why not?

A

Yes to reduce PPH

483
Q

How long does active management of the third stage of labour take?

A

30 mins

484
Q

What does active management of the third stage of labour involve?

A 
Uterotonic drugs (oxytocin)
Deferred clamping + cutting of cord (between 1 min to 5 min after delivery)
Controlled cord traction after signs of placental separation
485
Q

List things that warrant continuous CTG use during labour:

A

Suspected chorioamnionitis/sepsis/temp 38+
Severe HTN 160/110mmHg or above
Oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops during labour

486
Q

What could fresh vaginal bleeding be a sign of during labour?

A

Placental rupture

Placenta praevia

487
Q

Apart from mg sulphate what is another important aspect of treating severe pre-eclampsia/eclampsia?

A

Fluid restriction to avoid serious consequences of fluid overload

488
Q

Where is the pain typically in HELLP syndrome/pre-eclampsia?

A

Epigastric or RUQ

489
Q

When do uteruses tend to rupture?

A

During labour (may occur in 3rd trimester)

490
Q

What are RFs for uterine rupture?

A

Prev. c-section

491
Q

How does uterine rupture tend to present?

A

Maternal shock
Abdominal pain
Vaginal bleeding

492
Q

What causes symphysis pubis dysfunction?

A

Ligament laxity increased in response to hormonal changes of pregnancy

493
Q

How does symphysis pubis dysfunction tend to present?

A

Pain over pubic symphysis with radiation to groins and medial aspect of thighs
May see waddling gait

494
Q

What is UTI in pregnancy associated with an increased risk of?

A

Pre-term delivery

IUGR

495
Q

What causes RUQ in pre-eclampsia?

A

Stretching of liver capsule

496
Q

If a women presents in labour with is found to be pre-eclamptic, how do you manage her?

A 
IV labetalol (alt: oral nifedipine/hydralazine)
Diastolic BP target of 80-100mmHg and systolic <150mmHg
497
Q

Why do you have to have a high index of suspicion for chorioamnionitis?

A

Can be life-threatening to foetus and mother

498
Q

What causes chorioamnionitis?

A

Ascending bacterial infection of amniotic fluid –> membranes –> placenta

499
Q

What is a major RF for chorioamnionitis?

A

PROM

500
Q

How is chorioamnionitis managed?

A

Prompt delivery of foetus

IV antibiotics

501
Q

How does chorioamnionitis tend to present?

A

Uterine tenderness
Foul smelling discharge
Maternal fever, tachycardia, neutrophilia
Baseline foetal tachycardia

502
Q

How do RA symptoms tend to change during pregnancy?

A

Improve during

Flare after delivery

503
Q

Is methotrexate safe in pregnancy?

A

No - stop 6m before conception in MEN and WOMEN

504
Q

What RA drugs are considered safe during pregnancy?

A

Sulfasalazine
Hydroxychloroquine
Low dose corticosteroids
NSAIDs until the 32w

505
Q

Why should NSAIDs not be used by pregnant women after 32w gestation?

A

Due to risk of early closure of DA

506
Q

Why should pregnant pts with RA be referred to an obstetric anaesthetist?

A

Risk of alanto-axial subluxation

507
Q

Why must methotrexate be stopped prior to conception?

A

Teratogen - craniofacial defects, spine and rib defects, defects of digits
Can cause abortions

508
Q

What additional measure can help the effectiveness of the McRobert’s manoeuvre?

A

Suprapubic pressure

509
Q

If lochia persists beyond ___ weeks, what investigation should be done?

A

6 weeks
USS

May indicate retained products of conception

510
Q

What is the puerperium?

A

Period of 6w post childbirth in which the women’s reproductive organs return to normal

511
Q

What does a CTG measure?

A

Foetal HR and uterine contractions

512
Q

If a newborn has only 1 minor RF for early onset sepsis how should they be manaed?

A

Remain in hospital for at least 24h with regular obs

513
Q

2+ RFs or 1 red flag for early onset sepsis should be managed with?

A

Empirical benzylpenicillin and gentamicin + a full septic screen

514
Q

What are red flags for early onset sepsis?

A

Suspected/confirmed infection in another baby in case of multiple pregnancy
Parenteral antibx treatment given to women for confirmed/suspected invasive bacterial infection at time of labour or 24h before/after the birth
Resp distress starting >4h after birth
Seizures
Need for mechanical ventilation in term baby
Signs of shock

515
Q

What is Sheehan’s syndrome?

