WOMEN'S HEALTH - OBSTETRICS

Question 1

ECTOPIC PREGNANCY
What is an ectopic pregnancy?

Answer 1

• When a fertilised ovum implants outside of the uterine cavity, 98% tubal

Question 2

ECTOPIC PREGNANCY
Where is the most common site for an ectopic?
What is the most common site for a ruptured ectopic?

Answer 2

• Ampulla
• Isthmus

Question 3

ECTOPIC PREGNANCY
What is the epidemiology of ectopics?
What are some risk factors for ectopics?

Answer 3

• 1 in 100 incidence
• Previous ectopic (10% recurrence rate), PID, endometriosis, tubal surgery, IUCD, IVF + POP

Question 4

ECTOPIC PREGNANCY
What are some symptoms of ectopics?

Answer 4

• Amenorrhoea for 6-8w, PV bleeding (small amount, brown)
• Constant lower abdo (iliac fossa) pain
• D+V, dizziness + fainting

Question 5

ECTOPIC PREGNANCY
What are some signs of ectopics?

Answer 5

• Referred shoulder pain due to haemoperitoneum irritating diaphragm
• Abdo or rebound tenderness
• Cervical excitation/motion tenderness
• Peritonism or collapse if rupture

Question 6

ECTOPIC PREGNANCY
What are some crucial investigations for ectopics?

Answer 6

• Beta-hCG to confirm pregnant – should double every 48h in normal
• TVS = empty uterus, may show adnexal mass or free fluid

Question 7

ECTOPIC PREGNANCY
What are some other investigations for ectopics?

Answer 7

• FBC, group + save, serum progesterone <20nmol/L suggests failing pregnancy
• Laparoscopy gold standard but only used as necessary

Question 8

ECTOPIC PREGNANCY
What are the 3 management techniques for ectopic pregnancies?

Answer 8

• Expectant
• Medical
• Surgical

Question 9

ECTOPIC PREGNANCY
What is expectant management?
What are the indications?
What indicates that it has worked?

Answer 9

• Effectively do nothing
• Clinically stable (no Sx), ectopic <35mm, no heartbeat, serum hCG <1000IU/L (consider up to 1500) + able to return for follow up
• Serum hCG days 2, 4 + 7 (drop ≥15% then repeat weekly until negative)

Question 10

ECTOPIC PREGNANCY
What is medical management?
What are the indications?
What indicates that it has worked?

Answer 10

• Single dose IM 50mg/m^2 methotrexate
• No significant pain, unruptured ectopic <35mm, no heartbeat, serum hCG <1500 (consider up to 5000IU/L) + able to return for follow up
• hCG levels at days 4 + 7 then weekly, <15% fall = ?another dose

Question 11

ECTOPIC PREGNANCY
What are the requirements for methotrexate management?
What are some side effects?

Answer 11

• Satisfactory liver + renal functions
• Teratogenic so effective contraception for 3m
• Conjunctivitis, diarrhoea, abdo pain + stomatitis

Question 12

ECTOPIC PREGNANCY
What surgical management is offered?
What are indications?
What else should be given?

Answer 12

• Salpingectomy or salpingotomy
• Does not meet expectant or medical criteria (>35mm, visible heartbeat, ruptured)
• Anti-D for rhesus -ve in surgical management

Question 13

ECTOPIC PREGNANCY
How do you choose which type of surgical management to give?

Answer 13

• Salpingectomy if contralateral tube + ovary healthy to reduce recurrence
• Salpingotomy if contralateral tube defected
• Laparoscopy preferred to laparotomy unless haemodynamically unstable

Question 14

MISCARRIAGE
What is a miscarriage?

Answer 14

• Spontaneous termination of a pregnancy before 24w gestation

Question 15

MISCARRIAGE
What is the epidemiology of miscarriage?

Answer 15

• 15–20% of pregnancies with 85% in first trimester
• No increased risk of having another miscarriage after 1 but is after 2

Question 16

MISCARRIAGE
What are the 6 types of miscarriage?

Answer 16

• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Septic

Question 17

MISCARRIAGE
What are the most common causes of miscarriage in first trimester?

Answer 17

Chromosome abnormality –
- Autosomal trisomy most common (trisomy 16)
- Most common single chromosomal anomaly is 45X
- Increasing maternal age biggest risk

Question 18

MISCARRIAGE
What is the most common cause of miscarriage in the second trimester?

Answer 18

• Incompetent cervix

Question 19

MISCARRIAGE
What are some other causes of miscarriage?

Answer 19

• PCOS
• TORCH infections
• Iatrogenic (amniocentesis, CVS)
• Smoking, substance abuse

Question 20

MISCARRIAGE
What are some risk factors for miscarriage in the second trimester?

Answer 20

Previous cervical surgery, BV in 2nd trimester

Question 21

MISCARRIAGE
What is a threatened miscarriage?

Answer 21

• Foetus alive but miscarriage may occur (majority don’t)
• Painless vaginal bleeding with closed cervical os
• TVS = viable intrauterine pregnancy

Question 22

MISCARRIAGE
What is an inevitable miscarriage?

Answer 22

• Miscarriage will occur
• Heavy PV bleed with clots + crampy abdo pain with open cervical os (1 finger)
• POC not passed
• TVS = intrauterine gestation sac, foetus may be alive but miscarriage imminent

Question 23

MISCARRIAGE
What is an incomplete miscarriage?

Answer 23

• Not all POC been passed
• PV bleed, abdo pain + open cervical os with POC in canal
• Medical or surgical mx as infection risk

Question 24

MISCARRIAGE
What is a complete miscarriage?

Answer 24

• Full miscarriage occurred with all foetal tissue passing
• Bleeding + pain cease, uterus no longer enlarged, cervical os closed
• TVS = empty uterus, endometrial thickening <15mm, exclude ectopic

Question 25

MISCARRIAGE What is a missed miscarriage?

Answer 25

- Foetus not developed or died in utero but this is not recognised until bleeding occurs or TVS - TVS - non-viable intrauterine pregnancy (smaller than expected) e.g. 12w scan shows 9w foetus with no heartbeat

Question 26

MISCARRIAGE What is a blighted ovum?

Answer 26

- In missed miscarriage, a gestational sac >25mm but no embryonic/foetal pole

Question 27

MISCARRIAGE What is a septic miscarriage?

Answer 27

- Contents of uterus infected causing endometritis

Question 28

MISCARRIAGE What is a pregnancy of uncertain viability?

Answer 28

Small sac with no visible heartbeat, rescan 10–14d

Question 29

PREGNANCY OF UNKNOWN LOCATION What is a pregnancy of unknown location?

Answer 29

No sign of intrauterine, ectopic or retained POC but positive beta-hCG

Question 30

PREGNANCY OF UNKNOWN LOCATION What is the management of pregnancy of unknown location?

Answer 30

- Beta-hCG >1500IU/L ?ectopic - Significant distress = laparoscopy - Stable = repeat beta-hCG after 48h - If no Dx after 3 samples = expectant or methotrexate Mx

Question 31

MISCARRIAGE What are the generalised investigations and management of miscarriage?

Answer 31

- Refer to EPAU for Ix - Speculum exam = cervical os open/closed, remove POC if in cervical os - Serum beta-hCG levels - TVS = location + viability - Histological exam of any tissue passed vaginally

Question 32

MISCARRIAGE What would serum beta-hCG levels show in miscarriage?

Answer 32

- Serial testing as should double every 48h for first few weeks of pregnancy - Levels may be less than expected for dates - Falling indicates failing pregnancy

Question 33

MISCARRIAGE What is the first line management of miscarriage? What are the indications? What is the follow up?

Answer 33

- Expectant (wait 7–14d) - <6w, not bleeding heavily, no signs of infection - Urinary beta-hCG after 3w or repeat TVS if persistent or worse bleeding (or not started)

Question 34

MISCARRIAGE What is the medical management of a miscarriage? What is the follow up?

Answer 34

- PV/PO synthetic prostaglandin misoprostol - Contact HCP if no bleeding in 24h - Urinary beta-hCG 3w after to exclude ectopic or molar

Question 35

MISCARRIAGE What are the risks of expectant and medical management?

Answer 35

- Bleeding continuing - Increased pain - Infected POC - Failure

Question 36

MISCARRIAGE What are some indications for surgical management?

Answer 36

- Heavy bleeding - Infection - Failed other methods

Question 37

MISCARRIAGE What are the options for surgical management?

Answer 37

- Vacuum aspiration (suction curettage) under local as OP - Surgical Mx (evacuation of retained products of conception) under general

Question 38

MISCARRIAGE What else may be given in the management of miscarriage?

Answer 38

- Anti-D to rhesus -ve women if >12w, heavily bleeding or surgical Mx

Question 39

MISCARRIAGE What is a recurrent miscarriage?

Answer 39

- ≥3 consecutive miscarriages in the first trimester with the same biological father

Question 40

MISCARRIAGE What are some causes of recurrent miscarriage?

Answer 40

- Antiphospholipid syndrome - Hereditary thrombophilias (Factor V leiden deficiency, factor II prothrombin gene mutation, protein C/S deficiency) - Uterine abnormalities (uterine septate, fibroids) - Poor controlled chronic conditions (DM, thyroid, SLE)

Question 41

MISCARRIAGE What is antiphospholipid syndrome?

Answer 41

- Hypercoaguable state presenting with thrombosis + pregnancy issues (recurrent miscarriage) - Associated with antiphospholipid antibodies - Can occur on own or secondary to SLE

Question 42

MISCARRIAGE What is the management of antiphospholipid syndrome?

Answer 42

Low dose aspirin + LMWH

Question 43

MISCARRIAGE What are the investigations for recurrent miscarriage?

Answer 43

≥3 1st trimester, ≥1 in 2nd – - Lupus anticoagulant, anti-cardiolipin + phospholipid antibodies - Thrombophilia screen - Pelvic USS for structural issues - Cytogenic analysis of POC after 3rd miscarriage - Parental blood for karyotyping

Question 44

TERMINATING PREGNANCY What is the legal framework for terminating pregnancies?

Answer 44

- 1967 Abortion Act (+ 1990 amendment which reduced gestation from 28 to 24w)

Question 45

TERMINATING PREGNANCY What are the requirements for an abortion?

Answer 45

- <24w - Continuing pregnancy = great risk to physical or mental health of woman or existing children in family (clinical judgement)

Question 46

TERMINATING PREGNANCY When may an abortion be performed after 24w?

Answer 46

- Continuing is likely to risk mother's life - Prevents grave injury to physical or MH of woman - Substantial risk of serious handicap for baby

Question 47

TERMINATING PREGNANCY What are the legal requirements for an abortion?

Answer 47

- 2 registered medical practitioners must sign to agree indication - Must be registered medical practitioner in an approved premise

Question 48

TERMINATING PREGNANCY What is some pre-abortion care?

Answer 48

- Marie Stopes UK charity that provides abortion services (remote service if <10w gestation, phone consultation, meds issued remotely to take at home) - Women should be offered counselling

Question 49

TERMINATING PREGNANCY What is the medical management of abortion?

Answer 49

- More appropriate in earlier pregnancy, <24w, <10w can be done at home - Mifepristone (anti-progesterone) to halt pregnancy + relax cervix - Misoprostol (prostaglandin analogue) 24-48h after for contractions

Question 50

TERMINATING PREGNANCY What is done before surgical management of abortion?

Answer 50

- Cervical priming with mifepristone, misoprostol or osmotic dilators (>14w insert into cervix + gradually expand as absorb fluid to open cervical canal)

Question 51

TERMINATING PREGNANCY What is the surgical management of abortion?

Answer 51

- Cervical dilatation + vacuum aspiration of uterus contents <14w - Cervical dilatation + evacuation using forceps >14w - Rh -ve >10w = anti-D

Question 52

TERMINATING PREGNANCY What is post-abortion care?

Answer 52

- Pregnancy test at 3w - Contraception advice - Complications = infection (#1), bleeding, pain, failure or damage to genital tract

Question 53

HYPEREMESIS How common is nausea and vomiting in pregnancy?

Answer 53

- Very, particularly early on starts in early first trimester, peaks 8–12w + resolves 16–20w

Question 54

HYPEREMESIS What is believed to be responsible for N+V in pregnancy?

Answer 54

- Placental beta-hCG

Question 55

HYPEREMESIS When is N+V worse?

Answer 55

more severe in molar + multiple pregnancies where beta-hCG high

Question 56

HYPEREMESIS What are some associations of hyperemesis gravidarum?

Answer 56

- nulliparity, - hyperthyroid, - obesity, - decreased in smokers

Question 57

HYPEREMESIS What is the clinical presentation of hyperemesis gravidarum?

Answer 57

- Severe + excessive N+V - Associated with dehydration, ketosis + weight loss

Question 58

HYPEREMESIS What are the complications?

Answer 58

May lead to complications like Mallory-Weiss tear

Question 59

HYPEREMESIS What is the diagnostic triad for hyperemesis gravidarum?

Answer 59

Triad – - >5% weight loss compared to before pregnancy - Dehydration - Electrolyte imbalance

Question 60

HYPEREMESIS How is severity assessed?

Answer 60

Pregnancy-Unique Quantification of Emesis (PUQE) – - <7 mild, - 7-12 mod, - >12 severe

Question 61

HYPEREMESIS What are some investigations for hyperemesis gravidarum?

Answer 61

- Urine dipstick for ketones, MSU to exclude UTI - FBC (raised haematocrit) - U+Es (electrolyte imbalances + dehydration) - May have hypochloraemic metabolic alkalosis - Higher beta-hCG levels - USS to reassure + exclude multiple/molar

Question 62

HYPEREMESIS What would warrant hospital or EPAU admission?

Answer 62

- Unable to tolerate PO antiemetics or fluids - >5% weight loss compared to before pregnancy - Ketones present in dipstick (++ significant)

Question 63

HYPEREMESIS What is the inpatient management of hyperemesis gravidarum?

Answer 63

- Monitor U+Es - NBM until tolerate PO = IV fluids + anti-emetics - Vitamin supplements (incl. thiamine), may need artificial nutrition to prevent Wenicke-Korsakoff - Thromboprophylaxis with TED stockings + LMWH - Small + frequent meals when eating allowed

Question 64

HYPEREMESIS What is the community management of hyperemesis gravidarum?

Answer 64

- 1st line antiemetic = promethazine or cyclizine (anti-histamines) - 2nd line = ondansetron (5-HT3 antagonist) or metoclopramide (dopamine antagonist)

Question 65

HYPEREMESIS What alternative management can be used?

Answer 65

Complementary therapies like ginger or wrist acupressure

Question 66

ANTENATAL APPTS In terms of antenatal care... i) who is in charge of low risk pregnancies? ii) high risk pregnancies? iii) how many visits? iv) what would you do if reduced foetal movements?

