Pregnancy

Question 0

When is the dating scan performed?

Answer 0

8-14 weeks.

Question 1

When, in an expectant mother, should a blood test be performed for Hep B, HIV, rubella, and syphilis (immunity in some cases)?

Answer 1

8-12 weeks.

Question 2

When would a detailed US anomaly scan be performed?

Answer 2

18-20 weeks

Question 3

When does pre-eclampsia occur? What is the key triad?

Answer 3

Occurs after 20 weeks (I.e, second half of pregnancy).

Characterised by pregnancy-induced hypertension, oedema, and proteinurea.

Question 4

What vitamin needs to be commenced pre-conception?

Answer 4

Folic acid.

Question 5

What can cause PV bleeding in the first trimester? (4)

Answer 5

• Inevitable miscarriage.
• Threatened miscarriage.
• Ectopic pregnancy.
• Hydatidiform mole.

Question 6

Four skin disorders associated with pregnancy?

Answer 6

1) Pemphigoid gestationis
2) Pruritus gravidarum
3) Prurigo gravidarum
4) Polymorphic eruption of pregnancy

Question 7

What common skin changes (NOT disorders) in pregnancy? (5)

Answer 7

1) Generalised hyperpigmentation.
2) Local pigmentation of linea alba, areaolae, genitalae.
3) Spider naevi.
4) Palmer erythema.
5) Chloasma.

Question 8

What vaccinations may be given in pregnancy?

Answer 8

1) Influenza.
2) Tetanus.
3) Cholera.

Question 9

Which vaccinations must NOT be given in pregnancy?

Answer 9

1) MMR (never give).
2) Polio, typhoid, smallpox, yellow fever (not advisable, except for specific indication, I.e., benefit far outweighs risk).

Question 10

Why should large doses of vitamin A or liver products be avoided by the mother?

Answer 10

Teratogenic effect.

Question 11

How many live births are twins?

Answer 11

1:105

Question 12

How many pregnancies (as a ratio) are complicated by diabetes?

Answer 12

1:400 (CHECK THIS!)

Question 13

If a mother has cervical chlamydia, what is the likelihood she will pass it on to the child? What are the complications that can be caused for the child?

Answer 13

60%

Complications: neonatal conjunctivitis, neonatal pneumonia

Question 14

What antihypertensives are contraindicated during pregnancy? In what period of pregnancy is this most true? What are the risks?

Answer 14

ACE-inhibitors and ARB’s.
2nd and 3rd trimesters, though also bad in the first trimester.
Can cause increased risk of fetopathy (especially cardiac malformations), oligohydramnos, hypotension, renal failure, and intra-uterine death.
Note: beta blockers may also be problematic (see other card).

Question 15

In pregnancy, what antibiotics should be avoided, and which are safer to use?

Answer 15

Use: penicillins, cephalosporins (safe in pregnancy and breastfeeding), erythromycin.
Avoid: tetracyclines, aminoglycosides, quinolones (unless severe or life threatening infections), metronidazole (high dose), trimethoprim (1st trimester, folate antagonist), nitrofurantoin (at term-risk of neonatal haemolysis)

Question 16

Why should tetracyclines be avoided during pregnancy?

Answer 16

Can cause staining of neonatal bones and teeth.

If given IM can cause maternal liver failure.

Question 17

When should trimethoprim NOT be used after the first trimester?

Answer 17

In sulphonamide preparations (interferes with bile duct development).

Question 18

Why should streptomycin be avoided in pregnancy?

Answer 18

Can cause foetal auditory nerve damage.

Question 19

What anticoagulants are safe/unsafe to use in pregnancy? Why?

Answer 19

Warfarin is teratogenic (1st trimester especially, though should also be avoided 3rd trimester); can cause frontal bossing, short stature, blindness, mental retardation, midface hypoplasia, saddle nose, cardiac abnormalities, blindness.
Heparin cannot cross into the placenta, no effect on the foetus.
NSAIDS and salicylates - prolong gestation and labour; premature closure of ductus arteriosus; neonatal hypertension and haemorrhage.

Question 20

Are beta blockers useful for treating hypertension in pregnancy? Are there any risks?

