Womens health continued

Question 1

what is cervical cancer strongly associated with

Answer 1

HPV - 16 and 18

Question 2

how does HPV predispose someone to cancer

Answer 2

P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.

Question 3

what are risk factors for cervical cancer

Answer 3

Increased risk of catching HPV
Later detection of precancerous and cancerous changes (non-engagement with screening)
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)

Question 4

what are increased risks of catching HPV

Answer 4

Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms

Question 5

how does cervical cancer present

Answer 5

may be detected during cervical smears in otherwise asymptomatic women
abnormal vaginal bleeding
vaginal discharge
pelvic pain
dyspareunia

Question 6

what are appearances which may suggest cervical cancer

Answer 6

Ulceration
Inflammation
Bleeding
Visible tumour

Question 7

what are the grades of cervical intraepithelial neoplasia

Answer 7

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated

Question 8

what are notable exceptions for the smear test

Answer 8

Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum

Question 9

when are women called to the cervical screening programme

Answer 9

Every three years aged 25 – 49
Every five years aged 50 – 64

Question 10

what are the different cytology results someone can get

Answer 10

Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia

Question 11

what is the management for different smear results based on the public health england guidelines

Answer 11

Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy

Question 12

what is colposcopy

Answer 12

it is when a speculum is inserted and uses a colposcope to magnify the cervix which allows the epithelial lining of the cervix to be examined
stains such as acetic acid and iodine solution can be used to differentiate abnormal areas

Question 13

what is acetic acid

Answer 13

causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.

Question 14

what is schillers iodine test

Answer 14

involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.

Question 15

what is large loop excision of the transformation zone

Answer 15

it is a procedure called a loop biopsy which can be performed with local anaesthetic during colposcopy, which involves using diathermy to remove abnormal epithelial tissue of the cervix

Question 16

what is a cone biopsy

Answer 16

it is a treatment for cervical intraepithelial neoplasia and very early stages of cervical cancer. The surgeons removes a cone shaped piece of cervix

Question 17

what are the main risks of a cone biopsy

Answer 17

Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour

Question 18

what is the staging used for cervical cancer

Answer 18

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer:

Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis

Question 19

what is the management of cervical cancer

Answer 19

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

Question 20

what is the five year survival for cervical cancer

Answer 20

The 5-year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4

Question 21

what is pelvic exenteration

Answer 21

an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life.

Question 22

what is Bevacizumab

Answer 22

monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer. It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels.

Question 23

when is the HPV vaccine given and what does it protect you against

Answer 23

12-13 yrs before sexual activity
The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18:

Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer

Question 24

what is the most common type of endometrial cancer

Answer 24

adenocarcinoma
it is an oestrogen sensitive cancer

Question 25

what is endometrial hyperplasia

Answer 25

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

Question 26

what are the two kinds of endometrial hyperplasia

Answer 26

hyperplasia without atypia
atypical hyperplasia

Question 27

how is endometrial hyperplasia treated

Answer 27

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

Question 28

what are risk factors for endometrial cancer

Answer 28

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

Question 29

for endometrial protection what should women with PCOS be given

Answer 29

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

Question 30

what are protective factors against endometrial cancer

Answer 30

Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking

Question 31

how does smoking affect the risk of endometrial cancer

Answer 31

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

Question 32

how does endometrial cancer present

Answer 32

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

Question 33

what is the referral criteria for endometrial cancer

Answer 33

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

Question 34

what investigations are done for suspected endometrial cancer

Answer 34

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

Question 35

what are the stages of endometrial cancer

Answer 35

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

Question 36

how is endometrial cancer treated

Answer 36

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

Question 37

what are the types of ovarian cancers

Answer 37

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

Question 38

what is an epithelial cell ovarian tumour

Answer 38

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

Question 39

what are dermoid cysts/germ cell ovarian tumours

Answer 39

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).

Question 40

what are sex cord stromal ovarian tumours

Answer 40

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.

Question 41

what is a Krukenberg tumour

Answer 41

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.

