Womens health continued Flashcards

Question

what is endometrial hyperplasia

Answer 1

precancerous condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time

Answer 2

hyperplasia without atypia atypical hyperplasia

Answer 3

progestogens, with either: Intrauterine system (e.g. Mirena coil) Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

Answer 4

unopposed oestrogen Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Obesity Polycystic ovarian syndrome Tamoxifen type 2 diabetes hereditary nonpolyposis colorecta cancer/lynch syndrome

Answer 5

one of: The combined contraceptive pill An intrauterine system (e.g. Mirena coil) Cyclical progestogens to induce a withdrawal bleed.

Answer 6

Combined contraceptive pill Mirena coil Increased pregnancies Cigarette smoking

Answer 7

it reduces the risk of it as it is anti-oestrogenic Oestrogen may be metabolised differently in smokers Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme Smoking destroys oocytes (eggs), resulting in an earlier menopause

Answer 8

postmenopausal bleeding Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal vaginal discharge Haematuria Anaemia Raised platelet count

Answer 9

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than 12 months after the last menstrual period) NICE also recommends referral for a transvaginal ultrasound in women over 55 years with: Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Answer 10

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause) Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer Hysteroscopy with endometrial biopsy

Answer 11

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer: Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 12

The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO other treatment options include: A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina Radiotherapy Chemotherapy Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Answer 13

Epithelial cell tumours dermoid cysts/germ cell tumours sex cord stromal tumours metastasis

Answer 14

Epithelial cell tumours (tumours arising from the epithelial cells of the ovary) are the most common type. Subtypes of epithelial cell tumours include: Serous tumours (the most common) Endometrioid carcinomas Clear cell tumours Mucinous tumours Undifferentiated tumours

Answer 15

These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).

Answer 16

These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

Answer 17

a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.

Answer 18

Age (peaks age 60) BRCA1 and BRCA2 genes (consider the family history) Increased number of ovulations Obesity Smoking Recurrent use of clomifene early onset periods late menopause no pregnancies

Answer 19

Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk: Combined contraceptive pill Breastfeeding Pregnancy

Answer 20

non specific symptoms: Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites ovarian mass may press on the obturator nerve and cause referred hip/groin pain

Answer 21

Refer directly on a 2-week-wait referral if a physical examination reveals: Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass carry out further investigations before referral in women presenting with symptoms of possible cancer with a CA125: new Sx of IBS, abdo bloating, early satiety, pelvic pain, urinary frequency and weight loss

Answer 22

primary care: CA125 blood test (>35IU/ml is sig) and pelvic ultrasound look at the risk of malignancy index which takes into account: menopausal status, ultrasound findings and CA125 levels imaging: CT, histology, pancreatitis

Answer 23

require tumour markers for a possible germ cell tumour - alpha fetoprotein - human chorionic gonadotropin

Answer 24

CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125: Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 25

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is: Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 26

Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.

Answer 27

squamous cell carcinomas

Answer 28

Advanced age (particularly over 75 years) Immunosuppression Human papillomavirus (HPV) infection Lichen sclerosus Around 5% of women with lichen sclerosus get vulval cancer.

Answer 29

it is a premalignant condition which affects the squamous epithelium of the skin that can precede vulval cancer

Answer 30

it is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.

Answer 31

alternative type of VIN associated with lichen sclerosus and typically occurs in older women (aged 50 – 60 years).

Answer 32

Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation

Answer 33

Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: Irregular mass Fungating lesion Ulceration Bleeding

Answer 34

Suspected vulval cancer should be referred on a 2-week-wait urgent cancer referral. Establishing the diagnosis and staging involves: Biopsy of the lesion Sentinel node biopsy to demonstrate lymph node spread Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 35

The International Federation of Gynaecology and Obstetrics (FIGO) system is used to stage vulval cancer.

Answer 36

Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy

Answer 37

when a couple has been trying to conceive for 12 months without success

Answer 38

Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%) 40% of infertile couples have a mix of male and female causes.

Answer 39

The woman should be taking 400mcg folic acid daily Aim for a healthy BMI Avoid smoking and drinking excessive alcohol Reduce stress as this may negatively affect libido and the relationship Aim for intercourse every 2 – 3 days Avoid timing intercourse

Answer 40

in primary care: BMI, chlamydia screen, semen analysis, female hormone testing, rubella immunity in mother in secondary care: ultrasound of pelvis, hysterosalpingogram, laparoscopy and dye test

Answer 41

Serum LH and FSH on day 2 to 5 of the cycle Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle). Anti-Mullerian hormone Thyroid function tests when symptoms are suggestive Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea

Answer 42

Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Answer 43

type of scan used to assess the shape of the uterus and the patency of the fallopian tubes, via a small tube which is inserted into the cervix and a contrast medium is injected into the uterine cavity and fallopian tubes. If the dye doesnt fill the tubes then this will be seen on X ray and suggests obstruction tubal cannulation under Xray guidance can be performed during the procedure to open the tubed

Answer 44

During the procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes. This will not be seen when there is tubal obstruction. During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these.

Answer 45

weight loss for overweight patients clomifene letrozole - used instead of clomifene to stimulate ovulation gonadotropins - stimulate ovulation in women resistant to clomifene ovarian drilling metformin

Answer 46

anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH. it is used to help stimulate ovulation

Answer 47

Tubal cannulation during a hysterosalpingogram Laparoscopy to remove adhesions or endometriosis In vitro fertilisation (IVF)

Answer 48

surgical sperm retrieval surgical correction of obstruction is present intra-uterine insemination intracytoplasmic sperm injection - injecting sperm directly into cytoplasm of egg donor insemination

Answer 49

Abstain from ejaculation for at least 3 days and at most 7 days Avoid hot baths, sauna and tight underwear during the lead up to providing a sample Attempt to catch the full sample Deliver the sample to the lab within 1 hour of ejaculation Keep the sample warm (e.g. in underwear) before delivery

Answer 50

Several lifestyle factors may affect the results of semen analysis and the quality and quantity of sperm: Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 51

Semen volume (more than 1.5ml) Semen pH (greater than 7.2) Concentration of sperm (more than 15 million per ml) Total number of sperm (more than 39 million per sample) Motility of sperm (more than 40% of sperm are mobile) Vitality of sperm (more than 58% of sperm are active) Percentage of normal sperm (more than 4%)

Answer 52

it is a high number of sperm in a sample - more than 250 million per ml

Answer 53

it is a reduced number of sperm in the semen sample: Mild oligospermia (10 to 15 million / ml) Moderate oligospermia (5 to 10 million / ml) Severe oligospermia (less than 5 million / ml)

Answer 54

refers to very few sperm in the semen sample (less than 1 million / ml).

