OBS Flashcards

Question

Threatened miscarriage?

Answer 1

Vaginal bleeding with a closed cervix and a fetus that is alive

Answer 2

Vaginal bleeding with an open cervix Non viable pregnancy

Answer 3

Retained products of conception remain in the uterus after the miscarriage ○ Open cervical os ○ RPOC

Answer 4

Full miscarriage has occurred Closed cervical os, empty uterus Bleeding will have settled

Answer 5

Gestational sac is present but contains no embryo

Answer 6

- Mean gestational sac diameter - Foetal pole and crown rump length - Foetal heartbeat

Answer 7

Women with pregnancy less than 6 weeks gestation presenting with bleeding can be managed expectantly provided they have no pain or risk factors e.g. previous ectopic Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment Repeat urine pregnancy test performed after 7-10 days 0 if negative a miscarriage can be confirmed

Answer 8

Referral to early pregnancy assessment service for women with positive pregnancy test (more than 6 weeks gestation) and bleeding Early pregnancy assessment arrange USS 3 options - expectant, medical and surgical

Answer 9

First line for women without risk factors for heavy bleeding or infection 1-2 weeks are given to allow it to happen spontaneously. Repeat urine pregnancy test after 3 weeks If persistent or worsening bleeding then repeat USS

Answer 10

Mifepristone for missed miscarriage Misoprostol for incomplete miscarriage DO A PREGNANCY TEST AT 3 WEEKS AFTER

Answer 11

Binds to prostaglandin receptors and activates them Softening the cervix and stimulating uterine contractions Expedites the process of miscarriage - vaginal suppository or an oral dose

Answer 12

Anti progesterone that prevents uterus from supporting pregnancy by blocking the effects of progesterone

Answer 13

Heavier bleeding, pain, vomiting

Answer 14

Manual vacuum aspiration under local anaesthetic as an outpatient ○ Local applied to cervix ○ Tube attached to a specially designed syringe is inserted through the cervix into the uterus ○ Manually aspirate the contents of the uterus ○ Must be below 10 weeks gestation ○ More appropriate for women who have previously given birth ( parous) Electric vacuum aspiration under general anaesthetic ○ Traditional. Cervix is gradually widened using dilators, products of conception are removed through the cervix using an electric powered vacuum - Prostaglandins ( misoprostol) given before to soften the cervix - Anti rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage

Answer 15

3 or more consecutive spontaneous abortions Occurs in around 1% of women

Answer 16

* antiphospholipid syndrome * endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome * uterine abnormality: e.g. uterine septum * parental chromosomal abnormalities *smoking * hereditary thrombophilias

Answer 17

2 sperms fertilise an ovum

Answer 18

2 sperm fertilise an empty ovum

Answer 19

Can cause malignancy

Answer 20

Irregular vaginal bleeding Hyperemesis gravidarum Large for dates uterus Early failed pregnancy Hyperthyroidism

Answer 21

Lots of HCG USS to diagnose DEifnitiev diagnose made by histological examination of products of conception Suction curreatage SNOW STORM APPERANCE ON USS

Answer 22

Methotrexate Chemo for invasive disease

Answer 23

Antiphospholipid antibodies - blood becomes prone to clotting Hyper coagulable state Main associations with thrombosis and complications in pregnancy, particularly recurrent miscarriage Can occur on its own or secondary to autoimmune e.g. SLE

Answer 24

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

Answer 25

After; 3 or more first trimester miscarriages 1 or more second trimester miscarriages

Answer 26

- Uterine septum - Unicornuate uterus - Bicornuate uterus - Didelphis uterus - Cervical insufficiency Fibroids

Answer 27

- Inflammation Rare cause of miscarriage in second trimester

Answer 28

APL antibodies Testing for hereditary thrombophilias Pelvic USS Genetic testing of products of conception Genetic testing on parents

Answer 29

Increased levels of beta HCG - multiple pregnancies or trophoblastic disease Nulliparity Obesity Family or personal history

Answer 30

5% pre pregnancy weight loss Dehydration Electrolyte imbalance

Answer 31

PUQE score - quantification of emesis, score out of 15 U +Es Potassium Ketonuria

Answer 32

* Rest and avoid triggers e.g. odours * Bland, plain food, particularly in the morning * Ginger * P6 (wrist) acupressure * antiemetics

Answer 33

* antihistamines: oral cyclizine or promethazine * phenothiazines: oral prochlorperazine or chlorpromazine

