Obs 3a

Question 1

Ectopic Pregnancy Pathophysiology

Implantation of a fertilized ovum outside the uterus results in ectopic

RF: Damage to fallopian tubes (PID), Previous Ectopic Pregnancy, Smoking, Increasd Maternal Age, IVF, Endometriosis, IUCD,POP

Answer 1

• Pregnanxy which occurs in fallopian tube - more so ampulla (95%); can also occur at the cornu, cervix, ovary, and abdominal cavity.
• Can also implant in previous Caesarean section scars.
• trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo - bleeds into lumen which can be catastrophic
• More dangerous if in isthmus more likely to rupture

Question 2

Ectopic Pregnancy Signs And Symptoms

Answer 2

• 6-8 weeks amenhorroea, lower RLQ pain, vaginal bleeding (dark brown colour - usually less than normal period amount)
• peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
• dizziness, fainting or syncope may be seen
• Breast tenderness
• Diagnosis of a ruptured ectopic is usually clear, with signs of shock and acute abdomen. (rare presentation)

Examination findings

• abdominal tenderness
• cervical excitation (also known as cervical motion tenderness)
• adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Question 3

Ectopic Pregnancy Investigations & Management

Three methods of management: Expectant, Medical & Surgical

Answer 3

• Pregnancy test: +ve
• Transvaginal USS investigation of choice

Expectant

• Asymptomatic, <35mm, unruptured, no fetal heart beat, hCG <1000,
• can co exist with another pregnancy
• assumption that significant portion will resolve without treatment. keep monitoring

Medical

• <35mm, unruptured, no fetal heartbeat, minor symptoms, hCG <1500
• no co-existing pregnancy
• IM methotrexate with follow up!

Surgical

• > 35mm, can rupture, very painful,
• visible heart beat on USS
• B hCG >5000
• can co exist with another pregnancy
• Salpingectomy (complete removal of fallopian tube): no risk of infertility
• Salpingotomy: there is risk of infertility such as damage to contralateral fallopian tube, thats why this procedure is done

Anti-D often given with ectopic management if the woman is rh D negative

around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)

Question 4

Miscarriage Pathophysiology & Symptoms

5 types

Pregnancy which ends spontaneously before 24wks.

Answer 4

• Threatened: Vaginal bleeding (less than menstruation), Fetus alive, Cervical OS closed
• Inevitable: Heavy bleeding with clots and pains. OS open
• Complete: All fetal tissue has passed. OS closed with Uterus back to normal
• Missed: Delayed, dead fetus before 20 weeks without the symptoms of expulsion or pregnancy, light bleeding. OS closed
• Incomplete: pain & vaginal bleeding, not all fetus been discharged. OS open.

Signs
- Most common sign of miscarriage is vaginal bleeding.
- There can be abdominal pain as well. These will both resolve with a complete miscarriage.

Perform vaginal speculum to see whether OS is closed or opened.

Septic miscarriageis where the contents of the uterus are infected, causing endometritis. Vaginal loss is usually offensive, uterus tender; fever may be absent in some cases. With pelvic infection there is abdominal pain and peritonism.

Question 5

Miscarriage Management

Expectant, Medical & Surgical

Some situations are better managed surgically. NICE list the following:

• increased risk of haemorrhage
• she is in the late first trimester
• if she has coagulopathies or is unable to have a blood transfusion
• previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
• evidence of infection

Answer 5

Expectant
- after spontaneous miscarriage, bleeding and pain resolve, repeat USS not required.
- Women advised to take pregnancy test after 3 weeks and attend if positive. if fails then require med or surgical.

Medical
- Vaginal misoprostol
- expected clearance within 24h. if not then contact Dr.
- Pregnancy test @ 3wks

Surgical
- vacuum aspiration (suction curettage) or surgical management in theatre
- Under general anasthetic

Misoprostol: Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue

Question 6

9wk, 13wk, 15wk

Termination of Pregnacy

Abortion Action 1967

Upper limit of termination is 24wks

two registered medical practitioners must sign a legal document
only one rquired in emergency

Answer 6

• <9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
• Oral mifepristone and vaginal misoprostol
• <13 weeks: surgical dilation and suction of uterine contents
• > 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
• Multi-level pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG dropping (rather than just be positive or negative)

Method Depends on gestation period.

