Women's Health - Obstetrics

Question 1

Define antepartum haemorrhage and outline the main causes of it

Answer 1

Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.

• Occurs in 5% of pregnancies

Causes:
- No Identifiable cause in 40%
3 important causes:
- placenta praevia - painless bleeding
- placental abruption - painful bleeding
- Vasa praevia

• Infection
  me - also uterine rupture

Question 2

What is low lying placenta vs placenta praevia

Answer 2

Low-lying placenta is used when the placenta is within 20mm of the internal cervical os

Placenta praevia is used only when the placenta is over the internal cervical os. This is subdivided into partial and complete praevia (placenta completely covers the internal os)

Delivery of the placenta before baby is incompatible with survival.

Question 3

How is placenta praevia diagnosed, inc follow up Ix if present?

Answer 3

Diagnosed at the routine 20-week anomaly scan - used to assess the position of the placenta and diagnose placenta praevia.

The scan is then repeated at 32 weeks (and 36 weeks) because the lower segment of the womb can stretch, if more than 2cm away from the internal os can avoid caesarian section

Many women with placenta praevia are asymptomatic. It may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage). Bleeding usually occurs later in pregnancy (around or after 36 weeks).

Question 4

Management of delivery for low lying placenta - 2 things

Answer 4

Caesarian section - Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).

Corticosteroids are given between 34 and 36 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.

Emergency caesarean section may be required with premature labour or antenatal bleeding.

Advice:
- present if bleeding/pain
-avoid intercourse
- recurrent bleeding may require admission until delivery (remeber that lady in kings)

Question 5

What is the main complication of placenta praevia and how is it managed? (5 Mx options)

Answer 5

The main complication of placenta praevia is (MASSIVE - ME) haemorrhage before, during and after delivery. When this occurs, urgent management is required and may involve:

Emergency caesarean section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy

The last three are post natal haemorrhage magement.

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Explainatory Notes on antepatrtum haemorrhage (another card) - if bleeding stops delivery can be delayed

Clinical examination into coexisting symptoms such as pain, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal wellbeing.

An assessment of the fetal heart rate should be performed, usually with a cardiotocograph (CTG) in
women presenting with APH once the mother is stable or resuscitation has commenced, to aid decision

Ultrasound to establish cause of bleeding if unknown

Women with APH and associated maternal and/or fetal compromise are required to be delivered
immediately.

Question 6

What is vasa praevia? Type I vs II?

Answer 6

Under normal circumstances, the umbilical cord containing the fetal vessels (umbilical arteries and vein) inserts directly into the placenta. The fetal vessels are always protected, either by the umbilical cord or by the placenta.

In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.

There are two types of vasa praevia:

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord (the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta)

Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Question 7

Diagnosis of Vasa praevia

Answer 7

Vasa praevia may be diagnosed by ultrasound during pregnancy. This is the ideal scenario, as it allows a planned caesarean section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally.

It may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy.

It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix.

Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.

Question 8

Management of Vasa praevia - if diagnosed antenatally (Asymptomatic) vs diagnosed following antepartum haemorrhage

Answer 8

For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend:

Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation

Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs.

Question 9

What are the three types of morbidly adherent placenta?

Answer 9

Placenta accreta spectrum refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby.

There are three distinctions:
- placenta accreta is where the placenta implants at the surface of the myometrium, but not beyond
- Placenta increta is where the placenta attaches deeply into the myometrium
- Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

mnemonic: accreta - placenta is at the myometrium, intreat - placenta is in the myometrium, percreta is past the myometrium

Question 10

Diagnosis and management of morbidly adherent placenta? What are the options after delivery?

Answer 10

Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth. MRI scans may be used to assess the depth and width of the invasion.

Mx w/ early delivery by caesarian (35-37 weeks + antenatal steroids)

It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage

The options during caesarean are:
1. Hysterectomy with the placenta remaining in the uterus (recommended)
2. Uterus preserving surgery, with resection of part of the myometrium along with the placenta
3. Expectant management, leaving the placenta in place to be reabsorbed over time. Expectant management comes with significant risks, particularly bleeding and infection.

Question 11

What is placental abruption? how does it present?

Answer 11

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Don’t confuse this with uterine rupture

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

The typical presentation of placental abruption is with:

• Sudden onset severe abdominal pain that is continuous
• Vaginal bleeding (antepartum haemorrhage)
• Shock (hypotension and tachycardia)
• Abnormalities on the CTG indicating fetal distress
• Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
• remember concealed abruption - cervical os remains closed and any haemorrhage remains in the uterus - maternal shock and pain appears disproportionate to the amount of bleeding

There is no test- US only rules out placenta praevia as a cause of bleeding.

Question 12

severities of antepartum haemorrhage

Answer 12

The RCOG guideline (2011) defines the severity of antepartum haemorrhage as:

Spotting: spots of blood noticed on underwear
Minor haemorrhage: less than 50ml blood loss
Major haemorrhage: 50 – 1000ml blood loss
Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Question 13

What is maternal sepsis? What is septic shock?

What are the two causes of sepsis in pregnancy?

Answer 13

Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting the functioning of the organs of the body. It is still the leading cause of maternal death!

Severe sepsis is when sepsis results in organ dysfunction, such as hypoxia, oliguria or raised lactate. Septic shock is defined when arterial blood pressure drops (inflammation -> vasodilation) and results in organ hypo-perfusion.

Two key causes of sepsis in pregnancy are:

Chorioamnionitis
Urinary tract infections

Question 14

Signs of sepsis, Signs of Chorio, Signs of UTI

Answer 14

The non-specific signs of sepsis include:

Fever
Tachycardia
Raised respiratory rate (often an early sign)
Reduced oxygen saturations
Low blood pressure
Altered consciousness
Reduced urine output
Raised white blood cells on a full blood count
Evidence of fetal compromise on a CTG

MEOWS - maternaity early obstetric warning sustem monitors for the signs of sepsis.

Additional signs and symptoms related to chorioamnionitis include:

Abdominal pain
Uterine tenderness - why Tess did the abdo examine on women with PROM
Vaginal discharge

Additional signs and symptoms related to a urinary tract infection include:

Dysuria
Urinary frequency
Suprapubic pain or discomfort
Renal angle pain (with pyelonephritis)
Vomiting (with pyelonephritis)

Question 15

Management of maternal sepsis

inc Abx choice

Answer 15

Septic Six- BUFALO!

B- Blood cultures
U - Urine output
F- IV fluids
A - Empirical broad-spectrum antibiotics
L - Blood lactate level
O - oxygen to maintain sats 94-98%

Continous maternal and fetal monitoring (CTG) is required. Emergency C-section is indicated for signs of fetal distress.

Antibiotics used for maternal sepsis:
- piperacillin and tazobactam (tazocin) + gentamicin
- amoxicillin, clindamycin and genatimicin.

amoxicillin - gram positive coverage
Clinda - gram positive coverage
Gent - gram negative coverage.

Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.

Question 16

Fetal compromise on CTG - what are early, late and prolonged decellarations (how long do they last)? What is one significantly worrying sign on CTG

Answer 16

Early- vagus stimulation, these are normal
Late- hypoxia, fetus not coping
prolonged - compression of the cord

Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. The lowest point of the declaration corresponds to the peak of the contraction. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.

Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction (they don’t line up!). Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.

Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.

A sinusoidal CTG is a rare pattern to be aware of, as it can indicate severe fetal compromise. It gives a pattern similar to a sine wave, with smooth regular waves up and down that have an amplitude of 5 – 15 bpm. It is usually associated with severe fetal anaemia, for example, caused by vasa praevia with fetal haemorrhage.

Question 17

What is cord prolaspe?

biggest risk factor?

management?

Answer 17

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

The most significant risk factor for cord prolapse is when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique). Being in an abnormal lie provides space for the cord to prolapse below the presenting part. In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.

Management:
Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby.

Pushing the cord back in is not recommended -> (handling causes vasospasm).

When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. Woman lies in the left lateral position and Tocolytic medication (e.g. terbutaline) can be used to minimise contractions

Question 18

KEY - What is a post-partum haemorrhage. What are the two types? What are the main causes?