Answer 34

* oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. * oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days * Omeprazole for acid reflux * admission may be needed for IV hydration * normal saline with added potassium is used to rehydrate -Thiamine supplementation to prevent deficiency

Answer 35

- AKI - Wernicke's encephalopathy - Oesphagitis - Mallory weiss - VTW Fetal outcome

Answer 36

28 W gestation (unless severely will impact mother) 2 registered medical practitioners must sign legal document

Answer 37

* mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions * patient decision aids often refer to this as mimicking a miscarriage * this may be done at home depending on the gestation * takes time (hours to days) to complete and the timing may not be predictable a pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test

Answer 38

manual vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E) * cervical priming with misoprostol +/- mifepristone is used before procedures * women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia * following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity

Answer 39

* NICE recommend that women are offered a choice between medical or surgical abortion up to and including 23+6 weeks' gestation * patient decision aids are usually given to allow women to make an informed decision * after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate * before 10 weeks medical abortions are usually done at home

Answer 40

Spontaneous abortion Ectopic Hydadidiform mole

Answer 41

Spontaneous abortion Hydadidiform mole Placental abruption

Answer 42

Bloody show Placental abruption Placenta praaevia Vasa praevia

Answer 43

Placental abruption The placenta partially or completely detaches from the uterine wall before delivery. Symptoms include painful contractions and bleeding, and the uterus may feel tense. There is no treatment to stop placental abruption, and the course of care depends on the amount of bleeding, the gestational age, and the condition of the fetus. Placenta previa The placenta is attached in the lower part of the uterus, near or over the cervix. This condition occurs in about 1% of pregnancies. Symptoms include painless bleeding. Up to one-third of patients with early onset of bleeding from placenta previa are able to complete 36 weeks of gestation. Vasa previa Fetal blood vessels run near the internal cervical os. Symptoms include vaginal bleeding, rupture of membranes, and fetal deterioration. If vasa previa is suspected during labor or when the waters break, the baby needs to be born urgently, usually by emergency caesarean.

Answer 44

Supports uterine lining and suppresses immune response to foetal tissue

Answer 45

Promotes uterine growth and increases blood flow to the placenta

Answer 46

Maintains corpus leuteum in early pregnancy

Answer 47

- Increased GFR, medications are cleared much quicker - Increased renal blood flow and increased kidney size - Increased urinary output - Hydronephrosis - progesterone induced relaxation

Answer 48

- Increased GI volume ---> GORD - Relaxation of GI tract= delayed gastric emptying = constipation and GORD Nausea and vomiting

Answer 49

Total number of pregnancies a women has had Primigravida = patient pregnant for first time Multigravida = patient that is pregnant for at least the second time.

Answer 50

Number of times the women has given birth after 24 weeks gestation, regardless of whether the foetus was alive or stillborn

Answer 51

1st trimester = from start of pregnancy until 12 weeks gestation 2nd trimester = from 13 weeks until 26 weeks gestation 3rd trimester = from 27 weeks gestation until birth

Answer 52

Foetal movements start from around 20 weeks gestation, and continue until birth

Answer 53

Whooping cough from 16 weeks gestation Influenza when available in autumn or winter Live vaccines such as MMR are avoided

Answer 54

- Take folic acid 400mcg from before pregnancy to 12 weeks ( reduces neural tube defects) - Tale vitamin D supplement - Avoid vitamin A supplements or eating liver or pate - Don't drink alcohol - foetal alcohol syndrome - Don’t smoke - Avoid unpasteurised dairy or blue cheese - risk of listeriosis - Avoid undercooked or raw poultry - risk of salmonella - Continue moderate exercise but avoid contact sports - Flying increases VTE risk - Place care seatbelts above and below the bump

Answer 55

Miscarriage, small for dates, preterm delivery, foetal alcohol syndrome

Answer 56

- Microcephaly (small head) - Thin upper lip - Smooth flat philtrum - Short palpebral fissure (short horizontal distance from one side of the eye to the other) - Learning disability - Behavioural difficulties - Hearing and vision problems - Cerebral palsy

Answer 57

○ Foetal growth restriction ○ Miscarriage ○ Stillbirth ○ Preterm labour and delivery ○ Placental abruption ○ Cleft lip or palate ○ Sudden infant death syndrome (SIDS)

Answer 58

RCOG advises flying is generally okay in uncomplicated healthy pregnancies up to ○ 37 weeks in a single pregnancy ○ 32 weeks in a twin pregnancy After 28 weeks gestation, most airlines need a note from midwife/GP/obstetrician to state the pregnancy is going well and no additional risks!