Answer 55

Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to: Pathology of the pituitary gland or hypothalamus Suppression due to stress, chronic conditions or hyperprolactinaemia Kallman syndrome

Answer 56

Testicular damage from: Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer

Answer 57

Klinefelter syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia (absent testes)

Answer 58

Obstruction preventing sperm being ejaculated can be caused by: Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens (may be associated with cystic fibrosis) Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Answer 59

The initial steps for investigating abnormal semen analysis include a history, examination, repeat sample and ultrasound of the testes. Hormonal analysis with LH, FSH and testosterone levels Genetic testing Further imaging, such as transrectal ultrasound or MRI Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction Testicular biopsy

Answer 60

Management depends on the underlying cause, and can involve: Surgical sperm retrieval where there is obstruction Surgical correction of an obstruction in the vas deferens Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg Donor insemination involves sperm from a donor

Answer 61

fertilising an egg with sperm in a lab, then injecting the resulting embryo into the uterus

Answer 62

Each attempt has a roughly 25 – 30% success rate at producing a live birth.

Answer 63

Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfer

Answer 64

two protocols 1. GnRH agonists - goserelin injected in the luteal phase which stimulates the pituitary gland to secrete high FSH/LH. This causes negative feedback and the natural production of GnRH is suppressed 2. GnRH antagonist protocol: daily subcutaneous infections of GnRH antagonist starting from day 5-6 of ovarian stimulation. This suppresses LH

Answer 65

it involves using medications to promote the development of multiple follicles in the ovaries - done with subcutaneous injections of FSH over 10-14 days - when enough follicle have developed to an adequate size, FSH is stopped and hCG is given to stimulate the final maturation of the follicles

Answer 66

a needle is inserted through the vaginal wall into each ovary to aspirate the fluid from each follicle which will contain the mature oocytes - done under guidance of transvaginal ultrasound scan and under sedation (Not GA)

Answer 67

The male produces a semen sample around the time of oocyte collection. Frozen sperm from earlier samples may be used. The sperm and egg are mixed in a culture medium. Thousands of sperm need to be combined with each oocyte to produce enough enzymes (e.g. hyaluronic acid) for one sperm to penetrate the corona radiata and zona pellucida and fertilise the egg.

Answer 68

Dishes containing the fertilised eggs are left in an incubator and observed over 2 – 5 days to see which will develop and grow. They are monitored until they reach the blastocyst stage of development (around day 5).

Answer 69

After 2 – 5 days, the highest quality embryos are selected for transfer. A catheter is inserted under ultrasound guidance through the cervix into the uterus. A single embryo is injected through the catheter into the uterus, and the catheter is removed. Generally, only a single embryo is transferred. Two embryos may be transferred in older women (i.e. over 35 years). Any remaining embryos can be frozen for future attempts at transfer.

Answer 70

around day 16

Answer 71

progesterone - used to mimic the progesterone released by the corpus luteum during a typical pregnancy

Answer 72

Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome There is a small risk of complications relating to the egg collection procedure: Pain Bleeding Pelvic infection Damage to the bladder or bowel

Answer 73

it is a complication of ovarian stimulation during IVF infertility treatment and is associated with the use of hCG to mature the follicles during the final steps of ovarian stimulation

Answer 74

an increase in VEGF released by the granulosa cells of the follicles. This increased vascular permeability causing fluid to lead from the capillaries which can move into the extravascular space and cause oedema, ascites and hypovolaemia use of LH/FSH during ovarian stimulation results in the development of multiple follicles. OHSS is provoked by the trigger injection of hCG which stimulates the release of VEGF from follicles and cause the condition

Answer 75

Younger age Lower BMI Raised anti-Müllerian hormone Higher antral follicle count Polycystic ovarian syndrome Raised oestrogen levels during ovarian stimulation

Answer 76

Women are individually assessed for their risk of developing OHSS. During stimulation with gonadotrophins, they are monitored with: Serum oestrogen levels (higher levels indicate a higher risk) Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)

Answer 77

Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol) Lower doses of gonadotrophins Lower dose of the hCG injection Alternatives to the hCG injection (i.e. a GnRH agonist or LH)

Answer 78

Early OHSS presents within 7 days of the hCG injection. Late OHSS presents from 10 days onwards. Features of the condition include: Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)

Answer 79

Mild: Abdominal pain and bloating Moderate: Nausea and vomiting with ascites seen on ultrasound Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%) Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

Answer 80

Oral fluids Monitoring of urine output Low molecular weight heparin (to prevent thromboembolism) Ascitic fluid removal (paracentesis) if required IV colloids (e.g. human albumin solution) - patients with mild to moderate are usually managed as an outpatient. Severe cases require admission and critical cases may require admission to ICU

Answer 81

Haematocrit - when this goes up, this indicates less fluid in the intravascular space as the blood is becoming more concentrated

Answer 82

it is three or more consecutive miscarriages

Answer 83

10% in women aged 20 – 30 years 15% in women aged 30 – 35 years 25% in women aged 35 – 40 years 50% in women aged 40 – 45 years

Answer 84

Three or more first-trimester miscarriages One or more second-trimester miscarriages

