1
Q
what is placenta increta
A
severe complication where the placenta implants too deeply and its villi invade the muscular wall of the uterus (the myometrium), but don’t go all the way through it
usually no sx in pregnancy but can cause dangerous, life-threatening bleeding during childbirth and often requires a C-section, potentially followed by a hysterectomy
so only really realise it during childbirth
often suspected if pt has placental praevia or previous C section
2
Q
placenta increta and accreta
A
Placenta accreta involves the placenta attaching too deeply to the uterine wall, while placenta increta occurs when the placenta invades further into the muscular layer of the uterus (myometrium).
3
Q
what does a sudden collapse after Rom indicate
A
amniotic fluid embolism
4
Q
RFs for amniotic fluid embolism
A
C section
induction of labour
placenta praevia
increasing maternal age
pre eclampsia
asthma
multiparty
5
Q
signs / sx of amniotic fluid embolism
A
SOB
Chest pain
bleedings
chills/sweating
anxiety
hypoxia
hypertension
tachypnoea
cyanosis
bronchospasm
tachycardia
arrhythmia
MI
6
Q
when does amniotic fluid embolism occur
And how does it present
A
during / after labour
can occur as a sudden collapse after ROM
7
Q
how do you diagnose amniotic fluid embolism
A
Clinical diagnosis of exclusion
→ no definitive diagnostic tests
8
Q
what would an ABG in amniotic fluid embolism show
A
hypoxaemia
raised PaCO2
9
Q
management of amniotic fluid embolism
A
ABCDE + call ITU reg
A –> maintain patency
B –> high flow O2 +/- intubation
C —> 2 large bore cannulae + fluid resus
drugs –> ionotropics eg dopamine/dopabutamine/noradrenaline
(to improve heart contractility)
if haven’t already, consider delivery +/- hysterectomy
10
Q
how is anaemia in pregnancy defined
A
Hb <110g/L
11
Q
cut offs for oral iron therapy in 1st/2nd/3rd trimester/postpartum
A
First Trimester
<110g/L
Second/Third Trimester
<105g/L
Postpartum
<100g/L
12
Q
4 causes of folate deficiency
A
pregnancy
phenytoin
methotrexate
alcohol excess
13
Q
when are pregnant women screened for anaemia in multiple pregnancies
A
Booking clinic (8-12 weeks approx.)
20-24 weeks
28 weeks gestation
3 in total
14
Q
when are pregnant women screened for anaemia in single pregnancies
A
Booking clinic (8-12 weeks approx.)
28 weeks gestation
2 in total
15
Q
what does low MCV indicate
A
iron deficiency
16
Q
what does raised MCV indicate
A
B12 or folate deficiency
17
Q
iron prescription for iron deficiency in pregnancy
and when is it checked/followed up
A
oral ferrous sulphate
200mg 3 x per day
repeat FBC in 2 weeks to see if deficiency has been corrected
if it has, continue ferrous sulphate for 3 months to fully replenish iron supplies
18
Q
what is given for low B12
A
IM hydroxycobalamin injections
or
oral cyanocobalamin tablets
19
Q
what is the amount of folate all pregnant women should be taking, and until which week
A
folic acid 400mcg daily (until 12/40)
20
Q
how much folic acid should pregnant women with a folate deficiency take
A
5mg daily
21
Q
what are the indications of folate deficiency and need for 5mg daily rather than 400mcg
A
MORE H
Metabolic diseases (diabetes, coeliac)
Obesity (BMI >30)
Relative or personal history of neural tube defects
Epilepsy (on anti-epileptics)
Haemoglobinopathies
22
Q
How do you deal with intrapartum anaemia? (3)
A
Deliver on labour ward
IV access and G&S (group & save)
Active management of 3rd stage of labour to prevent PPH (postpartum haemorrhage)
□ Give oxytocin to help uterus contract and expel placenta
□ Controlled cord traction to help deliver placenta
□ Immediate clamping and cutting of umbilical cord
23
Q
3 complications of anaemia in pregnancy
A
Preterm baby
Postpartum depression
Spina bifida
24
Q
main symptoms/signs of asthma in pregnancy
A
Tachypnoea
prolonged expiratory phase
polyphonic wheeze
hyperinflated chest
25
when in the day are the symptoms of asthma worse
morning and night
26
main Ix for asthma in pregnancy
PEFR in a diary
27
what changes should be made to asthma medication in pregnancy
continue regular medications
but avoid bronchoconstrictors eg ergometrine during intrapartum
28
3 pieces of advice to give to pregnant women with asthma
smoking cessation
flu vaccine
monitor foetal movements daily after 28 weeks
29
Acute asthma exacerbation management? (5)
High flow O2
Salbutamol nebuliser
Ipratropium
Steroids (IV hydrocortisone or oral prednisolone)
IV magnesium sulphate
30
what is a possible complication of the prolonged hypoxia caused by asthma in pregnancy
FGR
31
what is a possible complication of steroid use for asthma in pregnancy
increased risk of cleft lip
32
define periparutm cardiomyopathy
New onset cardiomyopathy and heart failure within the last month of pregnancy to 5 months post-partum
33
how does peripartum cardiomyopathy lead to uterine hypo perfusion and increased pulmonary oedema
There’s a 40% rise in blood volume during pregnancy normally
Women with cardiac disease can’t increase cardiac output to meet this increased workload
34
what Ix should be done if a patient is pregnant and has cardiac disease
Echocardiogram at booking and 28 weeks
35
what is the management given to pregnant women with cardiac disease
Anticoagulation e.g. LMWH
36
which anticoagulants cannot be given in pregnancy
Warfarin is teratogenic in 1st trimester
37
which drugs should be avoided in pregnant women with cardiac disease
Ergometrine
38
contrast timings of baby blues, postnatal depression and puerperal psychosis
baby blues - within 1 week
postnatal depression - peaks at 3 months postpartum
puerperal psychosis - 2 weeks postpartum
39
how quickly does baby blues resolve
within 2 weeks after delivery
40
triad of postnatal depression
Low mood
Anhedonia
Low energy
41
How long do symptoms of postnatal depression need to last for diagnosis?