Question 42

what are risk factors for ovarian cancer

Answer 42

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

Question 43

what are protective factors for ovarian cancer

Answer 43

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

Question 44

how do ovarian tumours present

Answer 44

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

Question 45

what is the referral criteria for ovarian cancer

Answer 45

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

Question 46

what investigations are done for ovarian cancer

Answer 46

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

Question 47

what do women under 40 with a complex ovarian mass require investigation wise

Answer 47

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

Question 48

what are causes pf raised CA125

Answer 48

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

Question 49

what are the stages of ovarian cancer

Answer 49

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)

Question 50

what is the management of ovarian cancer

Answer 50

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

Question 51

what is the most common type of vulval cancer

Answer 51

squamous cell carcinomas

Question 52

what are risk factors for vulval cancer

Answer 52

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

Question 53

what is vulval intraepithelial neoplasia

Answer 53

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

Question 54

what is High grade squamous intraepithelial lesion

Answer 54

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

Question 55

what is Differentiated VIN

Answer 55

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

Question 56

what are the treatment options for VIN

Answer 56

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

Question 57

how does vulval cancer present

Answer 57

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

Question 58

what is the referral criteria for vulval cancer

Answer 58

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)

Question 59

what system is used to stage vulval cancer

Answer 59

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

Question 60

what is the management of vulval cancer

Answer 60

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

Question 61

when should infertility be investigated

Answer 61

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

Question 62

what are causes of fertility issues

Answer 62

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.

Question 63

what is general advice given to people to improve fertility issues

Answer 63

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

Question 64

what investigations are done with fertility issues

Answer 64

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

Question 65

what female hormones are tested when investigating fertility issues

Answer 65

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

Question 66

why is anti-mullerian hormone tested

Answer 66

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.

Question 67

what is a hysterosalpingogram

Answer 67

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

Question 68

what is laparoscopy and dye test

Answer 68

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.

Question 69

what is the management options for anovulation

Answer 69

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

Question 70

what is clomifene

Answer 70

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

Question 71

what is the management for tubal factors causing fertility issues

Answer 71

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

Question 72

what is the management for sperm problems causing infertility

Answer 72

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

Question 73

what are instructions given to men providing a sample for semen analysis

Answer 73

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

Question 74

what factors can affect semen analysis and sperm quality and quantity

Answer 74

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

Question 75

what are the normal results indicated by the WHO for semen analysis

Answer 75

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%)

Question 76

what is polyspermia

Answer 76

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

Question 77

what is oligospermia

Answer 77

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)

Question 78

what is cryptozoospermia

Answer 78

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

Question 79

what are pre-testicular causes of abnormal semen analysis

Answer 79

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

Question 80

what are testicular causes of abnormal semen analysis

Answer 80

Testicular damage from:
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer

Question 81

what genetic/congenital disorders can affect sperm

Answer 81

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

Question 82

what are post testicular causes of abnormal semen analysis

Answer 82

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)

Question 83

what investigations should be done if someone has an abnormal semen analysis

Answer 83

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

Question 84

what is the management for abnormal sperm sample

Answer 84

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

Question 85

what is in vitro fertilisation

Answer 85

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

Question 86

what is the percentage success rate for IVF

Answer 86

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

Question 87

what are the steps in the process of IVF

Answer 87

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

Question 88

what are the protocols for suppressing the menstrual cycle in IVF

Answer 88

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

Question 89

what is ovarian stimulation

Answer 89

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

Question 90

how are oocytes collected in IVF

Answer 90

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)

Question 91

how does oocyte insemination occur in IVF

Answer 91

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.

Question 92

how long is the embryo cultured for in IVF

Answer 92

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).

Question 93

when are embryos transferred into the mother in IVF

Answer 93

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.