Answer 85

Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities Genetic factors in parents (e.g. balanced translocations in parental chromosomes) Chronic histiocytic intervillositis Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

Answer 86

disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

Answer 87

Low dose aspirin Low molecular weight heparin (LMWH)

Answer 88

Factor V Leiden (most common) Factor II (prothrombin) gene mutation Protein S deficiency

Answer 89

Uterine septum (a partition through the uterus) Unicornuate uterus (single-horned uterus) Bicornuate uterus (heart-shaped uterus) Didelphic uterus (double uterus) Cervical insufficiency Fibroids

Answer 90

rare cause of recurrent miscarriage, particularly in the second trimester histocytes and macrophages build up in the placenta causing inflammation and adverse outcomes

Answer 91

placental histology showing infiltrates of mononuclear cells in the intervillous spaces

Answer 92

Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic ultrasound Genetic testing of the products of conception from the third or future miscarriages Genetic testing on parents

Answer 93

depends on underlying cause PRISM trial that suggests a benefit to using vaginal progesterone pessaries during early pregnancy for women with recurrent miscarriages presenting with bleeding

Answer 94

The legal framework for a termination of pregnancy is the 1967 Abortion Act. The 1990 Human Fertilisation and Embryology Act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks. - two registered medical practitioners must sign to agree an abortion is indicated - must be carried out in NHS hospital or approved premise

Answer 95

An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of: - The woman - Existing children of the family The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

Answer 96

Continuing the pregnancy is likely to risk the life of the woman Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 97

- abortion services can be accessed by self referral, by GP, GUM or family planning - Marie stopes UK is a remote service for women less than 10 weeks pregnant - women should be offered counselling and information to help decision making from a trained practitioner - informed consent is essential

Answer 98

Mifepristone (anti-progestogen) - halts the pregnancy and relaxing the cervix misoprostol (prostaglandin analogue) 1-2 days later - softens cervix and stimulates uterine contractions rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis

Answer 99

cervical dilation and suction of the contents of the uterus (usually up to 14 weeks) cervical dilation and evacuation using forceps (between 14 and 24 weeks) - prior to surgical abortion medications are used for cervical priming which involves softening and dilating of the cervix: misoprostol, mifepristone or osmotic dilators - rhesus negative women having surgical TOP should have anti-D prophylaxis

Answer 100

women may experience vaginal bleeding and cramps for up to 2 weeks after the procedure a urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete contraception is discussed and started where appropriate

Answer 101

Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures

Answer 102

8-12 weeks

Answer 103

hyperemesis gravidarum

Answer 104

RCOG guideline (2016) diagnoses hyperemesis are protracted nausea and vomiting in pregnancy plus: More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance

Answer 105

The severity can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15: < 7: Mild 7 – 12: Moderate > 12: Severe

Answer 106

Antiemetics: 1. prochlorperazine (stemetil) 2. cyclizine 3. ondansetron 4. metoclopramide ranitidine and omeprazole can be used if acid reflux is a problem mild cases can be managed with oral antiemetics, moderate-severe cases may require ambulatory care or admission

Answer 107

Unable to tolerate oral antiemetics or keep down any fluids More than 5 % weight loss compared with pre-pregnancy Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant) Other medical conditions need treating that required admission

Answer 108

IV or IM antiemetics IV fluids (normal saline with added potassium chloride) Daily monitoring of U&Es while having IV therapy Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome) Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission

Answer 109

- needs to be well controlled for at least three months before becoming pregnant - often the symptoms of RA will improve with - pregnancy and flare after delivery - treatment regime will need to be altered by a specialist: methotrexate is contraindicated, hydroxychloroquine is safe and considered first line. sulfasalazine is safe and corticosteroids may be used during flare ups

Answer 110

tend to be avoided due to them blocking prostaglandins (important in maintaining the ductus arteriosus as well as softening cervix and stimulating contractions) unless they are really necessary - particularly avoided in third trimester

Answer 111

they are used most frequently in pregnancy for high blood pressure caused by pre eclampsia - labetalol is 1st line

Answer 112

Fetal growth restriction Hypoglycaemia in the neonate Bradycardia in the neonate

Answer 113

they can reduce the production of urine in the fetus, as well as hypocalvaria which is the incomplete formation of the skull bones. Use can also cause: Oligohydramnios (reduced amniotic fluid) Miscarriage or fetal death Renal failure in the neonate Hypotension in the neonate

Answer 114

withdrawal symptoms in the neonate after birth. This is called neonatal abstinence syndrome (NAS). NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.

Answer 115

no it is considered teratogenic, it can cause: Fetal loss Congenital malformations, particularly craniofacial problems Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding

Answer 116

neural tube defects and developmental delay.

Answer 117

it is avoided in pregnant women or those planning on getting pregnant - avoided particularly in the 1st trimester as it is linked to congenital cardiac abnormalities particularly Ebsteins anomaly

Answer 118

the risks need to be balanced against the benefits, as there are side effects in pregnancy: First-trimester use has a link with congenital heart defects First-trimester use of paroxetine has a stronger link with congenital malformations Third-trimester use has a link with persistent pulmonary hypertension in the neonate Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management

Answer 119

it is a retinoid medication and is used to treat severe acne it is highly teratogenic and women taking it should be on very reliable contraception before, during and for one month after

Answer 120

NO - pregnant women shouldnt receive live vaccines

Answer 121

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

Answer 122

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.

Answer 123

oral aciclovir if they present within 24 hours and are more than 20 weeks gestation

Answer 124

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)

Answer 125

high rate of miscarriage or fetal death. It can also cause severe neonatal infection.