Complications post-TOP

• Infection can happen in up to 10% of TOP cases. Prophylactic Abx given
• Retained tissue 1%
• Haemorrage 1%
• Urine (shop) pregnancy tests often remain positive for up to 4 weeks post TOP - any longer indicates incomplete abortion

Question 7

consultant led care

Multiple pregnancy

Twins:1 in 80 & Triplets: 1 in 1000. Incidence of twins is increasing

dizygotic (non-identical, develop from two separate ova that were fertilized at the same time - more common)
monozygotic (identical, develop from a single ovum which has divided to form two embryos)

Answer 7

• Vomiting may be more marked in early pregnancy.
• Uterus will be larger than expected from the date and palpable before 12 weeks.
• Folic acid + iron + aspirin (if RF of Pre-eclampsia)
• Induction is usual at 37 weeks (DC twins) or 36 weeks (MC twins).
• In higher order pregnancies (>3) then try and recommend parents to reduce them to twins to avoid complications
• constant monitoring to avoid complications.
• When one twin has a congenital abnormality, selective termination should also be discussed here.

Antenatal complications
* polyhydramnios
* pregnancy induced hypertension
* anaemia
* antepartum haemorrhage
* Miscarriage,
* preterm labour
* intrauterine growth restriction
* Malpresentation
* twin-twin transfusion syndrome (TTTS) is where there ins unequal blood distribution between the twins – one twin depleted and other becomes overloaded.

Question 8

Gestational Diabetes

RF
- Previous gestational diabetes
- Previous macrosomic baby (>4.5kg)
- BMI >30
- Ethnic origin of Black Caribbean, Middle Eastern and South Asian
- Family history of diabetes (first degree)

Answer 8

• Glucose tolerance decreases in pregnancy due to altered carbohydrate metabolism and antagonistic effects of human placental lactogen, progesterone and cortisol.
• four weekly ultrasound scans to monitor fetal growth and amniotic fluid levels from 28 to 36 weeks gestation.
• trial of diet and exercise for 1-2 weeks, followed by metformin and then insulin.

• For the fetus, congenital abnormalities are more common.
• Birthweight is increased which has implications for birth, mainly posing a risk of shoulder dystocia.
• In addition, neonates at risk of neonatal hypoglycaemia which needs to be monitored for and managed appropriately.
• fasting glucose is >= 5.6 mmol/L
  2-hour glucose is >= 7.8 mmol/L

Question 9

Hypertension in Pregnancy

Raised BP without proteinuria

In normal pregnancy:
* blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
* after this time the blood pressure usually increases to pre-pregnancy levels by term

Answer 9

• Pregnancy-induced hypertension can be due to either pre-eclampsia or transient hypertension. This is when blood pressure rises above 140/90mmHg after 20 weeks gestation.
• Risks are worsening hypertension in the pregnancy, and the risk of developing pre-eclampsia – the risk is increased 6x. In

* No proteinuria, no oedema, resolves following birth.

• Ideally antihypertensive medications changed before pregnancy if pre-existing hypertension.
• ACE inhibitors avoided as these are teratogenic. Labetalol is normally used, with nifedipine as second-line agent.
• Prophylactic Aspirin started from wk12 as risk of pre eclampsia

Question 10

Pre-Eclampsia

1. New HTN 2. Oedema 3.Proteinuria

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things (above)

NICE guidelines state diagnosis made with:
- Systolic BP above 140mm/Hg
- Diastolic BP above 90mm/Hg
Plus any one of:
1. Proteinuria (1+ or more on urine dipstick)
1. Organ dysfunction (i.e. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
1. Placental dysfuncton (i.e. fetal growth restriction or abnormal Doppler studies)

Answer 10

• Symptoms occur late: headache, bluriness, nausea, epigastric pain, vomitting, oedema, reduced urine, brisk reflexes
• Aspirin used for prophylaxis; given from 12 weeks gestation until birth in women with a single high-risk factor or two or more moderate-risk factors.
• Labetalol first line, 2nd line: nifedipine
• IV hydralzine in critical cases
• Urgent secondary care management and ≥ 160/110 mmHg are likely to be admitted and observed

Patho: narrow spiral arteries..

Potential consequences of pre-eclampsia
* eclampsia
* other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
* fetal complications
* intrauterine growth retardation
* prematurity
* liver involvement (elevated transaminases)
* haemorrhage: placental abruption, intra-abdominal, intra-cerebral
* cardiac failure

Question 11

Risk factors of Pre-Eclampsia and Management

High Vs Moderate Risk.

Answer 11

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 risk factors
* 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

IV magnesium sulphate given during labour and in the 24 hours after to prevent seizures. Fluid restriction also used in severe cases to avoid fluid overload.
Planned early birth may be necessary – corticosteroids should be given in premature births before 34 weeks.

Question 12

Eclampsia

defined as the development of seizures in association pre-eclampsia.