A

Complication of severe PPH where pituitary gland undergoes ischaemic necrosis –> hypopituitarism

516
Q

What is the most common clinical feature of Sheehan’s syndrome?

A

Lack of post-partum milk production + amenorrhoea following delivery

517
Q

How do you diagnose Sheehan’s syndrome?

A

Inadequate prolactin and gonadotrophin stimulation tests in pts with hx severe PPH

518
Q

Define station

A

Term used to describe the head in relation to the level of the ischial spines

519
Q

What does station of 0 mean?

A

Head is directly at the level of the ischial spines

520
Q

What does station of -2 mean?

A

Head is 2cm above ischial spine

521
Q

What does station of +2 mean?

A

Head is 2cm below ischial spine

522
Q

In relation to rhesus disease:

What does sensitisation mean?

A

Process whereby foetal red cells (Rh +ve) enter the maternal circulation where the mother is Rh -ve this causes antibodies to form int he maternal circulation that can haemolyse foetal RBCs

523
Q

Why are NOACs CI in pregnancy?

A

Can cause placental haemorrhage + subsequent foetal prematurity/loss

524
Q

Why is warfarin CI in pregnancy?

A

Warfarin embyropathy if taken from weeks 6-13

(Nasal flattening –> severe mid face flattening and short limbs)

Exposure in 2nd/3rd trimester –> inc. risk of foetal haemorrhage

525
Q

What is the management of a late deceleration on CTG?

A

Foetal blood sampling

If foetus acidosis consider urgent delivery

526
Q

What is false labour?

A

(Irregular) contractions every 20m occurring in last 4 weeks of pregnancy

527
Q

At what two gestations are women screened for anaemia during pregnancy?

A

Booking visit

28 weeks

528
Q

What is the cut of for anaemia at the booking visit?

A

<11g/dl

529
Q

What is the cut of for anaemia at the 28 week visit?

A

<10.5g/dl

530
Q

What are the cut offs for anaemia in

a) the 1st trimester
b) the 2nd trimester
c) the 3rd trimester?

A

a) <110g/l
b) <105g/l
c) <100g/l

531
Q

How should you manage anaemia in pregnancy?

A

Oral iron supplements

Only investigate if no rise in Hb after 2w

532
Q

How should suspected DVT be investigated in pregnant women?

A

Compression duplex USS

533
Q

How should suspected PE be investigated in pregnant women?

A

ECG, CXR
If also sx/sx DVT –> compression duplex USS –> shows DVT treat for VTE and no further Ix req.

Consider V/Q or CTPA

534
Q

What is a con of using CTPA in pregnancy?

A

Pregnancy makes breasts particularly sensitive to radiation so increases lifetime risk of breast cancer

535
Q

What is a con of using V/Q scan in pregnancy?

A

Slightly increased risk of childhood cancer

536
Q

Can you use d-dimer in pregnancy?

A

No as it is often raised in pregnancy anyway

537
Q

How should PE/DVT be treated in pregnancy?

A

LMWH

538
Q

How do you carry out the woodscrew manoeuvre?

A

Put hand in vagina and rotate foetus 180 degrees to try and dislodge anterior shoulder from pubic symphysis

539
Q

What is normal variability on CTG?

A

Between 5 and 25bpm

540
Q

How is placenta accreta definitively managed?

A

Hysterectomy with placenta left in situ

attempts to remove only the placenta can lead to haemorrhage

541
Q

What is GBS also known as?

A

Streptococcus agalacticae

542
Q

What is the symphysis fundal height?

A

From top of pubic bone to top of uterus in cm

543
Q

What should the SFH match?

A

The no of weeks in gestation +/-2cm

544
Q

What are causes of increased nuchal translucency?

A

Down’s syndrome
Congenital heart defects
Abdominal wall defects

545
Q

What are causes of hyperechogenic bowel on US in pregnancy?

A

Cystic fibrosis
Down’s syndrome
CMV

546
Q

What are predisposing factors for aortic dissection in pregnancy?

A

HTN
Congenital heart disease
Marfan’s syndrome

547
Q

What are the majority of aortic dissections during pregnancy?

A

Type A dissections

548
Q

How does aortic dissection present?

A

Sudden tearing chest pain
Hypertensive
Aortic regurg murmur

Reproduction (28 decks)

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