Answer 126

Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures

Answer 127

infection caused by toxoplasma gondii causes: Intracranial calcification Hydrocephalus Chorioretinitis (inflammation of the choroid and retina in the eye)

Answer 128

can lead to several complications, particularly in the first and second trimesters. Complications are: Miscarriage or fetal death Severe fetal anaemia caused by infection of the erythroid progenitor cells in the bone marrow/liver Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome - mirror syndrome

Answer 129

Women suspected of parvovirus infection need tests for: IgM to parvovirus, which tests for acute infection within the past four weeks IgG to parvovirus, which tests for long term immunity to the virus after a previous infection Rubella antibodies (as a differential diagnosis)

Answer 130

Microcephaly Fetal growth restriction Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

Answer 131

When a woman that is rhesus-D negative becomes pregnant, we have to consider the possibility that her child will be rhesus positive Fetal blood will be exposed to the mothers circulation and the mother will be primed/sensitised to the rhesus D antigens usually this doesnt cause issues in the first pregnancy, however subsequent pregnancies the mothers anti D antibodies can cross the placenta. If the fetus is rhesus positive these antibodies will attack the babies red blood cells. This is called haemolytic disease of the newborn

Answer 132

IM anti-D injections given to rhesus negative mothers which works by attaching itself to the rhesus antigens and cause them to be destroyed.

Answer 133

Anti-D injections are given routinely on two occasions: 28 weeks gestation Birth (if the baby’s blood group is found to be rhesus-positive)

Answer 134

Anti-D injections should also be given at any time where sensitisation may occur, such as: Antepartum haemorrhage Amniocentesis procedures Abdominal trauma - given within 72 hours of sensitisation event

Answer 135

it is a check of how much fetal blood has passed into the mothers during a sensitisation event (after 20 weeks) - adding acid to a sample of mothers blood, and as fetal haemoglobin is more resistant to acid it persists in response to the added acid while maternal blood is destroyed

Answer 136

it is measures below the 10th centile

Answer 137

estimated fetal weight fetal abdominal circumference

Answer 138

ethnic group weight height parity

Answer 139

then the fetus is below the 3rd centile for their gestational age

Answer 140

a birth weight of less than 2500g

Answer 141

Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)

Answer 142

Small for gestational age simply means that the baby is small for the dates, without stating why. The fetus may be constitutionally small, growing appropriately, and not at increased risk of complications. Alternatively, the fetus may be small for gestational age due to pathology (i.e. FGR), with a higher risk of morbidity and mortality.

Answer 143

Placenta mediated growth restriction Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

Answer 144

Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions

Answer 145

Genetic abnormalities Structural abnormalities Fetal infection Errors of metabolism

Answer 146

Reduced amniotic fluid volume Abnormal Doppler studies Reduced fetal movements Abnormal CTGs

Answer 147

Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia long term complications include: CVD (hypertension), type 2 diabetes, obesity and mood and behavioural problems

Answer 148

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Answer 149

there are RCOG green top guidelines which lists major and minor risk factors and these are assessed at booking clinic - low risk women have monitoring of the symphysis fundal height at every antenatal appointment for 24 weeks - if the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler

Answer 150

if they have: Three or more minor risk factors One or more major risk factors Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

Answer 151

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

Answer 152

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

Answer 153

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)

Answer 154

when the weight of the newborn is more than 4.5 kg at birth or if the estimated fetal weight is above the 90th centile

Answer 155

Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby

Answer 156

Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare)

Answer 157

Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood

Answer 158

ultrasounds are done to exclude polyhydramnios and estimate fetal weight OGTT for gestational diabetes reduce risks of shoulder dystocia by having delivery on a consultant lead unit with experienced midwives, access to theatre, active management of the third stage, early decision for caesarean. NICE (2008) advise against induction of labour only on the grounds of macrosomia

Answer 159

Monozygotic - identical twins Dizygotic - non identical twins Monoamniotic - when they share one sac Diamniotic - two separate amniotic sacs monochorionic - share a single placenta dichorionic - two separate placentas

Answer 160

when there is two amniotic sacs and two placentas as each fetus will have its own nutrient supply

Answer 161

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

Answer 162

it 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).

Answer 163

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).

Answer 164

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Answer 165

Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Answer 166

this is when fetuses share one placenta one fetus may receive the majority of the blood (recipient) while the other (donor) is starved of blood the recipient gets more blood and is at risk of fluid overload with heart failure and polyhydramnios the donor is at risk of growth restriction, anaemia and oligohydramnios

Answer 167

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).

Answer 168

Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at: Booking clinic, 20 weeks gestation, 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

Answer 169

32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins Before 35 + 6 weeks for triplets

Answer 170

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 Elective caesarean is advised when the presenting twin is not cephalic presentation

Answer 171

preterm delivery low birth weight pre-eclampsia

Answer 172

bacteria present in the urine, without symptoms of infection. Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth.

Answer 173

during booking clinic and routinely throughout pregnancy

Answer 174

most common = E.coli Klebsiella pneumoniae (gram-negative anaerobic rod) Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)

Answer 175

Urinary tract infection in pregnancy requires 7 days of antibiotics. The antibiotic options are: Nitrofurantoin (avoid in the third trimester due to risk of neonatal haemolysis) Amoxicillin (only after sensitivities are known) Cefalexin - trimethoprim must be avoided in the first trimester as it is a folate antagonist therefore can cause congenital malformations (neural tube defects)

Answer 176

Booking clinic 28 weeks gestation

Answer 177

booking bloods >110g/l 28 weeks >105g/l post partum >100g/l

Answer 178

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.

Answer 179

increased plasma volume and B12 requirements in pregnancy can result in low B12 - women with low B12 should be tested for pernicious anaemia - if B12 is low: IM hydroxocobalamin injections or oral cyanocobalamin tablets

Answer 180

Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

Answer 181

The RCOG guidelines (2015) advise starting prophylaxis from: 28 weeks if there are three risk factors First trimester if there are four or more of these risk factors women are given low molecular weight heparin (enoxaparin, dalteparin, tinzaparin)

Answer 182

Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs Anti-embolic compression stockings

Answer 183

VTE: LMWH started immediately, before confirming the diagnosis. If it is confirmed then LMWH is continued for the remainder of pregnancy and 6 weeks postnatally or three months in total (whichever is loner) PE: Unfractionated heparin, thrombolysis, surgical embolectomy

Answer 184

Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.