Answer 59

Occurs twice - booking clinic - 28 weeks gestation

Answer 60

Plasma volume increases = reduction in haemoglobin concentration = blood is diluted due to higher plasma volume

Answer 61

LOW MCV- iron deficiency NORMAL MCV- physiological anaemia due to increased plasma volume of pregnancy RAISED MCV- b12 or folate deficiency

Answer 62

IRON - women with anaemia in pergnancy are started on iron replacement - ferrous sulfate 200mg once daily. When they arent anaemic, but have low ferritin ( indiciating low iron stores) may be started on supplementary iron B12 - increased plasma volume and b12 requirements = low b12 in pregnancy Women with low b12 should be tested for pernicious anaemia IM hydroxocobalamin injections or oral cyancobalamin tablets Folate - All women should already be taking folic acid 400mcg per day. If deficiency - 5mg per day

Answer 63

Occurs in the third trimester. Rapid accumulation of fat within the hepatocytes causing acute hepatitis HIGH risk of liver failure and mortality for both the mother and foetus

Answer 64

- Impaired processing of fatty acids in the placenta - Genetic condition in the foetus that impairs fatty acid metabolism - Most common cause is LCHAD deficiency in the fetus - autosomal recessive condition. Means the mother will also have one defective copy of the gene - LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. Fetus and placenta unable to break down fatty acids. They enter the mothers circulation and accumulate in the liver. Mothers defective copy of the gene may also contribute to the accumulation of fatty acids. = inflammation and liver failure

Answer 65

- Vague symptoms associated with hepatitis ○ General malaise and fatigue ○ Nausea and vomiting ○ Jaundice ○ Abdo pain ○ Anorexia - lack of apetite ○ Ascites

Answer 66

Raised bilirubin, raised WBC count, deranged clotting ( raised prothrombin time and INR) Low platelets

Answer 67

HELLP syndrome

Answer 68

Requires prompt delivery of the baby Treatment of the acute liver failure (if it occurs), including liver transplantation consideration

Answer 69

* Placental abruption * Placenta praevia – where the placenta is fully or partially attached to the lower uterine segment * Marginal placental bleed – small, partial abruption of the placenta which is large enough to cause revealed bleeding, but not large enough to cause maternal or fetal compromise * Vasa praevia – where fetal blood vessels run near the internal cervical os. It is characterised by a triad of (i) Vaginal bleeding; (ii) Rupture of membranes; and (iii) Fetal compromise * The bleeding occurs following membrane rupture when there is rupture of the umbilical cord vessels, leading to loss of fetal blood and rapid deterioration in fetal condition * Uterine rupture – a full-thickness disruption of the uterine muscle and overlying serosa. This usually occurs in labour with a history of previous caesarean section or previous uterine surgery such as myomectomy Local genital causes: * Benign or malignant lesions – e.g. polyps, carcinoma. cervical ectropion (common). Infections – e.g. candida, bacterial vaginosis and chlamydia.

Answer 70

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

Answer 71

Can lead to several adverse outcomes e.g. miscarriage, anaemia, small for gestational age and pre eclampsia Levothyroxine dose needs to be increased

Answer 72

ACE inhibitors, angiotensin receptor blockers and thiazide/thiaazide like diuretics need to be stopped

Answer 73

- Should take folic acid 5mg daily from before conception to reduce risk of neural tube defects - Pregnancy may worsen seizure control due to the additional stress, lack of sleep, hormonal changes etc. Not known to be harmful to the pregnancy other than the risk of physical injury * Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy * Sodium valproate is avoided as it causes neural tube defects and developmental delay * Phenytoin is avoided as it causes cleft lip and palate

Answer 74

- Autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. Inflammatory arthritis. Treated with disease-modifying anti rhuematic drugs ( DMARDs) - RA should be well controlled for 3 months before coming pregnant. Often symptoms improve during pregnancy and may falre after delivery - Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities - Hydroxychloroquine is considered safe during pregnancy and is often the first-line choice - Sulfasalazine is considered safe during pregnancy - Corticosteroids may be used during flare-ups

