Women's health - Obstetrics Flashcards

Question 1

Q

How many ANC visits are recommended in pregnancy?

Answer

A

10 antenatal visits in the first pregnancy if uncomplicated
7 antenatal visits in subsequent pregnancies if uncomplicated
women do not need to be seen by a consultant if the pregnancy is uncomplicated

Question 2

Q

What happens at a booking visit? When should this occur?

Answer

A

8 - 12 weeks (ideally < 10 weeks)

Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI

Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria

Question 3

Q

When does Early scan to confirm dates, exclude multiple pregnancy occur?

Answer

A

10-13+6 weeks

Question 4

Q

When does down’s syndrome screening including nuchal scan occur?

Answer

A

11-13+6 weeks

Question 5

Q

What happens at ANC at 16 weeks?

Answer

A

Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick

Question 6

Q

When is the anomaly scan?

Answer

A

18 - 20+6 weeks

Question 7

Q

What happens at ANC at 25 weeks if primip?

Answer

A

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

Question 8

Q

What happens at ANC at 28 weeks?

Answer

A

Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women

Question 9

Q

What happens at ANC at 31 weeks if primip?

Answer

A

Routine care: BP, urine dipstick, SFH

Question 10

Q

What happens at ANC at 34 weeks?

Answer

A

Routine care: BP, urine dipstick, SFH
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan

*the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’

Question 11

Q

What happens at ANC at 36 weeks?

Answer

A

Routine care: BP, urine dipstick, SFH
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues

Question 12

Q

What happens at ANC at 38 weeks?

Answer

A

Routine care: BP, urine dipstick, SFH

Question 13

Q

What happens at ANC at 40 weeks if primip?

Answer

A

Routine care: BP, urine dipstick, SFH
Discussion about options for prolonged pregnancy

Question 14

Q

What happens at ANC at 41 weeks?

Answer

A

Routine care: BP, urine dip, SFH
Discuss labour plans and possibility of induction

Question 15

Q

What test is done if there is a potential rhesus sensitisation situation in rhesus negative mothers in the 2nd/3rd trimester?

Answer

A

if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present

Question 16

Q

In which 8 situations should anti-D be given to rhesus -ve mothers?

Answer

A

-delivery of a Rh +ve infant, whether live or stillborn
-any termination of pregnancy
-miscarriage if gestation is > 12 weeks
-ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
-external cephalic version
-antepartum haemorrhage
-amniocentesis, chorionic villus sampling, fetal blood sampling
-abdominal trauma

Question 17

Q

What are the clinical features seen in baby and what is the treatment of haemolysis due to haemolytic disease of the foetus and newborn (HDFN) in rhesus disease?

Answer

A

-oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
-jaundice, anaemia, hepatosplenomegaly
-heart failure
-kernicterus

treatment: transfusions, UV phototherapy

Question 18

Q

Who will get blood glucose tested in pregnancy?

Answer

A

Surprisingly perhaps, NICE now recommends that blood glucose is only checked to those considered at risk (e.g. obesity, previous macrosomic baby, family history, Asian ethnicity)

Question 19

Q

What does increased AFP indicate?

Answer

A

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

Question 20

Q

What does decreased AFP indicate?

Answer

A

Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

Question 21

Q

What options are there for nausea and vomiting in pregnancy?

Answer

A

natural remedies - ginger and acupuncture on the ‘p6’ point (by the wrist) are recommended by NICE
antihistamines should be used first-line (BNF suggests promethazine as first-line)

Question 22

Q

Is vitamin D supplementation given in pregnancy?

Answer

A

NICE recommend ‘All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding’
‘women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement’. This was confirmed in 2012 when the Chief Medical Officer advised: ‘All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy’
particular care should be taken with women at risk (e.g. Asian, obese, poor diet)

Question 23

Q

What is the current advice on alcohol use in pregnancy?

Answer

A

in 2016 the Chief Medical Officer proposed new guidelines in relation to the safe consumption of alcohol following an expert group report.
the government now recommend pregnant women should not drink. The wording of the official advice is ‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.’

Question 24

Q

what 10 things are all women screened for in pregnancy?

Answer

A

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down’s syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Syphilis

Question 25

Q

Is Placenta praevia screened for in pregnancy?

Answer

A

only in high risk women

Question 26

Q

Is Psychiatric illness screened for in pregnanacy?

Answer

A

only in high risk women

Question 27

Q

Is Sickle cell disease screened for in pregnancy?

Answer

A

only in high risk women

Question 28

Q

Is Tay-Sachs disease screened for in pregnancy?

Answer

A

only in high risk women

Question 29

Q

Is Thalassaemia screened for in pregnancy?

Answer

A

Only in high risk women

Question 30

Q

Is Bacterial vaginosis routinely screened for in pregnancy?

Question 31

Q

Is chlamydia routinely screened for in pregnancy?

Question 32

Q

Is Cytomegalovirus routinely screened for in pregnancy?

Question 33

Q

Is fragile x routinely screened for in pregnancy?
s

Question 34

Q

Is Hep C routinely screened for in pregnancy?

Question 35

Q

Is Group B strep routinely screened for in pregnancy?

Question 36

Q

Is toxoplasmosis routinely screened for in pregnancy?

Question 37

Q

How to define APH

Answer

A

Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Question 38

Q

Placental abruption - describe
visible blood loss?
Pain?
Uterus examination?
Lie and presentation?
Fetal heart?
Coagulation problems?

Answer

A

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

Question 39

Q

Placental praevia - describe
visible blood loss?
Pain?
Uterus examination?
Lie and presentation?
Fetal heart?
Coagulation problems?

Answer

A

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

Question 40

Q

3 main causes of bleeding in first trimester pregnancy?

Answer

A

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

Question 41

Q

3 main causes of bleeding in second trimester pregnancy?

Answer

A

Spontaneous abortion
Hydatidiform mole
Placental abruption

Question 42

Q

4 main causes of bleeding in third trimester pregnancy?

Answer

A

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

Question 43

Q

Spontaneous abortion, describe:
-Threatened miscarriage
-Missed miscarriage
-Inevitable miscarriage
-Incomplete miscarriage
-Complete miscarriage

Answer

A

Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled. Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain. Complete miscarriage - little bleeding

Question 44

Q

What is the typical history and symptoms of ectopic pregnancy?

Answer

A

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

Question 45

Q

what is the typical history and findings of a Hydatidiform mole

Answer

A

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

Question 46

Q

What is the typical history and examinatoin of placental abruption?

Answer

A

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

Question 47

Q

What is the typical history and examination of placenta praevia?

Answer

A

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

Question 48

Q

what is the typical history and findings of vasa praevia?

Answer

A

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

Question 49

Q

Describe maternal advantages of breastfeeding

Answer

A

bonding
involution of uterus
protection against breast and ovarian cancer
cheap, no need to sterilise bottle
contraceptive effect (unreliable)

Question 50

Q

Describe immunological advantages of breastfeeding and medical

Answer

A

IgA (protects mucosal surfaces), lysozyme (bacteriolytic enzyme) and lactoferrin (ensures rapid absorption of iron so not available to bacteria)
reduced incidence of ear, chest and gastro-intestinal infections
reduced incidence of eczema and asthma
reduced incidence of type 1 diabetes mellitus

Reduced incidence of sudden infant death syndrome

Baby is in control of how much milk it takes

Question 51

Q

what are the disadvantages of breastfeeding?

Answer

A

Transmission of drugs

Transmission of infection (e.g. HIV) - advised to exclusively formula feed if have HIV, additionally to infant PEP and maternal antiretrovirals

Nutrient inadequacies (prolonged breast feeding may lead to vitamin D deficiency)

Vitamin K deficiency

Breast milk jaundice

Question 52

Q

What antibiotics should be avoided in breastfeeding?

Answer

A

ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

Question 53

Q

What psychiatric drugs should be avoided in breastfeeding?

Answer

A

lithium, benzodiazepines

Question 54

Q

Which of these drugs should be avoided whilst breast feeding - amoxicillin or aspirin?

Question 55

Q

Which of these drugs should be avoided whilst breast feeding - Levothyroxine or carbimazole?

Answer

A

Carbimazole

Question 56

Q

Which of these drugs should be avoided whilst breast feeding - Methotrexate or prednisolone?

Answer

A

Methotrexate

Question 57

Q

Which of these drugs should be avoided whilst breast feeding - Sulfonylureas or metformin?

Answer

A

Sulfonylurea (gliclazide)

Question 58

Q

Which of these drugs should be avoided whilst breast feeding - cytotoxic drugs or amitriptyline?

Answer

A

Cytotoxic drugs

Question 59

Q

Which of these drugs should be avoided whilst breast feeding - amiodarone or digoxin?

Answer

A

Amiodarone (hypothyroidism or hyperthyroidism in baby)

Question 60

Q

What is a galactocele? When does this occur?

Answer

A

Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast.

Question 61

Q

Does galactocele require further investigation?

Question 62

Q

What is lactation mastitis? what percentage of women does it affect? when does this most commonly occur?

Answer

A

Lactation mastitis is inflammation in the interlobular connective tissue of the breast, which may or may not be associated with infection. It occurs in around 10% on breast feeding women and is most common six weeks post-partum.

Question 63

Q

How does lactation mastitis present?

Answer

A

Clinically this presents as a painful breast, with fever, malaise and a tender, red, swollen and hard area of the breast, usually in a wedge-shaped distribution.

Question 64

Q

When should you suspect infectious mastitis over lactation mastitis?

Answer

A

Symptoms do not improve or are worsening after 12-24 hours despite effective milk removal.
The woman has a nipple fissure that is infected.
Bacterial culture is positive (breast milk culture is not routinely required unless mastitis is severe, there has been no response to antibiotics, or this is recurrent mastitis).

Answer 56

A

Management of mastitis focuses on relieving pain with simple analgesia and warm compresses, and encouraging complete emptying of the breast after feeding (this may require the woman to express the remaining milk by hand or by using a breast pump).

The BNF advises to treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.

If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.

Answer 57

A

frequent feeding in a breastfed infant is not alone a sign of low milk supply

Answer 58

A

nipple pain: may be caused by a poor latch
blocked duct (‘milk bleb’)
nipple candidiasis
Engorgement
Raynauds disease of the nipple

Answer 59

A

blocked duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried

Answer 60

A

nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby

Answer 61

A

Breast engorgement is one of the causes of breast pain in breastfeeding women. It usually occurs in the first few days after the infant is born and almost always affects both breasts. The pain or discomfort is typically worse just before a feed. Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle. Fever may be present but usually settles within 24 hours. The breasts may appear red.

Answer 62

A

Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.

Answer 63

A

Complications include blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply

Answer 64

A

In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.

Answer 65

A

Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Answer 66

A

Around 1 in 10 breastfed babies lose more than the ‘cut-off’ 10% threshold in the first week of life. The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory

Answer 67

A

Plasma glucose Target value
Fasting 5.3 mmol/L
One hour after a meal 7.8 mmol/L
Two hours after a meal 6.4 mmol/L

Answer 68

A

It complicates up to 1 in 20 pregnancies.
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes

Answer 69

A

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

Answer 70

A

the oral glucose tolerance test (OGTT) is the test of choice
women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks

Answer 71

A

these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

(5678)

Answer 72

A

newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week

Answer 73

A

women should be taught about self-monitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given

Answer 74

A

if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered

Answer 75

A

if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started

Answer 76

A

if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

Answer 77

A

glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 78

A

In women with gestational diabetes, offer a fasting plasma glucose at 6 weeks after birth to exclude diabetes
After 13 weeks, HbA1c testing can be performed instead of fasting plasma glucose
offering an annual HbA1c test is recommended for all women without type 2 diabetes who have a history of gestational diabetes.

Answer 79

A

weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation and aspirin
treat retinopathy as can worsen during pregnancy

Answer 80

A

detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts

Answer 81

A

tight glycaemic control reduces complication rates

Answer 82

A

polyhydramnios - 25%, possibly due to fetal polyuria
preterm labour - 15%, associated with polyhydramnios

Answer 83

A

-macrosomia (although diabetes may also cause small for gestational age babies)
-hypoglycaemia (secondary to beta cell hyperplasia)
-respiratory distress syndrome: surfactant production is delayed
-polycythaemia: therefore more neonatal jaundice
-malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
-stillbirth
-hypomagnesaemia
-hypocalcaemia
-shoulder dystocia (may cause Erb’s palsy)

Answer 84

A

First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L

Answer 85

A

the booking visit (often done at 8-10 weeks), and at
28 weeks

Answer 86

A

oral ferrous sulfate or ferrous fumarate
treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

Answer 87

A

Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin

Answer 88

A

Give the newborn hepatitis B vaccine

Answer 89

A

babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin

unless the mother is anti-HBe positive, if so they dont need the immunoglobulin

Answer 90

A

here is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 91

A

Edinburgh Postnatal Depression Scale
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%
includes a question about self-harm

Answer 92

A

Seen in around 60-70% of women

Typically seen 3-7 days following birth and is more common in primips

Mothers are characteristically anxious, tearful and irritable

Answer 93

A

Reassurance and support, the health visitor has a key role

Answer 94

A

Affects around 10% of women

Most cases start within a month and typically peaks at 3 months

Features are similar to depression seen in other circumstances

Answer 95

A

As with the baby blues reassurance and support are important

NICE CKS state ‘Most women with the baby blues will not require specific treatment other than reassurance’

Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant

Answer 96

A

fluoxetine is best avoided due to a long half-life

Answer 97

A

Affects approximately 0.2% of women

Onset usually within the first 2-3 weeks following birth

Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Answer 98

A

Admission to hospital is usually required, ideally in a Mother & Baby Unit

There is around a 25-50% risk of recurrence following future pregnancies

Answer 99

A

Either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
The woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait
The woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more)

Answer 100

A

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.

Answer 101

A

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

Answer 102

A

phenytoin
methotrexate
pregnancy
alcohol excess

Answer 103

A

macrocytic, megaloblastic anaemia
neural tube defects

Answer 104

A

all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

Answer 105

A

Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Answer 106

A

The first onset of recognised fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau. Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce.

Fetal movements should be established by 24 weeks gestation.

Answer 107

A

There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.

Answer 108

A

Reduced fetal movements is a fairly common presentation, affecting up to 15% of pregnancies. 3-5% of pregnant women will have recurrent presentations with RFM.

Answer 109

A

Posture
Distraction
Placental position
Medication
Fetal position
Body habitus
Amniotic fluid volume
Fetal size

Answer 110

A

Posture
There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing

Answer 111

A

Distraction
Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
§

Answer 112

A

Placental position
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements

Answer 113

A

Medication
Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements

Answer 114

A

Fetal position
Anterior fetal position means movements are less noticeable

Answer 115

A

Body habitus
Obese patients are less likely to feel prominent fetal movements

Answer 116

A

Amniotic fluid volume
Both oligohydramnios and polyhydramnios can cause reduction in fetal movements

Answer 117

A

Fetal size
Up to 29% of women presenting with RFM have a SGA fetus

Answer 118

A

Initially, handheld Doppler should be used to confirm fetal heartbeat.
If no fetal heartbeat detectable, immediate ultrasound should be offered.
If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement

Answer 119

A

If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat

Answer 120

A

If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.

Answer 121

A

If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Answer 122

A

Between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis

Answer 123

A

However, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication.

Answer 124

A

Chickenpox is caused by primary infection with varicella-zoster virus. Shingles is caused by the reactivation of dormant virus in dorsal root ganglion.

Answer 125

A

a syndrome now termed fetal varicella syndrome

Answer 126

A

Risks to the mother - 5 times greater risk of pneumonitis

Answer 127

A

risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks

Answer 128

A

features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Answer 129

A

shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester

Answer 130

A

severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 131

A

if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies

Answer 132

A

if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible

A second dose of VZIG may be required if a further exposure is reported and 3 weeks have elapsed since the last dose.

Answer 133

A

if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Answer 134

A

RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure

Answer 135

A

if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
if the woman is < 20 weeks the aciclovir should be ‘considered with caution’

Answer 136

A

Three stages
1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (but high recurrence rate in future pregnancies)

Answer 137

A

Postpartum thyroiditis can be definitively diagnosed based on three criteria:
1) Patient is within 12 months of giving birth
2) Clinical manifestations are suggestive of hypothyroidism
3) Thyroid function tests support diagnosis

Answer 138

A

Thyroid peroxidase antibodies are found in 90% of patient

Answer 139

A

thyrotoxic phase
propranolol is typically used for symptom control
not usually treated with anti-thyroid drugs as the thyroid is not overactive.
hypothyroid phase
usually treated with thyroxine

Answer 140

A

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

Answer 141

A

Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Answer 142

A

Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.

Answer 143

A

Pre-existing hypertension
Gestational hypertension/ Pregnancy induced hypertension
Pre-eclampsia

Answer 144

A

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

Answer 145

A

Occurs in 3-5% of pregnancies and is more common in older women

Answer 146

A

If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review

Answer 147

A

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)

No proteinuria, no oedema

Answer 148

A

Occurs in around 5-7% of pregnancies

Answer 149

A

Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

Answer 150

A

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 151

A

-eclampsia
-other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
-fetal complications
-intrauterine growth retardation
-prematurity
-liver involvement (elevated transaminases)
-haemorrhage: placental abruption, intra-abdominal, intra-cerebral
-cardiac failure

Answer 152

A

-hypertension: typically > 160/110 mmHg and –proteinuria as above
-proteinuria: dipstick ++/+++
-headache
-visual disturbance
-papilloedema
-RUQ/epigastric pain
-hyperreflexia
-platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 153

A

-hypertensive disease in a previous pregnancy
-chronic kidney disease
-autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
-type 1 or type 2 diabetes
-chronic hypertension

Answer 154

A

-first pregnancy
-age 40 years or older
-pregnancy interval of more than 10 years
-body mass index (BMI) of 35 kg/m² or more at first visit
-family history of pre-eclampsia
-multiple pregnancy

Answer 155

A

Reducing the risk of hypertensive disorders in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors

Answer 156

A

Occurs in around 5% of pregnancies

Answer 157

A

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 158

A

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 159

A

Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.

Answer 160

A

aim for monotherapy
there is no indication to monitor antiepileptic drug levels

Answer 161

A

sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate. It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.

The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice

Answer 162

A

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

Answer 163

A

Combined test is standard
these tests should be done between 11 - 13+6 weeks
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the hCG tends to lower

Answer 164

A

if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A

Answer 165

A

alpha-fetoprotein: low
unconjugated oestriol: low
human chorionic gonadotrophin : high
inhibin A: high

Answer 166

A

alpha-fetoprotein: low
unconjugated oestriol: low
human chorionic gonadotrophin : low
inhibin A: normal

Answer 167

A

alpha-fetoprotein: high
unconjugated oestriol: normal
human chorionic gonadotrophin : normal
inhibin A: normal

Answer 168

A

Both the combined and quadruple tests return either a ‘lower chance’ or ‘higher chance’ result
‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
‘higher chance’: 1 in 150 chance or less e.g. 1 in 100

Answer 169

A

If a woman has a ‘higher chance’ results she will be offered a second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS). Given the non-invasive nature of NIPT and extremely high sensitivity and specificity, it is likely this will be the preferred choice for the vast majority of women.

Answer 170

A

analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation

Answer 171

A

Down’s syndrome
congenital heart defects
abdominal wall defects

Answer 172

A

cystic fibrosis
Down’s syndrome
cytomegalovirus infection

Answer 173

A

Pregnant women with a BMI >= 30 kg/m² should receive 5 mg folic acid daily until the 13th week of pregnancy

Answer 174

A

In addition to patients with a BMI of more than 30 kg/m², folic acid should also be prescribed at a 5mg daily dose for those with diabetes, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD. Ideally, folic acid should be commenced whilst trying to conceive as this will further minimise NTD risk.

Answer 175

A

Maternal risks
-miscarriage
-venous thromboembolism
-gestational diabetes
-pre-eclampsia
-dysfunctional labour, induced labour
-postpartum haemorrhage
-wound infections

Answer 176

A

Fetal risks
-congenital anomaly
-prematurity
-macrosomia
-stillbirth
-increased risk of developing obesity and metabolic disorders in childhood
-neonatal death

Answer 177

A

Explain to women with a BMI of 30 or more at the booking appointment how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy

Answer 178

A

obese women should take 5mg of folic acid, rather than 400mcg
all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit
if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made

Answer 179

A

Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth.

Answer 180

A

pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases

Answer 181

A

induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation

Answer 182

A

Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies.

Answer 183

A

Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period. It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS. Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.

Answer 184

A

Risk factors for Group B Streptococcus (GBS) infection:
-prematurity
-prolonged rupture of the membranes
-previous sibling GBS infection
-maternal pyrexia e.g. secondary to chorioamnionitis

Answer 185

A

universal screening for GBS should not be offered to all women
the guidelines also state a maternal request is not an indication for screening

Answer 186

A

-women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. -They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
-if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date

Answer 187

A

-IAP should be offered to women with a previous baby with early- or late-onset GBS disease
-IAP should be offered to women in preterm labour regardless of their GBS status
-women with a pyrexia during labour (>38ºC) should also be given IAP
-benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Answer 188

A

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres

It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Answer 189

A

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.

Causes:
endometritis: most common cause
urinary tract infection
wound infections (perineal tears + caesarean section)
mastitis
venous thromboembolism

Management
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 190

A

Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.

abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia

Answer 191

A

Investigations
ALT is typically elevated e.g. 500 u/l

Answer 192

A

Management
support care
once stabilised delivery is the definitive management

Answer 193

A

the incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

Answer 194

A

in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks

Answer 195

A

sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
‘salt and pepper’ chorioretinitis
microphthalmia
cerebral palsy

Answer 196

A

suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss

Answer 197

A

suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
since 2016, rubella immunity is no longer routinely checked at the booking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

Answer 198

A

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

Answer 199

A

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

Answer 200

A

-where caesarean delivery is required
-antepartum haemorrhage within the last 7 days
-abnormal cardiotocography
-major uterine anomaly
-ruptured membranes
-multiple pregnancy

Answer 201

A

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

Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen

Answer 202

A

urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months

Around 2-3% go on to develop choriocarcinoma

Answer 203

A

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

Answer 204

A

Factors which reduce vertical transmission (from 25-30% to 2%)
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)

Answer 205

A

Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section

Answer 206

A

Neonatal antiretroviral therapy
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.

Answer 207

A

Epidemiology
5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix

Associated factors
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section

Answer 208

A

digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Answer 209

A

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

Answer 210

A

Epidemiology
occurs in approximately 1/200 pregnancies

Cause - not known but associated factors:
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age

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Women's health - Obstetrics Flashcards

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