Question 94

when is a pregnancy test performed in IVF

Answer 94

around day 16

Question 95

what is given to the woman from the time of oocyte collection until 8-10 weeks gestation in IVF

Answer 95

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

Question 96

what are the complications of IVF

Answer 96

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

Question 96

what is ovarian hyperstimulation syndrome

Answer 96

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

Question 97

what is the pathophysiology of OHSS

Answer 97

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

Question 98

what are risk factors for OHSS

Answer 98

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

Question 99

how can OHSS be prevented

Answer 99

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)

Question 100

what strategies are put in place with women who are at high risk of OHSS

Answer 100

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)

Question 101

what are features of OHSS

Answer 101

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)

Question 102

what are the different severities of OHSS

Answer 102

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)

Question 103

what is the management of OHSS

Answer 103

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

Question 104

what might be monitored to assess the volume of fluid in the intravascular space in OHSS

Answer 104

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

Question 105

what is recurrent pregnancy loss

Answer 105

it is three or more consecutive miscarriages

Question 106

what is the risk of miscarriage in different age groups

Answer 106

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

Question 107

when are investigations initiated for recurrent miscarriage

Answer 107

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

Question 108

what are causes of recurrent miscarriage

Answer 108

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)

Question 109

what is antiphospholipid syndrome

Answer 109

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.

Question 110

how is the risk of miscarriage reduced in women with antiphospholipid syndrome

Answer 110

Low dose aspirin
Low molecular weight heparin (LMWH)

Question 111

what are the key inherited thrombophilia’s to remember

Answer 111

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

Question 112

what uterine abnormalities can cause recurrent miscarriages

Answer 112

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

Question 113

what is chronic histiocytic intervillositis

Answer 113

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

Question 114

how is chronic histiocytic intervillositis diagnosed

Answer 114

placental histology showing infiltrates of mononuclear cells in the intervillous spaces

Question 115

what investigations can be done in someone having recurrent miscarriages

Answer 115

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

Question 116

what is the management of recurrent miscarriage

Answer 116

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

Question 117

what is the legal requirements for an abortion

Answer 117

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

Question 118

what are the criteria for performing an abortion on someone

Answer 118

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.

Question 119

when can an abortion be performed at any time of a pregnancy

Answer 119

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

Question 120

what pre-abortion care is given

Answer 120

• 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

Question 121

what is given for a medical abortion

Answer 121

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

Question 122

what is done for a surgical abortion

Answer 122

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

Question 123

what is done for post abortion care

Answer 123

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

Question 124

what are complications of abortion

Answer 124

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

Question 125

when does nausea and vomiting peak in pregnancy

Answer 125

8-12 weeks

Question 126

what is severe nausea and vomiting in pregnancy

Answer 126

hyperemesis gravidarum

Question 127

what hormone is thought to be responsible for nausea and vomiting in pregnancy

Answer 127

hCG

Question 128

what is the diagnosis criteria for hyperemesis gravidarum

Answer 128

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

Question 129

how is the severity of hyperemesis gravidarum assessed

Answer 129

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

Question 130

what is the management of hyperemesis gravidarum

Answer 130

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

Question 131

when might someone need admission for hyperemesis gravidarum

Answer 131

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

Question 132

what might be done in hospital for hyperemesis gravidarum

Answer 132

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

Question 133

what dose of folic acid should women with epilepsy be taking if pregnant

Answer 133

5mg daily

Question 134

how is rheumatoid arthritis managed in pregnancy

Answer 134

• 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

Question 135

what is recommended for use of NSAIDs in pregnancy

Answer 135

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

Question 136

are beta blockers used in pregnancy

Answer 136

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

Question 137

what complications can beta blockers cause in pregnancy

Answer 137

Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate

Question 138

what is the effect of taking ACEi/ARBs in pregnancy

Answer 138

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

Question 139

what can use of opiates in pregnancy cause in the fetus

Answer 139

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.

Question 140

is warfarin used in pregnancy

Answer 140

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

Question 141

what can use of sodium valproate cause in pregnancy

Answer 141

neural tube defects and developmental delay.

Question 142

is lithium used in pregnancy

Answer 142

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

Question 143

are SSRIs used in pregnancy

Answer 143

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

Question 144

what is isotretinoin and can it be used in pregnancy

Answer 144

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

Question 145

should women be given the MMR vaccine during pregnancy

Answer 145

NO - pregnant women shouldnt receive live vaccines

Question 146

what can ZVZ cause if contraced

Answer 146

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

Question 147

what should be done if a women has exposure to VZV in pregnancy

Answer 147

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.