40% of seizures occur post partum

Answer 12

• IV magnesium sulphate given during labour and in the 24 hours after to prevent
• Respiratory depression can occur
• calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload

Question 13

Anaemia in pregnancy

Pregnant women are screened for anaemia at:
* the booking visit (often done at 8-10 weeks), and at
* 28 weeks

Answer 13

NICE use the following cut-offs to determine whether a woman should receive oral iron therapy:
* First trimester < 110 g/L
* Second/third trimester < 105 g/L
* Postpartum < 100 g/L

Management
* oral ferrous sulfate or ferrous fumarate
* treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

Question 14

DVT/PE in pregnancy

• Compression duplex ultrasound should be done where there is suspicion of DVT
• ECG and chest x-ray should be performed in all patients suspcion of PE

Answer 14

• D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.
• CT Pulmonary Angiogram (CTPA) slightly increases the lifetime risk of maternal breast cancer
• Pregnancy makes breast tissue particularly sensitive to the effects of radiation
• V/Q (see clot in lung) scanning carries a slightly increased risk of childhood cancer

the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist

• The patient should receive LMWH immediately to avoid delay if PE is suspected. PE in pregnancy can cause hypoxia to the foetus and mother and potential cardiac arrest.

Question 15

Group B Strep

RF: Premature, previous sibling infxn, Maternal pyrexia

• Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period.
• It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS.
• Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.
  *

Answer 15

• women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
• women with a pyrexia during labour (>38ºC) should also be given IAP
• benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Question 16

Syphilis

8-12wk test for syphilis in pregnancy

• sexually transmitted infection caused by the spirochaete Treponema pallidum
• incubation period 9-90days

Answer 16

Primary
* chancre - painless ulcer at the site of sexual contact
* local non-tender lymphadenopathy
* often not seen in women (the lesion may be on the cervix)

Secondary (6-10wks)
* systemic symptoms: fevers, lymphadenopathy
* rash on trunk, palms and soles
* buccal ‘snail track’ ulcers (30%)
* condylomata lata (painless, warty lesions on the genitalia )

Tertiary
* Tertiary features
* gummas (granulomatous lesions of the skin and bones)
* ascending aortic aneurysms
* general paralysis of the insane
* tabes dorsalis
* Argyll-Robertson pupil

Diagnosis clinical features serology & microscopic examination of tissue

Management
intramuscular benzathine penicillin is the first-line management
- jarisch-Herxheimer reaction is sometimes seen following treatment (fever, rash) - self limiting

Question 17

congenital Syphilis

in preganant lady there is risk of miscarriages and still birth if she is infected with syphils

Answer 17

inflammation and hardening of the umbilical chord, rash, fever, low birth weight, high levels of cholesterol at birth, aseptic meningitis, anemia, monocytosis (an increase in the number of monocytes in the circulating blood), enlarged liver and spleen, jaundice (yellowish color of the skin), shedding of skin affecting the palms and soles, convulsions, mental retardation, periostitis (inflammation around the bones causing tender limbs and joints), rhinitis with an infectious nasal discharge, hair loss, inflammation of the eye’s iris and pneumonia.

Treat with penicillin

Question 18

Bacterial Vaginosis

not an STI

• overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Answer 18

Features

• vaginal discharge: ‘fishy’, offensive
• asymptomatic in 50%
• thin, white homogenous discharge
• clue cells on microscopy: stippled vaginal epithelial cells
• vaginal pH > 4.5
• positive whiff test (addition of potassium hydroxide results in fishy odour)
• No treatment for asymptomatic patients
• oral metronidazole for 5-7 days
• Topical Clindamycin alternative
• Relapse is common (within 3M)

Bacterial vaginosis in pregnancy
- results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
- Still treat with oral metronidazole

Question 19

Puerperal Infection

usually happens after the trauma of vaginal birth or caesarian delivery.

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.

Answer 19

Causes:
* endometritis: most common cause
* urinary tract infection
* wound infections (perineal tears + caesarean section)
* mastitis
* venous thromboembolism

MANAGEMENT
* if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Question 20

Varicella Zoster Exposure in pregnancy

fetal varicella syndrome

• 5 times greater risk of pneumonitis in mother
• risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
• studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
• features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Answer 20

If exposure occured
- Blood test for mother for Antibodies if unsure of previous Ix
- IV immunoglobulin for not previously exposed mother. Within 10days (less than 20wks)
- more than 20wks then Accyclovir. 7-14 days post exposure

Management of chickenpox in pregnancy
* if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
* there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk
* >20wks give accyclovir
* <20wks procede with caution when giving accyclovir

Question 21

What is a Hypoactive Uterus

Answer 21

Low resting tone and weakly propagated contractions. There is often a long interval between contractions and they are not particularly painful.