Answer 185

when the process of forming the lacunae is inadequate, the woman can develop pre-eclampsia there is high vascular resistance in the spiral arteries causing poor perfusion of the placenta. this causes oxidative stress and relieve of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function

Answer 186

Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease

Answer 187

Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia

Answer 188

systolic over 140, diastolic over 90 plus: proteinuria, or organ dysfunction or placental dysfunction

Answer 189

aspirin given from 12 weeks gestation until birth to women with: a single high risk factor two or more moderate risk factor

Answer 190

Labetolol is first-line as an antihypertensive Nifedipine (modified-release) is commonly used second-line Methyldopa is used third-line (needs to be stopped within two days of birth) Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia 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

Answer 191

large for dates fetus and macrosomia - shoulder distocia

Answer 192

The NICE guidelines (2015) list the risk factors that warrant testing for gestational diabetes: Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes (first-degree relative)

Answer 193

An OGTT is used in patients with risk factors for gestational diabetes, and also when there are features that suggest gestational diabetes: Large for dates fetus Polyhydramnios (increased amniotic fluid) Glucose on urine dipstick

Answer 194

between weeks 24-28

Answer 195

An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours. 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.

Answer 196

1. 4 weekly ultrasound scans to monitor fetal growth and amniotic fluid level from 28 -36 weeks 2. if the fasting is less than 7, trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin 2. if fasting glucose is above 7 start insulin +/- metformin 3. same as above in fasting glucose over 6 plus macrosomia 4. glibenclamide (sulfonylurea) is used if metformin isnt tolerated and insulin is refused

Answer 197

The NICE (2015) target levels are: Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below

Answer 198

with insulin and metformin, all other oral diabetic medications are stopped

Answer 199

retinopathy screening - performed after booking and at 28 weeks gestation

Answer 200

NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes - sliding scale insulin regime is considered during labour for women with T1DM (mix of dextrose and insulin)

Answer 201

Neonatal hypoglycaemia Polycythaemia (raised haemoglobin) Jaundice (raised bilirubin) Congenital heart disease Cardiomyopathy

Answer 202

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.

Answer 203

it is the reduced outflow of bile acids from the liver during pregnancy thought to be due to increased oestrogen and progesterone

Answer 204

increased risk of stillbirth

Answer 205

later in pregnancy - third trimester itching - main symptom fatigue dark urine pale greasy stools jaundice NO RASH

Answer 206

Liver function tests and bile acid checks - Abnormal LFT: AST, ALT, GGT - raised bile acids

Answer 207

Emollients to soothe skin antihistamines to help sleeping Water soluble vitamin K may be considered if clotting is deranged if bile acids and LFTs are severely deranged planned delivery is considered

Answer 208

rare condition that occurs in the third trimester of pregnancy. There is a rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. There is a high risk of liver failure and mortality, for both the mother and fetus.

Answer 209

impaired processing of atty acids in the placenta as a result of a genetic condition in the fetus which impairs fatty acid metabolism (LCHAD deficiency) this enzyme is important in fatty acid oxidation, and the unbroken fatty acids enter the mother circulation and accumulate in the liver

Answer 210

General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) Ascites

Answer 211

Liver function tests will show elevated liver enzymes (ALT and AST). Other bloods may be deranged, with: Raised bilirubin Raised WBC count Deranged clotting (raised prothrombin time and INR) Low platelets

Answer 212

obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery. Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Answer 213

it is pruritic and urticarial papules and plaques in the third trimester - usually begins on the abdomen and is associated with stretch marks it is characterised by urticarial papules, wheals (itch areas of skin) and plaques

Answer 214

Topical emollients Topical steroids Oral antihistamines Oral steroids may be used in severe cases

Answer 215

this is essentially eczema which flares up during pregnancy usually presents in the first and second trimester - E type: eczema type - inflamed, red, itchy skin - P type: prurigo type- intensely itchy papules typically affecting abdomen, back and limbs

Answer 216

Topical emollients Topical steroids Phototherapy with ultraviolet light (UVB) may be used in severe cases Oral steroids may be used in severe cases

Answer 217

it is increased pigmentation to patches of the skin on the face during pregnancy it is usually symmetrical, flat and affects sun exposed areas

Answer 218

sun exposure, thyroid disease and family history.

Answer 219

Avoiding sun exposure and using suncream Makeup (camouflage) Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care Procedures such as chemical peels or laser treatment (not usually on the NHS)

Answer 220

this is also known as lobar capillary haemangioma and is a benign rapidly growing tumour of capillaries presenting as a discrete lump with a dark or red appearance. - develops over days up to 1-2 cm in size and often occur on the fingers, upper chest, back, head or neck

Answer 221

When they occur in pregnancy, they usually resolve without treatment after delivery. Treatment is with surgical removal with histology to confirm the diagnosis.

Answer 222

rare autoimmune skin condition that occurs in pregnancy where autoantibodies are created which damage the connection between the dermis and epidermis causing them to separate and creating a space that can fill with fluid (large, fluid filled blisters - bullae) - typically occurs in second or third trimester as a itchy red papular or blistering rash around umbilicus which then spreads to other parts of the body

Answer 223

Fetal growth restriction Preterm delivery Blistering rash after delivery (as the maternal antibodies pass to the baby)

Answer 224

Topical emollients Topical steroids Oral steroids may be required in severe cases Immunosuppressants may be required where steroids are inadequate Antibiotics may be necessary if infection occurs

Answer 225

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

Answer 226

Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth

Answer 227

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os Partial praevia, or grade III – the placenta is partially covering the internal cervical os Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

Answer 228

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 229

those diagnosed early (20 week scan) will require a repeat transvaginal ultrasound scan at 32 and 36 weeks corticosteroids should be given at 34 and 35+6 weeks delivery is planned between 36 and 37 weeks with a planned caesarean section

Answer 230

a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os.