Answer 18

Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death (but not baby- antepartum with praevias and abruption…)

To be classified as postpartum haemorrhage, there needs to be a loss of:

500ml after a vaginal delivery
1000ml after a caesarean section
It can be classified as:

Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss

It can also be categorised as:
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth

There are four causes of postpartum haemorrhage, remembered using the “Four Ts” mnemonic:

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta) - this is the secondary cause, the others are primary usually
T – Thrombin (bleeding disorder)

Question 19

KEY - Management of post-partum haemorrhage

Also include management of secondary post-partum haemorrhage

Answer 19

Treat the Cause - 4 Ts:

Stopping the bleeding:

• mechanical stimulation (rubbing) the uterus
• catheritisation (full bladder prevents contraction)

Medical:
- syntocinon (oxytocin)
- Ergometrine - ME - Oxytocin causes rhythmic contractions, while ergometrine causes sustained contractions - together they are syntometrine.
- carboprost (haemobate- prostoglandin analogue -> contraction)
-tranexamic acid (anti-fibrinolytic)
- Misoprostol

Surgical treatment options involve:

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Secondary post-partum haemorrhage:
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Investigations involve:
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection

Management depends on the cause:
Surgical evaluation of retained products of conception
Antibiotics for infection

Question 20

What is the only known cause of shoulder dystocia? 4 complications?

Answer 20

1% of vaginal births

Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. This requires additional obstetric manoeuvres to enable delivery of the rest of the body.

Shoulder dystocia is an obstetric emergency:
The key complications of shoulder dystocia are:

Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

presentation - not testing just a reminder:
Shoulder dystocia presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head. There may be failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. The turtle-neck sign is where the head is delivered but then retracts back into the vagina.

Question 21

Management of Shoulder dystocia (5 steps)

Answer 21

External manoeuvres:
1. McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way - 90% resolve here

2. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis. (backs to maternal right/left - want to push on the back of the sholder)

Then internal manoeuvres:
3. rotational manoeuvre (rubins) - hands inside vagine push posterior aspect of anterior sholder and anterior aspect of posterior cholder to twist shoulders under the pubic synthesis
4. remove the posterior arm

5. If internal manoeuvres fail - Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Question 22

What are the three stages of labour?

What is partogram used for? What is monitored on the partogram and what does is crossing the alert line an indication for?

Answer 22

First stage (until 10cm dilation of the cervix) - subdivided into:
- latent first stage (up until 4cm)
-active first stage (active labour) (from 4cm-10cm)

Second stage - 10cm to delivery of the fetus

Third stage - from delivery of the fetus to delivery of the placenta

Partogram is for the First stage only! (remember second stage- pushing takes 1/2 hours)

Women are monitored for their progress in the first stage of labour using a partogram - cervical dilation and fetal head descent recorded amongst other things. Crossing the alert line is an indication for amniotomy (artificially rupturing the membranes) and a repeat examination in 2 hours. Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.

**Failure to progress in the first stage is less than 2cm dilation every 4 hours. **

Question 23

How long should the second stage of labour last?

Answer 23

The success of the second stage depends on “the three Ps”: power, passenger and passage. Delay in the second stage is when the active second stage (pushing) lasts over:

2 hours in a nulliparous woman
1 hour in a multiparous woman

Question 24

What is involved in active management of the third stage of labour?

Answer 24

Active management involves intramuscular oxytocin and controlled cord traction.

Question 25

Management of Failure to Progress (4 options)

Answer 25

The main options for managing failure to progress are:

• Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
• Oxytocin infusion
• Instrumental delivery (second stage only)
• Caesarean section

remember this is both first and second stage

Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

The condition of the fetus needs to be monitored throughout labour and delivery. Fetal compromise may mean delivery needs to be expedited, or example, with emergency caesarean section.

Question 26

Physiology of the second stage of labour - what are the 7 cardinal movements?

Why these movements - key understanding

Answer 26

Engagement: This occurs when the largest part of the baby’s head (usually the biparietal diameter) enters the pelvis. The baby is “engaged” in the pelvic inlet and begins the descent through the birth canal.

Descent: The baby moves downward through the birth canal, guided by uterine contractions. The descent is a continuous process throughout labor.

Flexion: The baby’s head flexes forward (chin to chest), allowing the smallest part of the head to present to the birth canal. This is essential for the head to fit through the pelvis.

Internal rotation: As the baby continues to descend, the head rotates to align with the mother’s pelvic axis, turning to face the mother’s back (occiput anterior position) in most cases. This helps the baby’s head fit more easily through the pelvic opening.

Extension: Once the baby’s head reaches the perineum, it extends backward as it emerges from the birth canal. The baby’s head is pushed out with the face first, followed by the chin and neck.

External rotation (Restitution): After the head is born, the baby’s head rotates externally to its original position (in relation to the body). This allows the shoulders to align for birth.

Expulsion: This is the final movement, where the baby’s shoulders and body are delivered after the head is out. The shoulders pass through the birth canal, followed by the rest of the body.
Explanation
- the pelvic inlet is widest side to side, the pelvic outlet is widest front to back
- the fetal skull is widest front to back (sagittally)
- enters the pelvic inlet Occiput tranverse so that the widest part of the skull aligns with the widest part of the pelvis, then internally rotates to exit at the pelvis outlet
- flexion of the head (chin to chest) - reduces the diameter of the head, if baby is OP this also increases diameter because baby can’t flex
- extend head around the pubic synthesis
-external rotation because shoulders are wider (not as long as the head sagittally, but wider than it coronally)

mnemonic - Every Day Fine Infants Enter Eager and Excited

Question 27

Diagnosing the onset of labour - 4 signs?

Answer 27

The signs of labour are:

• Show (mucus plug from the cervix)
• Rupture of membranes
• Regular, painful contractions (vs Braxton hicks which are occasional irregular contractions of the uterus - KEY)
• Dilating cervix on examination

Question 28

Summary of intrahepatic cholestasis of pregnancy
- what is it
- when does it present
- pathophysiology and presentation
- complication
- Ix
- Mx

Answer 28

Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver.

Occours in roughly 1% of pregnancies and usually presents with the third trimester

Bile acids are produced from the breakdown of cholesterol in the liver. In obstetric cholestasis the processing and outflow of bile acids is reduced and meaning that they build up in the blood. This causes pruritis (particularly in the palms of the hands and soles of the feet).

Complication - Bile acids are fetotoxic and OC is is associated with increased risk of stillbirth

Obstetric cholestasis will cause:

• Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
• Raised bile acids

LFTs and bile are used for monitoring- weekly. (if substantially elevated delivery is brough foward). Remeber ALP normally rises in pregnancy due to placental production. Other Ix - OC is a diagnosis of exclusion so other cause of raised LFTs are ecluded - hepititis bloods, US liver.

Management:
- The condition resolves after delivery of the baby - if LFTs deranged this needs to be brought forward to reduced risk of stillbirth
- emollients, topical menthol
- anti-histmamine help with sleeping, not itching (bile acids not histmaine causing the itch)
- vitamin K if PT is deranged
- Formerly used ursodeoxycholic acid - no longer advised

Question 29

Premature labour - definition and 3 classifications

Answer 29

Birth before 37 weeks gestation. The more premature, the worse the outcomes.

Babies born before 24 weeks are not concidered viable.

The WHO classify prematurity as:

Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm

Question 30

Define PROM, P-PROM and PLWIM

Answer 30

Different to a SROM (spontaneous - with contractions)

PROM - prelabour rupture of membranes - when fetal membranes rupture (waters break but contractions don’t occour) past 37 weeks gestation.

P-PROM - Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).

PLWIM: Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

KEY - This has different Ix but basically the same management!

Question 31

Prophylaxis of preterm labour?

Indications for a rescue suture?

Answer 31

This is for women who are found to have a short cervix I assume on routine scanning:

Vaginal progesterone:
cervical legnth <25mm between 16-24 weeks -> vaginal progesterone to decrease mymoetrium actvitiy and cervic remodelling

Prophalactic cervical cerclage - cervical legnth <25mm between 16-24 weeks + a previous premature birth or cervical traima (colposcopy + cone biopsy)

Rescue cervical cerclage - between 16-28 weeks where Painless cervical dilation occours without ROM to prevent progression and premature delivery. Contractions (painful tightenings), signs of chorio and ROM are absolute contraindications.