Answer 66

i) Midwife-led with GP input ii) Doctor/consultant led with midwives alongside iii) 10 if nulliparous, subsequent 7 iv) Handheld doppler for heartbeat – USS if not heard, CTG if present

Question 67

ANTENATAL APPTS Define... i) gestational age ii) estimated date of delivery iii) gravidity iv) parity

Answer 67

i) duration of pregnancy starting from date of LMP ii) 40w gestation iii) Total # of pregnancies iv) number of births ≥24w regardless of outcome

Question 68

ANTENATAL APPTS When is the first visit? What is done?

Answer 68

Booking 8–12w – - General info (diet, alcohol, smoking, folic acid + vitamin D advice, antenatal classes, family origin questionnaire - FBC, blood group, rhesus status, haemoglobinopathies - HIV, hep B + syphilis screening offered - Urine MC&S for asymptomatic bacteriuria

Question 69

ANTENATAL APPTS What is the recommended amount of folic acid?

Answer 69

- ALL 400mcg - 5mg if – AEDs, coeliac, DM, >30kg/m^2, NTD risk

Question 70

ANTENATAL APPTS When is the dating scan done? What happens?

Answer 70

11–13+6w – - Confirm viability - Singleton/multiple - Estimate gestational age with crown rump length (top of head > bottom of buttocks) - Detect major structural abnormalities like anencephaly - Offer combined test

Question 71

ANTENATAL APPTS When is the anomaly scan? What happens?

Answer 71

18–20+6w – - Detect major abnormalities (NTD, CHD, CNS abnormality, renal agenesis) - Around 20w foetal movements start + continue (refer if none by 24w)

Question 72

ANTENATAL APPTS After the anomaly scan, routine care is given but at what times?

Answer 72

- 25w (primis) - 28w (all) - 31w (primis) - 34w (all) - 36w (all) - 38w (all) - 40w (primis) - 41w (all)

Question 73

ANTENATAL APPTS What routine care is given at 25w for primis?

Answer 73

- BP, urine dipstick, symphysis-fundal height (after 20w should correlate to gestational age ± 2cm)

Question 74

ANTENATAL APPTS What routine care is given at 28w?

Answer 74

- BP, urine dipstick, SFH - OGTT if risk factors for GDM - Second screen for anaemia (FBC), blood group + rhesus status - First dose of anti-D prophylaxis if Rh-ve

Question 75

ANTENATAL APPTS What routine care is given at... i) 31w (primis)? ii) 34w? iii) 36w?

Answer 75

i) BP, urine dipstick, SFH ii) BP, urine dipstick, SFH + second dose of anti-D if Rh-ve iii) BP, urine dipstick, SFH, check presentation (?ECV), info about breastfeeding, vitamin K + baby blues

Question 76

ANTENATAL APPTS What routine care is given at... i) 38w? ii) 40w (primis)? iii) 41w?

Answer 76

i) BP, urine dipstick, SFH ii) BP, urine dipstick, SFH, discuss options for prolonged pregnancy iii) BP, urine dipstick, sFH, discuss induction

Question 77

ANTENATAL SCREENING What pre-test information should be provided before antenatal screening?

Answer 77

- Conditions screened for - When + how test carried out - How reliable test is - What results mean + options - False +ve/-ve + detection rates

Question 78

ANTENATAL SCREENING What are the 3 main syndromes screened for in pregnancy?

Answer 78

- Patau's (trisomy 13) - Edward's (trisomy 18) - Down's (trisomy 21)

Question 79

ANTENATAL SCREENING What screening is offered in early pregnancy and when?

Answer 79

Combined test (11–13+6w) – - Nuchal translucency (thickness of back of foetus' neck on USS) - Beta-hCG - Pregnancy associated plasma protein-A (PAPP-A)

Question 80

ANTENATAL SCREENING What results indicate higher risk for... i) nuchal translucency? ii) beta-hCG? iii) PAPP-A? What else is taken into account?

Answer 80

i) >6mm ii) Higher result iii) Lower result - Maternal age, USS crown rump length, detection rate 85%

Question 81

ANTENATAL SCREENING What screening is offered if the mother is too late for the combined test and when?

Answer 81

Triple or quadruple test 15–20w but only tests for Down's syndrome – - Beta-hCG - Alpha-fetoprotein - Oestriol - Inhibin (quadruple)

Question 82

ANTENATAL SCREENING What results indicate higher risk for... i) beta-HCG? ii) AFP? iii) oestriol? iv) inhibin?

Answer 82

i) Higher result ii) Lower result iii) Lower result iv) Higher result

Question 83

ANTENATAL SCREENING What risk score would warrant further invasive tests? What are those tests?

Answer 83

- >1:150 = screen +ve - Amniocentesis - Chorionic villus sampling (CVS)

Question 84

AMNIOCENTESIS What is amniocentesis?

Answer 84

It involves aspiration of amniotic fluid which contains foetal cells shed from the skin and gut. It is performed transabdominally with ultrasound guidance.

Question 85

AMNIOCENTESIS When is amniocentesis performed?

Answer 85

from 15 weeks onwards

Question 86

AMNIOCENTESIS What are the indications for amniocentesis?

Answer 86

o For karyotyping if screening tests suggest aneuploidy. o DNA analysis if parents are carriers of an identifiable mutation, like CF or thalassaemia. o For enzyme assays looking for inborn errors of metabolism. o For diagnosis of fetal infections such as CMV and toxoplasmosis.

Question 87

AMNIOCENTESIS What are the benefits of amniocentesis?

Answer 87

o Lower procedure-attributed miscarriage rate than CVS (71%). o Less risk of maternal contamination or placental mosaicism

Question 88

AMNIOCENTESIS What are the risks of amniocentesis?

Answer 88

o Miscarriage (1%) o Failure to culture cells o Full karyotyping may take 3wks.

Question 89

CHORIONIC VILLUS SAMPLING What is chorionic villus sampling?

Answer 89

Involves aspiration of some trophoblastic cells from the placenta under USS guidance. It is used for karyotyping Is usually performed transabdominally, occasionally transcervically.

Question 90

CHORIONIC VILLUS SAMPLING when is chorionic villus sampling performed?

Answer 90

Usually between 10-13 weeks

Question 91

CHORIONIC VILLUS SAMPLING what are the indications for chorionic villus sampling?

Answer 91

o For karyotyping if 1st trimester screening test suggests high risk for aneuploidy. o For DNA analysis if parents are carriers of an identifiable gene mutation such as cystic fibrosis or thalassaemia.

Question 92

CHORIONIC VILLUS SAMPLING what are the benefits of chorionic villus sampling?

Answer 92

Allows 1st trimester TOP if an abnormality is detected: o Can be performed surgically. o Can be done before the pregnancy has become physically apparent.

Question 93

CHORIONIC VILLUS SAMPLING what are the risks of chorionic villus sampling?

Answer 93

o Miscarriage as a result of CVS is estimated at 1%. o Increases risk of vertical transmission of blood-borne viruses such as HIV and hepatitis B. o False negative results (rare) from contamination with maternal cells—especially with DNA analysis requiring PCR. o Placental mosaicism producing misleading results—estimated at <1%.

Question 94

ANTENATAL SCREENING What other testing is available in the private sector? What does it involve?

Answer 94

- Non-invasive prenatal testing - Analyses fragments of foetal DNA in maternal blood - 99% accurate, done from 10w

Question 95

APH What is an antepartum haemorrhage (APH)?

Answer 95

- Genital tract bleeding after 24w gestation

Question 96

APH What are the causes of APH?

Answer 96

Majority idiopathic, dangerous causes – - Placental abruption or praevia - Vasa praevia - Morbidly adherent placenta

Question 97

APH What are some generic investigations for APH?

Answer 97

- Exclude placenta praevia with USS - Kleihauer test to confirm transplacental blood loss from foetus>mother

Question 98

APH What are some complications of APH?

Answer 98

- PPH, DIC - Premature labour - ITU admission - Maternal or foetal death - Sheehan's syndrome

Question 99

PLACENTA PRAEVIA What is placenta praevia?

Answer 99

- When placenta is inserted wholly, or in part, into the lower segment of the uterus (low lying placenta)

Question 100

PLACENTA PRAEVIA What are the grades of placenta praevia?

Answer 100

Minor (I or II) – - I = reaches lower segment but not internal os - II = reaches internal os but doesn't cover Major (III or IV) – - III = covers internal os before dilation (not when dilated) - IV = completely covers internal os - Cervical effacement + dilation > catastrophic bleeding + potential maternal + foetal death

Question 101

PLACENTA PRAEVIA What are some risk factors for placenta praevia?

Answer 101

- Embryos more likely to implant on lower segment scar from previous c-section - Multiple pregnancy - Multiparity - Previous praevia - Assisted conception

Question 102

PLACENTA PRAEVIA What is the clinical presentation of placenta praevia?

Answer 102

- PAINLESS PV bleeding, BRIGHT RED blood, shock IN proportion to visible loss - Foetus may have abnormal lie + presentation (breech + transverse) - Uterus is not tender

Question 103

PLACENTA PRAEVIA What are the investigations for placenta praevia?

Answer 103

- TV USS safe + more accurate - Can be Dx on routine antenatal USS (20w) - Repeat USS at 36w if minor or 32w if major - If over or close to internal os repeat scans every 2w

Question 104

PLACENTA PRAEVIA What are some complications of placenta praevia?

Answer 104

- PPH - Placenta accreta or percreta

Question 105

PLACENTA PRAEVIA What is the normal management of placenta praevia?

Answer 105

- Asymptomatic can stay at home if access to hospital, aware of risks/Sx, companion (rest + avoid intercourse) - <20mm from os = elective c-section ≥38w or earlier if bleeding does not settle - Anti-D if Rh-ve

Question 106

PLACENTA PRAEVIA What is the acute management of placenta praevia?

Answer 106

- ABCDE + admission - IV access, fluids (crystalloid), X-match blood, inform senior team + paeds - Foetal monitoring with CTG ± delivery - Steroids if <34w gestation

Question 107

PLACENTAL ABRUPTION What is placental abruption?

Answer 107

- Placenta prematurely separates (in part or fully) from uterus wall leading to APH from where the placenta was previously attached - Blood can accumulate behind placenta in uterine cavity or exit via cervix

Question 108

PLACENTAL ABRUPTION What are the major risk factors for placental abruption? What are some other risk factors?

Answer 108

- IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption - Cocaine use, multiple pregnancy or high parity, trauma

Question 109

PLACENTAL ABRUPTION What are the 2 types of abruption?

Answer 109

- Concealed = cervical os closed so haemorrhage remains in uterus – Maternal shock out of proportion with visible loss may > underestimation - Revealed = PV bleeding

Question 110

PLACENTAL ABRUPTION What is the clinical presentation of placental abruption?

Answer 110

- Sudden onset severe abdo PAIN which is continuous - PV bleeding often DARK red - Maternal shock (hypotension, tachycardia = adverse signs) - Foetal distress common on CTG (absent or abnormal FHR) - Posterior placenta may cause severe backache

Question 111

PLACENTAL ABRUPTION What are some investigations for placental abruption?

Answer 111

- Tender "woody" uterus on palpation (blood invading myometrium) - FBC, coagulation, X-match (may need catheter for urine output + U+Es for renal function) - USS + CTG for foetal wellbeing + exclude praevia

Question 112

PLACENTAL ABRUPTION What are the maternal and foetal complications of placental abruption?

Answer 112

- Shock, DIC, renal failure, PPH - IUGR, hypoxia + death

Question 113

PLACENTAL ABRUPTION What is the general management of placental abruption?

Answer 113

- Mum + foetus stable at <36w then admit + observe carefully, induce after 36w with amniotomy aiming for vaginal delivery, steroids if <34w - Anti-D if Rh-ve

Question 114

PLACENTAL ABRUPTION What is the management of acute placental abruption?

Answer 114

- A–E resus - IV access, fluids, ABO Rh compatible or O-ve blood - Mum unstable, foetal distress or heavy bleeding = emergency c-section - Steroids if <34w MUM COMES FIRST

Question 115

ADHERED PLACENTA What is a morbidly adhered placenta?

Answer 115

- The chorionic villi attach to the myometrium rather than being restricted within the decidua basalis

Question 116

ADHERED PLACENTA What are the different types of morbidly adhered placenta?

Answer 116

- Accreta = placenta invades into superficial myometrium - Increta = placenta invades deeper through the myometrium - Percreta = placenta invades through myometrium, into nearby organs of abdomen (bladder, bowel)

Question 117

ADHERED PLACENTA What are some risk factors for a morbidly adhered placenta?

Answer 117

- Previous c-sections (placenta attaches to site) - Myomectomy - Surgical TOP

Question 118

ADHERED PLACENTA What are some investigations for a morbidly adhered placenta?

Answer 118

- USS may show loss of definition between wall of uterus + abnormal vasculature - MRI scan if degree of adherence uncertain

Question 119

ADHERED PLACENTA What are some complications of a morbidly adhered placenta?

Answer 119

- Poor placental separation may occur > difficult to deliver placenta after baby delivered > retained products > infection risk - Delivery risks = PPH, transfusion, caesarean hysterectomy, ITU

Question 120

ADHERED PLACENTA What is the management of a morbidly adhered placenta?

Answer 120

- Elective LSCS at 36–37w - ?Caesarean hysterectomy - ?Leave in situ (expectant) - ?Uterus preserving surgery (resecting part of myometrium + placenta)

Question 121

ADHERED PLACENTA What is the acute management of a morbidly adhered placenta?

Answer 121

- Blood + blood products available - Local ITU availability - Tamponade with balloon - Hysterectomy last resort

Question 122

VASA PRAEVIA What is vasa praevia?

Answer 122

- Major foetal vessels run in membranes below the presenting foetal part, so they present before the foetus, unsupported by placental tissue or umbilical cord - Exposed mean prone to rupture + bleed

Question 123

VASA PRAEVIA What are some risk factors for vasa praevia?

Answer 123

- Placenta praevia - Multiple pregnancy - IVF pregnancy - Bilobed placentas

Question 124

VASA PRAEVIA What is the clinical presentation of vasa praevia?

Answer 124

- PV bleed straight after rupture of foetal membranes > rapid foetal distress - CTG abnormalities (bradycardia) with high foetal mortality - No major maternal risk just major foetal risk (massive haemorrhage)

Question 125

VASA PRAEVIA What is the management of vasa praevia?

Answer 125

- A–E approach, manage bleeding - Deliver c-section (elective if antenatally diagnosed, emergency if present with bleeding)

Question 126

PRE-ECLAMPSIA What is pre-eclampsia?