Answer 75

Block prostaglandins Prostaglandins are important in maintaining the ductus arteriosus in the foetus and neonate and they soften the cervix and stimulate uterine contractions at the time of delivery NSAIDs are avoided in pregnancy unless they are really necessary Particularly avoided in 3rd trimester as they an cause premature closure of the ductus arteriosus in the foetus Can delay labour

Answer 76

Labetalol is most frequently used in pregnancy First line for high BP caused by pre-eclampsia B Blockers can cause: - Foetal growth restriction - Hypoglycaemia in the neonate Bradycardia in the neonate

Answer 77

Medications that block the renin angiotensin system can cross the placenta and enter the foetus - Can affect the kidneys of neonate and reduce the production of urine (and therefore amniotic fluid- oligohydramnios) - Hypocalvaria - incomplete formation of skull bones - Miscarriage Hypotension in the neonate

Answer 78

Can cause withdrawal symptoms in the neonate after birth Neonatal abstinence syndrome (NAS) NAS presents between 3-72 hours after birth, with irritability, tachypnoea, high temperatures and poor feeding

Answer 79

May be used in younger patients with recurrent venous thrombosis, `AF or metallic mechanical heart valves Crosses the placenta + teratogenic in pregnancy Can cause: - Foetal loss - Congenital malformations, particularly craniofacial problems - Bleeding during pregnancy, postpartum haemorrhage, foetal haemorrhage, intracranial bleeding

Answer 80

Causes neural tube defects and developmental delay

Answer 81

Particularly avoided in 1st trimester as linked with congenital cardiac abnormalities. Associated with Ebstein's abnormality - where the tricuspid valve is set lower on the right of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle If used, levels need to be monitored closely. Enters breast milk so MUST BE AVOIDED in breastfeeding

Answer 82

First trimester - 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 Neonate's can experience withdrawal symptoms

Answer 83

HIGHLY teratogenic, causing miscarriage and congenital defects Women need very reliable contraception, before during and for one month after taking isotretinoin

Answer 84

6 months off for women and males

Answer 85

Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. Risk is highest before 10 weeks gestation Before getting pregnant - ensure they’ve had the MMR vaccine When in doubt - can be tested for rubella immunity Pregannt women should not receive the MMR vaccine as its live

Answer 86

- Congenital deafness - Congenital cataracts - Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Answer 87

Dangerous in pregnancy as can lead to; - More severe cases in the mother such as varicella pneumonitis, hepatitis, encephalitis - Foetal varicella syndrome Severe neonatal varicella infection( if infected around delivery)

Answer 88

they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure. When chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.

Answer 89

When infection occurs in the first 28 weeks of gestation ○ 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 ( choriorentitis)

Answer 90

Can get through processed meats, blue cheese etc High rate of miscarriage, fatal death, severe neonatal infection

Answer 91

Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures

Answer 92

Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters. Complications are: * Miscarriage or foetal death * Severe foetal anaemia * Hydrops fetalis (fetal heart failure) * Maternal pre-eclampsia-like syndrome

Answer 93

Affects children Self limiting, rash and symptoms usually fade over 1-2 weeks Non specific viral symptoms After 2-5 days = rash appears like slapped cheeks Few days later- reticular mildly erythematous rash affecting the trunk and limbs appears ( reticular means net like)

Answer 94

Paro virus b19 Mirror syndrome. It can be a rare complication of severe fetal heart failure (hydrops fetalis). It involves a triad of hydrops fetalis, placental oedema and oedema in the mother. It also features hypertension and proteinuria.

Answer 95

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

Answer 96

- Microcephaly - Fetal growth restriction Other intracranial abnormalities e.g. ventriculomegaly and cerebellar atrophy

Answer 97

- 3 copies of chromosome 21 - Trisomy 21 - All women are offered screening for downs syndrome during pregnancy

Answer 98

- First line and most accurate screening test - Performed between 11 and 14 weeks gestation - USS measures nuchal translucency, which is the thickness of the back of the neck - Downs syndrome is one cause of nuchal thickness greater than 6mm

Answer 99

bHCG - higher result indicates greater risk pregnancy associated plasma protein A - lower result indicates greater risk

Answer 100

Performed between 14 and 20 weeks gestation Identical to the triple test, bt includes testing for inhibit A in blood (greater risk)

Answer 101

Risk score When the risk is greater than 1/150, women is offered amniocentesis ( amniotic fluid aspiration) or chorionic villus sampling ( USS guided biopsy)