Question 32

Investigations for PROM

Management for PROM vs P-PROM

Answer 32

Ix for PROM/P-PROM:
Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.

Where there is doubt about the diagnosis, tests can be performed:

• Insulin-like growth factor-binding protein-1 (IGFBP-1)
• Placental alpha-microglobin-1 (PAMG-1)

Management if at term - PROM:
- IOL if not spontaneously in labour by 24 hours
- Antibiotics - Pen G only given if GBS isolated
- monitor for signs of Chorio

Management if Preterm - PROM (before 37 weeks):
- Prophylactic Erythromycin for 10 days, or until labour is established if within ten days
- Induction of labour may be offered from 34 weeks to initiate the onset of labour

Note - steroids may be given between 34-36 weeks but IOL should not be delayed after 34 weeks

Additionally if before 34 weeks:
Aim here is for increased gestation!!
- Prophylactic Erythromycin for 10 days, or until labour is established if within ten days
- Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain - given within 24 hours of labour
- Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour - given before 34 weeks to allow time to give the corticosteroids
- IOL at 34 weeks but not before (aim to get to 34 weeks)

Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Me- Erythromycin is only given to the preterms!

Question 33

Key Card:
What is preterm labour with intact membranes?

Ix?

Management of PLWIM

Answer 33

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

Diagnosis:
<30 weeks - clinical
>30 weeks - TV USS shows cervical length less than 15mm (above this preterm labour is unlikely)

Foetal fibronectin is an alternative test to vaginal ultrasound. Foetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour.

Management of Preterm labour
- CTG monitoring
- tocolysis with nifedipine (CCB) - only for 48 hours to buy time for steroids and IV magnesium sulphate
- maternal corticosteroids (before 35 weeks) - reduce respiratory distress syndrome (2 doses 24 hours apart)
- IV magnesium sulphate (before 34 weeks) - neuroprotection (cerebral palsy). Given within 24 hours of delivery
- delayed cord clamping - increase circulating blood volume and Haemoglobin in the baby

ME - Preterm Labour whether just a PPROM (not contracting but membranes ruptured) or a PLWIM (contracting but membranes intact) is managed exactly the same way. If before 34 weeks you try and give 2 doses of IM betamethasone and IV mag sulphate, using tocolysis to buy time. Erythromycin is given to everyone before 37 weeks if the membranes break. You aim to get women before 34 weeks to 34 weeks and then once at 34 weeks you try and Induce labour - i think the baby is grown enough basically….

Question 34

For women given IV magnesium sulphate, what monitoring is required?

Answer 34

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

Question 35

Lecture - what are the four stages of cervical remodelling?

Answer 35

cervical remodelling - occurs in four phases. It becomes soft and stretchy so that it is ready for birth.
1. Softening (no loss of strength).
2.Ripening- loss of strength. KEY TO KNOW THIS APPARENTLY
3. Dilation happens with contractions
4. Repair - post partum.

Question 36

Lecture - what is the most common cause of preterm birth?

Answer 36

Most common cause of preterm birth is infection:
- intrauterine bacterial infections - could be ascending from vagina
- blood borne transplacental infection
- retrograde from the fallopian tube, iatrogenic during invasive procedures

Explanation - the infection triggers an inflammatory response that causes the cervix to ripen and the uterus to contract.

Others:
- Ischemia - common placental findings in those without infection. If there is insufficient blood flow to the placenta due to invasion of the spiral arteries in formation, then causes still birth or small for dates
- uterine overstimulation - stretching more than expected than gestation (twins, polyhydramnios, uterus structural anomaly) might activate the uterus early than expected
- Cervical weakness - previous surgery (LLETZ for CIN), interrupted structural integrity

Question 37

What is the biggest risk factor for abnormally adherent placenta?

How is it diagnosed?

Answer 37

The major risk factors for placenta accreta spectrum are previous caesarean delivery, history of accreta in a previous pregnancy, and other uterine surgery.

Women with a history of previous caesarean section seen to have an anterior low-lyingmplacenta (where teh scar is you knob!) or placenta praevia at the routine fetal anomaly scan should be specifically screened for placenta accreta spectrum.

Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth. MRI scans may be used to assess the depth and width of the invasion.

Can be a cause of post-partum haemorrage, also diagnosed with difficulty delivering the placenta, if diagnosed antenatally.

Question 38

When Triaging a pregnant lady what 3 key Sx do the midwives ask - useful things for your history

Answer 38

Movements
Pain
Bleeding or fluid loss from down below

Question 39

What is a normal fetal heart rate

Answer 39

110-160 bpm

Question 40

Management of reduced fetal movements?

Side note - Diagnostic Ix for stillbirth?

Answer 40

Reduced fetal movements are usually nothing serious but occassionally they are a sign of fetal death. A Hx needs to consider risk factors for IUD such as FGR, congential abnormalities and placental insufficiency (inc pre-eclampsia)

1. Auscultate the fetal heart to exclude fetal death
2. CTG to exclude fetal compromise if the pregnancy is over 28+0 weeks of gestation.
3. Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman presenting with RFM after 28+0 weeks of gestation if the perception of RFM persists despite a normal CTG or if there are any additional risk factors for FGR/stillbirth.

Ultrasound scan assessment should include the assessment of abdominal circumference and/or estimated fetal weight to detect the SGA fetus, and the assessment of amniotic fluid volume. THIS CAME UP

Note for stillbirth - Ultrasound scan is the investigation of choice for diagnosing intrauterine fetal death (IUFD). It is used to visualise the fetal heartbeat to confirm the fetus is still alive. (Management is Vaginal birth with IOL - first line).

SUMMARY CTG and USS

Question 41

What is the bishop score and when is it used?

Answer 41

USED TO MONITOR IOL - The bishop score is an assessment of ‘cervical ripeness‘ based on measurements taken during vaginal examination. It is checked prior to induction, and during induction to assess progress:

• A score of 7 - suggests the cervix is ripe or ‘favourable’ – this means that there is a high chance of a response to interventions made to induce labour (i.e amniotomy).
• A score below this suggests cervical ripening (vaginal prostaglandins) may be required to prepare the cervix.
• Failure of a cervix to ripen despite use of prostaglandins may result in the need for a caesarean section.

NOTE- remember prostaglandins are just preparation for an IOL, not the IOL itself (IOL is booked days later at sheffield - amniotomy and syntocinon).

Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):

Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2) - posterior (hard to reach), mid/anterioir - look at a diagram
Cervical dilatation (scored 0 – 3)
Cervical effacement/legnth (scored 0 – 3)
Cervical consistency (scored 0 – 2) - firm, average or soft

Question 42

Methods of induction of labour

Answer 42

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, performing it increases the likelihood of spontaneous delivery, reducing the need for a formal induction. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

Vaginal Prostaglandins - Vaginal prostaglandins form the mainstay of induction of labour, and are the preferred primary method as advised by NICE guidelines (2008). Prostaglandins act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus.

Cervical ripening balloon - applies pressure about and blow the cervix which softens and dilates the cervix so that amniotomy can then be used. It is used when vaginal prostaglandins are not preferred. Previous C-section (scar dihesence risk), multiparous women or prostaglandins have failed.

Amniotomy releases prostaglandins in an attempt to expedite labour. It is only performed when the cervix has been deemed as ‘ripe’ (see Bishop Score below). Often, an infusion of artificial oxytocin (Syntocinon) will be given alongside an amniotomy, acting to increase the strength and frequency of contractions. The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes. NICE guidelines (2008) advise that amniotomy +/- oxytocin should NOT be used as the primary method of IOL, unless use of prostaglandins are contraindicated e.g. high risk of uterine hyperstimulation.

CTG monitoring and the bishop score are used to monitor induction of labour.

ME - for VBAC, prostaglandins cannot be used, oxytocin is sometimes used with caution but increases risk of uterine rupture

Question 43

Indications for induction of labour (1 key + 4)

Answer 43

Induction of labour can be used where patients go over the due date. IOL is offered between 41 and 42 weeks gestation.