Answer 20

Beta blockers can be useful in reducing moderate hypertension, but not for treating pre-eclampsia.
They can cause intra-uterine growth retardation (3rd trimester) and foetal bradycardia.

Question 22

What is the safest anti epileptic to use in pregnancy?

Answer 22

Carbamazepine.

Question 23

What is puerperium? How long does it last?

Answer 23

This is the time during which the mother’s altered anatomy, physiology and biochemistry returns to the non-pregnant state. This process is said to have an onset at the third stage of labour and is completed six weeks later.
Note, legally for the definition of post partum psychiatric illness the length of the puerperium is considerably longer - 12 months.

Question 24

What are the three components of labour? What are they composed of?

Answer 24

1) Power: primary involves uterine contractions;
secondary involves voluntary muscles of the
diaphragm and abdominal walls.
2) Passages: a) bony: pelvic bone (see “pelvimetry”)
b) soft: uterus, vagina, vulva, supporting tissues
3) Passengers: the fetus (see “presentation”), placenta and membranes.

Question 25

How many stages of labour are there?

Answer 25

Three.

Question 26

What defines the first stage of labour?

Answer 26

When all three of these criteria are met:

1) Regular, painful contractions - if well established, contractions last 50-60 seconds, and occur every 2-4 min.
2) Progressive dilation of the cervical os.
3) Breaking of waters (a show).

Question 27

How long does the first stage of labour last?

Answer 27

Women should be informed that, while the length of established first stage of labour varies between women, first labours last on average 8 hours and are unlikely to last over 18 hours. Second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours

Question 28

What is the difference between latent and established first stage of labour?

Answer 28

Latent - a period of time, not necessarily continuous, when there are painful contractions, and cervical effacement up to 4cm.
Established - regular, painful contractions, and cervical effacement is more than 4cm and progressive.

Question 29

In the first stage of labour, how quickly does cervical dilation proceed?

Answer 29

Roughly 1cm per hour.

Question 30

What has the biggest influence on the duration of the first stage of labour?

Answer 30

Uterine activity.
Cephalopelvic relationship.
Foetal attitude.

Question 31

What is the second stage of labour? What is it divided into?

Answer 31

Full dilation to the birth of the baby.
a) Passive - the finding of full dilatation of the cervix prior to or in the absence of involuntary expulsive contractions
b) Active - the baby is visible; expulsive contractions;
active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions

Question 32

If a nulliparous woman has inadequate contractions at the onset of the second stage of labour, what intervention should be considered?

Answer 32

Use of oxytocin + regional analgesia.

Question 33

How long should the second stage of labour be expected to last?

Answer 33

Up to 3 hours in nulliparous women, up to 2 hours in parous women.

Question 34

What is the third stage of labour?

Answer 34

Third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes.

Question 35

What are the active management and physiological management techniques for the third stage of labour?

Answer 35

1) Active management of the third stage involves a package of care which includes all of these three components:
a) routine use of uterotonic drugs
b) early clamping and cutting of the cord
c) controlled cord traction
2) Physiological management of the third stage involves a package of care which includes all of these three components:
a) no routine use of uterotonic drugs
b) no clamping of the cord until pulsation has ceased
c) delivery of the placenta by maternal effort.

Question 36

What defines a prolonged third stage of labour?

Answer 36

Third stage of labour is diagnosed as prolonged if not completed within 30 minutes of the birth of the baby with active management and 60 minutes with physiological management.

Question 37

What is the average length of third stage of labour?

Answer 37

5 minutes (active) or 20+ minutes (physiological).

Question 38

When is delivery of the baby complete?

Answer 38

When the placenta and membrane have been checked for completeness (including three cord vessels) and the birth canal has been checked for damage.

Question 39

When is changing from physiological to active management of the third stage indicated? (3)

Answer 39

1) Women’s desire to artificially shorten the third stage.
2) Haemorrhage.
3) Failure to deliver placenta within 1 hour.

Question 40

Which management option for the third stage is advised? Why?

Answer 40

Active management - reduced risk of haemorrhage and shortens the third stage.

Question 41

What is a cartogram and what does it record?