Answer 231

Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.

Answer 232

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 233

Low lying placenta IVF pregnancy Multiple pregnancy

Answer 234

Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation if antepartum haemorrhage occurs emergency caesarean section is required

Answer 235

when the placenta separates from the wall of the uterus during pregnancy

Answer 236

Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (consider domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use

Answer 237

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

Answer 238

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

Answer 239

obstetric emergency - important to consider concealed haemorrhage as well Urgent involvement of a senior obstetrician, midwife and anaesthetist 2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother steroids to mature fetal lungs + anti-D in rhesus negative women emergency caesarean

Answer 240

it is when the placental implants deeper through and past the endometrium

Answer 241

Superficial placenta accreta is where the placenta implants in 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

Answer 242

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 243

It can present with bleeding (antepartum haemorrhage) in the third trimester It may be diagnosed on antenatal ultrasound scans It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.

Answer 244

MDT approach - additional management at birth due to risk of bleeding: complex uterine surgery, blood transfusions, intensive care for the mother, neonatal intensive care delivery is planned between 35-36+6 weeks steroids are given to mature fetal lungs options during surgery are: hysterectomy, uterus preserving surgery, expectant management

Answer 245

1. Complete breech, where the legs are fully flexed at the hips and knees 2. Incomplete breech, with one leg flexed at the hip and extended at the knee 3. Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee 4. Footling breech, with a foot is presenting through the cervix with the leg extended

Answer 246

those breech before 36 weeks often turn spontaneously External cephalic version can be used at 37 weeks to attempt to turn the baby if ECV fails women can do a vaginal delivery (safer for mother), or elective caesarean section (safer for baby)

Answer 247

this is a technique used to attempt to turn a fetus it is about 50% successful - women are given tocolysis to relax the uterus before the procedure (terbutaline) - it is done after 36 weeks for nulliparous women and after 37 weeks for women who have given birth previously - Rhesus negative women require anti-D prophylaxis and a kleihauer test is used to quantify exposure of the mother to fetal blood

Answer 248

Unexplained (around 50%) Pre-eclampsia Placental abruption Vasa praevia Cord prolapse or wrapped around the fetal neck Obstetric cholestasis Diabetes Thyroid disease Infections, such as rubella, parvovirus and listeria Genetic abnormalities or congenital malformations

Answer 249

Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back (as opposed to either side) having risk factors for small for gestational age

Answer 250

Reduced fetal movements Abdominal pain Vaginal bleeding

Answer 251

ultrasound scan - vaginal birth is first line for most women after IUFD, with either induction or expectant management Dopamine agonists can be used to suppress lactation after stillbirth

Answer 252

Genetic testing of the fetus and placenta Postmortem examination of the fetus (including xrays) Testing for maternal and fetal infection Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Answer 253

4Ts and 4Hs: Thrombosis (i.e. PE or MI) Tension pneumothorax Toxins Tamponade (cardiac) Hypoxia Hypovolaemia Hypothermia Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities - also add eclampsia and intracranial haemorrhage

Answer 254

Obstetric haemorrhage Pulmonary embolism Sepsis leading to metabolic acidosis and septic shock

Answer 255

after 20 weeks gestation the uterus is a significant size, when a woman lies on her back the mass of the uterus can compress the inferior vena cava and aorta reducing blood returning to the heart - reduces CO and causes hypotension this can be enough to lead to loss of CO and cause cardiac arrest

Answer 256

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

Answer 257

vaginal progesterone (prevents the cervix remodelling in preparation for deliver) - offered between 16-24 weeks cervical cerclage - offered between 16-24 weeks who had previous premature birth or cervical trauma

Answer 258

Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1

Answer 259

alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

Answer 260

Fetal monitoring (CTG or intermittent auscultation) Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour 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 Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Answer 261

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

Answer 262

The Bishop score is a scoring system used to determine whether to induce labour. 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) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2)

Answer 263

membrane sweep - at 40 weeks to initiate labour vaginal prostaglandin E2 - pessary/gel/tablet cervical ripening balloon - used when prostaglandins arent preferred artificial rupture of membranes - only when there are reasons not to use prostaglandins oral mifepristone plus misoprostol - where intrauterine fetal death has occurred

Answer 264

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour Bishop score before and during induction of labour to monitor the progress

Answer 265

it is the main complication of induction of labour with vaginal prostaglandins - where the contraction of the uterus is prolonged and frequent causing fetal distress and compromise - lasting longer than 2 minutes - more than 5 uterine contractions every 10 minutes

Answer 266

Removing the vaginal prostaglandins, or stopping the oxytocin infusion Tocolysis with terbutaline caesarean and surgery to repair uterus

Answer 267

One above the fetal heart to monitor the fetal heartbeat One near the fundus of the uterus to monitor the uterine contractions

Answer 268

Sepsis Maternal tachycardia (> 120) Significant meconium Pre-eclampsia (particularly blood pressure > 160 / 110) Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain

Answer 269

1. Contractions – the number of uterine contractions per 10 minutes 2. Baseline rate – the baseline fetal heart rate 3. Variability – how the fetal heart rate varies up and down around the baseline 4. Accelerations – periods where the fetal heart rate spikes 5. Decelerations – periods where the fetal heart rate drops

Answer 270

1. Reassuring - 110-160 variability 5-25 2. non reassuring - 100-109 or 161-180 variability less than 5 for 30-50 minutes or more than 25 for 15-25 minutes 3. abnormal - below 100, over 180, variability less than 5 for over 50 minutes or more than 25 for over 25 minutes

Answer 271

Early decelerations Late decelerations Variable decelerations Prolonged decelerations

Answer 272

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

Answer 273

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. Late decelerations are caused by hypoxia in the fetus

Answer 274

abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia

Answer 275

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.