Question 22

What is Oligohydraminos and its Causes

Answer 22

• Reduction of Amniotic Fluid
• <500ml at 32-36 weeks + amniotic fluid index (AFI) < 5th percentile.

Causes
* premature rupture of membranes
* fetal renal problems e.g. renal agenesis
* intrauterine growth restriction
* post-term gestation
* pre-eclampsia

Renal agenesis is a complete absence of one (unilateral) or both (bilateral) kidneys, whereas in renal aplasia the kidney has failed to develop beyond its most primitive form.

Question 23

What is Polyhydramnios and its causes

Answer 23

• Too much aminotic fluid around the fetus

Causes
- Gestational Diabetes
- Oesophageal atresia (Fetus unable to swallow)
- Twin to transfusion syndrome
- Fetal Infection

Both oligohydramnios and polyhydramnios can cause reduce fetal movement

Can cause
- Post partum Haemorhage
- Breech Presentation
- Cord prolapse

Question 24

Different presentations of Fetus

5 different types

Answer 24

1. Cephalic (Ideal) - Longtitudinal
2. Breech - Longtitudinal
3. Oblique
4. Transverse

Specifically Occipito-Anterior cephalic with flexion

Question 25

Breech Presentation Management and Diagnosis | 3-4% risk. Preterm risk 25% ## Footnote presentation of buttocks is breech presentation. Risk factors for breech presentation * uterine malformations, fibroids * placenta praevia * polyhydramnios or oligohydramnios * fetal abnormality (e.g. CNS malformation, chromosomal disorders) * prematurity (due to increased incidence earlier in gestation)

Answer 25

- Extended breech (70%) - both legs extended at knee - Flexed breech (15%) - Both legs flexed at knee - Footling breech (15%) - or or both feet below bottox Diagnosis from 37wk onwards or woman in labour - USS confirmation Management - from 36wk (nulliparous) 37 (multiparous) attempt to turn baby to cephalic **external cephalic version** - Done without anaesthetic (uterine relaxant may be given) and with both hands on abdomen - CTG performed straight after and anti-D given if rhesus negative mother. - If fails then C-section is indicated at 39wk - or planned vaginal breech birth - C-secion has less complications. | epigastric pain common; hhead is normally palpable at the fundus. ## Footnote Attemptin to turn (ECV) Not performed * if fetus compromised, * vaginal delivery contraindicated, * twins, membranes ruptured * recent antepartum haemorrhage.

Question 26

Oblique & Transverse Lie | transverse marignally more common - oblique easier to correct ## Footnote - Scapulo anterior most common postion in transverse. RF * Most commonly occurs in women who have had previous pregnancies * Fibroids and other pelvic tumours * Pregnant with twins or triplets * Prematurity * Polyhydramnios * Foetal abnormalities

Answer 26

- Early gestation transverse lie is common - Abdo Exam: the head and buttocks are not palpable at each end of the uterus. USS allows visually observation of lie. - Before 36 weeks gestation: no management required - perform external cephalic version (ECV) - Elective caesarian section: this is the management for women where the patient opts for caesarian section or ECV has been unsuccessful or is contraindicated. - condraindications mentioned in card previous. ## Footnote Complications: * Pre-term rupture membranes (PROM) * Cord-prolapse (20%) * If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK. ( **compound presentation** occurs when your baby’s arm or leg is next to the main presenting part, usually the head.)

Question 27

Abnormal Lie Causes

Answer 27

- Polyhydraminos - Allows more room to move - High parity (more than 5 previous pregnancies) - Multiple Pregnancy (hard to move so fixed in one position) - Placenta Praveia or Pelvic tumours - Unstable lie in nulliparous women is rare and usually indicates obstruction. Management - After 37 weeks, the woman is often admitted due to risk of membrane rupture and USS performed to look for identifiable causes. - Either ECV is indicated or C-Section - In absence of obstruction, an abnormal lie will usually stabilise before 41 weeks. At this stage, or if woman is in labour, the persistently abnormal lie is delivered by caesarean; in some situations ECV and then amniotomy performed. ## Footnote There is a risk of cord prolapse following spontaneous rupture of membranes, as well as risk of prolapse of hand, foot or shoulder once in labour. If neglected, obstruction can eventually cause uterine rupture.