Answer 126

- Pregnancy induced HTN + proteinuria at >20w gestation - Results due to abnormal development of the placenta

Question 127

PRE-ECLAMPSIA How can pre-eclampsia be classified?

Answer 127

- Mild-mod = pre-eclampsia without severe HTN (<160/110) and NO Sx, biochemical or haematological impairment - Severe = pre-eclampsia w/ severe HTN ± Sx ± biochem ± haem impairment - Early <34w, late >34w

Question 128

PRE-ECLAMPSIA What is the normal physiology of the placenta?

Answer 128

- Spiral arteries dilate + develop into large utero-placental arteries, supplying lots of blood to the endometrium > placenta + foetus

Question 129

PRE-ECLAMPSIA What is the pathophysiology of pre-eclampsia?

Answer 129

- Spiral arteries do not remodel + dilate but become fibrous so utero-placental arteries deliver less blood > placental ischaemia

Question 130

PRE-ECLAMPSIA What is the result of placental ischaemia?

Answer 130

- Pro-inflammatory protein + thromboplastin release leads to endothelial damage > vasoconstriction, clotting dysfunction + increased vascular permeability - Ultimately leads to poor renal perfusion > RAAS activation > HTN, proteinuria ± oedema > pre-eclampsia + eclampsia (if continues)

Question 131

PRE-ECLAMPSIA What are the... i) high risk ii) moderate risk factors for pre-eclampsia?

Answer 131

i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM) ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2

Question 132

PRE-ECLAMPSIA What are the 2 main causes of symptoms in pre-eclampsia?

Answer 132

- Local areas of vasospasm leading to hypoperfusion - Oedema due to increased vascular permeability + hypoproteinaemia

Question 133

PRE-ECLAMPSIA What symptoms are caused by local areas of vasospasm and what area is affected?

Answer 133

Renal = glomerular damage (low GFR) – - Oliguria + proteinuria Retinal – - Visual disturbances (blurred, flashing lights, scotoma) Liver = injury + swelling stretches liver capsule – - RUQ or epigastric pain

Question 134

PRE-ECLAMPSIA What symptoms are caused by oedema?

Answer 134

- Face, hands + legs (generalised) - SOB + cough (pulmonary) - Headaches, confusion + seizures in eclampsia (cerebral)

Question 135

PRE-ECLAMPSIA What are the signs of pre-eclampsia?

Answer 135

- Raised BP + proteinuria are hallmarks - Rapid weight gain, RUQ tenderness - Ankle clonus (brisk reflexes normal in pregnancy but not clonus) - Papilloedema if severe

Question 136

PRE-ECLAMPSIA How can a diagnosis of pre-eclampsia be made?

Answer 136

- BP ≥140/90mmHg - Proteinuria in a 24h collection (>0.3g) or dipstick with +

Question 137

PRE-ECLAMPSIA What blood investigations would you do in pre-eclampsia?

Answer 137

- FBC with platelets (thrombocytopenia) - Serum uric acid levels (raised due to renal issues) - LFTs (elevated liver enzymes ALT + AST)

Question 138

PRE-ECLAMPSIA What other investigations could you perform in pre-eclampsia?

Answer 138

- Proteinuria on dipstick (++ or +++ is severe) - Protein:Creatinine ratio (PCR) ≥30ng/nmol = significant proteinuria - Accurate dating + USS to assess foetal growth

Question 139

PRE-ECLAMPSIA What are the 2 big complications of pre-eclampsia?

Answer 139

- Eclampsia - HELLP syndrome

Question 140

PRE-ECLAMPSIA What is eclampsia? What causes it?

Answer 140

- Generalised tonic-clonic seizures in a patient with a Dx of pre-eclampsia - Hypoalbuminaemia > hypovolaemia > cerebral hypoperfusion

Question 141

PRE-ECLAMPSIA What is the management of eclampsia?

Answer 141

IV magnesium sulfate to prevent + treat seizures – - Reduces DIC risk as reduced platelet aggregation - Continue 24h after last seizure or delivery Treat HTN with labetalol 1st line or nifedipine Stabilise mum and delivery baby

Question 142

PRE-ECLAMPSIA What needs to be monitored when giving magnesium sulfate?

Answer 142

- Magnesium levels for toxicity - Reduced reflexes, confusion + respiratory depression - Calcium gluconate first line

Question 143

HELLP What is HELLP syndrome?

Answer 143

HELLP syndrome is a subtype of severe pre-eclampsia characterized by - hemolysis (H), - elevated liver enzymes (EL), - low platelets (LP). Usually occurs within 7 days of delivery.

Question 144

HELLP How does HELLP syndrome present?

Answer 144

➢ Nausea/vomiting ➢ Hypertension ➢ Brisk tendon reflexes ➢ RUQ/Epigastric pain ➢ General malaise/headache ➢ Oedema/bleeding ➢ Visual problems, jaundice

Question 145

HELLP what other condition is HELLP associated with?

Answer 145

- 10% have antiphospholipid syndrome

Question 146

HELLP what are the risk factors for HELLP?

Answer 146

➢ White ethnicity ➢ Maternal age >35 yrs. ➢ Obesity ➢ Chronic hypertension ➢ DM ➢ Autoimmune disorders ➢ Abnormal placentation and multiple gestation ➢ Previous pregnancy with preeclampsia

Question 147

HELLP what are the investigations for HELLP?

Answer 147

➢ FBC with platelets: hemolysis, elevated LFT, low platelets ➢ Peripheral blood smear, serum LDH, uric acid ➢ LFT, Bilirubin ➢ Fetal ultrasound

Question 148

HELLP what is the management for HELLP?

Answer 148

➢ Seizure prophylaxis (magnesium sulfate), IV dexamethasone, labetalol. IM beclametasone when patient <36wks ➢ Delivery is definitive treatment (should be done when patient is 37+ wks)

Question 149

PRE-ECLAMPSIA What are some other important complications of pre-eclampsia?

Answer 149

- DIC, CVA (haemorrhagic) - Multi-organ failure (renal, hepatic) - Foetus = IUGR (poorly perfused placenta), prematurity, placental abruption

Question 150

PRE-ECLAMPSIA What should be given to women who are at high or moderate risk of pre-eclampsia and why?

Answer 150

- 75mg aspirin PO OD at 12w until birth - Spiral arteries form around 12w so thought to help them develop

Question 151

PRE-ECLAMPSIA What medical treatment can be given for pre-eclampsia?

Answer 151

Treat HTN with – - PO Labetalol first line (can use IV if severe + inpatient) - PO nifedipine (used if asthmatic) - Hydralazine too - ACEi = CONTRAINDICTAED

Question 152

PRE-ECLAMPSIA What is the criteria for outpatient management of pre-eclampsia? What care is given?

Answer 152

- BP <160/110, no or low proteinuria (≤+, <0.3g/24h) + no symptoms - Weekly review of bloods, twice weekly mother + foetal evaluation (HBPM + urine) - Any changes > hospital

Question 153

PRE-ECLAMPSIA What is the definitive cure of pre-eclampsia? What are the indications? What method is preferred?

Answer 153

- Delivery (around 36w) - Mother = liver/renal failure, HELLP, eclampsia, severe Sx - Foetal = severe IUGR, oligohydramnios, abnormal CTG - PV + neuraxial techniques for spinal/epidural preferred

Question 154

PRE-ECLAMPSIA What is the management of pre-eclampsia during delivery?

Answer 154

- Regular investigations (BP, urinalysis, bloods, CTG, fluid balance chart (restrict if severe) - BP control (IV labetalol first line of nifedipine if asthmatic) - IV magnesium sulfate prophylaxis during labour + 24h after

Question 155

PRE-ECLAMPSIA What are the 3 other types of HTN in pregnancy conditions?

Answer 155

- Chronic HTN - Gestational/pregnancy induced HTN - Pre-eclampsia superimposed on chronic HTN

Question 156

PRE-ECLAMPSIA What is chronic HTN?

Answer 156

- HTN diagnosed prior to pregnancy, before 20w gestation or that develops during pregnancy but does not resolve postpartum

Question 157

PRE-ECLAMPSIA What is gestational or pregnancy induced HTN?

Answer 157

- New HTN >20w gestation with NO proteinuria that resolves after giving birth - 25% will progress to pre-eclampsia

Question 158

PRE-ECLAMPSIA What is pre-eclampsia superimposed on chronic HTN?

Answer 158

- HTN + no proteinuria <20w with new onset proteinuria after 20w - HTN + proteinuria <20w with sudden rise in proteinuria or BP when HTN was well controlled, or development of thrombocytopenia or abnormal ALT/AST

Question 159

IUGR What is intrauterine growth restriction (IUGR)?

Answer 159

- Baby has not maintained its growth potential (slows or creases) - I.e. drops below centile line it was following > pathological

Question 160

IUGR What are the two types of IUGR?

Answer 160

- Symmetrical = entire body is proportionately small, tends to be seen in early onset IUGR, TORCH + chromosomal abnormalities - Asymmetrical = undernourished foetus that is compensating by directing most of its energy to maintain growth of vital organs like brain + heart

Question 161

IUGR What might be seen in asymmetrical IUGR?

Answer 161

Head-sparing effect – - Normal head size but small abdominal circumference + thin limbs - Mostly secondary to placental insufficiency

Question 162

IUGR What is small for gestational age (SGA)?

Answer 162

- Estimated foetal weight (EFW) or abdominal circumference (AC) below 10th centile for their gestational age - May be constitutionally small with no pathology identified (parental height)

Question 163

IUGR What is low birth weight?

Answer 163

- Baby born with a weight <2.5kg (regardless of gestational age)

Question 164

IUGR What are the 3 broad categories causing IUGR?

Answer 164

- Placental insufficiency (most common cause) - Maternal factors - Foetal factors

Question 165

IUGR What are some placental causes of IUGR?

Answer 165

- Abnormal trophoblast invasion (pre-eclampsia, placenta accreta) - Infarction, abruption, location (praevia)

Question 166

IUGR What are some maternal causes of IUGR?

Answer 166

- Chronic disease (HTN, cardiac, CKD) - Substance abuse (cocaine, alcohol) smoking, previous SGA baby - Autoimmune - Low socioeconomic status - >40

Question 167

IUGR What are some foetal causes of IUGR?

Answer 167

- Genetic abnormalities (trisomies 13/18/21, Turner's) - Congenital infections (TORCH) - Multiple pregnancy

Question 168

IUGR What are some complications of IUGR?

Answer 168

- Hypoglycaemia - Risk of necrotising enterocolitis - Neonatal jaundice - Hypothermia - Respiratory issues - Long-term sequelae include T2DM, HTN, obesity, behavioural problems, CP

Question 169

IUGR What causes... i) hypoglycaemia? ii) necrotising enterocolitis? iii) neonatal jaundice?

Answer 169

i) Blood directed away from liver>brain so glycogen stores don't develop adequately ii) Reduced blood to bowel iii) Compensatory polycythaemia for reduced oxygen supply from mother if reduced placental perfusion

Question 170

IUGR What causes... i) hypothermia? ii) respiratory problems?

Answer 170

i) No fat stores developed so cannot thermoregulate, large surface area ii) Kidney hypoperfusion > decreased urine output > oligohydramnios > inadequate lung development

Question 171

IUGR What are the investigations for IUGR?

Answer 171

- BP + urine dipstick (?pre-eclampsia) - Karyotyping (?foetal) - Infection screen, TORCH (?infection)

Question 172

IUGR When would you be concerned about IUGR? What would you do?

Answer 172

- SFH < 10th centile, slow or static growth or crossing centiles - Refer for serial growth scans (USS) every 2w, umbilical artery doppler + amniotic fluid volume - MCA doppler performed after 32w

Question 173

IUGR What is umbilical artery doppler for? What happens if it's abnormal?

Answer 173

- Assesses if baby is getting enough blood - Abnormal = twice weekly review

Question 174

IUGR What is the management (and the indications of management) for IUGR?

Answer 174

Consider delivery (corticosteroids if <34w to mature foetal lungs) if – - Static growth on growth charts - Absent end-diastolic flow (AEDF, abnormal doppler) - Abnormal CTG (foetal distress) - MCA doppler PI <5% delivery by 37w (early sign of foetal hypoxia in SGA, shows increased diastolic flow > head-sparing effect)

Question 175

MULTIPLE PREGNANCY What is meant by a monozygotic multiple pregnancy?

Answer 175

identical (come from single zygote)

Question 176

MULTIPLE PREGNANCY What is meant by dizygotic multiple pregnancy?

Answer 176

non-identical (come from two different zygotes > diamniotic + dichorionic)

Question 177

MULTIPLE PREGNANCY What is meant by mono/diamniotic multiple pregnancy?

Answer 177

share/two separate amniotic sacs

Question 178

MULTIPLE PREGNANCY What is meant by a mono/dichorionic multiple pregnancy?

Answer 178

share/two separate placentas

Question 179

MULTIPLE PREGNANCY What are some predisposing factors to multiple pregnancies?

Answer 179

- Previous twins, FHx, increasing parity + maternal age, IVF, race (Afro-Caribbean)

Question 180

MULTIPLE PREGNANCY What is one way of preventing them?

Answer 180

No more than 2 embryos transferred per IVF cycle

Question 181

MULTIPLE PREGNANCY What is the clinical presentation of multiple pregnancies?

Answer 181

- Uterus larger than expected for dates - May suffer from hyperemesis gravidarum - Multiple foetal poles may be palpable at >24w - Multiple foetal hearts on auscultation - Majority diagnosed on dating scan

Question 182

MULTIPLE PREGNANCY What are some maternal and foetal complications of multiple pregnancy?

Answer 182

- Anaemia, HTN, APH + PPH, preterm birth, stillbirth - Twin-twin transfusion syndrome, IUGR, polyhydramnios, malpresentation

Question 183

MULTIPLE PREGNANCY What is twin-twin transfusion syndrome?

Answer 183

- Associated with monoamniotic monochorionic twins - Recipient gets majority of blood so is larger with polyhydramnios - Donor is starved of blood + can become anaemic, recipient worse off (hydrops) - Severe cases > laser ablation of connecting vessels

Question 184

MULTIPLE PREGNANCY What is the antenatal care for multiple pregnancies?

Answer 184

- High risk – 5mg folic acid, iron supplements to prevent anaemia - Additional scans for growth restriction + twin-twin transfusion (2w from 16w for monochorionic, 4w from 20w for dichorionic)

Question 185

MULTIPLE PREGNANCY What is the management of multiple pregnancies?

Answer 185

- Steroids if <34w - Monochorionic/amniotic twins = elective c-section 32-34w - Diamniotic twins = 37–38w, vaginal if presenting twin cephalic but may need c-section for second

Question 186

OLIGOHYDRAMNIOS What is oligohydramnios? What is it defined as?