Answer 102

New test for detecting abnormalities in the foetus during pregnancy Involves blood test from mother DNA

Answer 103

MDT - OT, speech and language, physio, dietician etc

Answer 104

* Regular thyroid checks (2 yearly) * Echocardiogram to diagnose cardiac defects * Regular audiometry for hearing impairment * Regular eye checks

Answer 105

Feotus that measures below the 10th centile for their gestational age

Answer 106

Estimated fatal weight Fetal abdominal circumference

Answer 107

When the fetus is below the 3rd centile for their gestational age. Low birth weight is defined as a birth weight of less than 2500g.

Answer 108

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)- when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta

Answer 109

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

Answer 110

Conditions that affect the transfer of nutrients across the placenta: * Idiopathic * Pre-eclampsia * Maternal smoking * Maternal alcohol * Anaemia * Malnutrition * Infection * Maternal health conditions

Answer 111

* Genetic abnormalities * Structural abnormalities * Fetal infection * Errors of metabolism

Answer 112

Small for gestational age Reduced amniotic fluid volume Abnormal doppler studies Reduced foetal movements Abnormal CTGs

Answer 113

* Fetal death or still birth * Birth asphyxia * Neonatal hypothermia * Neonatal hypoglycaemia

Answer 114

CVD ( HTN) T2DM Obesity Mood and behavioural problem s

Answer 115

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

Answer 116

* 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 Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results). This reduces the risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section. Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.

Answer 117

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

Answer 118

Constitutional, maternal diabetes, previous macrosomia, maternal obesity or rapid weight gain, overdue, male baby

Answer 119

Shoulder dystocia, failure to progress, perineal tears, instrumental delivery/ caesarean, PPH, uterine rupture ( rare)

Answer 120

Birth injury - erbs palsy, clavicular fracture, foetal distress, hypoxia Neonatal hypoglycaemia Obesity on childhood and later life T2DM in adulthood

Answer 121

USS to exclude polyhydramnios and estimate foetal weight Oral glucose tolerance test for gestational diabetes

Answer 122

Pruitic and urticarial papules and plaques of pregnancy Itchy rash that starts in 3rd trimester Papules, wheals and plaques Abdomen

Answer 123

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

Answer 124

Eczema that flares up during pregnancy Women that have never suffered with eczema and those with pre existing eczema Presents in first and second trimesters 2 types

Answer 125

* E-type, or eczema-type: with eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest. * P-type, or prurigo-type: with intensely itchy papules (spots) typically affecting the abdomen, back and limbs.

Answer 126

Condition usually gets better after delivery Topical emollients Topical steroids Phototherapy with UV Oral steroids

Answer 127

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

Answer 128

28 weeks if there are 3 risk factors First trimester if there are 4 or more risk factors

Answer 129

New onset hypertension ( <140/90) after 20 weeks .. AND - proteinurea - maternal organ dysfunction Occurring after 20 weeks when the spinal arteries of the placenta form abnormally = high vascular resistance in these vessels.

Answer 130

Labetalol Contraindicated in asthma though so nifedipine for them! If severe = IV magnesium sulphate

Answer 131

Seizures CV complications Pulmonary oedema Placental abruption HELLP - haemolysis, elevated liver enzymes, low platelets

Answer 132

Hypertension occurring in the second half of pregnancy Systolic >140 or diastolic >90 No proteinuria and no oedema Resolves following birth

Answer 133

HTN Proteinruea Oedema

Answer 134

When seizure occur as a result of pre eclampsia

Answer 135

High-risk factors are: * Pre-existing hypertension * Previous hypertension in pregnancy * Existing autoimmune conditions (e.g. systemic lupus erythematosus) * Diabetes * Chronic kidney disease Moderate-risk factors are: * Older than 40 * BMI > 35 * More than 10 years since previous pregnancy * Multiple pregnancy * First pregnancy * Family history of pre-eclampsia

Answer 136

Aspirin From 12 weeks if one high risk factor or more than one moderate risk factor

Answer 137

Headache Visual disturbances or blurriness Nausea and vomiting upper abdo or epigastric pain Oedema Reduced urine output Brisk reflexes

Answer 138

* Systolic blood pressure above 140 mmHg * Diastolic blood pressure above 90 mmHg PLUS any of: * Proteinuria (1+ or more on urine dipstick) * Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) * Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Answer 139