Question 148

what should be done if a woman develops a chicken pox rash in pregnancy

Answer 148

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

Question 149

what are the features of congenital varicella syndrome

Answer 149

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 150

what are the risks of listeria infection in pregnancy

Answer 150

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

Question 151

what are the features of congenital CMV

Answer 151

Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures

Question 152

what is the classic triad of congenital toxoplasmosis

Answer 152

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

Question 153

what are the complications of contracting parvovirus B19 in pregnancy

Answer 153

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

Question 154

what should be done in pregnant women with suspected parvovirus infection

Answer 154

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)

Question 155

what are the symptoms of congenital zika syndrome

Answer 155

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

Question 156

what is the pathophysiology of resus incompatibility in pregnancy

Answer 156

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

Question 157

what is the management of rhesus incompatibility in pregnancy

Answer 157

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

Question 158

when are Anti-D injections given in pregnancy

Answer 158

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)

Question 159

what points are anti-D injections also given in pregnancy beside the routine occasions

Answer 159

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

Question 160

what is the kleihauer test

Answer 160

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

Question 161

what is a small for gestational age fetus

Answer 161

it is measures below the 10th centile

Question 162

what two measurements on ultrasound are used to assess fetal size

Answer 162

estimated fetal weight
fetal abdominal circumference

Question 163

what parameters are used to produce a customised growth chart

Answer 163

ethnic group
weight
height
parity

Question 164

what is defined as severe growth restriction

Answer 164

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

Question 165

what is low birth weight defined as

Answer 165

a birth weight of less than 2500g

Question 166

what are the two categories for causes of small for gestational age

Answer 166

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)

Question 167

what is the difference between small for gestational age and fetal growth restriction

Answer 167

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.

Question 168

what are the two categories for causes of fetal growth restriction

Answer 168

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

Question 169

what are placenta mediated causes of growth restriction in a fetus

Answer 169

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

Question 170

what are non placental mediated causes for growth restriction

Answer 170

Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism

Question 171

what are signs that indicate fetal growth restriction

Answer 171

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

Question 172

what are complications of fetal growth restriction

Answer 172

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

Question 173

what are risk factors for small for gestational age

Answer 173

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

Question 174

how are small for gestational age babies monitored

Answer 174

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

Question 175

when are women booked for serial growth scans with umbilical artery doppler

Answer 175

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)

Question 176

women who are at risk of small for gestational age or have a small for gestation age baby what is measured during serial ultrasound scans

Answer 176

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

Question 177

what are the critical steps for managing small for gestational age

Answer 177

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

Question 178

what investigations should be done if a fetus is identified as small for gestational age

Answer 178

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 179

when are babies defined as large for gestation age

Answer 179

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

Question 180

what are causes of macrosomia (LGA)

Answer 180

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

Question 181

what are the risks of macrosomia (LGA)on the mother

Answer 181

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

Question 182

what are risks of macrosomia (LGA) to the baby

Answer 182

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

Question 183

what is the management of macrosomia (LGA)

Answer 183

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

Question 184

what are the types of multiple pregnancy

Answer 184

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

Question 185

what is the best outcomes for twins in terms of the amniotic sac and placenta

Answer 185

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

Question 186

how do you determine the type of twins on an ultrasound scan

Answer 186

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

Question 187

what is the lambda/twin peak sign

Answer 187

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).

Question 188

what does the T sign indicate in twins

Answer 188

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 189

what are risks of twins to the mother

Answer 189

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

Question 190

what are the risk of having twins to the fetuses and neonates

Answer 190

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

Question 191

what is twin twin transfusion syndrome

Answer 191

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

Question 192

what is twin anaemia polycythaemia sequence

Answer 192

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 193

how are twins managed antenatally

Answer 193

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

Question 194

when is the birth planned for twins

Answer 194

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

Question 195

how are twins delivered

Answer 195

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

Question 196

what does UTI in pregnant women increase the risk of

Answer 196

preterm delivery
low birth weight
pre-eclampsia

Question 197

what is asymptomatic bacteriuria

Answer 197

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.