at least 2 weeks
42
main investigation for screening tool for postnatal depression
Edinburgh Postnatal Depression Scale
43
cut off score for Edinburgh Postnatal Depression Scale
score >=10 is used for screening, but score >=13 indicates postnatal depression
44
baby blues tx
no tx required
45
post natal depression tx
mild
moderate
severe
mild
- support, self help
moderate
- CBT
- SSRIs
--> Sertraline
Severe
- specialist psychiatry services
46
what is the risk of SSRI tx in 1st trimester
Increased risk of congenital heart defects
47
what is the risk of SSRI tx in 3rd trimester
Risk of persistent pulmonary hypertension of the newborn
48
how to manage puerperal psychosis
Admission to mother and baby unit
Urgent assessment from specialist mental health services
CBT
Antidepressants e.g. SSRIs like fluoxetine/sertraline
Antipsychotics e.g. olanzapine/haloperidol/risperidone
Mood stabilisers e.g. lithium/valproate/carbamazepine
49
which extra scans need to be done for pregnant women with epilepsy
Serial growth scans every 4 weeks from 28-36 weeks gestation
50
how much folic acid should women with epilepsy take if they intend to get pregnant, and when should they start it
5mg daily
well before conception
51
what is the main aim for epilepsy management for women who intend to get pregnant
monotherapy (use of only one anti epileptic drug)
52
the safest 3 antiepileptic drugs in pregnancy
Levetiracetam
Lamotrigine
Carbamazepine
53
what is the most dangerous anti epileptic in pregnancy and why
sodium valproate
causes neural tube defects
no females of child bearing age should start it without specialist input
54
what risk does phenytoin use in pregnancy pose, and what should women take if they're on it
risk of cleft lip and palate
should take Vit K in last month of pregnancy to prevent clotting disorders of newborn
55
Is breastfeeding allowed for mothers taking anti-epileptics?
yes
56
what does raised ALP in pregnancy indicate
normal
pregnancy can cause ALP to be raised, doesn't need to be pathological
57
rash in pregnant woman with peri umbilical sparing
diagnosis
polymorphic eruption of pregnancy
58
rash in pregnant woman, mostly on face, neck, chest, extensor surfaces of limbs
diagnosis
atopic eruption of pregnancy
59
which antihypertensive medications need to be stopped in pregnancy
ACE inhibtors
ARB
60
Placenta accreta increases the risk of....
postpartum haemorrhage
61
Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) do not occur before....