Answer 41

The partogram is a series of charted measurements which are used to assess the progress of labour.
Information recorded includes: Maternal - BP (hourly), heart rate (hourly), temperature (once unless abnormal) Contractions - length, frequency, strength. Baby - heart rate (hourly), liquor.
Also - maternal state of mind, drugs administered etc.

Question 42

What is placenta praevia? How many grades are there and what do they mean?

Answer 42

Placenta praevia is said to occur when a placenta is situated in the lower uterine segment. There are degrees of abnormality associated with increasing need for a caesarian section instead of NVD; these are:
1st - just reaching the lower segment (minor praevia)
2nd - reaches the internal cervical os
3rd - crosses the os (major praevia)
4th - completely crossing the os

Question 43

What percentage of pregnancies are complicated by placenta praevia? What is the main complication?

Answer 43

0.5 % of pregnancies; main complication is antepartum haemorrhage.

Question 44

In placenta praevia, why are only some women offered another transabdominal USS? Which subset of women is this? At what time are they offered this? What if this scan is unclear?

Answer 44

Because most low-lying placentas detected at the routine anomaly scan will resolve by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 36 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.

Question 45

What are the clinical features of placenta praevia? What is the presentation?

Answer 45

Placenta praevia usually occurs after 30 weeks gestation.
It presents with recurrent, painless vaginal bleeding. The initial bleed commonly ceases spontaneously. Its onset is usually unprovoked, although occasionally it may follow intercourse. The amount of blood lost is highly variable, i.e, from a few spots to several pints. The blood is bright red.
On examination the uterus is usually very relaxed and the fetal parts are readily palpable. The presenting part is usually not engaged and may be deviated to one side.
DO NOT PERFORM A VAGINAL EXAMINATION as severe haemorrhage may be provoked by disturbing blood vessels lying across the os.

Question 46

What is the management of placenta prevae?

Answer 46

The principle objective of management is to prolong the pregnancy until the fetus is mature. Optimally, this is a gestational age of 37 weeks: the neonatal mortality rate is not improved by further intrauterine development.
Immediate steps include:
a) admission to hospital that is equipped to deal with this condition.
b) bed rest
c) cross matching of blood
d) transfusion if severe haemorrhage: use O Rh-ve blood

Question 47

Why is C-section favoured in placenta praevia?

Answer 47

Caesarian section is often favoured in placenta praevia as the immediate delivery of the fetus and the placenta allows the uterus to contract to stop the bleeding. It also avoids the marginal risk of cervical lacerations which complicate a vaginal delivery.

Question 48

What is the prognosis of placenta praevia? (5 points)

Answer 48

• Not usually dangerous for mother or baby.
• Far greater risk in placenta abruption.
• Postpartum haemorrhage is more common with placenta praevia, because of reduced ability for lower segment to retract.
• Over 50% of patients are close to term when bleeding occurs, and the majority of these are managed conservatively. Generally, it is the mothers with excessive haemorrhage, and more rarely premature labour, that must be delivered.
• Premature babies are more common within a placenta praevia population than in the general population, and they have a greater morbidity and mortality.

Question 49

What is the definition of antepartum haemorrhage? How many pregnancies does it occur in? How many maternal deaths are caused by it?

Answer 49

This is bleeding from the vagina after 24 weeks gestation up until labour. Before 24 weeks, bleeding heralds threatened or inevitable abortion.
APH occurs in 2% of pregnancies and is an important cause of foetal and maternal death - 30% of maternal deaths are caused by APH, of which 50% are associated with avoidable factors.

Question 50

How should a minor antepartum haemorrhage be managed in the community?

Answer 50

Keep patient at rest, quiet and flat on left-hand side
Do not perform a digital examination
Refer to hospital

Question 51

Why should a digital examination not be performed on a patient who is having an antepartum haemorrhage?

Answer 51

In case of placenta praevia

Question 52

What steps should be taken in-hospital to a patient suffering from a minor antepartum haemorrhage?

Answer 52

history and examination
do not perform digital examination - in case of placenta praevia
observe regularly - CTG to monitor fetal well being
check heamoglobin, platelets, clotting, and group and save serum
consider IV access
arrange ultrasound scan
give anti-D to rhesus negative mothers
follow obstetric unit protocol re: steroid prophylaxis against hyaline membrane disease
further management dependent on cause

Question 53

What comparisons can be made between placenta praevia and placental abruption? (6)

Answer 53

a) pain:
abruption - constant
placenta praevia - painless
b) obstetric shock
abruption - the actual amount of bleeding may be far in excess of vaginal loss
placenta praevia - obsetric shock in proportion to amount of vaginal loss
c) uterus
abruption - uterus is tender and tense
placenta praevia - uterus is non-tender
d) foetus
abruption - normal presentation and lie
placenta praevia - may have abnormal presentation and/ or lie
e) foetal heart
abruption - fetal heart distressed/absent
placenta praevia - in general, fetal heart normal
f) associated problems:
abruption - may be a complication of pre-eclampsia, may cause disseminated intravascular coagulation
placenta praevia - small antepartum haemorrhage may occur before larger bleed

Question 54

What is placental abruption? What are the different presentations?

Answer 54

Pathological separation of the placenta from its uterine attachment results in a maternal bleed from the opened sinuses.
There is a spectrum of presentation:
a) concealed - no actual bleeding is seen - it remains in the uterus
b) revealed - blood tracks between the membranes and the uterus and escapes vaginally
c) mixed - most usual

Question 55

How does placental abruption present? What is more common, what is more rare?

Answer 55

The symptoms and signs of placental abruption vary enormously. Even the absence of ultrasound identification does not rule out a life-threatening placental abruption.
In classical extreme, profuse abruption, pain, shock, uterine rigidity and absent fetal heart sounds are evident. Consumptive coagulopathy - hypofibrinogenaemia of less than 150mg/dL, renal failure and uteroplacental apoplexy - extravasation of blood into the uterine musculature and serosa - are rarer signs.
In milder cases, the following symptoms and signs can occur singly, in combination, or none may be present at all:
a) vaginal bleeding
b) uterine tenderness and back pain
c) fetal distress
d) high frequency uterine contractions of low tone
e) idiopathic preterm labour
f) hypotension leading to rapid shock
The differential diagnosis is that of other causes of vaginal bleeding in the third trimester, and so it is often principally necessary to rule out placenta praevia by clinical inspection and ultrasound. Unfortunately, and contrary to popular belief, abruption and placenta praevia may both present with or without pain.

Question 56

Is a woman who had a placental abruption in one pregnancy, more at risk during subsequent pregnancies?

Answer 56

Yes - the recurrence rate is as high as 1:10 - so subsequent pregnancies are treated as high risk. (The background rate is 1:200 pregnancies).

Question 57

What are the two strongest associations for placental abruption?

Answer 57

Trauma and hypertension.

Question 58

Deficiency of what may possibly be associated with placental abruption? Why?

Answer 58

It has been suggested also that abruption may be caused by folate deficiency because:
Abruptio placentae is found more often in multiparous women with low socio-economic status
There is an association between megaloblastic anaemia and abruption. However:
Megaloblastic anaemia is common in Nigeria but abruption is not
Folate supplements are not protective

Question 59

Other than the two main factors associated with placental abruption, what other factors seem to be linked? (11)

Answer 59

a) past obstetric history of abruptio placentae
b) multiple pregnancy
c) increasing age
d) high parity
e) low socio-economic status
f) renal infection
g) drugs - smoking, cocaine
h) uterine anomaly or tumour
i) sudden uterine decompression - may endanger the second or subsequent children in multiple births
j) short umbilical cord
h) pressure from the enlarged uterus on the inferior vena cava

Question 60

What are the grades of placental abruption?

Answer 60

a) Mild - a small area of placental separation, blood loss less than 200ml.
b) Moderate - up to a third of the placenta separates, bleeding is more severe (200-600ml)
c) Severe - more than half the placenta separates.

Question 61

What is the difference in typical clinical presentation in the three grades of placental abruption?

Answer 61

a) Mild - may be abdominal discomfort + tender uterus.
b) Moderate - abdominal pain; tachycardia but no signs hypovolaemia. tender uterus. Foetal heart sounds present.
c) Severe - severe abdominal pain, tender and rigid uterus (may be impossible to feel uterus); foetal heart sounds reduced or absent; patient may be in hypovolaemic shock.