Question 198

when is asymptomatic bacteriuria tested for in pregnancy

Answer 198

during booking clinic and routinely throughout pregnancy

Question 199

what are common causes of UTI

Answer 199

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

Question 200

what is the management of UTI in pregnancy

Answer 200

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)

Question 201

when are women screened for anaemia in pregnancy

Answer 201

Booking clinic
28 weeks gestation

Question 202

what are the normal ranges for haemaglobin during pregnancy

Answer 202

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

Question 203

what is the management for women who have iron deficiency anaemia in pregnancy

Answer 203

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.

Question 204

what is done in women with low B12 in pregnancy

Answer 204

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

Question 205

what are risk factors for developing a VTE in pregnancy

Answer 205

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

Question 206

in women with VTE risk factors what is the management

Answer 206

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)

Question 207

what other mechanical prophylaxis may be given in pregnancy if low molecular weight heparin is contraindicated

Answer 207

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

Question 208

what is the management of a pregnant women who has presented with VTE or PE

Answer 208

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

Question 209

what is pre-eclampsia

Answer 209

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.

Question 210

what is the pathophysiology of pre-eclampsia

Answer 210

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

Question 211

what are high risk factors for developing pre-eclampsia

Answer 211

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

Question 212

what are the moderate risk factors for developing pre-eclampsia

Answer 212

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

Question 213

how is pre-eclampsia defined

Answer 213

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

Question 214

what is the prophylaxis for pre-eclampsia

Answer 214

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

Question 215

what is the medical management of pre-eclampsia

Answer 215

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

Question 216

what is the most significant immediate complication of gestational diabetes

Answer 216

large for dates fetus and macrosomia
- shoulder distocia

Question 217

what are risk factors for the development of gestational diabetes

Answer 217

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)

Question 218

Which mothers is the OGTT used to test for gestational diabetes

Answer 218

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

Question 219

when is the OGTT given in pregnancy

Answer 219

between weeks 24-28

Question 220

how is the OGTT performed

Answer 220

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.

Question 221

what is the management of gestational diabetes

Answer 221

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
3. if fasting glucose is above 7 start insulin +/- metformin
4. same as above in fasting glucose over 6 plus macrosomia
5. glibenclamide (sulfonylurea) is used if metformin isnt tolerated and insulin is refused

Question 222

what are the target levels for blood glucose a woman with gestational diabetes should aim for

Answer 222

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

Question 223

what dose of folic acid should women with pre-existing diabetes be given in pregnancy

Answer 223

5mg

Question 224

how are women with pre-existing type 2 diabetes managed in pregnancy

Answer 224

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

Question 225

what screening is very important to do in pregnancy with women who have pre-existing diabetes

Answer 225

retinopathy screening - performed after booking and at 28 weeks gestation

Question 226

when should women with pre-existing diabetes give birth

Answer 226

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)

Question 227

what are babies of mothers with diabetes at risk of

Answer 227

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

Question 228

what blood glucose level should babies be maintained at

Answer 228

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.

Question 229

what is obstetric cholestasis

Answer 229

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

Question 230

what risk is obstetric cholestasis associated with

Answer 230

increased risk of stillbirth

Question 231

how does obstetric cholestasis present

Answer 231

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

Question 232

what investigations should be done on women with suspected obstetric cholestasis

Answer 232

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

Question 233

what is the management of obstetric cholestasis

Answer 233

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

Question 234

what is acute fatty liver of pregnancy

Answer 234

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.

Question 235

what is the pathophysiology of acute fatty liver

Answer 235

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

Question 236

how does acute fatty liver of pregnancy present

Answer 236

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

Question 237

what might blood show in acute fatty liver of pregnancy

Answer 237

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

Question 238

what is the management of acute fatty liver of pregnancy

Answer 238

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.