Question 28

C-Section. The Facts. ## Footnote Indications * absolute cephalopelvic disproportion * placenta praevia grades 3/4 * pre-eclampsia * post-maturity * IUGR * fetal distress in labour/prolapsed cord * failure of labour to progress * malpresentations: brow * placental abruption: only if fetal distress; if dead deliver vaginally * vaginal infection e.g. active herpes * cervical cancer (disseminates cancer cells) **Cephalopelvic disproportion:** when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in "failure to progress" in labor for mechanical reasons.

Answer 28

1. Lower C Section (99%) 2. Classic C Section - Vertical Incision suprauterus. contraindication to future vaginal birth due to classical cesarean scar Categories 1. Immediate threat to baby and mum - must be done within 30mins 2. MaternalCompromise but life not in immediate danger - 75mins 3. Delivery is inicated now but there is no threat to life 4. Elective C section | Can cause subfertility: due to postoperative adhesions ## Footnote planned VBAC (vaginal birth after C section) is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery

Question 29

Uterine Rupture | RF: Prev C Section, BMI, High parity, Age, Oxytocin use ## Footnote Complication of Labour when uterus ruptures - serosa ruptures and contents of uterus are released into peritoneal cavity

Answer 29

- Significant bleeding - baby might end up in peritoneal cavity - high morbidity and mortality for both mother and foetus - Acute unwell mother and abnormal CTG - Uterine contractions stop - Hypotension and tachycardia ## Footnote Emergency Management - Resus and Transfusion may be required - Emergency C section neccessary - this is to remove baby and stop bleeding - Repair of uterus or removal (hysterectomy) depending on severity

Question 30

# P-PROM Defining ROM, SROM, PROM, P-PROM

Answer 30

**ROM**: Rupture of membranes, amniotic sac has ruptured **SROM**: Spontaneous Rupture of membreanes **PROM**: pre labour rupture of membranes, sac rupture before labour **P-PROM**: preTerm pre labour rupture of membranes, before 37wks ## Footnote Complications of PPROM fetal: prematurity, infection, pulmonary hypoplasia maternal: chorioamnionitis **Management P-PROM** A sterile speculum examination should be performed (**to look for pooling of amniotic fluid in the posterior vaginal vault**) but digital examination should be avoided due to the risk of infection. Ultrasound may also be useful to show oligohydramnios. **IGFB-1 raised as well as PAMG-1** - oral erythromycin should be given for 10 days (prevent chorioamnionitis) - antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome - Consider delivery at 34wks

Question 31

# babies non viable <23wks Prematurity pathophysiology | Giving birth before 37wks ## Footnote Causes - Cervical weakness - Chorioamnionitis. Ascending Ix - Multi Pregnancy - Uterine abnormalities - Placental Abruption And Decidual Haemorrhage

Answer 31

**Under 28 weeks**: extreme preterm **28 – 32 weeks**: very preterm **32 – 37 weeks**: moderate to late preterm Categorised as: PPROM, P-SROM

Question 32

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

Answer 32

* Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour. * More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely. | Management Below ## Footnote * 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 33

Cord Prolapse | RF: Tumour, fibroids, narrow pelvis, prematuriy, polyhydroaminos, ## Footnote **Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. When membranes are ruptured** - if left untreated can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Answer 33

- Abnormal fetal heart rate - Mother on all fours, head down - put 500ml in bladder to apply pressure - tocolytics may be used to reduce uterine contractions - DO NOT handle cord as it can lead to spasm - some instances push back into vagina to keep it warm - Emergency C section indicated unless full dilation then deliver using instruments. | Around 50% of cord prolapses occur at artificial rupture ## Footnote *presenting part of the fetus may be pushed back into the uterus to avoid compression - unless its past introitus then risk of spasm* If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in caesarian sections being used in breech presentations.

Question 34

Instrumental Delivery | Vaginal delivery using Ventouse suction cup or forceps

Answer 34

Indications - Failure to progress - fetal distress - Maternal exhaustion - Control of head in various fetal positions - Increased risk of requiring an instrumental delivery when an epidural is in place for analgesia | Co-Amoxiclav given as prophylaxis ## Footnote Risks Having an instrumental delivery increases the risk to the mother of: * Postpartum haemorrhage * Episiotomy * Perineal tears * Injury to the anal sphincter * Incontinence of the bladder or bowel * Nerve injury (obturator or femoral nerve) Fetus * Cephalohaematoma with ventouse (parietal region, doesnt cross suture) * Facial nerve palsy with forceps * Subgaleal haemorrhage (rare) blood b/ween skull and scalp * Caput succedaneum (ventouse) (crosses suture lines)

Question 35

# off shoot of placenta praveia Risks of Placenta Accreata | Placenta Attachment to myometrium of uterus. ## Footnote RF: previous Csections, Placenta praevia