* Labetolol is first-line as an antihypertensive * Nifedipine (modified-release) is commonly used second-line * Methyldopa is used third-line (needs to be stopped within two days of birth) * Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia * IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures * Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Answer 140

Corticosteroids for fetal lungs

Answer 141

IV magnesium sulphate

Answer 142

Haemoysis Elevated liver enzymes Low Platelets Combination of features that occurs as a complication of pre eclampsia and eclampsia

Answer 143

HTN occurring in the second half of pregnancy - after 20 weeks

Answer 144

Diabetes triggered by pregnancy Caused by reduced insulin sensitivity during pregnancy, and resolves after birth

Answer 145

Previous gestational diabetes Previous macrocosmic baby BMI >30 First degree relative with diabetes Family origin with a high prevalence of diabetes - black Caribbean, Middle Eastern and south asian

Answer 146

Oral glucose tolerance test

Answer 147

should be screened with Ogtt at 24-28 weeks!

Answer 148

- Fasting glucose >5.6 mmol/L - 2 hour glucose >7.8mmol/L

Answer 149

- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin - Fasting glucose above 7 mmol/l: start insulin ± metformin - Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

Answer 150

Weight loss Stop hypoglycaemic agents, apart from metformin, and commence insulin Folic acid 5mg/day from pre conception to 12 weeks gestation Detailed anomaly scan at 20 weeks Retinopathy screening ( can worsen in pregnancy) Planned delivery between 37 and 38+6 weeks

Answer 151

Neonatal hypoglycaemia Polycythaemia Kaundice Congenital heart disease Cardiomegaly Need close monitoring for neonatal hypoglycaemia

Answer 152

IV dextrose or NG feeding

Answer 153

Large for dates foetus and macrosomia and shoulder dystocia

Answer 154

Reduced outflow of bile acids from the liver Condition resolves after delivery Increased risk of premature delivery Bile acids build up in the blood causing itching

Answer 155

Pruritus, typically worse palms, soles and abdomen Raised bilirubin jaundice usually 3rd trimester NO RASH

Answer 156

Abnormal LFTs Raised bile acids Normal for ALP to increase in pregnancy because the placenta produces it

Answer 157

Induction of labour at 37-38 weeks Urosodeoxycholic acid Vitamin K supplementation

Answer 158

Placenta is attached in the lower portion of the uterus, lower than the presenting part of the foetus OVER the internal cervical OS Notable cause of antepartum haemorrhage

Answer 159

Previous C section Previous placenta praaevia Older maternal age Maternal smoking Structural uterine abnormalities Assisted reproduction

Answer 160

Shock in proportion to visible loss No pain Uterus non tender Bleeding usually occurs later in pregnancy

Answer 161

Digital vaginal examination should not be performed before USS as it may provoke severe haemorrhage Often picked up on routine 20 week abnormal USS Transvaginal USS

Answer 162

Corticosteroids to mature foetal lungs, given risk of preterm delivery Different incisions may eb made into the skin and uterus Emergency C section

Answer 163

IM anti D injections to rhesus D negative women. Given at 28 weeks and at birth

Answer 164

The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.

Answer 165

Where foetal vessels are within the foetal membranes and travel across the internal cervical os Vessels are exposed, outside protection of the umbilical cord or placenta

Answer 166

type 1 = fetal vessels exposed as a velamentous umbilical cord Type 2 = 2 fetal vessels exposed as they travel to an accessory placental lobe

Answer 167

Low lying placenta IVF pregnancy Multiple pregnancy

Answer 168

May be diagnosed by uSS during pregnancy May present with antepartum haemorrhage with bleeding during 2nd or 3rd trimester of pregnancy May be detected by vaginal examination during labour when foetal vessels are seen in membranes through dilated cervix May be detected during labour

Answer 169

Corticosteroids given from 32 weeks to mature foetal lungs Elective caesarean section

Answer 170

When the placenta separates from the wall of the uterus during pregnancy Site of attachment can bleed extensively after the placenta separates Significant cause of antepartum haemorrhage

Answer 171

- Previous placental abruption - Pre-eclampsia - Bleeding early in pregnancy - Trauma - Multiple pregnancy - Foetal growth restriction - Multigravida - Increased maternal age - Smoking - Cocaine or amphetamine use