Question 239

what is polymorphic eruption of pregnancy

Answer 239

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

Question 240

how is polymorphic eruption of pregnancy managed

Answer 240

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

Question 241

what is atopic eruption of pregnancy

Answer 241

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

Question 242

what is the management of atopic eruption of pregnancy

Answer 242

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

Question 243

what is melasma

Answer 243

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

Question 244

what is melasma associated with

Answer 244

sun exposure, thyroid disease and family history.

Question 245

what is the management of melasma

Answer 245

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)

Question 246

what is pyogenic granuloma

Answer 246

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

Question 247

how are pyogenic granulomas managed

Answer 247

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

Question 248

what is pemphigoid gestationis

Answer 248

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

Question 249

what are the risks to the fetus in pemphigoid gestationis

Answer 249

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

Question 249

what is the treatment for pemphigoid gestationis

Answer 249

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

Question 250

what is the difference between low lying placenta and placental praevia

Answer 250

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

Question 251

what are the risks of placental praevia on the mother

Answer 251

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

Question 252

what re the grades of placenta praevia

Answer 252

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

Question 253

what are the risk factors for developing placenta praevia

Answer 253

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

Question 254

what is the management of placental praevia

Answer 254

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

Question 255

what is vasa praevia

Answer 255

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

Question 256

what are the two instances when the fetal vessels can be exposed outside the protection of the umbilical cord or placenta

Answer 256

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.

Question 257

what are the two types of vasa praevia

Answer 257

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

Question 258

what are the risk factors for vasa praevia

Answer 258

Low lying placenta
IVF pregnancy
Multiple pregnancy

Question 259

what is the management of vasa praevia

Answer 259

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

Question 260

what is placental abruption

Answer 260

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

Question 261

what are the risk factors for placental abruption

Answer 261

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

Question 262

how does placental abruption present

Answer 262

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

Question 263

what is the classification of a minor, major and massive antepartum haemorrhage in pregnancy

Answer 263

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 264

what is the management for placental abruption

Answer 264

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

Question 265

what is placental accreta

Answer 265

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

Question 266

what are the three definitions of placenta accreta depending on the depth of insertion

Answer 266

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

Question 267

what are risk factors for placenta accreta

Answer 267

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

Question 268

how does placental accreta present

Answer 268

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.

Question 269

how is placenta accreta managed

Answer 269

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

Question 270

what are the types of breech presentation

Answer 270

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

Question 271

what is the management of breech babies

Answer 271

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)

Question 272

how does external cephalic version work

Answer 272

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

Question 273

what are causes of stillbirth

Answer 273

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

Question 274

what factors increase the risk of stillbirth

Answer 274

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

Question 275

what are three key symptoms of stillbirth that should always be asked during pregnancy

Answer 275

Reduced fetal movements
Abdominal pain
Vaginal bleeding

Question 276

how is stillbirth diagnosed and managed

Answer 276

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

Question 277

what testing can be carried out after stillbirth to determine cause

Answer 277

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

Question 278

what are the reversible causes of adult cardiac arrest

Answer 278

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

Question 279

what are the three major causes of cardiac arrest in pregnancy

Answer 279

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

Question 280

what is aortocaval compression

Answer 280

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

Question 281

how is resuscitation done in pregnancy

Answer 281

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

Question 282

what prophylaxis can be done for preterm labour

Answer 282

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

Question 283

if there is doubt is membranes have ruptured what tests can be performed

Answer 283

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

Question 284

what is fetal fibronectin

Answer 284

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.

Question 285

what are options which can be used to improve the outcome of preterm labour

Answer 285

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

Question 286

what situations would it be beneficial to induce labour early

Answer 286

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

Question 287

what is the bishop score

Answer 287

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)

Question 288

what are the options for induction of labour

Answer 288

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

Question 289

what are the two means of monitoring during labour

Answer 289

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

Question 290

what is uterine hyperstimulation

Answer 290

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

Question 291

what is the management of uterine rupture

Answer 291

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

Question 292

what two factors are measured to get the CTG readout

Answer 292

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

Question 293

what are indications for continuous CTG monitoring

Answer 293

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

Question 294

what are the 5 key features to look at on a CTG

Answer 294

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

Question 295

what are reassuring, non reassuring and abnormal baseline rates and variability on CTG

Answer 295

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

Question 296

what are the four types of decelerations on CTG

Answer 296

Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations

Question 297

what are early decelerations

Answer 297

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

Question 298

what are late decelerations

Answer 298

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

Question 299

what are variable decelerations

Answer 299

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

Question 300

what are prolonged decelerations

Answer 300

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.