Answer 35

* Placenta does not separate during labour then there is a risk of post-partrum haemorrhage, ## Footnote 3 types **accreta**: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis **increta**: chorionic villi invade into the myometrium and wall **percreta**: chorionic villi invade through the perimetrium (wall)

Question 36

Placenta Praevia | Placenta planted in lower uterus ## Footnote Associated factors * multiparity * multiple pregnancy * embryos are more likely to implant on a lower segment scar from previous caesarean section

Answer 36

* no pain * uterus not tender * lie and presentation may be abnormal * digital vaginal examination should not be performed as it may trigger haemorrhage * USS best to examine Management - at 34wks inpatient major bleeding will require fluid resuscitation and delivery of the fetus by caesarean section. - Indications for delivery are reaching 37-38 weeks gestation, massive bleeding (>1500ml), or continuing significant bleeding of lesser severity. ## Footnote Classical grading I - placenta reaches lower segment but not the internal os II - placenta reaches internal os but doesn't cover it III - placenta covers the internal os before dilation but not when dilated IV ('major') - placenta completely covers the internal os

Question 37

Placental abruption | RF: cocaine, HTM, Preeclampsia, IUGR ## Footnote Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Answer 37

* shock out of keeping with visible loss * pain constant * tender, tense uterus * normal lie and presentation * fetal heart: absent/distressed Diagnosis made on cliical grounds Management **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 ## Footnote Maternal * shock * DIC * renal failure * PPH Fetal * IUGR * hypoxia * death

Question 38

What is Vasa Praevia

Answer 38

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

Question 39

# 4 Ts Post Patrum Haemorrhage | blood loss >500ml post vag delivery ## Footnote Primary wihin 24h Secondary 24h-6wk (Retained placental rissue or endometriosis)

Answer 39

1. Tone - Utrine atony (weak muscles of uterus) 2. Trauma - Perineal tear 3. Tissue (retained placenta) 4. Thrombin (clotting disorder) | RF: Prev PPH, Long labour, Pre-eclamps, Polyhydro, Age, Csection, ## Footnote * Management - Life threat - perfom ABC - Crystalloid infusion - Palpate uterus to stimulate contactions - catheter, group & saveed - IV oxytocin - IV/IM ergometrine (not in HTN) - Carboprost IM (no asthma) - Misoprostol sublingual. Surgery (if medical failed) - intrauterine balloon tamponade - Severe cases then hysterectomy performed

Question 40

Rhesus Disease | D antigen

Answer 40

- Rh -ve mother pregs with Rh+ve baby, Major incident where blood crosses over (miscarriage, csection etc) - Mother now makes IgM antibodies to +ve blood but Igm Cant cross barrier so in subsequent pregnancy with Rh +ve IgG can cross placenta so antibodies cause lysis of RBC + rhesus disease of newborn (haemolytic Jaundice) preventions - test mothers to see if -ve or +ve - give anti D at 28 or 34wks - anti-D is prophylaxis - once sensitization has occurred it is irreversible - if event is in 2nd/3rd trimester give large dose of anti-D and perform **Kleihauer test** - determines proportion of fetal RBCs present ## Footnote - Give anti D immunoglobulin within 72h of birth (dead or alive) when miscarriage, RH+ve bby, TOP, haemorrhage, abdo trauma Babys should have Coombs test - Symptoms: Oedema, Jaundice, Hepatosplenomegaly ,HF, Kernicterus, - trasfustion to treat, UV phototherapy

Question 41

Ix in Pregnancy | CMV, HIV, Rubella, Toxoplasmosis, Parovirus, HSV

Answer 41

CMV: cause of childhood handicap & deafness, IUGR in pregnancy w/pnuemonia and thrombocytopenia. a lot of times no effect. HSV: neonatal Ix rare but has high mortality. Csectionindicated if Ix in mother 6wks. neonates given Accyclovir Congenital Rubella: deafness, cardiac disease, Eye problems, mental retardation. TOP is offered if mother Infected before 16wk parovirus: In fetus causes anaemia (normalluy slapped cheek syndrome) fetal hydrops seen HIV: Pre-eclapsia risk raised so is gestational diabtes, can lead to still birth or prematurity Toxoplasmosis: Fetal infection follows in about 30%; this is more common as pregnancy progresses, but earlier infection is more likely to result in severe sequelae. mental handicap, spasticities. Hydrocephalus | Chylamydia & gonorrohoea: neonatal conjunctivitis

Question 42

HELLP syndrome | Haemolysis Elevated Liver(enzymes) Low(platelet count) ## Footnote Serious condition that develops in late stages of pregnancy

Answer 42

- Overlaps with pre-eclampsia but no prev hisitory so unlinked* - Nausea & Vomitting - RUQ pain - Lethargy - Hemolysis of blodd, raised liver enzymes and low platelet count - Treatment: Deliver baby ## Footnote *around 10-20% of patients with severe preeclampsia will go on to develop HELLP.