Answer 186

- Abnormally low levels of amniotic fluid during pregnancy - Amniotic fluid index <5th centile for gestational age

Question 187

OLIGOHYDRAMNIOS What are some causes of oligohydramnios?

Answer 187

- PROM or SROM - Renal agenesis (Potter's syndrome) or non-functional kidneys - Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output - Genetic anomalies - Obstructive uropathy

Question 188

OLIGOHYDRAMNIOS What is the clinical presentation of oligohydramnios?

Answer 188

- May have experienced leaking fluid or feeling damp - Measure SFH - Sterile speculum may show pool of liquor in birth canal

Question 189

OLIGOHYDRAMNIOS What are some investigations for oligohydramnios?

Answer 189

- USS foetus = AFI or maximum pool depth calculated + doppler - TORCH screen as may be infection - Test fluid for IGFBP-1 or PAMG-1 if concerned about PPROM. - Foetal CTG for signs of distress

Question 190

OLIGOHYDRAMNIOS What are some complications of oligohydramnios?

Answer 190

- 2nd trimester = poor prognosis due to PPROM leading to premature delivery + pulmonary hypoplasia > resp distress - Muscle contractures as amniotic fluid allows foetal to move limbs in utero

Question 191

OLIGOHYDRAMNIOS What is the management of oligohydramnios?

Answer 191

- Treat as PROM if present - Frequent monitoring of growth for IUGR

Question 192

POLYHYDRAMNIOS What is amniotic fluid (liquor)?

Answer 192

- Fluid between baby + amnion (sac) acts as a cushion around foetus to protect it from trauma - Foetus can swallow amniotic fluid which helps create urine + meconium

Question 193

POLYHYDRAMNIOS What is polyhydramnios?

Answer 193

- Abnormally large levels of amniotic fluid - AFI >95th centile for gestational age

Question 194

POLYHYDRAMNIOS What are the causes of polyhydramnios?

Answer 194

- Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops - Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)

Question 195

POLYHYDRAMNIOS How may polyhydramnios present?

Answer 195

- Maternal discomfort - LGA - Foetal parts hard to palpate - Taut uterus

Question 196

POLYHYDRAMNIOS What are the investigations for polyhydramnios?

Answer 196

- Exclude GDM with OGTT - USS foetus to calculate AFI or maximum pool depth - TORCH screen as can be cause by viral infections

Question 197

POLYHYDRAMNIOS What are some complications of polyhydramnios?

Answer 197

- Preterm delivery - Malpresentation - Maternal discomfort from abdo distension

Question 198

POLYHYDRAMNIOS What is the management of polyhydramnios?

Answer 198

- If severe = amnioreduction or NSAIDs (indomethacin) - If preterm assess risk of delivery with cervical scan ± foetal fibronectin assay

Question 199

POLYHYDRAMNIOS What are the risks of amnioreduction and indomethacin?

Answer 199

- Associated with infection + placental abruption - Associated with premature closure of ductus arteriosus so not used beyond 32w

Question 200

RHESUS DISEASE What are rhesus antigens?

Answer 200

- On surface of red blood cells + differs to the ABO groups - A+ve is blood group A with rhesus D antigens

Question 201

RHESUS DISEASE What is the pathophysiology of rhesus disease in the first pregnancy?

Answer 201

- Rh-ve woman exposed to Rh+ve foetal blood, her immune system recognises as foreign + produce antibodies against rhesus D (sensitisation) - Usually no issues in 1st pregnancy as IgM produced that cannot cross placenta

Question 202

RHESUS DISEASE What is the pathophysiology of rhesus disease in subsequent pregnancies?

Answer 202

- Memory cells produce IgG which can cross placenta so if Rh+ve foetus will attack leading to haemolysis (haemolytic disease of newborn) with jaundice + hydrops fetalis (abnormal accumulation of fluid)

Question 203

RHESUS DISEASE What events are considered potential sensitising events?

Answer 203

- Delivery of Rh+ve infant - APH - Amniocentesis or CVS - Abdo trauma - ECV - Surgical Mx of ectopic + miscarriage - PV bleed >12w

Question 204

RHESUS DISEASE What are some investigations for rhesus disease?

Answer 204

- Kleihauer test (check how much foetal blood > mother's blood after event) - All babies born to Rh-ve women should have cord blood at delivery for FBC, blood group + Direct Coombs (antiglobulin) test for antibodies on baby's RBC

Question 205

RHESUS DISEASE What is the Kleihauer test?

Answer 205

- Add acid + foetal Hb more resistant to acid so number of cells that still contain Hb represents remaining foetal cells

Question 206

RHESUS DISEASE What is the management of rhesus disease?

Answer 206

- Prophylaxis crucial as sensitisation is irreversible - IM anti-D routinely at 28w, 34w + after birth but also potential events - Newborn haemolysis > exchange transfusions (severe) or UV phototherapy

Question 207

RHESUS DISEASE How does anti-D work?

Answer 207

- Immunoglobulin attaches to Rh D antigens on foetal blood in maternal circulation preventing recognition

Question 208

GESTATIONAL DIABETES What is Gestational Diabetes Mellitus (GDM)?

Answer 208

- Carbohydrate intolerance during pregnancy which often resolves after birth

Question 209

GESTATIONAL DIABETES What is the pathophysiology of GDM?

Answer 209

- Increased insulin resistance due to placental production of anti-insulin hormones - Allows post-prandial glucose peak to be higher for longer to spare glucose for foetus (main source of nutrients) - If maternal pancreas cannot increase insulin production to combat this > GDM

Question 210

GESTATIONAL DIABETES What are some anti-insulin hormones produced by the placenta?

Answer 210

- Main one is human placental lactogen (hPL) - Also glucagon + cortisol

Question 211

GESTATIONAL DIABETES What are some risk factors for GDM?

Answer 211

- BMI >30kg/m^2 - PMH of GDM - FHx of DM (first-degree) - Asian + Afro-Caribbean ethnicity - Previous macrosomic baby

Question 212

GESTATIONAL DIABETES What is the clinical presentation of GDM?

Answer 212

- May be asymptomatic or present with polydipsia, polyuria, nocturia + fatigue

Question 213

GESTATIONAL DIABETES What is the diagnostic investigation for GDM? Who is given this?

Answer 213

- OGTT (75g glucose given in morning after a fast) - Anyone with previous GDM at booking + 24–28w - Anyone with risk factors at 24-28w

Question 214

GESTATIONAL DIABETES What OGTT results are diagnostic for GDM?

Answer 214

5-6-7-8 rule: - Baseline/fasting >5.6mmol/L - At 2h >7.8mmol/L

Question 215

GESTATIONAL DIABETES What are the foetal risks of GDM?

Answer 215

- Macrosomia - Polyhydramnios - Birth trauma - Stillbirth + miscarriage - Congenital malformations (CHD, NTD, cleft palate) - Neonatal hypoglycaemia - RDS, polycythaemia - Obesity + T2DM later in life

Question 216

GESTATIONAL DIABETES What causes macrosomia?

Answer 216

Excess foetal glucose > hyperinsulinaemia + so increased fat deposition

Question 217

GESTATIONAL DIABETES What causes polyhydramnios?

Answer 217

Excess foetal glucose > polyuria

Question 218

GESTATIONAL DIABETES What causes birth trauma?

Answer 218

Cephalopelvic incompatibility, shoulder dystocia

Question 219

GESTATIONAL DIABETES What causes neonatal hypoglycaemia?

Answer 219

Climatization + hyperinsulinaemia

Question 220

GESTATIONAL DIABETES What are the maternal risks of GDM?

Answer 220

- Pre-eclampsia - DKA or hypos - UTIs - IHD - Nephropathy, retinopathy

Question 221

GESTATIONAL DIABETES What pre-conceptual advice should be given to women with pre-existing diabetes?

Answer 221

- Contraception until good diabetic control - 5mg folic acid until 12w - Stop any ACEi or statins - Retinopathy screening at booking + 28w - Aspirin 75mg OD at 12w to reduce pre-eclampsia risk - Monitor BMs regularly

Question 222

GESTATIONAL DIABETES What is the management of pre-existing T1DM?

Answer 222

Insulin with dose adjustment for normal changes to glucose metabolism in pregnancy

Question 223

GESTATIONAL DIABETES What is the management of pre-existing T2DM?

Answer 223

Only metformin is safe, may need upgrading to insulin

Question 224

GESTATIONAL DIABETES What is the management of GDM?

Answer 224

- Fasting glucose <7 = lifestyle (low GI foods, exercise) > metformin after 1-2w if targets not met - Fasting glucose ≥7 = insulin ± metformin - Fasting glucose ≥6 + macrosomia or other complications = insulin - Glibenclamide if cannot tolerate metformin or decline insulin

Question 225

GESTATIONAL DIABETES When should the foetus be delivered in... i) pre-existing DM? ii) GDM

Answer 225

i) 37–39w ii) No need before 41w

Question 226

VTE IN PREGNANCY What is VTE? What is the significance?

Answer 226

- DVTs + PEs = large cause of mortality in obstetrics - High risk during postpartum period, top cause of direct maternal death

Question 227

VTE IN PREGNANCY What are the... i) high ii) intermediate risk factors of VTE?

Answer 227

i) PMH of VTE, antenatal LMWH requirements, high-risk thrombophilia or low risk + FHx ii) Smoking, parity >3, age >35, BMI >30, reduced mobility, multiple pregnancy, pre-eclampsia, gross varicose veins, IVF

Question 228

VTE IN PREGNANCY What is the clinical presentation of VTE in pregnancy?

Answer 228

- Swollen, warm, tender, red calf, Homan's sign (calf pain on dorsiflexion) > DVT - SOB, sudden CP (pleuritic), haemoptysis, tachycardia > PE

Question 229

VTE IN PREGNANCY What are the investigations for VTE?

Answer 229

- ECG in PE commonly shows sinus tachycardia, rarely S1Q3T3 - Doppler USS diagnostic for DVT - FBC, U+Es, LFTs, clotting screen, CXR if ?PE - CTPA gold standard for PE, can do V/Q scan

Question 230

VTE IN PREGNANCY How do you manage VTE risk in pregnancy?

Answer 230

- Risk assessment at booking, antenatal admissions + postnatally - Antenatal: LMWH from 28w if increased risk or ASAP if high risk - Postnatal: LMWH for 10d if increased risk or 6w if high risk - TED stockings - Low risk Mx = mobilise early, hydration

Question 231

VTE IN PREGNANCY What is the management of a VTE event? Any contraindications?

Answer 231

- Embolectomy + anticoagulate ASAP with LMWH - Do NOT use warfarin (or DOACs) as can cross placenta + may cause foetal abnormalities (CHD) + intracranial bleeding

Question 232

OBSTETRIC CHOLESTASIS What is obstetric cholestasis?

Answer 232

- Intrahepatic cholestasis = reduced outflow of bile acids from liver

Question 233

OBSTETRIC CHOLESTASIS What are some associations?

Answer 233

- Asian women, thought to be due to increased oestrogen + progesterone levels

Question 234

OBSTETRIC CHOLESTASIS What is the clinical presentation of obstetric cholestasis?

Answer 234

- Typically later in pregnancy (3rd trimester) - Itchy skin (palms of hands + soles of feet) but with NO rash – WORSE at night - Jaundice, pale greasy stools + dark urine less common

Question 235

OBSTETRIC CHOLESTASIS What are the investigations for obstetric cholestasis?

Answer 235

- Clotting screen (prothrombin time) deranged - Abnormal LFTs + raised bile acids (ALT, AST, GGT + bilirubin raised, ALP too but that is normal in pregnancy), monitor LFTs weekly

Question 236

OBSTETRIC CHOLESTASIS Why can clotting be deranged in obstetric cholestasis?

Answer 236

- Bile acids important for fat soluble vitamin absorption like vitamin K

Question 237

OBSTETRIC CHOLESTASIS What are the complications of obstetric cholestasis?

Answer 237

- Maternal = vitamin K deficiency (may lead to PPH) - Foetal = stillbirth (#1), increased risk of prematurity (often iatrogenic)

Question 238

OBSTETRIC CHOLESTASIS What is the management of obstetric cholestasis?

Answer 238

- Ursodeoxycolic acid first line to improve LFTs + bile acids - Induce labour at 37–38w to reduce stillbirth risk - Vitamin K supplementation - Emollients (calamine lotion to sooth skin) - Antihistamines to help sleep

Question 239

INFECTIONS + PREGNANCY What is Group B strep (GBS) infection?

Answer 239

- Infection caused by Strep agalactiae

Question 240

INFECTIONS + PREGNANCY What can Group B strep (GBS) infection in pregnancy cause?

Answer 240

Most common cause of early-onset severe infection (Sepsis) in neonates

Question 241

INFECTIONS + PREGNANCY How is group B strep infection spread?

Answer 241

Commonly found in maternal bowel flora

Question 242

INFECTIONS + PREGNANCY What are the risk factors of group B strep?

Answer 242

- Prematurity, - prolonged ROM, - previous GBS sibling, - maternal pyrexia

Question 243

INFECTIONS + PREGNANCY When should you screen?

Answer 243

If previous GBS in pregnancy either intrapartum IV Abx prophylaxis or test in late pregnancy (3-5w before EDD) + IV Abx if +ve

Question 244

INFECTIONS + PREGNANCY When would you give intrapartum IV Abx? What would you give?

Answer 244

- Previous baby with GBS (no screening), preterm labour or pyrexia >38 during labour - Benzylpenicillin

Question 245

INFECTIONS + PREGNANCY What are the risks of Varicella zoster?

Answer 245

- Maternal risk = 5x greater risk of pneumonitis - Foetal varicella syndrome = skin scarring, microphthalmia, limb hypoplasia, microcephaly + learning difficulties

Question 246

INFECTIONS + PREGNANCY What is the management of chickenpox exposure in pregnancy?

Answer 246

- Any doubt in immunity, check for varicella zoster IgG - ≤20w + not immune = VZIG within 10d - >20w + not immune = VZIG or aciclovir days 7–14 post-exposure

Question 247

INFECTIONS + PREGNANCY What is the management of chickenpox infection in pregnancy?

Answer 247

- PO aciclovir if ≥20w + presents within 24h of rash onset - <20w then consider

Question 248

ANAEMIA + PREGNANCY Why is anaemia common in pregnancy?

Answer 248

- Hb normally falls slightly in pregnancy due to increased plasma volume diluting Hb

Question 249

ANAEMIA + PREGNANCY What are some causes?

Answer 249

Physiological, Fe deficiency (increased demand), B12 or folate deficiency

Question 250

ANAEMIA + PREGNANCY What are some risk factors?