Question 301

what is fetal scalp stimulation

Answer 301

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

Question 302

what is the rule of 3’s for fetal bradycardia

Answer 302

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

Question 303

what is a sinusoidal CTG

Answer 303

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 304

what is the mnemonic used to assess the features of a CTG in a structured way

Answer 304

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)

Question 305

what is oxytocin infusion in labour used for

Answer 305

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

Question 306

when is ergometrine used in labour

Answer 306

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

Question 307

when are prostaglandins used in pregnancy

Answer 307

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)

Question 308

when is nifedipine used in pregnancy

Answer 308

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

Question 309

when is terbutaline used in pregnancy

Answer 309

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

Question 310

when is carboprost used in labour

Answer 310

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

Question 311

when is tranexamic acid used in patients

Answer 311

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

Question 312

when is delay in the first stage of labour considered

Answer 312

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

Question 313

what is a partogram and what does it measure

Answer 313

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

Question 314

when is delay in the second stage of labour considered

Answer 314

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

Question 315

what are the different lies a baby can be in

Answer 315

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

Question 316

what is delay of the third stage of labour defined as

Answer 316

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

Question 317

what pain medication is used in pregnancy

Answer 317

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

Question 318

what are adverse effects of an epidural

Answer 318

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

Question 319

what is umbilical cord prolapse

Answer 319

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

Question 320

what is the most significant risk factors for umbilical cord prolapse

Answer 320

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

Question 321

what is the management of umbilical cord prolapse

Answer 321

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

Question 322

what are the risks of instrumental delivery

Answer 322

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

Question 323

what is the main complication of a ventouse delivery for baby

Answer 323

cephalohaematoma

Question 324

what is the main complication of forceps delivery for baby

Answer 324

facial nerve palsy

Question 325

what are indications for instrumental delivery

Answer 325

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

Question 326

what nerve injury can occur in the mother during instrumental delivery

Answer 326

The affected nerves may be:
Femoral nerve
Obturator nerve

Question 327

what nerve injuries can occur during birth that are unrelated to instrumental delivery

Answer 327

Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve

Question 328

what circumstances are perineal tears common

Answer 328

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

Question 329

what is the classification of perineal tears

Answer 329

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

Question 330

what are the third degree subcategories for perineal tears

Answer 330

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

Question 331

what is the management of perineal tears

Answer 331

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

Question 332

what are short term complications after perineal tear repair

Answer 332

Pain
Infection
Bleeding
Wound dehiscence or wound breakdown

Question 333

what are lasting complications that can come from perineal tears

Answer 333

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

Question 334

what is perineal massage

Answer 334

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.

Question 335

what are the two classifications of post partum haemorrhage

Answer 335

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

Question 336

what are the two sub-classifications of major PPH

Answer 336

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

Question 337

what is the immediate management if someone has a post partum haemorrhage

Answer 337

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

Question 338

what are the mechanical treatment options for stopping bleeding in PPH

Answer 338

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

Question 339

what are the medical treatments to stop bleeding in a PPH

Answer 339

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

Question 340

what are the surgical treatments to stopping bleeding in a PPH

Answer 340

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

Question 341

what are risk factors for PPH

Answer 341

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

Question 342

what are indications for elective caesarean

Answer 342

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

Question 343

what are the 4 types of emergency caesarean

Answer 343

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.