Question 43

Obstetric Cholestasis | Intrahepatic cholestasis of Pregnancy ## Footnote Due to abnormal sensitivity to the cholestatic effects of oestrogens. Characterised by the reduced outflow of bile acids from the liver. Due to this reduced outflow, the bile acids build up in the blood leading to classic symptoms of pruritus.

Answer 43

- Pruitis (worse on palms, soles and abdomen) - Clinically detectable Jaundice - Raised Billirubin; fatigue, dark urine, pale stools Managed - Labour induced at 37-8 weeks - Ursodeoxycholic acid - Vit K | risk of premature delivery, still birth, meconium pasage

Question 44

What is Anterpartum Haemorrhage?

Answer 44

-Bleeding from genital tract after 24wks of pregnancy prior to delivery of fetus - Placental abruption and placental praveia - Do not perform digital vaginal examination as risk of haemorrhage

Question 45

Foetal Monitoring | 10 antenatal visits 1st pregs, 7 visits subsequent pregs (uncomplicated) ## Footnote Avoid - listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat - salmonella: avoid raw or partially cooked eggs and meat, especially poultry - risks of smoking including low birthweight and preterm birth should be discussed - the government now recommend pregnant women should not drink - Avoid Vit A supplementation - Air travel after 37 wk (32 if there is complications)

Answer 45

* <10wk - Booking visit, gen advice, BP BMI Bloods, STI, Urine test * 10-13+6wk - Date scans (exclude twins) * 11-13+6wk Down Syndrome scan * 16wk - Blood results and any anomalies * 18-20+6 wk - Anomaly scan * 28 wk - Second screen for HB etc. Anti D prophylaxis for relevant women * 31wk - Routine * 34wk - second dose AntiD and birth plan * 36wk - chek baby presentation - offer ECV if indicated * 38wk 0 routine ## Footnote Supplements - Folic Acid 400mcg before conception to 12wk - reduced nueral tube defect. - Iron supplements not routinely iffered - Vit D (daily 4000 IU) - for nausea and vomitting take ginger & accupuncture on p6 point (wrist) - Antihistamine first line - Promethazine -

Question 46

Induction of Labour | Artifically starting labour - 20% of pregnancies ## Footnote Indications - Prolonged pregnancy - PPROM and no labour has started - Diabetic Mother - Pre-eclampsia - Rhesus issues.

Answer 46

- **Bishop score** is used (looks@ cervical position, consistency, effacement, dilation) - <5 labour unlikely to start w/out indctions - >8 cervix is favourable for spontaneous labour **Methods** - Membrane sweep - using finger - **Vaginal Prostaglandin E2** (preferred) - Maternal Oxytocin infusion - Amniotomy (break waters) - Cervical ripening balloon ## Footnote Complication: uterine hyperstimulation can lead to feotal hypoxemia, acidemia or even uterine rupture - Urgently stop vaginal prostaglandin

Question 47

Labour | regular and painful contractions associated with cervical dilation ## Footnote Signs of labour include * regular and painful uterine contractions * a 'bloody' show (shedding of mucous plug) * rupture of the membranes (not always) * shortening and dilation of the cervix

Answer 47

**Stage 1**: True labour to cervical dilation - Latent 0-3cm dilation - Active 3-10cm - Head enters in occipito lateral and delivers in occupito anterio. **Stage 2**: full dilation to delivery of fetus - passive: no pushing but full dilation - Active: dilation and pushing - less painful - lasts 1hour (if longer consider instruments) - Fetal bradycardia **Stage 3**: post delivery of fetus, delivery placenta and membranes ## Footnote Monitoring in Labour - Fetal HR using CTG continously or every 15m - Contactions every 30m - Maternal PR - 60m - BP and Temp & urine - 4h

Question 48

# 4 degress Perineal Tears | RF: large baby, Shoulder dystocia, forceps, primigravida ## Footnote Occurs when the external vaginal opening is too narrow to accommodate the baby

Answer 48

1st degree: injury limited to frenulum of the labia minora and superficial skin - No repair needed 2nd degree: includes the perineal muscles, but not the anal sphincter - suturing 3rd degree: includes the anal sphincter, but not the rectal mucosa - Repair in theatre 4th degree: includes the rectal mucosa - Repair in theatre | - Broad-spectrum antibiotics to reduce the risk of infection

Question 49

IUGR | intrauterine growth restriction ## Footnote Pathological determinants of fetal growth cause IUGR – include pre-existing maternal disease, maternal pregnancy complications, multiple pregnancy, smoking and drug use, maternal infections, extreme exercise, congenital abnormalities and malnutrition.