Answer 276

done at times of decelerations, an acceleration in response to stimulation is a reassuring sign

Answer 277

3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)

Answer 278

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.

Answer 279

DR C BRaVADO DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression (given an overall impression of the CTG and clinical picture)

Answer 280

Induce labour Progress labour Improve the frequency and strength of uterine contractions Prevent or treat postpartum haemorrhage

Answer 281

it is used to stimulate smooth muscle contraction, and may be used during the third stage of labour - has severe side effects as it acts on smooth muscle in blood vessels and GI tract, should be avoided in eclampsia - used as syntometrine which is a combination of oxytocin and ergometrine

Answer 282

This is used for induction of labour, and can come in one of three forms: Vaginal pessaries (Propess) Vaginal tablets (Prostin tablets) Vaginal gel (Prostin gel)

Answer 283

Calcium channel blocker It has two main uses in pregnancy: Reduce blood pressure in hypertension and pre-eclampsia Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

Answer 284

Beta 2 agonist It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour. also used to perform ECV

Answer 285

Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate - avoid in asthma patients

Answer 286

Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage. - antifibrinolytic medication

Answer 287

when there is either: Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women

Answer 288

used for monitoring a womans progress in the first stage of labour, monitors: cervical dilation descent of fetal head maternal pulse, BP, temp and urine output fetal heart rate contraction frequency status of membranes, presence of liquor and whether its stained with blood/meconium drugs and fluids which have been given

Answer 289

when the active second stage (pushing) lasts over: 2 hours in a nulliparous woman 1 hour in a multiparous woman

Answer 290

Longitudinal lie – the fetus is straight up and down Transverse lie – the fetus is straight side to side Oblique lie – the fetus is at an angle

Answer 291

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

Answer 292

1. Simple analgesia: paracetamol 2. Gas and Air (Entonox) 3. IM Pethidine or Diamorphine (opioid injections) 4. Patient controlled analgesia - remifentanil 5. Epidural - into the epidural space outside the dura mater. options are levobupivacaine or bupivacaine mixed with fentanyl

Answer 293

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 294

this is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina after ROM

Answer 295

when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique)

Answer 296

emergency caesarean section - when the baby is compressing a prolapsed cord the presenting part can be pushed up to prevent compression - women can lie in left lateral position or knee chest position - tocolytic medication can be used to minimise contractions while wating for caesarean

Answer 297

key risks to mum are Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve) The key risks to remember to the baby are: Cephalohaematoma with ventouse Facial nerve palsy with forceps subgaleal haemorrhage intracranial haemorrhage skull fracture spinal cord injury

Answer 298

cephalohaematoma

Answer 299

facial nerve palsy

Answer 300

Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions

Answer 301

The affected nerves may be: Femoral nerve Obturator nerve

Answer 302

Lateral cutaneous nerve of the thigh Lumbosacral plexus Common peroneal nerve

Answer 303

First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries

Answer 304

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin Second-degree – including the perineal muscles, but not affecting the anal sphincter Third-degree – including the anal sphincter, but not affecting the rectal mucosa Fourth-degree – including the rectal mucosa

Answer 305

3A – less than 50% of the external anal sphincter affected 3B – more than 50% of the external anal sphincter affected 3C – external and internal anal sphincter affected

Answer 306

first degree usually done require sutures anything larger than first degree usually requires sutures third or fourth degree is likely to require repairing in theatre to prevent complications: broad spectrum Abx, laxatives, physio, follow up

Answer 307

Pain Infection Bleeding Wound dehiscence or wound breakdown

Answer 308

Urinary incontinence Anal incontinence and altered bowel habit (third and fourth-degree tears) Fistula between the vagina and bowel (rare) Sexual dysfunction and dyspareunia (painful sex) Psychological and mental health consequences

Answer 309

Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.

Answer 310

Minor PPH – under 1000ml blood loss Major PPH – over 1000ml blood loss OR Primary PPH: bleeding within 24 hours of birth Secondary PPH: from 24 hours to 12 weeks after birth

Answer 311

Moderate PPH – 1000 – 2000ml blood loss Severe PPH – over 2000ml blood loss

Answer 312

Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 313

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) Catheterisation (bladder distention prevents uterus contractions)

Answer 314

Oxytocin (slow injection followed by continuous infusion) Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

Answer 315

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

Answer 316

Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear

Answer 317

Previous caesarean Symptomatic after a previous significant perineal tear Placenta praevia Vasa praevia Breech presentation Multiple pregnancy Uncontrolled HIV infection Cervical cancer

Answer 318

Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes. Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes. Category 3: Delivery is required, but mother and baby are stable. Category 4: This is an elective caesarean, as described above.

Answer 319

Skin Subcutaneous tissue Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) Rectus abdominis muscles (separated vertically) Peritoneum Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap Uterus (perimetrium, myometrium and endometrium) Amniotic sac

Answer 320

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

Answer 321

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure Prophylactic antibiotics during the procedure to reduce the risk of infection Oxytocin during the procedure to reduce the risk of postpartum haemorrhage Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

Answer 322

it is possible provided the cause of the caesarean is unlikely to reoccur - contraindications is previous uterine rupture, classical caesarean scare (vertical) or usual contraindications to vaginal delivery

Answer 323

Chorioamnionitis Urinary tract infections

Answer 324

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

Answer 325

maternity early obstetric warning system (MEOWS)

Answer 326

Abdominal pain Uterine tenderness Vaginal discharge

Answer 327

Septic six - take blood, lactate and urine output, give abx, fluids and oxygen continuous maternal and fetal monitoring emergency caesarean may be indicated antibiotics - piperacillin and tazobactam plus gentamicin/ amoxicillin clindamycin and gentamicin

Answer 328

it is where amniotic fluid passes into the mothers blood - usually occurs around labour and delivery the amniotic fluid contains fetal tissue which causes an immune reaction. This leads to systemic illness

Answer 329

Increasing maternal age Induction of labour Caesarean section Multiple pregnancy

Answer 330

can present similar to anaphylaxis, sepsis or PE Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest

Answer 331

supportive medical emergency - ABCDE resuscitation and immediate caesarean if there is cardiac arrest

Answer 332

when the muscle layer of the uterus ruptures - incomplete - uterine serosa surrounding the uterus retains intact - complete - serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity

Answer 333

previous caesarean section (main RF) Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 334

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

Answer 335

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).