Answer 250

Menorrhagia, malaria, hookworm, twins, poor diet

Question 251

ANAEMIA + PREGNANCY What are some investigations for anaemia?

Answer 251

- FBC (normal ranges >110g/L at booking, >105g/L at 28w) - Microcytic hypochromic = Fe deficiency - Macrocytic = B12 or folate - Iron studies = TIBC (high), serum iron (low), serum ferritin (low but acute phase) - Haematinics, intrinsic factor Ab if ?pernicious

Question 252

ANAEMIA + PREGNANCY What are the complications of iron deficiency anaemia? How is it managed?

Answer 252

- LBW + preterm delivery - Ferrous sulfate 200mg TDS - If not anaemic but low ferritin indicating iron stores then start them on it - Vitamin C can increase absorption of iron

Question 253

ANAEMIA + PREGNANCY What is the management of macrocytic anaemias?

Answer 253

- Pernicious = IM hydroxocobalamin - B12 deficiency = B12 tablets (cyanocobalamin) - Folate = increased from 400mcg to 5mg/day to reduce NTD.

Question 254

PROM What is the physiology of ruptured membranes?

Answer 254

- Foetal membranes = chorion + amnion strengthened by collagen - SROM occurs naturally at any point prior to or during labour due to weakening in chorion/amnion, rarely born en caul - ARM can augment or induce labour

Question 255

PROM What is prelabour rupture of membranes? What are the risks?

Answer 255

Rupture of amniotic sac at least 1h prior to onset of labour at >37w - minimal risk as advanced gestation

Question 256

PROM What is i) prelabour rupture of membranes? ii) preterm prelabour rupture of membranes? What are the risks?

Answer 256

i) Rupture of amniotic sac at least 1h prior to onset of labour at >37w ii) Rupture of amniotic sac prior to onset of labour pre-term (<37w) - PROM = minimal risk as advanced gestation - PPROM = risk of chorioamnionitis + spontaneous labour

Question 257

PROM What are some risk factors for (P)PROM?

Answer 257

- Previous PROM/preterm - Smoking - Polyhydramnios - Amniocentesis

Question 258

PROM What is the clinical presentation of (P)PROM?

Answer 258

- Gush or constant trickle or dampness from vagina - Clear fluid

Question 259

PROM What are some investigations for PROM?

Answer 259

- Sterile speculum 1st for pooling of amniotic fluid - USS may show oligohydramnios if speculum normal - Ferning test (cervical secretion on glass slide shows fern-pattern crystals) - Test fluid for IGFBP-1 or PAMG-1 - CTG for foetus (tachycardia is suggestive of infection)

Question 260

PROM What is IGFBP-1 or PAMG-1?

Answer 260

- Insulin-like growth factor-binding protein-1 - Placental alpha-microglobin-1 - High concentrations of these proteins in amniotic fluid

Question 261

PROM What are some complications of PPROM?

Answer 261

- Risk of prematurity, chorioamnionitis, pulmonary hypoplasia

Question 262

PROM What is the management of PPROM?

Answer 262

- 1st line = IM corticosteroids if foetus <34w - Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d or until labour is established if within 10d - Consider induction at 34w (trade off)

Question 263

STAGES OF LABOUR What is the WHO definition of normal birth?

Answer 263

- Spontaneous in onset, low risk at start + remaining throughout labour + delivery - Infant born spontaneously in the vertex position between 37–42w - After birth, mother + infant are in good condition (aka no interventions)

Question 264

STAGES OF LABOUR What are 7 important hormones in labour?

Answer 264

- Prostaglandins - Oxytocin - Oestrogen - Beta-endorphins - Adrenaline - Prolactin - Relaxin

Question 265

STAGES OF LABOUR What is the role of prostaglandins in labour?

Answer 265

Aids with cervical ripening (effacement)

Question 266

STAGES OF LABOUR What is the role of oxytocin in labour?

Answer 266

Produced by hypothalamus, secreted by post. pituitary, surge at labour inhibits progesterone to prepare smooth muscle for uterine contractions, milk ejection reflex postpartum

Question 267

STAGES OF LABOUR What is the role of oestrogen in labour?

Answer 267

Surges at onset of labour to inhibit progesterone to prepare smooth muscle for labour

Question 268

STAGES OF LABOUR What is the role of beta-endorphins in labour?

Answer 268

Natural pain relief

Question 269

STAGES OF LABOUR What is the role of adrenaline in labour?

Answer 269

Released as birth imminent to give energy

Question 270

STAGES OF LABOUR What is the role of prolactin in labour?

Answer 270

Produced + secreted by ant. pituitary, allows process of milk production in mammary glands when oestrogen + progesterone decline postpartum

Question 271

STAGES OF LABOUR What is the role of relaxin in labour?

Answer 271

Released from placenta to soften ligaments + cartilage of pelvis so it can expand (cervix, vaginal tissues, perineum)

Question 272

STAGES OF LABOUR What are Braxton-Hicks contractions?

Answer 272

- 'Practice' contractions from 3rd trimester - Irregular + not felt by everyone - Mild cramp, last few minutes then ease

Question 273

STAGES OF LABOUR What are signs of labour?

Answer 273

- Show (shedding of mucus plug from cervix that prevents ascending bacteria) - Rupture of membranes - Shortening + dilation of cervix - Regular painful contractions

Question 274

STAGES OF LABOUR What is the physiology of contractions?

Answer 274

- Start in fundus (pacemaker) - Retraction/shortening of muscle fibres with each contraction pulls lower segment of uterus towards fundus - Causes cervical dilation + forces foetus down causing pressure on cervix

Question 275

STAGES OF LABOUR What is the first stage of labour? How is it further divided?

Answer 275

- From onset of labour (true contractions) until the cervix is fully dilated - Latent phase = from 0–3cm dilation - Active phase = from 3–10cm

Question 276

STAGES OF LABOUR What is the difference between latent and active phase of the first stage of labour?

Answer 276

- Latent: cervix begins to efface, irregular contractions, 'show', can last 2–3d (usually 6h) - Active: stronger, more regular contractions (4:10), cervix continues effacing

Question 277

STAGES OF LABOUR How quickly are women expected to dilate during the active phase?

Answer 277

- Primis = 0.5cm/h, - multiparous = 1cm/h

Question 278

STAGES OF LABOUR What is the second stage of labour? How is it further divided?

Answer 278

- From full dilation to delivery of the foetus - Passive stage: complete dilation but no pushing (often 1 hour) - Active stage: maternal pushing until delivery

Question 279

STAGES OF LABOUR What is considered a delay in the active second stage of labour? What does success depend on?

Answer 279

- >2h in nulliparous, 1h in multiparous - 3Ps (power, passenger + passage [?Psyche of mum])

Question 280

STAGES OF LABOUR Once the foetus has been delivered, what should be assessed and when? What does it calculate?

Answer 280

- APGAR score - 1, 5 + 10 minutes - 10–7 = normal - 6–4 = moderately depressed - <4 = severely depressed

Question 281

STAGES OF LABOUR What are the parts of the APGAR score?

Answer 281

Activity – absent 0, flexed arms + legs 1, active 2 Pulse – absent 0, <100bpm 1, >100bpm 2 Grimace – floppy 0, minimal response to stimulation 1, prompt response to stimulation 2 Appearance – blue 0, blue extremities 1, pink 2 Respiration – absent 0, slow + irregular 1, vigorous cry 2

Question 282

STAGES OF LABOUR What is the third stage of labour? What should it involves?

Answer 282

- From birth of the foetus to expulsion of placenta - Physiological Mx = placenta delivered by maternal effort without medications or cord traction, cord clamped + cut after stops pulsating

Question 283

STAGES OF LABOUR What should be done after delivery of the placenta?

Answer 283

- Examine placenta + membranes to check complete as RPOC can cause serious PPH or infection

Question 284

STAGES OF LABOUR What can be used when monitoring labour?

Answer 284

Partogram is graphic record of key maternal + foetal data – - FHR every 15m (low risk = intermittent auscultation) high = continuous CTG - Contractions every 30m (4 in 10 in established labour) - Maternal pulse every 60m - Maternal BP, temp, urine (ketones + protein) + VE to assess progress every 4h - Drugs, IV fluids given + Cervical dilation noted too

Question 285

STAGES OF LABOUR Why can partograms be useful?

Answer 285

- Have alert + action line - Indicates slow progression so if at action line = take action - Provides clear guidance on when to intervene, alert means be wary - Point at which progression stops is useful to see where problem is

Question 286

STAGES OF LABOUR What are the 6 cardinal movements of labour?

Answer 286

- Engagement + descent - Flexion - Internal rotation - Extension (crowning) - Restitution/external rotation - Expulsion

Question 287

STAGES OF LABOUR What is engagement?

Answer 287

- Passage of presenting part into pelvic inlet - Entire head felt = 5/5ths palpable aka not engaged - Unable to feel head = 0/5ths palpable aka fully engaged - Foetus is engaged when >50% of presenting part descended into pelvis

Question 288

STAGES OF LABOUR What is descent? How can descent be described? What is descent encouraged by?

Answer 288

- Downward passage of presenting part through bony pelvis - Position of baby's head (cm) in relation to mother's ischial spines - Increased abdo muscle tone and increased frequency + strength of contractions

Question 289

STAGES OF LABOUR How can descent of the baby be described?

Answer 289

In relation to ischial spines in cm – - –5 = baby high up at around the pelvic inlet - 0 = head at ischial spines (engaged) - +5 = foetal head descended further out

Question 290

STAGES OF LABOUR What position is the foetal head during engagement and descent?

Answer 290

- Occiput transverse

Question 291

STAGES OF LABOUR What is flexion?

Answer 291

- Uterine contractions exert pressure down foetal spine towards occiput + cause neck flexion, allowing circumference of foetal head to reduce

Question 292

STAGES OF LABOUR What is internal rotation? Why does it occur?

Answer 292

- Foetus passively internally rotates from OT to OA/OP to allow shoulders to negotiate pelvic inlet - Pelvic inlet widest diameter is transverse (side-side)

Question 293

STAGES OF LABOUR What is extension?

Answer 293

- Foetal occiput slips beneath suprapubic arch allowing head to extend + foetal head is born, usually facing maternal back (occiput anterior)

Question 294

STAGES OF LABOUR What is restitution?

Answer 294

- Shoulders only now negotiating pelvic outlet so head externally rotates to face mother's L/R medial thigh so shoulders can pass - Pelvic outlet widest diameter is A-P (front-back)

Question 295

STAGES OF LABOUR What is expulsion? How may this be assisted?

Answer 295

- Ultimately ends with delivery of foetus - Gentle downwards traction > deliver shoulder below suprapubic arch - Gentle upwards traction > deliver posterior shoulder (caution with excessive force as may cause brachial plexus damage)

Question 296

STAGES OF LABOUR What is caput? What is moulding?

Answer 296

- Diffuse swelling of scalp caused by pressure of scalp against dilating cervix during labour - Caput may lead to moulding of the head (oblong not round shape) but this often disappears after a few days

Question 297

FAILURE TO PROGRESS What are the 2 types of abnormal progression in labour?

Answer 297

- Slow from beginning (primary dysfunctional labour) – may be insufficient uterine contractions - Sudden slowing of labour (secondary arrest) – may be cephalopelvic disproportion

Question 298

FAILURE TO PROGRESS How can you assess a woman failing to progress?

Answer 298

- Palpate abdomen for lie, head + contractions (may need USS) - CTG, colour of amniotic fluid, VE

Question 299

FAILURE TO PROGRESS What factors may influence the mode of delivery of a baby in failure to progress?

Answer 299

- Baby size + presentation - Well-being of baby + mother - How long labour has been going on for - Maternal exhaustion - Pelvic adequacy

Question 300

FAILURE TO PROGRESS What may be calculated when considering inducing labour? What does it calculate?

Answer 300

- Bishop score = used to calculate how likely spontaneous labour is to occur - Score <5 = unripe cervix (less likely for induction success) - Score >9 = favourable cervix ready for labour or induction

Question 301

FAILURE TO PROGRESS What are the components of the Bishop score?

Answer 301

- Cervical dilation – <1cm (0), 1-2 (1), 3-4 (2), >5cm (3) - Cervical consistency – firm (0), intermediate (1), soft (2) - Cervical effacement – <30% (0), 40-50 (1), 60-70 (2), 80% (3) - Cervical position – posterior (0), intermediate (1), anterior (2) - Foetal station – –3 (0), -2 (1), -1/0 (2), ≥1 (3)

Question 302

FAILURE TO PROGRESS What are some methods of inducing labour?

Answer 302

- Membrane sweep - Prostaglandin E2 (PGE2) pessary or gel like dinoprostone - Cervical ripening balloon (gently inflates + dilates cervix) - Amniotomy if not ruptured already - Oxytocin analogue (syntocinon) infusion to cause uterine contractions

Question 303

FAILURE TO PROGRESS What is the process of a membrane sweep?

Answer 303

- Done before meds to try + encourage labour to start on its own (promotes positive feedback of stretch > oxytocin release)

Question 304

FAILURE TO PROGRESS What is the process of PGE2? What might it be used for?

Answer 304

- Stimulates contraction of uterine muscles + ripens cervix - Improve Bishop score by cervical ripening so can induce - Uterine hyperstimulation (>5 in 10 for 20m or contraction >2m) - ?Remove PGE2, ?terbutaline tocolytic

Question 305

FAILURE TO PROGRESS What is a risk of PGE2? How to manage that risk?

Answer 305

- Uterine hyperstimulation (>5 in 10 for 20m or contraction >2m) - ?Remove PGE2, ?terbutaline tocolytic

Question 306

FAILURE TO PROGRESS What are some indications and contraindications for inducing labour?

Answer 306

- PROM, IUGR, pre-eclampsia, obstetric cholestasis - Severe degree of placenta praevia, transverse foetal lie, severe cephalopelvic disproportion, low Bishop score

Question 307

OBSTRUCTED LABOUR What is obstructed labour?

Answer 307

Obstructed labour is the failure of the fetus to descend through the birth canal, because there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions. The obstruction usually occurs at the pelvic brim, but occasionally it may occur in the pelvic cavity or at the outlet of the pelvis. When labour is prolonged because of failure to progress, there is a high risk that the descent of the fetus will become obstructed.

Question 308

OBSTRUCTED LABOUR What are the different types of causes of obstructed labour?

Answer 308

- Power (most common) - Passage - Passenger - Psyche (maternal exhaustion in second stage)

Question 309

OBSTRUCTED LABOUR How can 'power' cause obstructed labour?

Answer 309

- Poor or uncoordinated uterine contractions - Either the uyerine contractions are not strong enough to efface and dilate the cervix in the first stage of labour or the muscular effort of the uterus is insufficient to push the baby down the birth canal during the second stage. - Common in primigravida women - May need instrumental delivery or syntocinon

Question 310

OBSTRUCTED LABOUR How can 'passage' cause obstructed labour?