Answer 172

Sudden onset severe abdominal pain that is continuous Vaginal bleeding Shock ( hypotension and tachycardia) Abnormalities on the CTG indicating foetal distress Characteristic woody( hard) abdomen on palpation - indicating a large haemorrhage

Answer 173

Spotting - spots of blood Minor = <50ml Major = 50-1000ml Massive = more than 1000ml or signs of shock

Answer 174

Revealed - bleeding tracks down from the site of placental seperation and drains through the cervix. Results in vaginal bleeding Concealed - bleeding remains within the uterus, and typically forms clot retroplacentally. Bleeding is not visible but can be severe enough to cause systemic shock

Answer 175

Fetus alive and < 36 weeks * fetal distress: immediate caesarean * no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks * fetal distress: immediate caesarean * no fetal distress: deliver vaginally Fetus dead induce vaginal delivery Rhesus-D negative women require anti-D prophylaxis when bleeding occurs. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Answer 176

Birth of a dead foetus after 24 weeks gestation. Result of intrauterine fetal death

Answer 177

Unexplained Pre eclampsia Placental abruption Vasa praevia Cord prolapse Obstetric cholestasis Diabetes Thyroid disease Infections Genetic abnormalities

Answer 178

Foetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back

Answer 179

Risk assessment for SGA or FGR babies - they are closely monitored Safety netting - reduced foetal movements, abdo pain and vaginal bleeding

Answer 180

USS to diagnose the death Rhesus negative women require anti D Vaginal birth- mifepristone and misoprostol Cabergoline used to suppress lactation after still birth

Answer 181

Prematurity, multiparity, polyhydramnios, twin pregnancy, cehalopelvic disproportion, abnormal presentation

Answer 182

* cord prolapse is an obstetric emergency * the presenting part of the fetus may be pushed back into the uterus to avoid compression * if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm * the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out ○ the left lateral position is an alternative * tocolytics may be used to reduce uterine contractions * retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Answer 183

- INVESTIGATE WITH A HANDHELD DOPPLER ○ If no detal heartbeat detectbale 0 immediate USS Foetal movements should be established by 24 weeks

Answer 184

1st stage = from onset of labour until 10cm cervical dilation 2nd stage = from 10cm cervical dilation until delivery of the baby 3rd stage = from delivery of the baby until delivery of the placenta

Answer 185

From onset of labour ( true contractions) until 10cm cervical dilation Cervical dilation and effacement Mucus plug falls out 3 phases

Answer 186

Latent phase - from 0 to 3cm dilation of the cervix. Progresses at around 0.5cm per hour. Irregular contractions Active phase- from 3cm to 7cm dilation of the cervix. Progresses at around 1cm per hour. Regular contractions Transition phase - from 7cm to 10cm dilation of the cervix. Progresses at 1cm per hour. Regular contractions

Answer 187

Occasional irregular contractions of the uterus felt during the 2nd and 3rd trimester of pregnancy temporary and irregular tightening or mild cramping in the abdomen NOT TRUE contractions. dont indicate onset of labour. dont progress or become regular

Answer 188

Show (mucus plug from the cervix) Rupture of membranes Regular, painful contractions Dilating cervix on examinati

Answer 189

Regular painful contractions AND dilation of the cervix from 4cm onwards

Answer 190

Membrane sweep Vaginal prostaglandin E2 Cervical ripening balloon Artificial rupture of membranes Oral mifepristone

Answer 191

Foetal distress - Pain - Exhaustion - Unsuccessful IOL - unable to achieve vaginal birth Hyperstimulation - Uterine rupture - Cord prolapse - Iatrogenic intervention - Instrumental delivery

Answer 192

Whether to induce labour

Answer 193

Cat 1 - emergency, <30 mins (during labour) Cat 2 - emergency, 60-75 mins (during labour) Cat 3 - semi elective, 24 hours ( can't wait for labour to start naturally) Cat 4- elective, planed

Answer 194

- Foetal distress, maternal compromise Twins, praevia, breech, previous LSCS, previous tear

Answer 195

>500ml loss after vaginal delivery or >1000ml after c section

Answer 196

Minor = under 1000ml blood loss Major = over 1000ml blood loss

Answer 197

Tone- uterine atony trauma - perineal tear Tissue - retained placenta Thrombin - clotting/bleeding disorder

Answer 198

- Previous PPH - Prolonged labour - Multiple pregnancy - Pre eclampsia - Obesity - Emergency c section - Retained placenta - Macrosomia - Instrumental delivery