Induction of labour is also offered in situations where it is beneficial to start labour early, such as:

Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death - mifepristone and misoprostol

Question 44

Aside from failure (requiring ECS), what is the main complication of induction of labour and how is it managed?

Answer 44

Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins or IV oxytocin infusion. This is where the contraction of the uterus is prolonged and frequent. Uterine hyperstimulation can lead to:

Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture

The two criteria often given are:

Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes

Management of uterine hyperstimulation involves:

Removing the vaginal prostaglandins, or stopping the oxytocin infusion Tocolysis with terbutaline

Question 45

KEY understanding - When is instrumental delivery indicated (2)?

Answer 45

ONLY USED IN THE SECOND STAGE - if there is failure to progress (malpositioning, maternal exhuastion) or fetal distress

(failure to progress is after 2 hours in nulliparous women (one hour for decent, one hour pushing) or 1 hour pushing in multiparous.

If there is failure to progress or fetal compromise before 10cm then emergency CS is used. OMG this is key hun!

In general, the pre-requisites for performing an instrumental delivery are:

Fully dilated
Ruptured membranes
Cephalic presentation
Fetal head at least at the level of the ischial spines, and no more than 1/5 palpable per abdomen

Question 46

Risk of Instrumental delivery? - baby (forceps vs ventous), mum - they are the same

Answer 46

The key risks to remember to the baby are:
- Cephalohaematoma with ventouse (blood between the skull and periosteum)
- Facial nerve palsy with forceps

Maternal risks:
- PPH
- episiotomy and perineal tears
- incontinence of bladder or bowel
- nerve injuries: obturator (weakness of hip adduction, medial thigh numbness - makes sense) or femoral nerve (weakeness of knee extension, numbness of anteroir thigh and medial leg) - THESE DISTRUBUTIONS MAKE SENSE WHEN YOU THINK ABOUT THE MUSCLES.

SEPERATE TOM TIP: It is worth remembering there is an increased risk of requiring an instrumental delivery when an epidural is in place for analgesia.

Question 47

KEY
What is failure to progress?

What three things affect progress in labour?

What are the criteria for delay in labour for the first stage?

Criteria for failure to progress in the second stage Second stage?

Answer 47

Failure to progress refers to when labour is not developing at a satisfactory rate - for any of the three stages. This increases the risk to the fetus and the mother.

Progress in labour is influenced by the three P’s:

Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)

///

Delay in active phase labour (4-10cm) is considered when there is either:

Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women

(Me - remeber it is common for the latent phase of labour to last between 18 and 24 hours)
///

The second stage of labour lasts from 10cm dilation of the cervix to delivery of the baby. Delay in the second stage is when the active second stage (pushing) lasts over:

2 hours in a nulliparous woman
1 hour in a multiparous woman

Question 48

Define delay in the third stage of labour?

Answer 48

The third stage of labour is from delivery of the baby to delivery of the placenta. Delay in the third stage is defined by the NICE guidelines (2017) as:

More than 30 minutes with active management
More than 60 minutes with physiological management

Active management involves intramuscular oxytocin and controlled cord traction.

Sidenote: After delivery of the plancenta the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.

Question 49

Management of Breech Presentation

Answer 49

Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus. About 5% of pregnancies are breech presentation by 37 weeks

Where ECV fails, women are given a choice between vaginal delivery and** elective caesarean section**. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.

When the first baby in a twin pregnancy is breech, caesarean section is required.

Question 50

Types of Breech - probs low yield

Answer 50

Complete breech, where the legs are fully flexed at the hips and knees - tuck
Incomplete breech, with one leg flexed at the hip and extended at the knee
Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee - pike
Footling breech, with a foot is presenting through the cervix with the leg extended

Question 51

KEY - Management of placental abruption

Answer 51

This is basically management of any massive antepartum haemorrhage:

There are no reliable tests for diagnosing placental abruption. It is a clinical diagnosis based on the presentation.

Placental abruption is an obstetric emergency. The urgency depends on the amount of placental separation, extent of bleeding, haemodynamic stability of the mother and condition of the fetus. It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding.

The initial steps with major or massive haemorrhage is ABCDE approach:
- Fluids and transfusions as required, Crossmatch 4 units
- CTG monitoring of the fetus
- Close monitoring of the mother

Emergency caesarean section may be required where the mother is unstable, or there is fetal distress.

Ultrasound - to exclude a placenta praevia but note that abruption is a clinical diagnosis. Be careful i think if there is signs of FD or maternal compromsie go for the CS- got this wrong in the mock.

Antenatal steroids are offered between 24 and 34 + 6 weeks gestation to mature the fetal lungs in anticipation of preterm delivery. Basically the delivery is happening regardless of gestation, this just helps. Not the same as in a praevia where if bleeding stops then delayed

Rhesus-D negative women require anti-D prophylaxis when bleeding occurs. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

There is an increased risk of postpartum haemorrhage after delivery in women with placental abruption. Active management of the third stage is recommended.

Question 52

KEY - How is antepartum haemorrhage a managed

Answer 52

ME card based on patient.info:

Estimate amount of blood loss. This is often underestimated and needs to combined with an assessment of signs of clinical shock:

Minor haemorrhage = blood loss <50 ml and has stopped.

Major haemorrhage = blood loss 50-1000 ml with no signs of shock.

Massive haemorrhage = blood loss >1000 ml and/or signs of shock.

Fetal monitoring

Arrange urgent ultrasound to exclude placenta praevia; ultrasound cannot exclude placental abruption, which is a clinical diagnosis.

Severe bleeding or Fetal distress: urgent delivery of the baby, irrespective of gestational age. Fetal compromise is an important indicator of reduced circulating blood volume.

Blds - FBC, coagulation screen and G&S (transfusion not expected) cross-match (transfusion-likely).

With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin6 .

Maternal corticosteroids should be offered to any woman at risk of preterm birth, who is between 24+0 and 33+6 weeks of gestation

This is a general card, Once a cause is identified follow the management for those codnitons - placenta praevia (planned delviery at 36 wks and steroids), vasa praevia (planned delivery at 34 weeks) , abruption (likely delivery, may be conservative)

Question 53

What is uterine rupture?

Main risk factor?

How does it present?

Management?

Answer 53

DO NOT CONFUSE UTERINE RUPTURE WITH PLACENTAL ABRUPTION:

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

The main risk factor for uterine rupture is a previous caesarean section - TESTED. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin).

Presentation:
Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of:

• Abdominal pain
• Vaginal bleeding
• Ceasing of uterine contractions
• Hypotension
• Tachycardia
• Collapse

Management
Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 54

DIVIDER

NOW NON LABOUR AND DELIVERY CARDS…

Question 55

What are the steps (5 key ones) to the examination of the pregnant abdomen?

Answer 55

SLeeP EAsy
- introduction, consent and pain?
- GI - previous ECS scar?

Palpation:

• symphyseal-fundal height
• the lie - how many poles can you feel in the fundus
  
  • 1 - longitudinal - most common
  • 2 - transverse (-) or oblique (\ /)
• the presentation- FACE FEET, ballot each pole, cephalic or breech
  
  • head feels boney vs bottom feel softer
• the engagement - how many fifths?
• fetal back → auscultation anterior shoulder (110-160bpm)

Question 56

Pre-eclampsia - Define:
- chronic hypertension
- pregnancy-induced hypertension
- pre-eclampsia
- severe pre-eclampsia
- eclampsia

Answer 56

Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.

Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, notably proteinuria.

Severe pre-eclampsia is pregnancy induced hypertension + proteinuria + neurological (headache, visual dirsturbance, clonus), hepatorenal (deranged LFTs, hepatomegaly, reduced platelets - HELLP), clotting

Eclampsia is when seizures occur as a result of pre-eclampsia.

Question 57

Diagnosis of pre-eclampsia

What test is used in women suspected of having pre-eclampsia

Answer 57

The NICE guidelines (2019) advise a diagnosis can be made with a:

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg

PLUS any of:
1. Proteinuria (1+ or more on urine dipstick)
2. Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
3. Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Question 58

Pathophysiology - by what mechanism does pre-eclampsia lead to eclampsia

Answer 58

This is a me card
Third spacing!!!