Answer 310

- Labour may be prolonged if the mother’s pelvis is too small for the baby to pass through or the pelvis has an abnormal shape, or if there is a tumour or other physical obstruction in the pelvis. - Common in developing countries, risk of infection, fistulas

Question 311

OBSTRUCTED LABOUR How can 'passenger' cause obstructed labour?

Answer 311

The fetus is the passenger travelling down the birth canal. Prolonged labour may occur if the fetal head is too large to pass through the mother’s pelvis, or the fetal presentation is abnormal. Includes hydrocephalus.

Question 312

OBSTRUCTED LABOUR what are the clinical signs of an obstructed labour?

Answer 312

* Mother anxious, weak, exhausted * Rupture of membranes * Tachy, low blood pressure, high RR... * Foul smelling meconium from vagina * Concentrated urine * Oedema (vulva/cervix) * Caput * Malpresentation and Malposition * Bandl’s Ring

Question 313

OBSTRUCTED LABOUR what are the investigations for an obstructed labour?

Answer 313

* Partograph – rate of cervical dilatation vs rate of foetal head descent. Compares it with normal

Question 314

OBSTRUCTED LABOUR what is the management of an obstructed labour?

Answer 314

* C section * Supportive treatment (IV, analgesia...)

Question 315

OBSTRUCTED LABOUR what are the complications of an obstructed labour?

Answer 315

* Fistula - Vagina and bladder/rectum/ureter/urethra * Still birth * PPH * Shock/sepsis * Paralytic ileus

Question 316

MALPRESENTATION What is malpresentation? What are the different types?

Answer 316

- Presenting part of foetus is not the vertex of the foetal head - Shoulder = c-section - Breech (leg/bottom) = ECV or c-section - Brow = c-section - Face = c-section likely

Question 317

FAILURE TO PROGRESS What is the difference between brow and face presentation?

Answer 317

- Brow: head between full flexion + extension, associated with mentovertical diameter (chin to highest point of vertex) - Face: head hyperextended >120, associated with submentobregmatic diameter (junction of neck/lower jaw to anterior fontanelle)

Question 318

FAILURE TO PROGRESS In terms of 'passenger' in failure to progress, what is important about position?

Answer 318

- Refers to foetal head position on VE - Anterior/posterior fontanelles as landmarks, OA ideal - If OP at delivery means head is at posterior quadrant of pelvis requiring greater rotation which can prolong labour

Question 319

FAILURE TO PROGRESS How would you manage failure to progress in the first stage of labour?

Answer 319

- PGE2 if low bishop score as if not cannot induce - Oxytocin infusion ± amniotomy (if membranes not ruptured) > reassess in 2h - CTG with foetal blood sample if concerns, consider c-section if doesn't help

Question 320

FAILURE TO PROGRESS How would you manage failure to progress in the second stage of labour?

Answer 320

- Allow to push for 2h if nulliparous or 1h if multiparous - No imminent delivery obstetric review for ?instrumental or c-section

Question 321

FAILURE TO PROGRESS How would you manage failure to progress in the third stage of labour? What are the indications for management?

Answer 321

- IM oxytocin to cause uterus contraction to expel placenta - Cord clamp + careful cord traction to guide placenta out - Haemorrhage or >60m delay in physiological management (delay in active Mx is >30m)

Question 322

FAILURE TO PROGRESS What are the consequences of failure to progress?

Answer 322

- Foetal = distress, hypoxia (HIE, cerebral palsy), morbidity + mortality - Maternal = bleeding, tears, amniotic fluid embolism

Question 323

BREECH What is breech presentation? What are the risks?

Answer 323

- When baby's buttocks/legs lies over the maternal pelvis - Longitudinal lie but head at fundus - Risk of hypoxia + trauma

Question 324

BREECH What are some causes/risk factors for breech presentation?

Answer 324

- Idiopathic - Prematurity as baby may not have turned itself yet - Previous breech - Uterine abnormalities (bicornuate uterus), fibroids - Placenta praevia - Foetal abnormalities (CNS malformation - Multiple pregnancy - Poly/oligohydramnios

Question 325

BREECH What are the 3 types of breech presentation?

Answer 325

- Extended (Frank) = most common, hips flexed, both legs extended with feet by head, buttocks presenting - Flexed (Complete) = hips + knees flexed so buttocks + feet presenting (Cannonballing) - Footling = one leg flexed, one extended, foot hanging through cervix

Question 326

BREECH Which breech is most associated with cord prolapse and why?

Answer 326

- Footling - Nothing to act as plug over cervix if membranes ruptured

Question 327

BREECH What are the investigations for breech?

Answer 327

- Ideally antenatal Dx with USS, if <36w unimportant unless in labour - Abdo exam = longitudinal lie, head palpated at fundus, presenting part not head, foetal heart best heard high up uterus

Question 328

BREECH What is the management of breech?

Answer 328

- External cephalic version to move baby to correct position at 37w - C-section if ECV unsuccessful or contraindicated

Question 329

BREECH What are some contraindications for ECV?

Answer 329

- Absolute = pre-eclampsia, APH, oligohydramnios, foetal compromise - Relative = maternal HTN, foetal abnormality, 1 previous c-section

Question 330

FOETAL LIE What is foetal lie? What are the 4 types of lie?

Answer 330

- Position of the foetus in relation to the mother's body - Longitudinal, transverse, oblique, unstable

Question 331

FOETAL LIE What is longitudinal lie?

Answer 331

Straight up + down

Question 332

FOETAL LIE What is transverse lie?

Answer 332

Side-side, foetus perpendicular to long axis of uterus

Question 333

FOETAL LIE What is oblique lie?

Answer 333

Angle

Question 334

FOETAL LIE What is unstable lie?

Answer 334

Lie is actively changing (may be transverse, longitudinal, cephalic or breech)

Question 335

FOETAL LIE What are some risk factors for foetal lie?

Answer 335

- Multiparity (>P2) with lax uterus (common) - Polyhydramnios, prematurity - Uterine abnormalities, fibroids - Placenta praevia - Foetal abnormalities

Question 336

FOETAL LIE What are some investigations for foetal lie?

Answer 336

- Abdo exam = neither head nor buttocks presenting - Transverse = ovoid uterus wider at sides, lower pole empty, head in flank - USS can be used to confirm lie, often antenatally

Question 337

FOETAL LIE What are some complications of abnormal lie?

Answer 337

- May result in pre-term rupture of membranes - Membrane rupture risks cord prolapse (longitudinal lie prevents descent of cord) so transverse lie = highest risk of prolapse

Question 338

FOETAL LIE What is the management for foetal lie?

Answer 338

Stable but transverse – - ECV >36w even in early labour if membranes intact - C-section if fails or pt choice Unstable lie – - Admit whilst unstable from 37w so c-section if labour starts

Question 339

FOETAL LIE What are the contraindications to ECV for transverse lie?

Answer 339

- Maternal rupture in last 7d - Multiple pregnancy (except for 2nd twin) - Major uterine abnormality

Question 340

CTG What are the indications for a continuous cardiotocography (CTG)?

Answer 340

- During labour for every woman - High risk pregnancies - Pyrexia (?chorioamnionitis) - Severe HTN ≥160/110 - Oxytocin use - Fresh bleeding

Question 341

CTG How do you interpret a CTG?

Answer 341

Dr C Bravado – - Dr = define risk (high risk = continuous - C = contractions (bottom trace shows frequency) - Bra = baseline rate - V = variability - A = accelerations - D = decelerations - O = overall assessment

Question 342

CTG What might different foetal baseline rates tell you?

Answer 342

- >160 may be maternal pyrexia, prematurity, chorioamnionitis - <110 may be maternal beta-blockers, increased foetal vagal tone

Question 343

CTG What does reduced variability tell you?

Answer 343

- Reduced variability may be hypoxia, lactic acidosis, prematurity - 40m reduced variability accepted as baby may be sleeping

Question 344

CTG What are accelerations? What do they show you?

Answer 344

- Rise in baseline HR by 15 for ≥15s - Reassuring as baby moving

Question 345

CTG What are decelerations? What are the 3 types and their causes?

Answer 345

- Fall in baseline HR by 15 for ≥15s - Early = peak of contraction corresponds with trough of depression (head compression from uterine contraction = normal) - Late = deceleration after contraction (hypoxia = placental insufficiency, asphyxia) - Variable = vary in shape + timing (cord compression)

Question 346

CTG What are the features of a reassuring CTG for... i) baseline? ii) variability? iii) accelerations? iv) decelerations?

Answer 346

i) 110–160bpm ii) >5bpm iii) Present iv) Early

Question 347

CTG What are the features of a non-reassuring CTG for... i) baseline? ii) variability? iii) decelerations?

Answer 347

i) 100–109bpm or 161–180bpm ii) <5bpm for 40–90m iii) Variable

Question 348

CTG What are the features of an abnormal CTG for... i) baseline? ii) variability? iii) decelerations?

Answer 348

i) <100bpm or >180bpm ii) <5bpm for >90m iii) Late

Question 349

CTG What makes a CTG... i) suspicious? ii) pathological?

Answer 349

i) 1 non-reassuring ii) ≥2 non-reassuring or 1 abnormal

Question 350

CTG What are the pros of CTGs?

Answer 350

- Allows long-term monitoring - Can pick up on foetal distress - Can be on constantly to identify any slight changes

Question 351

CTG What are the cons of CTGs?

Answer 351

- No improvement in perinatal outcomes in low-risk pregnancies - Foetal exposure to USS ionisation - Ambulatory monitoring may not be possible - Doesn't give true beat to beat FHR monitoring or morphological Ax of heart

Question 352

FOETAL ECG What is a foetal ECG? What are the pros? What are the cons?

Answer 352

- Obtained via scalp - Gold standard for FHR, true beat to beat information - Invasive, associated with scalp injury + perinatal infection, only during labour when membranes ruptured + >2cm dilated

Question 353

FOETAL ECG What is an alternative to scalp ECG?

Answer 353

- Abdominal foetal ECG - Can be used ambulatory at home but only for high risk, morphological analysis possible + non-invasive

Question 354

CORD PROLAPSE What is cord prolapse? What is the danger?

Answer 354

- Umbilical cord descends below the presenting part of the foetus after rupture of the membranes - Presenting part can compress cord or exposure of cord leads to vasospasm > significant risk of foetal morbidity + mortality from hypoxia

Question 355

CORD PROLAPSE What are some risk factors for cord prolapse?

Answer 355

- Prematurity - Polyhydramnios - Long umbilical cord - Malpresentation (Footling breech + transverse lie) - Multiparity + multiple pregnancy - Placenta praevia

Question 356

CORD PROLAPSE What are the investigations for cord prolapse?

Answer 356

- Foetal CTG distress (heart decelerations + bradycardia) - Dx via VE (cord at introitus), speculum confirms

Question 357

CORD PROLAPSE What is the management of cord prolapse?

Answer 357

- 999/emergency buzzer, neonatal team - Fill bladder with 500ml warmed saline via catheter (elevate presenting foetal part + lift off cord) - Left lateral position with head down or knee-chest position - Presenting part pushed back into uterus to prevent compression - Avoid handling cord > vasospasm - Tocolytics like terbutaline (SABA) to abolish contractions if delivery not imminently available

Question 358

SHOULDER DYSTOCIA What is shoulder dystocia?

Answer 358

- Failure of anterior shoulder to pass under symphysis pubis after delivery of foetal head

Question 359

SHOULDER DYSTOCIA What are some risk factors for shoulder dystocia?

Answer 359

- Macrosomia - Maternal DM - High maternal BMI - Cephalopelvic disproportion - Post-maturity - Previous shoulder dystocia

Question 360

SHOULDER DYSTOCIA What is the clinical presentation of shoulder dystocia?

Answer 360

- Head remaining tightly applied to vulva or retracting (turtle neck sign) - Failure of restitution (head does not turn sideways)

Question 361

SHOULDER DYSTOCIA What are the maternal and neonatal complications of shoulder dystocia?

Answer 361

- PPH, perineal tears (3rd/4th degree), psychological impact - Hypoxia, cerebral palsy, injury to brachial plexus, Erb's palsy, fits, # humerus or clavicle

Question 362

SHOULDER DYSTOCIA Explain what is the result of... i) erb's palsy? ii) clavicle fracture?

Answer 362

i) Injury of C5/6 nerves causing paralysis of arm, looks limp, waiters tip position ii) Painful movements, shoulder asymmetry

Question 363

SHOULDER DYSTOCIA What is the management of shoulder dystocia?

Answer 363

HELPERR[R] – - Help (call with emergency buzzer, obs, neonates) - Evaluate for episiotomy (enlarge opening) - Legs = McRobert's - Pressure = suprapubic - Enter = pelvis for rotation - Remove = posterior arm - Replace = head in vagina + deliver by section (Zavanelli)

Question 364

SHOULDER DYSTOCIA What is McRobert's manoeuvre? Why is it done?

Answer 364

- Hips fully flexed + abducted (knees to abdo) - Posterior pelvic tilt lifting symphysis pubis up + out of way

Question 365

SHOULDER DYSTOCIA What are the 3 rotational manoeuvres?

Answer 365

- Rubin II = pressure on post. aspect of ant. shoulder to help deliver under symphysis pubis - Woods' screw = Rubin II + pressure on ant. aspect of post. shoulder - Reverse woods' screw = pressure on ant. aspect of ant. shoulder + post. aspect of post. shoulder in opposite way

Question 366

INSTRUMENTAL DELIVERY What are some indications for instrumental delivery?

Answer 366

- Failure to progress in second stage. - Foetal or maternal distress + maternal exhaustion in second stage - Control of head in various foetal positions (incl. breech)

Question 367

INSTRUMENTAL DELIVERY What are the types of instrumental delivery?

Answer 367

- Ventouse = suction cup on a cord on baby's head with traction - Forceps = 2 curved pieces of metal attach either side of baby's head + grip with traction

Question 368

INSTRUMENTAL DELIVERY What are the main risks of ventouse delivery?

Answer 368

- Cephalohaematoma = collection of blood between periosteum + skull from damaged blood vessels, does not cross suture lines, presents hours after - Caput Succedaneum = Crosses Sutures, diffuse oedema outside periosteum due to pressure to a specific area of scalp, resolve in few days, conehead present at birth

Question 369

INSTRUMENTAL DELIVERY What are the main risks of forceps delivery?

Answer 369

- Maternal = vaginal tears, anal sphincter trauma - Foetal = facial nerve palsy (main), bruises on baby's face, fat necrosis > hardened lumps of fat on baby's cheek that will resolve spontaneously over time, skull #

Question 370

INSTRUMENTAL DELIVERY What are some maternal consequences of instrumental delivery?