Answer 49

* IUGR, or fetal growth restriction (FGR) describes fetuses that have failed to reach their own ‘growth potential’ * may not necessarily end up small, however most IUGR cases will be Small for Gestational Age. * The amniotic fluid volume is often reduced * Blood pressure and urine must be checked due to risk of pre-eclampsia, particularly before 34 weeks. * delivery should be arranged over 37 weeks# * IUGR gestation >37 weeks: delivery indicated, by induction or c-section if CTG abnormal. | Diagnosis of SGA is made by USS.

Question 50

Downs Syndrome Quadruple test

Answer 50

Down's syndrome: quadruple test result ↓ AFP ↓ oestriol ↑ hCG ↑ inhibin A

Question 51

Symphysis Fundal Height ## Footnote The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres

Answer 51

- match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm - if this isnt the case then perform a ultrasound

Question 52

Galactocele

Answer 52

- Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. - A build up of milk creates a cystic lesion in the breast. - The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Question 53

Infertility | RF: Male, Unexplaine, Ovulation failure, tubal damage, other causes. ## Footnote Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years

Answer 53

- Semen analysis - Serum Progesterone 7 days before next period - Progesterone <16: reffer to specialists, 16-30: Repeat test. >30 indicates ovulation ## Footnote Key counselling points * folic acid * aim for BMI 20-25 * advise regular sexual intercourse every 2 to 3 days * smoking/drinking advice

Question 54

Shoulder Dystocia | complication of vaginal cephalic delivery ## Footnote * usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis. * Shoulder dystocia is a cause of both maternal and fetal morbidity.

Answer 54

- Diagnosis usually obvious when the shoulders fail to deliver during the next contraction after delivery of the head. **Turtle sign** - if 5 mins elapsed risk of cerebral damage. - MacRoberts Manouvere. - An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options. | RF GDiabetes, Macrosomia, previous sibling incident ## Footnote Risk of fetal hypoxia, death and fetal trauma in the form of fractures (usually long bones of the arm or clavicle), or brachial plexus injury. For the mother, there is increased risk of bleeding and perineal trauma including third and fourth degree tears.

Question 55

Hypermesis Gravidarum | excessive nausea and vomitting. ## Footnote common b/ween 8-12wk can also go up to 20wk RF: multiple pregs, trophoblastic disease, Hyperthyroidism, nulliparity, obesity - Smoking Protective Consider Admision if 1. N&V, cant keep fluids down, or oral antiemetics 2. N&V w/ketonuria and weight loss

Answer 55

1. 5% pre pregnancy weight loss 2. dehydration 3. electorlyte imbalances - PUQE used to score severity of NV in Pregs Oral **Cyclizine or Promethazine** antihistamine * **Metaoclopramide** (2nd Line) - extrapyramidal side fx so not to be used past 5 days * **ondansetron** during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. * ginger and P6 (wrist) acupressure If Admitted give the following * 0.9% saline with potassium * avoid dextrose/glucose as it can lead to wernickes encephalopathy ## Footnote Complications Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth

Question 56

Hydatidiform Mole | Gestational Trophoblastic disorders. ## Footnote Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Answer 56

- Bleeding in first or early 2nd trimester - Hypermesis exxagerrated - Enlarged uterus copared to gestational size - high hCG - ultrasound: 'snow storm' appearance of mixed echogenicity ## Footnote urgent referral to specialist centre - evacuation of the uterus is performed effective contraception is recommended to avoid pregnancy in the next 12 months

Question 57

Still Birth ## Footnote In the UK the rate is 1 in 200 pregnancies -slightly lower in developed countries. Those who have one stillbirth are 3-5x more likely to have another.

Answer 57

Causes: IUGR, smoking, chromosomal abnormality, diabetesm pre eclampsia, Infection - Fetus delivered after 24wks of life with no signs of life - Induction of labour usually arranged – Caesarean section avoided if possible. - Postnatal management needed – debrief and plans made for future pregnancies. The mother is at high risk of mental illness. ## Footnote Diagnosis can be made using ultrasound scans. Glucose tolerance testing is currently only used in the UK when women are considered at high risk – testing frequently omitted by accident.