Question 344

what are the layers of the abdomen that need to be dissected through in a caesarean

Answer 344

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

Question 345

what are the two kinds of incision used in a caesarean section

Answer 345

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)

Question 346

what measures can be done to reduce risks during a caesarean section

Answer 346

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

Question 347

can a woman give birth vaginally after a caesarean

Answer 347

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

Question 348

what are the two key causes of sepsis in pregnancy

Answer 348

Chorioamnionitis
Urinary tract infections

Question 349

what are non specific signs of sepsis

Answer 349

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

Question 350

what chart is used to monitor women and their chance of sepsis

Answer 350

maternity early obstetric warning system (MEOWS)

Question 351

what are signs of chorioamnionitis

Answer 351

Abdominal pain
Uterine tenderness
Vaginal discharge

Question 352

what is the management of sepsis in pregnancy

Answer 352

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

Question 353

what is amniotic fluid embolism

Answer 353

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

Question 354

what are the main risk factors for amniotic fluid embolism

Answer 354

Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy

Question 355

how does amniotic fluid embolism present

Answer 355

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

Question 356

what is the management of amniotic fluid embolism

Answer 356

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

Question 357

what is uterine rupture

Answer 357

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

Question 358

what are risk factors for uterine rupture

Answer 358

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

Question 359

how does uterine rupture present

Answer 359

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

Question 360

what is the management of uterine rupture

Answer 360

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 361

what is uterine inversion

Answer 361

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

Question 362

how does uterine inversion present

Answer 362

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.

Question 363

what are the options for treating uterine inversion

Answer 363

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

Question 364

in girls what is the sign of the the onset of puberty

Answer 364

the development of breast buds

Question 365

what is tanner stage 1 for female puberty

Answer 365

under 10
no pubic hair
no breast development

Question 366

what is tanner stage 2 for female puberty

Answer 366

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

Question 367

what is tanner stage 3 for female puberty

Answer 367

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

Question 368

what is tanner stage 4 for female puberty

Answer 368

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

Question 369

what is tanner stage 5 for female puberty

Answer 369

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

Question 370

how does the primary follicle develop

Answer 370

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)

Question 371

how does the secondary follicle develop

Answer 371

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

Question 372

how do antral follicles develop

Answer 372

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

Question 373

what is the process of fertilisation

Answer 373

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

Question 374

what is a polar body

Answer 374

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

Question 375

how does the blastocyst develop

Answer 375

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

Question 376

how does implantation occur

Answer 376

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

Question 377

when do the cells of the embryoblast start to differentiate

Answer 377

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

Question 378

what are the two layers of the chorion

Answer 378

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

Question 379

what week does the embryonic disc develop into the fetal pole

Answer 379

week 5 - splits into the ectoderm, mesoderm, endoderm

Question 380

what does the endoderm become in the body

Answer 380

GIT
lungs
liver
pancreas
thyroid
reproductive system

Question 381

what does the mesoderm become

Answer 381

heart
muscle
bone
connective tissue
blood
kidneys

Question 382

what does the ectoderm become

Answer 382

skin
hair
nails
teeth
CNS

Question 383

when does the fetal heart form

Answer 383

week 6

Question 384

how do spiral arteries develop

Answer 384

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.

Question 385

how does the placenta develop

Answer 385

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.

Question 386

how do the lacunae develop

Answer 386

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.

Question 387

what are the 5 functions of the placenta

Answer 387

Respiratory
Renal/excretion
Nutrition
immunity
endocrine

Question 388

what immunoglobulin crosses the placenta

Answer 388

IgG

Question 389

what waste products are filtered from the fetus via the placenta

Answer 389

urea and creatinine

Question 390

what endocrine functions does the placenta have

Answer 390

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)

Question 391

what are the hormonal changes during pregnancy

Answer 391

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

Question 392

what are the respiratory changes in pregnancy

Answer 392

increased tidal volume
increased resp. rate

Question 393

what are the renal changes in pregnancy

Answer 393

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

Question 394

what are the haematological changes in pregnancy

Answer 394

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

Question 395

what are the cardiovascular changes in pregnancy

Answer 395

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

Question 396

what are the uterine changes in pregnancy

Answer 396

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

Question 397

what are Braxton hicks contractions

Answer 397

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