Answer 370

- Infection (co-amox stat) - PPH - Episiotomy - Tears - Incontinence

Question 371

C-SECTION What are some indications for c-section?

Answer 371

- Placenta praevia (3/4) - IUGR - Uncontrolled HIV - Active herpes - Cephalopelvic disproportion - Pre-eclampsia - Post-maturity

Question 372

C-SECTION What are the different categories of c-section?

Answer 372

- 1 = immediate threat to life of mother/baby. Decision>delivery time = 30m - 2 = not imminent threat to life but c-section required urgently due to compromise. Decision>Delivery time = 75m - 3 = c-section required but both stable - 4 = elective section

Question 373

C-SECTION What two types of anaesthesia can be used in c-sections? What else is given in c-sections?

Answer 373

- General - Regional block (spinal) - H2 receptor antagonists or PPIs, prophylactic Abx, oxytocin (PPH), LMWH for VTE prophylaxis

Question 374

C-SECTION What are the indications for general anaesthesia? What are the cons?

Answer 374

- Imminent threat to mother ± foetus, C/I to regional, maternal preference, failed regional technique - Aspiration, failed intubation, awareness, damage to mouth/throat

Question 375

C-SECTION What are the pros and cons for spinal anaesthesia?

Answer 375

- Safer, see baby immediately, partner present, improved post-op analgesia - Hypotension, headache, discomfort with pressure sensations, failure

Question 376

C-SECTION What are the complications of c-sections?

Answer 376

- Surgical risk (bleeding, infection/endometritis, VTE) - Damage risk (ureter, bladder, bowel, vessels) - Future pregnancies (increased risk of uterine rupture, placenta praevia, stillbirth + repeat section) - Baby (risk of lacerations, increased incidence in transient tachypnoea)

Question 377

C-SECTION Is vaginal birth after caesarean (VBAC) allowed? What are the contraindciations?

Answer 377

- Yes provided cause of caesarean is unlikely to recur, 75% success rate - Previous uterine rupture, classical caesarean scar

Question 378

PAIN RELIEF What are some non-pharmacological pain relief for labour?

Answer 378

- Trained support - Relaxation techniques, hypnotherapy - Massage, water births - Comfortable position + environment for birth

Question 379

PAIN RELIEF What simple analgesia can be used in labour?

Answer 379

- Paracetamol + codeine useful in early labour - Avoid NSAIDs

Question 380

PAIN RELIEF What is Entonox? What are the pros? What are the cons?

Answer 380

- Gas + air (N2O + O2 50/50 mixed) - Rapid onset analgesia, minimal SEs, self-limiting, available for home delivery - Theoretic risk of bone marrow suppression, greenhouse gas, N+V

Question 381

PAIN RELIEF What opioids can be used for pain relief?

Answer 381

- Single shot IM opioids (diamorphine, pethidine) - Patient-controlled analgesia via IV cannula (fentanyl, alfentanil, remifentanil)

Question 382

PAIN RELIEF What are some important notes about single shot opioids?

Answer 382

- Lipid soluble so crosses placenta rapidly - Diamorphine 2x as potent as morphine so faster onset - Pethidine metabolites can cause seizures so avoid in epileptics

Question 383

PAIN RELIEF What are some important notes about PCA?

Answer 383

- Fentanyl = very lipid soluble, rapid onset of action, long half-life - Alfentanil + remifentanil = shorter half-lives

Question 384

PAIN RELIEF What are some side effects from opioids?

Answer 384

- Foetal = resp depression, diminishes breast seeking + feeding behaviour - Maternal = euphoria + dysphoria, N+V, can prolong 1st + 2nd stages, resp depression + pruritus

Question 385

PAIN RELIEF What regional techniques can be used for pain relief? How is this performed?

Answer 385

- Epidural, spinal or combined spinal epidural (CSE) - Epidural at L3/4 'Tuffiers' line connecting 2 iliac crests bisects L4 vertebral body or USS to avoid cord damage

Question 386

PAIN RELIEF What causes labour pain in... i) first stage? ii) second stage?

Answer 386

i) Uterine contraction at T10-L1 ii) Perineum + vaginal stretching S2-4 (pudendal)

Question 387

PAIN RELIEF What 4 regimes can be given for regional techniques?

Answer 387

- Intermittent = high conc LA, labour intensive, periods of inadequate analgesia + haemodynamic instability - Continuous = low dose LA + opioid, less labour intensive, constant analgesia + haemodynamic stability - Continuous + bolus = greater maternal satisfaction - CSE = rapid onset, high satisfaction, reduced LA dose

Question 388

PAIN RELIEF What medications can be given epidurally?

Answer 388

- LA like bupivacaine - Opioids like fentanyl, diamoprhine

Question 389

PAIN RELIEF What sequential effects do regional techniques have?

Answer 389

- Autonomic (vasodilation = reduced MAP) - Sensory (analgesia) - Motor (motor blockade) + fever

Question 390

PAIN RELIEF What are the indications for regional techniques?

Answer 390

- Maternal request - HTN/pre-eclampsia - Cardiac disease - Induced labour - Multiple births - Instrumental/op delivery likely

Question 391

PAIN RELIEF What are some complications of regional techniques?

Answer 391

- Potential for spinal cord damage - Hypotension + bradycardia - Haematoma/abscess at injection site - Anaphylaxis if allergic - Post-dural puncture headache

Question 392

PAIN RELIEF What is a post-dural puncture headache? How does it present? What is the management?

Answer 392

- Leak of CSF + reduced CSF pressure, within 1–2d (up to 7) - Headache, worse when upright, improves when flat - Supportive, pain >72h = epidural blood patch, IV caffeine

Question 393

PAIN RELIEF What are some contraindications to regional techniques?

Answer 393

- Absolute = maternal refusal, local infection, allergy to LA - Relative = coagulopathy, systemic infection, fixed cardiac output

Question 394

PAIN RELIEF What are some side effects from regional techniques?

Answer 394

- Foetal = tachycardia (maternal pyrexia), diminishes breast-feeding behaviour - Maternal = increased length of 1st + 2nd stages, need more oxytocin, increased need for instrumental, loss of mobility + bladder control, pyrexia

Question 395

PERINEAL TEARS What is a perineal tear?

Answer 395

- External vaginal opening is too narrow to accommodate the baby, leading to a ripping of the skin in that area as the baby's head comes through

Question 396

PERINEAL TEARS What is the classification of perineal tears?

Answer 396

- 1st degree = limited to superficial skin of perineum - 2nd degree = above PLUS perineal muscles (includes episiotomy) - 3rd degree = above PLUS anal sphincter involvement - 4th degree = above PLUS injury to rectal mucosa

Question 397

PERINEAL TEARS How are third degree tears further classified?

Answer 397

- 3A = <50% of external anal sphincter thickness torn - 3B = >50% of EAS thickness torn - 3C = EAS + internal anal sphincter torn

Question 398

PERINEAL TEARS What are some risk factors for perineal tears?

Answer 398

- Primigravida - Macrosomia - Shoulder dystocia - Forceps

Question 399

PERINEAL TEARS What is an episiotomy?

Answer 399

- Diagonal incision (45 degrees) from opening of vagina downwards + laterally (medio-laterally) to avoid anal sphincter damage or midline in anticipation of needing additional room to delivery baby (e.g. prior to forceps) – suture after - Should be done under LA

Question 400

UTERINE RUPTURE What is a uterine rupture?

Answer 400

- Complication of labour where myometrium bursts

Question 401

UTERINE RUPTURE What are the two types?

Answer 401

- Incomplete = peritoneal lining surrounding uterus intact - Complete = peritoneal lining ruptures so uterine contents released into peritoneal cavity

Question 402

UTERINE RUPTURE What is the risk?

Answer 402

Significant haemorrhage, high morbidity + mortality for baby + mother

Question 403

UTERINE RUPTURE What are some risk factors for uterine rupture?

Answer 403

- VBAC - Previous uterine surgery - Increased BMI - High parity - Congenital uterine abnormalities - Oxytocin use

Question 404

UTERINE RUPTURE What are the clinical features of uterine rupture?

Answer 404

- Tenderness over previous uterine scars - PV bleed, maternal shock - CTG = foetal distress + no or cessation of contractions

Question 405

UTERINE RUPTURE What is the management of uterine rupture?

Answer 405

- ABCDE resus - Cross match blood - Urgent laparotomy to stop bleeding - Repair or remove uterus - C-section to save baby

Question 406

PPH What is a primary postpartum haemorrhage (PPH)?

Answer 406

Primary = loss of >500ml blood in the first 24h after delivery - Minor = 500–1000ml estimated blood loss - Major = >1000ml, clinically in shock

Question 407

PPH What is a secondary postpartum haemorrhage (PPH)?

Answer 407

Secondary = excessive blood loss from genital tract between 24h–12w after delivery (can result in Sheehan's syndrome)

Question 408

PPH What are the primary causes of PPH?

Answer 408

Primary (4Ts) – - Tone (uterine atony = most common) - Trauma (perineal tear) - Tissue (retained products) - Thrombin (clotting issue e.g. DIC in pre-eclampsia)

Question 409

PPH What are the secondary causes of PPH?

Answer 409

Secondary most common cause is retained placental tissue, endometritis

Question 410

PPH What are the risk factors for PPH?

Answer 410

- Before birth = previous PPH, APH, twins/triplets, pre-eclampsia, obesity, polyhydramnios - Labour = prolonged, c-section, perineal tear or episiotomy, macrosomia

Question 411

PPH How might uterine atony present in PPH?

Answer 411

- Unpalpable uterus on abdo exam (should normally be palpable in period following birth)

Question 412

PPH What are some preventative measures to reduce risk and consequences of PPH?

Answer 412

- Treat anaemia during antenatal period - Empty bladder (?catheter) as full bladder reduces uterine contractions - Active Mx of third stage (IM oxytocin) - IV TXA during c-section in third stage of labour if high risk

Question 413

PPH What is the acute management of PPH?

Answer 413

- ABCDE resus - 2x large bore cannulas - Group + X match - Activate major haemorrhage protocol for quick blood access - IV fluids/bloods

Question 414

PPH What mechanical treatment can be trialled in PPH?

Answer 414

- Rub uterus through abdomen to stimulate contraction

Question 415

PPH What is the role of medical management in PPH? What is the medical management of PPH?

Answer 415

- All stimulate uterine contractions - IV syntocinon - IV/IM ergometrine, C/I in HTN as vasoconstrictor (can combine with syntocinon as syntometrine) - IM carboprost, caution in asthma (prostaglandin analogue) - Sublingual misoprostol (prostaglandin analogue)

Question 416

PPH After failed medical management, what is the surgical management of PPH?

Answer 416

- Intrauterine balloon tamponade (1st line in uterine atony) - B-lynch sutures (suture around uterus to compress it) - Internal iliac/uterine artery ligation (reduces blood flow to stop bleeding) - Hysterectomy as last resort (may save life)

Question 417

MENTAL HEALTH What are some red flags in terms of maternal mental health?

Answer 417

- Recent change in mental state or new Sx - New thoughts or acts of violence/self-harm - New + persistent feelings of incompetency as mother or estrangement from baby

Question 418

MENTAL HEALTH Why can mental health disorders be difficult to detect in the puerperium?

Answer 418

- Fear of treatment - Fear of children being removed - Cultural lack of recognition - Denial - Stigma

Question 419

BABY BLUES What are baby blues?

Answer 419

- Brief period of tearfulness, anxiety + emotional lability starting 3–10d after birth

Question 420

BABY BLUES How common is it?

Answer 420

Affects up to 70% of women, classically primiparous

Question 421

BABY BLUES What is the management?

Answer 421

Reassure natural to feel emotional + overwhelmed, health visitor obs

Question 422

POSTNATAL DEPRESSION What is postnatal depression?

Answer 422

- Depressive episode, temporally related to childbirth, within 6m post-partum

Question 423

POSTNATAL DEPRESSION What are some risk factors?

Answer 423

PMH/FHx of MH issues, Hx of abuse, lack of support/relationships, low socioeconomic status, unemployed

Question 424

POSTNATAL DEPRESSION What can be used to measure postnatal depression?

Answer 424

- Edinburgh postnatal depression scale = screening tool, >10 suspect

Question 425

POSTNATAL DEPRESSION How does postnatal depression present?

Answer 425

Typical depression Sx but may include worries about baby's health or ability to cope adequately, feeling detached from the baby

Question 426

POSTNATAL DEPRESSION What is the management of postnatal depression?

Answer 426

- Early identification + close monitoring of those at risk - CBT may help, sertraline + paroxetine if severe as safer in breastfeeding - ?Hospital admission if thoughts of self or baby-harm

Question 427

POSTPARTUM/PUERPERAL PSYCHOSIS What is postpartum/puerperal psychosis?

Answer 427

- Acute psychotic episode with peak occurrence at 2w postpartum

Question 428

POSTPARTUM/PUERPERAL PSYCHOSIS What are some risk factors?

Answer 428

FHx/PMH of MH (esp. postpartum psychosis), traumatic birth or pregnancy, primiparous

Question 429

POSTPARTUM/PUERPERAL PSYCHOSIS What is the clinical presentation of postpartum psychosis?

Answer 429

- Prominent affective Sx (mania or depression with psychotic Sx) - Schizophreniform disorder (lasts <6m) - Emotional lability, delusions, hallucinations, suicidality, infanticide

Question 430

POSTPARTUM/PUERPERAL PSYCHOSIS What is the management of postpartum psychosis?

Answer 430

- Assess suicide risk + risk to baby - Often inpatient admission (mother + baby unit) - Antipsychotics ± antidepressants or mood stabilisers (carbamazepine), ECT for major affective disorder - Psychoeducation for pt + family, CBT - Children + family social service involvement

Question 431

OBESITY IN PREGNANCY what are the risks for the mother relating to obesity in pregnancy?

Answer 431

o Maternal death or severe morbidity. o Cardiac disease. o Spontaneous 1st trimester or recurrent miscarriage. o Pre-eclampsia. o Gestational diabetes. o Thromboembolism. o Post-CS wound infection. o Infection from other causes. o PPH. o Low breast-feeding rates.

Question 432

OBESITY IN PREGNANCY what are the risks for the baby relating to obesity in pregnancy?

Answer 432

o Stillbirth and neonatal death. o Congenital abnormalities. o Prematurity

Question 433

CERVICAL SHOW what is cervical show?

Answer 433

- when the cervix effaces, the mucous plug comes loos and passes out of the vagina (could have blood) - seen in the latent phase.

Question 434

SICKLE CELL DISEASE IN PREGNANCY what are the risks of sickle cell disease during pregnancy?

Answer 434

* Crises are more common during pregnancy * Increased risk of pre-eclampsia * Increased risk of delivery by CS due to fetal distress

Question 435

SICKLE CELL DISEASE IN PREGNANCY what are the foetal risks in sickle cell disease?

Answer 435

- miscarriage - IUGR - prematurity - stillbirth

Question 436

SICKLE CELL DISEASE IN PREGNANCY what is the management?

Answer 436

- Pre-Pregnancy counselling - Stop iron chelating agents before pregnancy - Give folic acid and penicillin prophylaxis for hypersplenism - Screen for UTI infections each visit - Crisis Treatment: Analgesics, oxygen, hydration, and antibiotics if infection is suspected - Regular foetal monitoring - Aim for vaginal delivery

Question 437

FOETAL HYDROPS what is foetal hydrops?

Answer 437

Fetal hydrops is the abnormal accumulation of serous fl uid in two or more fetal compartments. This may be pleural or pericardial effusions, ascites, skin oedema, polyhydramnios, or placental oedema.

Question 438

FOETAL HYDROPS what are the different types?

Answer 438

immune and non-immune

Question 439

FOETAL HYDROPS what is the pathophysiology?

Answer 439

an imbalance of interstitial fluid production and inadequate lymphatic return. This can result from congestive heart failure, obstructed lymphatic flow, or decreased plasma osmotic pressure.

Question 440

FOETAL HYDROPS what are the causes of immune foetal hydrops?

Answer 440

results from blood group incompatibility between the mother and the fetus causing fetal anaemia. THIS IS RHESUS DISEASE OF THE NEWBORN**

Question 441

FOETAL HYDROPS what are the causes of non-immune foetal hydrops

Answer 441

- severe anaemia (parvovirus B19, thalassaemia, G6PD) - cardiac abnormalities - chromosomal abnormalities (trisomies 13, 18 and 21) - genetic conditions - other infections (toxoplasmosis, rubella, CMV, varicella) - structural abnormalities (CCAM, diaphragmatic hernia) - twin-to-twin transfusion syndrome - chorioangioma

Question 442

FOETAL HYDROPS what are the investigations?

Answer 442

- ultrasound (diagnostic) - foetal blood/amniotic fluid sampling - maternal blood sampling

Question 443

FOETAL HYDROPS what is the management?

Answer 443

depends on the cause - anaemia = in-utero blood transfusion - pleural effusions/CCAM = shunt - twin-to-twin transfusion syndrome = laser photocoagulation of placental anastomoses - cardiac arrhythmias = maternal digoxin + flecanide

Question 444

LOW BIRTH WEIGHT what is a low birth weight defined as?

Answer 444

an infant born weighing 5.5 pounds (2500 grams) or less. ➢ Very low: less than 3.3 pounds ➢ Normal: 5.5 to 8.8 pounds ➢ High: more than 8.8 (could be due to GDM)

Question 445

LOW BIRTH WEIGHT what are the risk factors for low birth weight?

Answer 445

➢ Low socioeconomic ➢ History of abuse ➢ Age (<15 or >35) ➢ Race (black, ethnic minorities...)

Question 446

LOW BIRTH WEIGHT what are the causes of low birth weight?

Answer 446

➢ Preterm birth (before 37 weeks gestation) ➢ Genetics (could be chromosomal abnormalities...) ➢ Uteroplacental insufficiency ➢ Multiple pregnancy ➢ Substance abuse (smoking, drinking alcohol, illicit drug) causing IUGR ➢ Chronic conditions and infections (hypertension, rubella, CMV, syphilis, toxoplasmosis, BV...) ➢ Medications (sodium valproate, ramipril, warfarin...)

Question 447

LOW BIRTH WEIGHT what are the consequences of a low birth weight?

Answer 447

➢ Feeding struggles ➢ Respiratory distress syndrome ➢ Jaundice ➢ Infections ➢ PDA ➢ Intraventricular hemorrhage ➢ Retinopathy of prematurity, and hearing problems ➢ Intellectual and developmental disabilities ➢ Diabetes ➢ High blood pressure ➢ Heart disease ➢ Obesity

Question 448

LOW BIRTH WEIGHT what is the management?

Answer 448

➢ IV fluids or gavage feeding ➢ Light therapy ➢ Supplemental surfactant or oxygen ➢ Surgery or medications (ROP or PDA), and for intraventricular hemorrhage ➢ Kangaroo care (skin to skin contact) ➢ Primary prevention: Avoid drinking, smoking and unhealthy diet during pregnancy. Get the flu vaccine

Question 449

LOW BIRTH WEIGHT what is the primary prevention for low birth weight?

Answer 449

Primary prevention: Avoid drinking, smoking and unhealthy diet during pregnancy. Get the flu vaccine

Question 450

UTEROPLACENTAL INSUFFICIENCY what is it?

Answer 450

It is an uncommon but serious complication of pregnancy. It occurs when the placenta does not develop properly or is damaged. This blood flow disorder is marked by a reduction in the mother’s blood supply. The complication can also occur when the mother’s blood supply doesn’t adequately increase by mid-pregnancy.

Question 451

UTEROPLACENTAL INSUFFICIENCY what are the causes of uteroplacental insufficiency?

Answer 451

➢Abnormal trophoblast invasion: ▪ Pre-eclampsia ▪ Placenta accreta ➢ Abruption ➢ Infarction ➢ Placenta previa ➢ Tumor: chorioangiomas ➢ Abnormal umbilical cord or cord insertion (i.e., two vessel cord) ➢ Maternal diabetes ➢ Maternal hypertension ➢ Anemia ➢ Smoking ➢ Drug abuse (cocaine, heroin, methamphetamine) ➢ Antiphospholipid syndrome ➢ Renal disease ➢ Advanced age

Question 452

UTEROPLACENTAL INSUFFICIENCY what is the presentation?

Answer 452

➢ Depending on the cause ➢ Mother may notice uterus is smaller than previous pregnancies ➢ Fetus may be moving less than expected ➢ IUGR ➢ Vaginal bleeding or preterm labor contractions (i.e., during placental abruption)

Question 453

UTEROPLACENTAL INSUFFICIENCY what are the maternal complications?

Answer 453

preeclampsia, placental abruption, preterm labor, and delivery

Question 454

UTEROPLACENTAL INSUFFICIENCY what are the foetal complications?

Answer 454

Oxygen deprivation (cerebral palsy), learning disabilities, hypothermia, hypoglycemia, hypocalcemia, polycythemia, premature labor, stillbirth, death

Question 455

UTEROPLACENTAL INSUFFICIENCY what are the investigations?

Answer 455

➢ USS ➢ Maternal alpha fetoprotein levels ➢ CTG

Question 456

UTEROPLACENTAL INSUFFICIENCY what is the management?

Answer 456

➢ Avoid precipitating factors (drugs, smoking, alcohol... ➢ Treat underlying cause ➢ Education on preeclampsia, frequent monitoring, possibly steroid injections, possible delivery. ➢ FETAL SURVEILLANCE

Question 457

PUERPERAL INFECTION what is it defined as?

Answer 457

Temperature of above 38 degrees Celsius in the first 14 days following delivery.

Question 458

PUERPERAL INFECTION what are the genital causes?

Answer 458

- uterine infection - perineal wound infection

Question 459

PUERPERAL INFECTION what are the predisposing factors for uterine infection?

Answer 459

- Caesarean section, - Pre-labour rupture of membranes, - Intrapartum chorioamnionitis, - Prolonged labor, - Multiple pelvic examinations, - Internal fetal monitoring—use of scalp electrodes/intrauterine pressure catheters, - other risk factors, e.g., anemia, low socio-economic status.

Question 460

PUERPERAL INFECTION what is the presentation of uterine infection?

Answer 460

Fever usually in proportion to the extent of infection. Foul smelling, profuse, and bloody discharge. Subinvolution of uterus. Tender bulky uterus on abdominal examination.

Question 461

PUERPERAL INFECTION what are the non-genital causes?

Answer 461

1. Breast causes (mastitis, abscess) 2. UTI (i.e., from catheter, hypotonic bladder, KEEPS bacteria) 3. Thrombophlebitis (high risk of DVT and PE) 4. Respiratory complications (mainly women with CS; due to atelectasis, aspiration, or bacterial pneumonia) – hence the need for prophylactic antibiotics before CS! 5. Abdominal wound infection

Question 462

PUERPERAL INFECTION what are the investigations?

Answer 462

➢ FBC ➢ Blood Cultures ➢ MSU ➢ Swabs from cervix and lochia for chlamydia and bacterial infections ➢ Wound swabs ➢ Throat swabs ➢ Sputum culture and CXR

Question 463

PUERPERAL INFECTION what is the management?

Answer 463

➢ Supportive (analgesics/NSAIDS, wound care, ice packs...) ➢ Antibiotics (for endometritis – IV clindamycin and gentamicin until >24hrs afebrile) ➢ Surgical (drain abscess, secondary repair of wound, drainage of hematomas...)

Question 464

CHLAMYDIA IN PREGNANCY what are the risks of chlamydia infection during pregnancy?

Answer 464

- preterm labour - PROM - low birth weight - infection during delivery (conjunctivitis and pneumonia)

Question 465

CHLAMYDIA IN PREGNANCY what is the management?

Answer 465

- azithromycin 1g OD followed by 500mg orally OD for 2 days - erythromycin 500mg QD for 7 days - amoxicillin 500mg TD for 7 days

Question 466

GONORRHOEA IN PREGNANCY what are the risks?

Answer 466

- miscarriage - premature birth - low birth weight - PROM - chorioamnionitis - eye infection in newborn

Question 467

GONORRHOEA IN PREGNANCY? what is the management?

Answer 467

500mg ceftriaxone IM single dose

Question 468

SYPHILIS IN PREGNANCY what are the risks?

Answer 468

congenital syphilis - premature births - still births - multi-organ problems to brain, eyes, heart, skin, teeth and bones

Question 469

SYPHILIS IN PREGNANCY what is the management?

Answer 469

penicillin

Question 470

TRICH VAGINALIS IN PREGNANCY what are the risks?

Answer 470

- PROM - preterm births - low birth weight - female newborns can acquire infection during birth

Question 471

TRICH VAGINALIS IN PREGNANCY what is the management?

Answer 471

metronidazole

Question 472

UTIs IN PREGNANCY why are UTIs more common in pregnancy?

Answer 472

due to dilation of the upper renal tract and urinary stasis (hypoactive bladder)

Question 473

UTIs IN PREGNANCY why are pregnant women screened for asymptomatic bacteriuria at their booking visit?

Answer 473

it can lead to symptomatic infection if left untreated

Question 474

UTIs IN PREGNANCY what are the signs and symptoms?

Answer 474

- typical UTI symptoms = frequency, dysuria - cystitis = urgency, frequency, dysuria, hematuria, proteinuria, suprapubic pain - Pyelonephritis = fever, rigors, loin pain (also hyperemesis or preterm labor)

Question 475

UTIs IN PREGNANCY what are the investigations?

Answer 475

* Urine analysis (nitrities and leukocytes) * MSU * Bloods * Renal USS

Question 476

UTIs IN PREGNANCY what are the treatments?

Answer 476

* Oral antibiotics - Asymptomatic bacteriuria: 3 days - Cystitis 7 days

Question 477

UTIs IN PREGNANCY what is the management of pyelonephritis?

Answer 477

antibiotics (IV) for 10-14 days - Pyelonephritis needs IV antibiotics until pyrexia settles and vomiting stops. IV fluids and antipyretics too.

Question 478

UTIs IN PREGNANCY how can UTIs be prevented?

Answer 478

* Increase fluid intake * Double voiding and emptying bladder after sex * Cranberry juice * Prophylactic antibiotics

Question 479

UTIs IN PREGNANCY what are the antenatal risk factors for UTIs?

Answer 479

- previous infection - renal stones - diabetes mellitus - immunosuppression - polycystic kidneys - congenital abnormalites of renal tract - neuropathic bladder

Question 480

UTIs IN PREGNANCY what are the postpartum risk factors?

Answer 480

the risk is mainly associated with catheterisation - prolonged labour - prolonged 2nd stage - C-section - pre-eclampsia

Question 481

UTIs IN PREGNANCY what is the management?

Answer 481

antibiotics (depends on sensitivities) - penicillin amoxicillin - cephalosporin - gentamycin (have to monitor levels to minimise risk of ototoxicity)

Question 482

UTIs IN PREGNANCY which antibiotics should be avoided in first trimester and why?

Answer 482

trimethoprim it is a folate antagonist so can reduce folate levels

Question 483

UTIs IN PREGNANCY which antibiotics should be avoided in the third trimester and why?

Answer 483

- nitrofurantoin - risk of haemolytic anaemia in newborn with G6PD - sulfonamides - risk of kernicterus in newborn due to displacement of protein binding of bilirubin

Question 484

UTIs IN PREGNANCY which antibiotics are contraindicated in pregnancy?

Answer 484

- tetracyclines - cause permanent staining of teeth and problems with skeletal development - ciprofloxacin - causes skeletal problems

Question 485

CEPHALOPELVIC DISPROPORTION what is it?

Answer 485

a rare complication of birth where the baby's head does not clear the opening of the pelvis

Question 486

CEPHALOPELVIC DISPROPORTION what are the neonatal factors that may cause it?

Answer 486

- large baby size due to: - past due date - excessive maternal weight gain during pregnancy - FHx of large babies - gestational diabets - multiparity - parents are obese

Question 487

CEPHALOPELVIC DISPROPORTION what are the maternal factors that may cause it?

Answer 487

- small pelvis due to: - birthing in adolescence - pelvic malformations (bony growths) - petite birthing parent - previous trauma e.g. fractured pelvis

Question 488

CEPHALOPELVIC DISPROPORTION what can increase the risk?

Answer 488

- flat (platypelloid) pelvic opening - heart-shaped (android) pelvis

Question 489

CEPHALOPELVIC DISPROPORTION what are the signs and symptoms?

Answer 489

- failure to progress - 1st labour and last >20hrs - previously given birth and lasts >14hrs - baby's head is not moving towards pelvic opening - contractions aren't strong enough to move baby along birth canal - slow/no thinning or dilation of cervix

Question 490

CEPHALOPELVIC DISPROPORTION how is it diagnosed?

Answer 490

- check cervix to see if it is opening - foetal monitor to assess contractions - palpate abdomen to assess foetal position - can be diagnosed via USS if baby is growing fast

Question 491

CEPHALOPELVIC DISPROPORTION what is the management?

Answer 491

- vacuum extraction or forceps - c-section

Question 492

CEPHALOPELVIC DISPROPORTION what are the complications?

Answer 492

- shoulder dystocia - vaginal tears - postpartum haemorrhage