Answer 336

rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out - life threatening obstetric emergency - incomplete is where the fundus descends inside uterus or vagina but not to vaginal opening - complete is the uterus descending through and out of the vagina

Answer 337

Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse. An incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.

Answer 338

1. Johnson manoeuvre - using a hand to push the fundus back into the abdomen. Hand and forearm must be inserted into the vagina and held in place for several minutes 2. Hydrostatic methods - filling vagina with fluid to inflate the uterus back into the normal position 3. Surgery - laparotomy and uterus put back into normal position

Answer 339

the development of breast buds

Answer 340

under 10 no pubic hair no breast development

Answer 341

age 10 -11 light and thin pubic hair breast buds form from behind the areola

Answer 342

age 11-13 course and curly pubic hair breast begins to elevate beyond the areola

Answer 343

age 13-24 adult like pubic hair but not reaching the thigh areolar mound forms and projects from surrounding breast

Answer 344

above 14 years pubic hair extending to medial thigh areolar mounds reduce and adult breasts form

Answer 345

Primordial follicles grow and become primary follicles. These primary follicles have three layers: The primary oocyte in the centre The zona pellucida The cuboidal shaped granulosa cells the granulosa cells secrete the material that becomes the zona pellucida and oestrogen as they grow they develop a surrounding theca folliculi layer (inner layer of this is the theca interna which secretes androgen hormones)

Answer 346

as primary follicles become secondary follicles they grow larger and develop small fluid filled gaps between the granulosa cells. Once the follicle reaches the secondary follicle stage they have FSH receptors and further development requires FSH stimulation

Answer 347

the secondary follicle develops a single large fluid filled area within the granulosa cells called the antrum. This fills with increasing amounts of fluid making the follicle expand rapidly the corona radiata is made of granulosa cells and surrounds the zona pellucida and the oocyte at this point one follicle becomes the dominant follicle and the others start to degrade

Answer 348

when sperm enter the fallopian tube they will penetrate the corona radiata and zona pellucida to fertilise the egg when the sperm enters the egg the 23 chromosomes of the egg multiply into two sets, one set combine with the sperm chromosomes and the other float off to the side and create a polar body

Answer 349

just before ovulation the primary oocyte undergoes meiosis, splitting the 46 chromosomes in the oocyte into two leaving 23, the other 23 float off and become a polar body

Answer 350

the combination of the egg and sperm produces a zygote this rapidly divides to create a mass of cells called a morula as it travels along the fallopian tube a fluid filled cavity gathers within the group of cells and it becomes a blastocyst the blastocyst contains the main group of cells in the middle (embryoblast), and surrounding the embryoblast and blastocele is the trophoblast

Answer 351

when the blastocyst arrives at the uterus 8-10 days after ovulation it reaches the endometrium the cells of the trophoblast undergo adhesion to the stroma of the endometrium, forming the syncytiotrophoblast which forms projections into the stoma the cells of the stoma become decidua which provides nutrients to the trophoblast when it implants the syncytiotrophoblast starts to produce bHCG

Answer 352

about a week after fertilisation - splits into two with the yolk sac on one side and the amniotic cavity on the other the embryonic disc develops into the fetal pole and eventually into the fetus

Answer 353

the cytotrophoblast and the syncytiotrophoblast. The cytotrophoblast is the inner layer and the syncytiotrophoblast is the outer layer, which is embedded in the endometrium.

Answer 354

week 5 - splits into the ectoderm, mesoderm, endoderm

Answer 355

GIT lungs liver pancreas thyroid reproductive system

Answer 356

heart muscle bone connective tissue blood kidneys

Answer 357

skin hair nails teeth CNS

Answer 358

The myometrium sends off artery branches into the endometrium. Initially, these arteries grow straight outwards like plant shoots. As they continue to grow, they coil into a spiral. These thick-walled and coiled arteries are bunched together, making the endometrial tissue highly vascular. These are known as the spiral arteries.

Answer 359

The chorionic villi (syncytiotrophoblast that grows into endometrium) nearest the connecting stalk of the developing embryo are the most vascular and contain mesoderm. This area is called the chorion frondosum. The cells in the chorion frondosum proliferate and become the placenta. The connecting stalk becomes the umbilical cord. Placental development is usually complete by 10 weeks gestation.

Answer 360

Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.

Answer 361

Respiratory Renal/excretion Nutrition immunity endocrine

Answer 362

urea and creatinine

Answer 363

production of hCG around week 10 oestrogen - allows muscles and ligaments of uterus and pelvis to expand, cervix soft progesterone - placenta takes over by 5 weeks, role is to maintain pregnancy and relaxes uterine muscles (SA= reflux, constipation, hypotension, headaches, skin flushing)

Answer 364

increased steroid hormones increased T3/T4 increased prolactin increased melanocyte stimulating hormone increased oestrogen increased progesterone increased HCG

Answer 365

increased tidal volume increased resp. rate

Answer 366

increased blood flow increased GFR increased sodium reabsorption increased water reabsorption increased protein excretion physiological hydronephrosis

Answer 367

increased red blood cell production increased white blood cells reduced platelets decreased haematocrit increased clotting factors decreased albumin increased ALP (placenta)

Answer 368

increased blood volume increased plasma volume increased cardiac output decreased vascular resistance decreased blood pressure vasodilation varicose veins

Answer 369

100g - 1.1kg hypertrophy increased cervical discharge ectropion vagina hypertrophy, increased discharge, candida, bacteria

Answer 370

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen