Women's health - Obstetrics Flashcards

Question

Is Placenta praevia screened for in pregnancy?

Answer 1

only in high risk women

Answer 2

only in high risk women

Answer 3

only in high risk women

Answer 4

only in high risk women

Answer 5

Only in high risk women

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

Spontaneous abortion Ectopic pregnancy Hydatidiform mole

Answer 10

Spontaneous abortion Hydatidiform mole Placental abruption

Answer 11

Bloody show Placental abruption Placenta praevia Vasa praevia

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

Answer 22

lithium, benzodiazepines

Answer 23

Carbimazole

Answer 24

Methotrexate

Answer 25

Sulfonylurea (gliclazide)

Answer 26

Cytotoxic drugs

Answer 27

Amiodarone (hypothyroidism or hyperthyroidism in baby)

Answer 28

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.

Answer 29

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.

Answer 30

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.

Answer 31

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 32

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 33

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

Answer 34

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

Answer 35

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 36

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

Answer 37

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 38

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

Answer 39

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

Answer 40

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 41

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 42

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 43

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 44

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 45

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 46

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 47

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 48

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

Answer 49

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 50

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

Answer 51

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

Answer 52

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 53

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 54

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 55

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 56

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

Answer 57

tight glycaemic control reduces complication rates

Answer 58

1. polyhydramnios - 25%, possibly due to fetal polyuria 2. preterm labour - 15%, associated with polyhydramnios

Answer 59

-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 60

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

Answer 61

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

Answer 62

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 63

Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin

Answer 64

Give the newborn hepatitis B vaccine

Answer 65

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 66

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

Answer 67

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 68

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 69

Reassurance and support, the health visitor has a key role

Answer 70

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 71

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 72

fluoxetine is best avoided due to a long half-life

Answer 73

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 74

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 75

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 76

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

Answer 77

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 78

phenytoin methotrexate pregnancy alcohol excess

Answer 79

macrocytic, megaloblastic anaemia neural tube defects

Answer 80

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 81

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 82

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 83

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 84

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 85

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

Answer 86

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

Answer 87

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 88

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

Answer 89

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

Answer 90

Fetal position Anterior fetal position means movements are less noticeable

Answer 91

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

Answer 92

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

Answer 93

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

Answer 94

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 95

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

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

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

Answer 100

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

Answer 101

a syndrome now termed fetal varicella syndrome

Answer 102

Risks to the mother - 5 times greater risk of pneumonitis

Answer 103

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 104

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

Answer 105

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

Answer 106

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 107

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

Answer 108

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 109

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 110

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

Answer 111

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 112

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

Answer 113

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 114

Thyroid peroxidase antibodies are found in 90% of patient

Answer 115

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 116

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 117

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 118

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 119

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

Answer 120

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no oedema

Answer 121

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

Answer 122

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 123

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema

Answer 124

Occurs in around 5-7% of pregnancies

Answer 125

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

Answer 126

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 127

-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 128

-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 129

-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 130

-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 131

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 132

Occurs in around 5% of pregnancies

Answer 133

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 134

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 135

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 136

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

Answer 137

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 138

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

Answer 139

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 140

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 141

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

Answer 142

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

Answer 143

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

Answer 144

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 145

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 146

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 147

Down's syndrome congenital heart defects abdominal wall defects

Answer 148

cystic fibrosis Down's syndrome cytomegalovirus infection

Answer 149

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

Answer 150

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 151

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

Answer 152

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

Answer 153

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 154

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 155

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 156

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 157

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 158

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

Answer 159

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 160

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 161

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 162

-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 163

-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 164

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 165

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 166

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 167

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

Answer 168

Management support care once stabilised delivery is the definitive management

Answer 169

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 170

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

Answer 171

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 172

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 173

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 174

-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 175

-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 176

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

Answer 177

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 178

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 179

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 180

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 181

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 182

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 183

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 184

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 185

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 186

Epidemiology occurs in approximately 1/200 pregnancies Cause - not known but associated factors: proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age

Women's health - Obstetrics Flashcards

(221 cards)