Third-spacing occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or “third” space—the nonfunctional area between cells . This can cause potentially serious problems such as oedema, reduced cardiac output, and hypotension. Hypertension -> cerebral oedema -> seizure

yes interstitial fluid usually isn’t a problem, but here there is high pressure leading to too much interstitial fluid -> oedema

Question 59

Pathophysiology of pre-eclampsia. How does pregnancy lead to hypertension?

Answer 59

Lacunae form at around 20 weeks gestation for exchange with chorionic villi. When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation.

Background:
Trophoblast invades endometrium -> Endometrial spiral arteries break down and form lacunae (lakes) in the intervillous space. Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation. These lacunae surround the chorionic villi (a bit like alveoli knots of fetal vessels) , separated by the placental membrane. Oxygen, carbon dioxide and other substances can diffuse across the placental membrane between the maternal and fetal blood.

Look at a diagram xx

Question 60

Medical Management of pre-eclampsia, including prophylaxes

Answer 60

Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with:

A single high-risk factor - chronic hypertension, previous pregnancy induced hypertension, autoimmune disease, diabetes, CKD
Two or more moderate-risk factors - maternal age over 40, BMI over 35, 10+ since previous pregnancy, first pregnancy, family history, multiple pregnancy

Medical management of pre-eclampsia is with:

• Labetolol is first-line as an antihypertensive
• Nifedipine (modified-release) is commonly used second-line
• methyldopa is third line
• IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
• Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Treating to aim for a blood pressure below 135/85 mmHg. Admission for women with a blood pressure above 160/110 mmHg. IV hydralazine may be used in severe pre-eclampsia

Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur. (remember Lisa- birth is the only cure) Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.

In women with pre-exsitng/chronic hypertension - management is the same as pregnancy induced hypertension. They need aspirin prophylaxis, treatment with labetalol -> nifedipine -> methyldopa. Treatment target is 135/85mmHg. Remeber ACE inhibitors are contraindicated, as are ARBs, thiazides.

Question 61

Mx of eclampsia

Answer 61

Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

Question 62

What is baby blues and how is it managed

Answer 62

Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers. It presents with symptoms such as:

• Mood swings
• Low mood
• Anxiety
• Irritability
• Tearfulness

Baby blues may be the result of a combination of:

• Significant hormonal changes
• Recovery from birth
• Fatigue and sleep deprivation
• The responsibility of caring for the neonate
• Establishing feeding
• All the other changes and events around this time

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

Question 63

What is postnatal depression and how is it managed (3)

Answer 63

Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of:

• Low mood
• Anhedonia(lack of pleasure in activities)
• Low energy

Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed.

Treatment is similar to depression at other times:

• Mild casesmay be managed with additional support, self-help and follow up with their GP
• Moderate casesmay be managed withantidepressant medications(e.g. SSRIs) andcognitive behavioural therapy
• Severe casesmay need input from specialist psychiatry services, and rarely inpatient care on themother and baby unit

Note- different to baby blues (huge hormonal and life change for a few weeks after birth)

Question 64

What screening tool is used for post natal depression

Answer 64

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.

There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

Question 65

What is puerperal psychosis? How is it managed?

Answer 65

puerperal - 6 weeks after birth whilst body reverts to non-pregnant condition

Puerperal psychosis is a rare (1 in 1000) but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:

• Delusions
• Hallucinations
• Depression
• Mania
• Confusion
• Thought disorder

Women with puerperal psychosis need urgent assessment and input from specialist mental health services.

Treatment is directed by specialist services, and may involve:

• Admission to themother and baby unit
• Cognitive behavioural therapy
• Medications (antidepressants,antipsychoticsormood stabilisers)
• Electroconvulsive therapy(ECT)

Question 66

What is the most common cause of polyhydramnios

Answer 66

Gestational diabetes - fetus has polyurea

Less liekly but also worth remembering oesophageal atresia - baby not swallowing

Question 67

What is the difference between small for gestational age and interuterine growth restriction

Answer 67

The causes of SGA can be divided into two categories:

SGA - can just be constitutional small (matching the mothers size) and growing steadily on the growth chart

Inter-uterine growth restriction - when the foetus is failing to meet their growth potential (plateau on the foetal growth chart) due to a pathology reducing the amount of nutrients and oxygen being delivered to the foetus through the placenta

Extra…

The causes of fetal growth restriction can be divided into two categories:

Placenta mediated growth restriction - pre-eclampsia, maternal smoking, anaemia, malnutrition
Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

Question 68

CAME UP
What is hyperemesis gravidarum?

What stage of preganacy is N+V worst normally

Answer 68

The severe form of nausea and vomiting in pregnancy is called hyperemesis gravidarum. Hyper- refers to lots, -emesis refers to vomiting and gravida- relates to pregnancy.

Plus 5% weight loss, dehyrdation or electrolyte imbalance

Management is with anti-emetics
- prochlorperazine
- cyclizine
- ondansetron
-metoclopramide

Nausea and vomiting are normal during early pregnancy. Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks. Symptoms can persist throughout pregnancy. It is thought to be caused by placental production of hCG

Question 69

NOT ON THE LIST

9 classes of drugs that are best avoided in pregnancy. all but 2 are contraindicated. Not on the list but i recon very helpful to know.

Answer 69

Not an exhuastive list!

NSAIDs - gnerally avoided because they block prostaglandins (important in maintaining the ductus arteriosus) and delay labour (prostaglandins stimulate uterine contractions). Aspirin works differently.

Beta blockers (except labetalol) - can cause fetal growth restriction, hypoglycemia and bradycardia in the neonate

ACE inhibitors - cross the placenta and cause oligohydramnios (reduced perfusion of foetal kidneys), hypocalvaria (incomplete formation of skill bones), Interuterine death

Opiates - OKAY - can cause neonatal abstinence syndrome after birth (withdrawal). NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.

Warfarin - teratogenic

Sodium valproate - teratogenic

isotretinoin (severe acne) - teratogenic

lithium (mania Rx) - cardiac abnormalities if used in the first trimester. other antipsychotics are preferred

SSRIs - OKAY - are the most commonly used antidepressants in pregnancy. Untreated depression can be significant in pregnancy so needs to be balanced with the risks. Main risk is persistent pulmonary hypertension in the neonate.

Question 70

Gestational diabetes - what are the 2 most significant complications?

Answer 70

The most significant immediate complication of gestational diabetes is a large for dates fetus and macrosomia. This has implications for birth, mainly posing a risk of shoulder dystocia.

The other is neonatal hypoglycaemia. Babies become accustomed to the high glucose levels during pregnancy and struggle to maintain their blood glucose afar birth. Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.

Longer-term, women are at higher risk of developing type 2 diabetes after pregnancy.

Question 71

What is the screening test for gestational diabetes?
Which women are screened?
Interpretation of the results of the screening test?

Answer 71

OGTT around25 weeks is the screening test

Woman with previous gestational diabetes are offered screening shortly after booking clinic and again around 25 weeks gestation

Risk factors that warrent testing for gestational diabetes:
Previous gestational diabetes - OGTT at booking!
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative) - not gestational just tyoe 1 or 2

OGTT is also used when there are features that suggest gestational diabetes:

• Large for dates fetus
• Polyhydramnios (increased amniotic fluid)
• Glucose on urine dipstick - if 2+ glycosuria on one occasion, or 1+ on two occasions.

Normal results are:

Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.

TOM TIP: It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.

Question 72

Management of gestational diabetes

Answer 72

Four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation.