Answer 199

Treating anaemia during the antenatal period Giving birth with empty bladder ACtive management of the third stage - IM oxytocin in the 3rd stage IV TXA can be used during C section in higher risk patients

Answer 200

anagement - ABC - cannula, bloods, warmed IV fluid - Mechanical ○ Palpate the uterine fundus and rub to stimulate contraction ○ Catheterization - bladder distention prevents uterus contractions - Medical ○ IV oxytocin - slow injection followed by IV infuction ○ Ergometrine - slow IV or IM ○ Carboprost IM - caution in asthma ○ Misoprostol (sublingual) TXA IV - antifibrinolytic that reduces bleeding Surgical ○ Intrauterine balloon tamponade ○ B lynch suture ○ Uterine artery ligation Hysterectomy

Answer 201

- Occurs from 24 hours to 12 weeks postpartum - More likely to be due to retained products of conception or infection - USS, swabs for infection Surgical evaluation or abx

Answer 202

POP and implant are safe in breast feeding and can be started anytime The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks). A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but nCot inserted between 48 hours and four weeks of delivery (UKMEC 3).

Answer 203

Phenytoin Methotrexate Pregnancy alcohol excess

Answer 204

* all women should take 400mcg of folic acid until the 12th week of pregnancy * women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy * women are considered higher risk if any of the following apply: ○ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD ○ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. ○ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 205

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour -

Answer 206

aspirin 75-150mg daily from 12 weeks gestation until the birth

Answer 207

High High risk factors hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension moderate first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy

Answer 208

oral labetalol Nifedipine (e.g. if asthmatic) and hydralazine may also be used

Answer 209

Check for varicella antibodies Oral aciclovir! From day 7-14 after exposure - not immediately

Answer 210

a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) digital examination should be avoided due to the risk of infection if pooling of fluid is not observed, NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1) ultrasound may also be useful to show oligohydramnios

Answer 211

Regular obs Oral erythromycin for 10 days Antenatal corticosteroids Consider Iv mag sulphate Delivery recommended at 37 weeks gestation

Answer 212

Assessing whether induction of labour will be required

Answer 213

Cervix is ripe/ favourable

Answer 214

vaginal prostaglandins or oral misoprostol mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean

Answer 215

amniotomy and an intravenous oxytocin infusion

Answer 216

Uterine hyperstimulation prolonged and frequent uterine contractions

Answer 217

intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia uterine rupture (rare)

Answer 218

removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started consider tocolysis

Answer 219

Initially, request senior help and ask the mother to hyperflex their legs (also called McRobert's manouvere) and apply suprapubic pressure. . If this method fails, episiotomy is required to allow internal manouveres. A number of potential options, including Wood's screw manouvere and grasping and manipulation of the posterior arm are then possible. Last resorts include symphisiotomy and the Zavanelli manouvere (which includes Caesarean section, however by this point fetal damage is often irreversible).j

Answer 220

Palpate the uterine fungus IV oxytocin, ergometrine IM/IV (unless history of HTN), carboprost IM (unless history of asthmma _ Intrauterine balloon tamponade is first line Then- B Lynch, ligation of uterine arteries

Answer 221

From 24 hours - 12 weeks usually occurs due to retained placenta tissue or endometritis

Answer 222

Lamotrigine, carbamazepine and levetiracetam

Answer 223

NO! No proteinurea MUST OCCUR AFTER 20 WEEKS GESTATION

Answer 224

ADMIT AND OBSERVE

Answer 225

IV ab during labour - benzylpenicillin

Answer 226

Lower abdominal pain, foul swelling discharge and fever post partum Mixed infection - aerobic and anaerobic - strep and staph Leading cause of puerperal pyrexia

Answer 227

Endometritis, UTI, wound infection, mastitis, VTE

Answer 228

fever >38 degrees in first 2W after childbirth

Answer 229

Clindamycin + gentamycin

Answer 230

Calcium gluconate

Answer 231

Involving anal sphincter Repair in theatre

Answer 232

Perineal muscle injury, not involving sphincter Repair on ward with a suitablely trained midwife/ clinician

Answer 233

Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa require repair in theatre by a suitably trained clinician

Answer 234

Do not require tear Superficial damage, no muscle involvement

Answer 235

Primigravia, large babies, precipitant labour, shoulder dystocia, forceps delivery

OBS Flashcards

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