Fasting glucose below 7 - **Diet and exercise -> if not controlled metformin -> insulin **

Insulin + metformin needs straight away to be used if there is a fasting glucose >7, or >6 with macrosomia

Lecture - Metformin if lifestyle not working or sig high, insulin if metformin isnt enough. Targets are 5.3 fasting and 7.8 1 hour post-pyrandial

woman are managed in joint diabetes and antenatal clinics and need to monitor their blood glucose several times a day. Targert blood glucose is <5.3 fasting, <7.8 post meal (very similar to test values 5678)

Women with gestational diabetes can give birth up to 40 + 6. If uncomplicated (no macrosomnia or other pre-eclampsia then 40+6), if complicated GDM then 37-39 and may need sliding scale Insulin infusion during labour

Question 73

How are women with pre-existing diabetes managed in pregnancy? 4 key points

Answer 73

Women with type 2 diabetes are managed using metformin and insulin, and other oral diabetic medications should be stopped.

Retinopathy screening should be performed shortly after booking and at 28 weeks gestation.

Planned delivery between 37-39 weeks is recommended (gestational is up to 41 weeks). Lecture: can be IOL but elective CS is recommended recommended if EFW>4.5kg.

Type 1 diabetes - sliding scale insulin regime during labour.

Question 74

Anaemia in pregnancy :

• At what stage in pregnancy are women screened for anaemia?
• What screening Ix are used? (2 main ones everyone gets)
• what are the normal Hb levels?

Answer 74

Women are routinely screened for anaemia twice during pregnancy:

Booking clinic
28 weeks gestation

Ix
FBC- (Hb level):

Normal Hb levels are 110, 105 and 100 in the 1st, 2nd, 3rd trimester (usually in women 120, men 136)

The mean cell volume (MCV) can indicate the cause of the anaemia:

Low MCV may indicate iron deficiency or (thalassaemia)
Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy
Raised MCV may indicate B12 or folate deficiency

Women are offered haemoglobinopathy screening at the booking clinic for thalassaemia (all women) and sickle cell disease (women at higher risk). Both are causes of severe anaemia in pregnancy - managed with folic acid and transfusions.

Additional investigations are not routinely performed, by may help establish the cause of the anaemia. They may include: Ferritin, B12, Folate

Background:
Defined as low concentration of haemoglobin. During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume.

It is important to optimise the treatment of anaemia during pregnancy so that the woman has reasonable reserves, in case there is significant blood loss during delivery.

Also just makes women feel SOB, fatigue, dizzyness like normal.

Question 75

Management of anaemia in pregnancy, treatment for:
- iron deficiency
- B12 deficiency
- Folate defciency
- haemogloninopathy

Answer 75

Women with anaemia in pregnancy are started on iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron.

B12 deficiency is treated with IM hydroxocobalamin. Often it is physiological (increased plasma volume and B12 requirements) but women with B12 deficiency should have testing for intrinsic factor antibodies (pernicious)

Folate - already on 400mcg. women should go onto 5 mg if folate deficient.

thalassemia and sickle cell - They require high dose folic acid (5mg), close monitoring and transfusions when required

Question 76

What is oligohydramnios? what causes it - 3 key things?

Answer 76

Oligohydramnios occurs when the amniotic fluid index is < 5th centile for gestational age. Amniotic fluid is usually recorded as the amniotic fluid index (Amniotic fluid index is calculated by measuring maximum cord-free vertical pocket of fluid in four quadrants of the uterus and adding them together.

Amniotic fluid is primary comprised of foetal urine output. As such the most common causes of oligohydramnios are:

• premature ROM (amniotic fluid leaks)
• placental insufficiency (blood flow to the brain is prioritised so poor blood flow to foetal kidneys)
• structural problems with the renal kidneys - renal agenesis
• there are others but these are the main ones.

Management then follows a PROM (delivery after 34 weeks, steroids IV magnesium sulfate, erhtyromycin) or a placetnal insufficiency pathway (early delivery, usually before 36 weeks.

Question 77

What is polyhydramnios? Cause?

Answer 77

It is defined by an amniotic fluid index that is above the 95th centile for gestational age (snap - opposite to oligohydramnios)

The main cause for this is idiopathic, but other key causes need to be investigated for:
- structural abnormality - oesophageal/duodenal atresia (down’s sydnrome)
- fetal infection
- gestational diabetes (OGTT)

In contrast to oligohydramnious, if the fetus has no abnormalities then prognosis is good and no management is required. If the maternal symptoms are severe (e.g breathlessness), an aminoreduction can be considered

Question 78

What is small for gestational age

what two measurements on ultrasound are used to assess the foetal size

Answer 78

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age (i think nationally universal growth chart).Severe SGA is when the fetus is below the 3rd centile for their gestational age. Low birth weight is defined as a birth weight of less than 2500g.

Two measurements on ultrasound are used to assess the fetal size:

Estimated fetal weight (EFW)
Fetal abdominal circumference (AC) - i think this is key because if growth restricted the head isnt small but the body is?

This came up and i put head circumferance!

Question 79

Signs of fetal growth restriction - 3

Answer 79

• small for gestational age on scan
• reduced liquor volume
• reduced fetal movements

Question 80

Monitoring for SGA?

Management of Small for gestational age?

what further Ix are performed?

Answer 80

Women at risk or with SGA are** monitored closely with serial ultrasound scans** measuring:

• Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
• Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
• Amniotic fluid volume

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Management
The critical management steps are:

Identifying those at risk of SGA
Aspirin is given to those at risk of pre-eclampsia
Treating modifiable risk factors (e.g. stop smoking)
Serial growth scans to monitor growth
Early delivery where growth is static, or there are other concerns - abnormal doppler results. If pretermdelivery is, corticosteroids may be required.

When a fetus is identified as SGA, investigations to identify the underlying cause include:

Blood pressure and urine dipstick for pre-eclampsia
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotyping for chromosomal abnormalities
Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

Question 81

Which way round - umbilical arteries and veins

Answer 81

The backwards bit is the oxygenation status (bit like the pulmonary system) - the artereis still come after the fetal heart. Remember the palcenta and cord and fetal organs not maternal.

So the 2 umbilical arteries are branches of the fetal iliac arteries carrying deoxygenated blood and waste to the placenta

The umbilical vein carries OXYGENATED blood (the backwards bit) from the placenta to the ductus venosus.

Question 82

When is a foetus considered large for gestational age (macrosomnia)? Main cause? Main risk?

Answer 82

When the weight of the newborn is more than 4.5kg at birth. During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

Main causes:
- constitutional
- gestational diabetes
- maternal obesity
- overdue
- male baby

Complication
- shoulder dystocia -> birth injury (Erbs palsy, clavicular fracture, fetal distress, hypoxia)

Question 83

Ix for large for gestational age babies?

Management?

Answer 83

USS - exclude polyhydramnios and estimate fetal weight

OGGT - for gestational diabetes

Babies are defined as being large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth. During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

Most women with large for gestational age pregnancy will have a successful vaginal delivery. NICE guidelines (2008) advise against induction of labour only on the grounds of macrosomia. Risk of shoulder dystocia can be reduced by delivery on a consultant led unit. However for gestational diabetes delivery is reommended before 40+6 IOLs.

The main risk with a large for gestational age baby is shoulder dystocia. The risks at delivery can be reduced by Delivery on a consultant lead unit, in case SD occours.

Question 84

SGA babies are monitored with serial ultrasound scans (growth scans). What three things are measured on scan.

Answer 84

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring:

• Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
• Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
• Amniotic fluid volume

FAR BEYOND MED SCHOOL BUT USEFUL:
A raised pulsatility index suggests impaired placental perfusion. NOTE THIS- IT IS INVERSELY PROPORTIONAL TO PERFUSION. In normal pregnancies, umbilical PI starts at high values and then decreases progressively toward term. This indicates that normal placental development entails a progressive decrease in the impedance of the umbilical vascular bed to blood flow.

My understanding - it is the difference in blood flow in the umbilical artery (from fetus to placenta) between the peak systolic flow (fetal heart beating) and end diastolic flow. if the placental resistance is high then there is a big difference because when the fetal heart is in diastole the flow is massively reduced.

Question 85

Retained products of conception:
- definition
- presentation
- diagnosis
- management

Answer 85

Retained products of conception refers to when pregnancy-related tissue (e.g. placental tissue or fetal membranes) remain in the uterus after delivery. It can also occur after miscarriage or termination of pregnancy.

Sx:
- vaginal bleeding that doesnt improve with time
- abnormal vaginal discharge
- pelvic pain
- fever - infection

Diagnosis is with Ultrasound

Management:
Surgical! ERPC -evacuation of RPC under GA.

Key complications are endometritis and ashermans syndrome (damaged endometrium leads to adhesions).

Question 86

What is postpartum endometritis?

Answer 86

Endometritis refers to inflammation of the endometrium, usually caused by infection. It can occur in the postpartum period, as infection is introduced during or after labour and delivery. The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.

Endometritis occurs more commonly after caesarean section compared with vaginal delivery. Prophylactic antibiotics are given during a caesarean to reduce the risk of infection.

Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria.

Endometritis can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea. When endometritis occurs unrelated to pregnancy and delivery, it is usually part of pelvic inflammatory disease, which is covered elsewhere.

Question 87

Post partum endometritis

• Presentation
• Diagnosis and managment

Answer 87

Sx:
Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis

Ix:
- Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
- Urine culture and sensitivities
- Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).
- blood cultures if septic

Management:
- Septic patients - septic six, broad-spectrum IV antibiotics - clindamycin and gentamicin
- milder symptoms -co-amoxiclav (BS oral)

Question 88

VTE in pregancy - what prophalaxis is used and criteria for is offering it?

Answer 88

VTE - includes DVT and PE (potentially fatal). Oestrogen in pregnancy makes the blood hypercoagulable. thrombus also occours due to stagnation of blood.

PE is a significant cause of maternal death. The risk is highest in the postpartum period

Women should have their VTE risk assessed at booking and again at birth.

The RCOG guidelines (2015) advise starting prophylaxis with LMWH from:
- 28 weeks if there are three risk factors
- First trimester if there are four or more of these risk factors

It is continued throughout the antenatal period and for six weeks postnatally. Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals).

Don’t rote learn these - risk factors for VTE in pregnancy:
- smoking
- parity 3<
- age 35<
- BMI 30<
- pre-eclampsia
- gross varicose vains
- imobility
- IVF
- family history
- thrombophilia

Question 89

What is the main prenancy-related complication of genital herpes? What is the managment?

Answer 89

The main issue with genital herpes during pregnancy is the risk of neonatal herpes simplex infection contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality.

Management:
Management of genital herpes in pregnancy depends on whether it is the first episode of genital herpes (primary infection) or recurrent genital herpes.

Primary gential herpes contracted before 28 weeks:
- aciclovir during the inital infection
- prophalactic aciclovir from 36 weeks
- if asymptomatic they can have a normal delivery, if symptomatic then caesarean section.

Primary genital herpes contracted after 28 weeks gestation
- the same as above (inital and prophalactic aciclovir) however, Caesarean section is recommended in all cases to reduce the risk of neonatal infection.

Recurrent gential herpes (infected before pregnancy -> antibodies cross the placenta)
- low risk of neonatal infeciton even if symptomatic during delivery, so vaginal delivery is possible
- prophalactic aciclovir is considered from 36 weeks

Question 90

Management of HIV in pregnancy

Answer 90

The mother’s viral load will determine the mode of delivery:

• <50 - normal vedilvery
• > 50 - consider a pre-labour caesarean section
• > 400 - pre-labour caesarean section is recommended

Zidovudine:
IV zidovudine is given during labour and delivery if the viral load is >1000 or unknown

prophalatic zidovudine is given to baby regardless or viral load, with additonal drugs for high risk babies

Breast feeding:
HIV can be trasnmitted through breastfeeding so it is avoided. It can be attempted with monitoring if the viral load is undetectable.

Me - women should continue taking their ART during prenancy, many are safe a few arent - i think way more specialist than your level x

Question 91

KEY
What is involved in Antenatal screening for Down’s Syndrome? What happens if the results are high risk?

Answer 91

First line - the combined test:
- performed between 11 and 14 weeks gestation
- screens for trisomy’s - down’s syndrome, Edward’s and Patau’s syndrome (down’s- lifelong learning disabilities and cardiac abnormalities, the other two are incompatible with life)
- combines results from ultrasound and maternal blood tests
- ultrasound - nuchal translucency (neck thickness) >6mm
- Maternal blood tests for two hormones - Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk; Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk

• other screening tests include the triple and quadruple test - Inhibin A and oestrradiol for 14-20 weeks

The screening test provide a risk score for the fetus having down’s syndrome. If the screening tests come back as high risk the woman if offered further testing. This involves taking a sample of fetal cells for karyotyping:
- Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).-
- Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
- Non-invasive prenatal testing (NIPT) testing is a new, non invasive test that examines fragments of DNA in the maternal blood, arising from the placental tissue to detect down’s. It is not a definitive test (like the invasive) but it is very good.

Question 92

Treatment of post-partum anaemia

Answer 92

Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.

Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):

Hb under 100 g/l – start oral iron (e.g. ferrous sulfate)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron

Question 93

Urinary tract infection in pregnancy:

Lower urinary tract infection involves infection in the bladder, causing cystitis (inflammation of the bladder). Upper urinary tract infection involves infection up to the kidneys, called pyelonephritis.

What is the main risk of UTI in pregnancy?

Unlike the rest of the population, pregnant women checked for asymptomatic bacteriuria. How is this done?

Causes of UTI in pregnancy - Bacterial species?

KEY - Management:
- How many days
- drug choice? - 3 things to know, which drugs should you be cautious with

Answer 93

Pregnant women are at higher risk of developing lower urinary tract infections and pyelonephritis. Urinary tract infections in pregnant women increase the risk of preterm delivery. They may also increase the risk of other adverse pregnancy outcomes, such as low birth weight and pre-eclampsia.

Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth. Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S).

Ix:
Urine Dipstick - Nitrites are a more accurate indication of infection than leukocytes.

During pregnancy, midstream urine (MSU) samples are routinely sent to the microbiology lab to be cultured and to have sensitivity testing.

Causes:
KEEPS Mnemonic
Klebsiella pneumoniae (gram-negative anaerobic rod)
Escherichia coli (E. coli) - MOST COMMON (found in faeces and spreads to bladder).
Enterococcus
Pseudomonas aeruginosa - me also proteus babes xx
Staphylococcus saprophyticus
Candida albicans (fungal) - an addition to KEEPS

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Management

ME - ASYMPTOMATIC BACTERURIA - PRESCRIBE IMMEDIATELY, NO FURTHER IX

Urinary tract infection in pregnancy requires 7 days of antibiotics.

The antibiotic options are:

Nitrofurantoin (avoid in the third trimester- neonatal haemolysis)
Amoxicillin (only after sensitivities are known)
Cefalexin

Trimethoprim is avoided in pregnancy - folate antagonist

Note for context- non pregnant women is Trimethoprim or Nitro for 3 days, a week is long…

Question 94

Multiple pregnancy- what are the types of twins in terms of zygotic, amniotic and chorionic. Which types of twin have the best outcomes?

Answer 94

There are some key definitions to become familiar with relating to twin and multiple pregnancy:

Monozygotic: identical twins (from a single zygote that then splits in two)
Dizygotic: non-identical (from two different zygotes- 2 eggs, two sperm)
Monoamniotic: single amniotic sac
Diamniotic: two separate amniotic sacs
Monochorionic: share a single placenta
Dichorionic: two separate placentas

The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Question 95

How is multiple prengnancy diagnosed?

Signs - how are different types of twins diagnosed?

Answer 95

Multiple pregnancy is usually diagnosed on the booking ultrasound scan. Ultrasound is also used to determine the:

Gestational age
Number of placentas (chorionicity) and amniotic sacs (amnionicity)
Risk of Down’s syndrome (as part of the combined test)

When determining the type of twins using an ultrasound scan:

Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
Monochorionic diamniotic twins have a membrane between the twins, with a T sign
Monochorionic monoamniotic twins have no membrane separating the twins

The lambda sign, or twin peak sign, refers to a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane. This indicates a dichorionic twin pregnancy (separate placentas).

The T sign refers to where the membrane between the twins abruptly meets the chorion, giving a T appearance. This indicates a monochorionic twin pregnancy (single placenta).

Question 96

What is twin-twin transfusion syndrome?

Name a a very similar but less severe condition?

Answer 96

Twin-Twin Transfusion Syndrome

Twin-twin transfusion syndrome occurs when the fetuses share a placenta - monochorionic. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses.

When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the fetuses.

Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Question 97

Management of multiple pregnancy:

• additional antenatal magement x2
• birth is planned for what gestation
• mode of delivery - monoamniotic twins? diamniotic twins?

Answer 97

Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:

Booking clinic
20 weeks gestation - ADDITIONAL, the others are standard for all mothers
28 weeks gestation

Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome:

2 weekly scans from 16 weeks for monochorionic twins
4 weekly scans from 20 weeks for dichorionic twins

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Planned early delivery is used to help reduce the risk of fetal death. The dates of delivery varies from 32 weeks for monochorionic monoamniotic twins to 37-38 weeks for dichorionic diamniotic twins.

Corticosteroids are given before delivery to help mature the lungs

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Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks.

Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks):

Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
Caesarean section may be required for the second baby after successful birth of the first baby (if breech they might try conversion still, or breech vaginal delivery, or CS)
Elective caesarean is advised when the presenting twin is not cephalic presentation

Question 98

3 reasons - Why is chicken pox is dangerous in pregnancy?
- test for immunity
- management of chicken pox exposure in pregnancy - 3 things
- management of chicken pox infection in pregnancy - 1 thing
- Risk to the fetus?

Answer 98

Chickenpox is caused by the varicella zoster virus (VZV). It is dangerous in pregnancy because it can lead to:

• More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
• Fetal varicella syndrome
• Severe neonatal varicella infection (if infected around delivery)

Mothers that have previously had chickenpox are immune and safe. When in doubt, IgG levels for VZV can be tested. A positive IgG for VZV indicates immunity. Women that are not immune to varicella may be offered the varicella vaccine before or after pregnancy** - cannot give during pregnancy!**

Exposure to chickenpox in pregnancy:

• When the pregnant woman has previously had chickenpox, they are safe
• When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe.
• When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.
• When the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.

Congenital varicella syndrome occurs in around 1% of cases of chickenpox in pregnancy. It occurs when infection occurs in the first 28 weeks of gestation. The typical features include:

Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes located in specific dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)

Question 99

What is the main risk of Group B strept infection in pregnancy?

What two infections does it cause in prengnancy?

Management?

Answer 99

Group B streptococcus (GBS/ Streptococcus agalactiae) is a commensal bacterium found in the vagina or rectum of ~25% of pregnant women.

In most cases, this colonisation causes no symptoms or sequelae. However, sometimes, particularly in the presence of certain risk factors, GBS can cause an neontal infection (typically sepsis, pneumonia, or meningitis) – early onset GBS disease of the newborn.

The incidence rate of early onset GBS is 0.05%. There is a 5% mortality rate in babies that develop GBS.

The RCOG recommends that GBS is not screened for routinely, so only women identified as being high risk for GBS infection will be tested. High risk may include those with symptoms of UTI or chorioamnionitis during pregnancy, those with STI symptoms pre-pregnancy or those with a previous GBS infected baby. Prematurity is another risk factor.

Ix:
- vaginal and rectal swabs
- urine culture

Management:
High dose intravenous penicillins (usually benzylpenicillin (Pen G), or cefuroxime or clindamycin in penicillin-allergic patients) throughout labour will be indicated in women with:

GBS positive swabs
A UTI caused by GBS during this pregnancy
Previous baby with GBS infection.
Pyrexia during labour
Preterm Labour
Rupture of membranes >18 hours

GBS positive and PROM is an indication for immediate induction.

Caesarian does not require antibiotics because baby is exposed to GBS after ROM.

Question 100

Chlamydia management in preganacy vs normally?

Pregnancy related complications of chlamydia?

Answer 100

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.

Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:

• Azithromycin
• Erythromycin
• Amoxicillin

A test of cure is not routinely recommended. However, a test of cure should be used in pregnancy.

///
Pregnancy-related complications include:

Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)

Chlamydial conjunctivitis can affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.

Question 101

Gonnorrhoea Management in Pregnancy vs Normal

What is the key complication of gonorrhoea infection in pregnancy?

Answer 101

For uncomplicated gonococcal infections:

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

In Pregnancy:

A single dose of intramuscular ceftriaxone 1g - SAME AS ABOVE
Azithromycin can be used if not possible to give ceftriaxone.
DO NOT PRESCRIBE QUINOLONE ANTIBIOTICS (CIPROFLACCICIN) TO PREGNANT PEOPLE

All patients should have a follow-up “test of cure.”

Pregnancy complications, including spontaneous abortion, premature labour, early rupture of fetal membranes, perinatal mortality, and gonococcal conjunctivitis in the newborn. me - It is basically the same as chlamydia

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

Question 102

Syphillis in Pregnancy:
- How is syphillis transmitted?
- Ix used to screen for syphillis in pregnancy?
- complications of syphillis in pregnancy?
- Rx?
- how is baby assessed at birth?

Answer 102

Syphillis can be transmitted vertically from mother to baby during pregnancy. It is part of three diseases that are screened for with a blood test at the midwife booking appointment (HIV, Hep B, syphillis). If the syphillis is identified and treated with Antibiotics early in the pregnancy, there is low chance of transmission to the foetus. The baby may also be examed after birth to access if it needs treatment for syphillis.

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.

Untreated syphilis infection in pregnancy is associated with multiple adverse outcomes including hydrops, preterm labour, low birth weight, foetal loss and congenital syphilis in the newborn. Congenital syphillis can present with a large variety of health problems (neurological, hepatomegaly, rashes…) in the first few weeks of life or years later.

A single deep intramuscular dose of benzathine benzylpenicillin (penicillin G) is the standard treatment for syphillis

Examination and blood tests in the baby at birth to access for congential syphillis, and treatment if required (IV penecillin) - EVEN ASX BABIES ARE TESTED

Question 103

Trichomoniasis in pregnancy:
- 2 key complications
- presentation - 2 unique things to remember
- management

Answer 103

Trichomonas vaginalis is a type of protozoan spread through sexual intercourse.

Pregnancy-related complications such as preterm delivery and low birthweight infant (<2500g). It also predisposes for maternal postpartum sepsis

Presentation:
- itchying, dysuria, dypareunia
- vaginal discharge - the typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
- Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.

The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).

Treatment is with metronidazole for 7 days. High-dose metronidazole (2 g single dose) is not recommended during pregnancy and breastfeeding - note, this is a possible treatment for non-pregnant individuals.

Question 104

Uterine Rupture vs Placental Abruption:
- what are they
- risk factors
- presentation

Answer 104

Uterine Rupture: A full-thickness tear in the uterine wall, often at the site of a previous surgical scar (e.g., cesarean section or myomectomy).

Placental Abruption: Premature separation of the placenta from the uterine wall before delivery.

Common Causes:

Uterine Rupture:
Prior uterine surgery (e.g., cesarean section, myomectomy).
Trauma (e.g., car accidents, uterine instrumentation).
Excessive uterine stimulation (e.g., from oxytocin or prostaglandins).
Obstructed labor or macrosomia.

Placental Abruption: Not linked to prioir CS
Hypertension (chronic or preeclampsia).
Trauma (e.g., motor vehicle accidents).
Smoking, cocaine use.

Presentations :
- both show CTG compromise, PV bleeding (althought can be concelled) and abdominal pain
- UR: Contractions typically stop and the uterus lose tone or feel irregular due to the disruption of the uterine wall and leaking of fetal parts or amniotic fluid into the peritoneal cavity.
- PA: The uterus becomes hypertonic (INCREASED) and may feel rigid or board-like or woody due to ongoing bleeding behind the placenta causing myometrial irritation.

Management is similar with both requiring EMCS although less severe abruptions are less urgent…

Question 105

When in pregnancy do all women routinely routine US scans?

Answer 105

In the UK, pregnant women are typically offered at least two ultrasound scans during their pregnancy:

• 12 week dating scan: During this scan, the sonographer will measure the baby and use the measurements to estimate the due date.
• 20 week Fetal anomoly scan