20 weeks
62
with diagnosis should bloods and leukocytes on a urine dipstick prompt you to consider
stones
63
Down's syndrome is suggested by ".." HCG, "..." PAPP-A, "..." nuchal translucency
Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
64
Hyperemesis gravidarum usually occurs before .... weeks gestation
20
65
4 RF for hyperemesis gravidarum
Increased bhCG levels:
Multiple pregnancies
Trophoblastic disease (molar pregnancy)
Nulliparity
Obesity
66
protective factor for hyperemesis gravidarum
smoking
67
diagnostic triad for hyperemesis gravidarum
≥5% pre-pregnancy Weight loss
Electrolyte imbalance
Dehydration
68
what is seen on U&Es in hyperemesis gravidarum
Hypokalaemia & hyponatraemia
69
what scoring system is used for hyperemesis gravidarum
Pregnancy-unique quantification of emesis (PUQE) score
70
PUQE score for mild , moderate , severe hyperemesis gravidarum
<7/15 = mild
7-12/15 = moderate
12/15 = severe
71
simple measures for hyperemesis gravidarum management
Rest & avoid triggers
Eat bland/plain food esp in morning
Ginger
Acupressure on wrist at PC6 point
72
1st line tx for hyperemesis gravidarum
Antihistamines (oral cyclizine or promethazine)
73
how often can cyclizine be taken for hyperemesis gravidarum
50mg tablets up to 3x daily
74
2nd line tx for hyperemesis gravidarum
Antiemetics
→ oral ondansetron (5HT3 receptor antagonist) or prochlorperazine (D2 receptor antagonist)
75
risk of odansetron in 1st trimester
Small increased risk of baby having cleft lip/palate
76
risk of metoclopramide
May cause extrapyramidal side effects such as acute dystonia, akathisia, Parkinsonism, tardive dyskinesia
So shouldn’t take for more than 5 days
77
referral triad for hyperemesis gravidarum
Unable to keep liquids or oral antiemetics down
Ketonuria and/or >5% weight loss
Comorbidity e.g. UTI
78
what 2 things should be supplemented/replenished during admission for hyperemesis gravidarum
IV fluids with potassium --> for rehydration
thiamine supplements --> prevent wermocles encephalopathy
79
sudden severe adnominal pain in 3rd trimester
patient cold to touch
likely diagnosis
placental abruption
visible bleeding doesn't need to be present for diagnosis
80
what is sweet and fecal breath (fetter hepaticus) a sign of
liver failure
81
jaundice pruritus and raised bilirubin in third trimester
diagnosis
intrahepatic cholestasis of pregnancy
82
tx for intrahepatic cholestasis of pregnancy
ursodeoxycholic acid (symptomatic relief)
83
monitoring for intrahepatic cholestasis of pregnancy
weekly LFTs
84
does intrahepatic cholestasis of pregnancy pose a risk to mother or baby
baby - increased risk of stillbirth
85
jaundice, abdo pain, N&V in third trimester
acute fatty liver of pregnancy
86
what is raised in acute fatty liver of pregnancy
ALT
(elevated to around 500)
87
acute fatty liver of pregnancy vs cholestasis
both in third trimester
cholestasis: jaundice pruritis, less severe disease, no risk to mother, increased risk of still birth
acute fatty liver: jaundice pain, N&V, raised ALT, severe disease - can result in pre eclampsia
88
what risk can acute fatty liver of pregnancy pose for the mother
can cause pre eclampsia
89
definitive management of acute fatty liver of pregnancy
delivery
90
what does HELLP syndrome stand for
Haemolysis, Elevated Liver enzymes, Low Platelets
91
what does raised AFP in pregnancy indicate
neural tube defects
92
what does decreased AFP in pregnancy indicate
Down syndrome
93
a C section is performed and pt has a major obstetric haemorrhage post-delivery, requiring resuscitation with blood products. It is noted that she had abnormal placenta implantation of the uterine wall. Previous ultrasound showed an ordinary lie of the placenta"
diagnosis
placenta accreta
(increases risk of PPH, and the position of the placenta is not the issue, its the layer in which it is implanted. it implants into myometrium instead of endometrium)
(placenta praaevia is the position, placenta is over cervical os)
94
what changes in thyroid hormones can be seen in normal pregnancy
Raised total T3 and T4 but normal fT3 and fT4
normal TSH
high Thydoir binding globulin can be seen during pregnancy, which results in elevated total levels of T3 and T4
95
after taking ulipristal acetate women should wait "x" days before starting regular hormonal contraception
5 days
96
"..." or "..." are the SSRIs of choice in breastfeeding women
Sertraline or paroxetine
97
can MMR vaccine be given in pregnancy?
NO
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant; to avoid becoming pregnant for 28 days after receipt of MMR vaccine (CDC 2013)
98
what is the recurrence rate of postnatal psychosis
25-50%
99
A cut-off of "x" g/Lshould be used in the postpartum period to determine if iron supplementation should be taken
100
100
what extra measures should be taken for the foetus if mother has Hep B
The infant should receive hepatitis B immunoglobulin (HBIG) and the first dose of hepatitis B vaccine within 24 hours of birth, followed by completion of the vaccination schedule.
101
folic acid should be taken
throughout pregnancy
or
until week "x"
until week 12 of pregnancy
102
can paroxetine be used in pregnancy
and what risk can it pose
can be used, but should be avoided unless the benefits outweigh the risks
can increase risk of congenital malformations
103
what 5 situations would warrant continuous CTG monitoring whilst in labour
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
104
How does blood pressure normally change during pregnancy
Falls in first half of pregnancy before rising to pre-pregnancy levels before term.
105
elevated prolactin
secondary hypothyroidism
hypogonadism
diagnosis
stalk compression by a non-functioning pituitary adenoma
106
what prolactin level is indicative pf a macroprolactinoma (big enough to cause compression of pituitary gland and therefore affect other hormone levels)
>250
(>500 is definitive diagnosis)
107
which psychiatric drug can cause hyperprolcatinaemia and hypogonadotrophic hypogonadism
olanzapine (schizophrenia drug)
108
where should women with post partum psychosis be hospitalised
mother and baby unit
(mother has a bed, baby has a cot and they're kept under observation - not separated)
109
what are the potential complications for the foetus in a pregnancy women infected with parvovirus B19
hydrops fetalis
fetal death
110
when is parvovirus B19 infective
infectious from up to 3 weeks before the rash develops. It is no longer infectious once the rash appears.
111
what testing should be done for pregnant women in contact with someone with parvovirus
serological blood testing, testing for parvovirus specific IgM and IgG
112
what does this parvovirus serology test result indicate, and what action needs to be taken?
IgG positive & IgM negative
Shows immunity to parvovirus. Reassure, no further action.
113
what does this parvovirus serology test result indicate, and what action needs to be taken?
IgG negative & IgM positive
non-immune. Recent parvovirus infection in last 4 weeks. Refer immediately for further tests/fetal medicine.
114
what does this parvovirus serology test result indicate, and what action needs to be taken?
IgG negative & IgM negative
repeat test in 4 weeks. If both tests still negative, this confirms susceptibility, but no recent infection. Reassure, further action required only if subsequent exposure occurs.
115
Hormonal contraception can be started "x" after using levonorgestrel (Levonelle) for emergency contraception
immediately
BUT should also use barrier procession of the first 7 days
116
when can hormonal contraception be restarted after taking the morning after pill (levonorgestrel) vs EllaOne (ulipristal acetate)
and what advice should eb given
morning after pill (levonorgestrel)
- can start immediately after
EllaOne (ulipristal acetate)
- can start 5 days after
for both, should use barrier contraception as well for the first 7 days
117
what LFT pattern is seen in intrahepatic cholestasis of pregnancy
give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT
118
what are the causes of erythema nodosum
NO - idiopathic
D - drugs (penicillin sulphonamides)
O - oral contraceptive/pregnancy
S - sarcoidosis/TB
U - ulcerative colitis/Crohn's disease/Behçet's disease
M - microbiology (streptococcus, mycoplasma, EBV and more)
119
which cancer drug increases the risk of VTE
tamoxifen
120
what specific monitoring is recommended when starting hydroxychloroquine treatment
visual acuity and fundoscopy (may result in severe retinopathy)
121
what should be giving to pregnant women with a previous VTE history, and for how long
LMWH
throughout pregnancy and until 6 weeks postnatal
122
what bishop score indicates that labour is unlikely to start without induction
score < 5
123
what is hydrops fetalis
serious condition characterized by an abnormal accumulation of fluid in two or more areas of a fetus or newborn, leading to swelling and impacting organ function
124
what is the cause of anencephalic fetus
deficiency of folic acid intake during pregnancy
baby is born without parts of the brain and skull
125
what are the usual causes of macrosomia
maternal diabetes or obesity
126
what is a likely complication of a foetus being alpha thalassemia major (ie homozygous)
hydrops fetalis
127
does antibiotics affect the functioning of contraceptive pillhich antibiotics reduce the effectiveness of the POP
P450 inducers (e.g. rifampicin)
128
in which patients should cylizine be prescribed with caution
patients with heart failure as it may cause a fall in cardiac output
129
what do subcostal recessions and grunting in infant indicate
respiratory distress
130
infant has mildly raised respiratory rate with increased work of breathing in the hours after labour
likely diagnosis ? and what element of delivery could be a risk factor for this
tachypnoea of the newborn (TTN)
C section is a risk factor
131
name 4 risk factors for tachypnoea of the newborn (TTN)
C section delivery
male infant
birth asphyxia
gestational diabetes
132
when does PIH (pregnancy induced hypertension) manifest
after 20 weeks gestation
133
high bp and low potassium
likely diagnosis?
primary hyperaldonstronism eg Conns syndrome
134
indications for IV iron therapy
iron deficiency anemia when oral iron is ineffective, not tolerated, or when a rapid increase in iron is needed, such as in cases of chronic bleeding, malabsorption, or severe deficiency
135
which pills are taken continuously without breaks
POP
136
if pt misses usual time that she takes her POP containing desogestrel, it can be taken immediately with no further action if less than "x" hours have elapsed since the usual time of taking the pill
12 hours
137
what actions should be taken if pt misses her usual time of taking her POP Norway pill
if within 3 hours of normal time, take pill and no further action required
if > 3 hours, take pill immediately, continue with normal pill taking, but also use condoms for next 48 hrs
138
what does the Pearl Index of a contraception mean
the number of unintended pregnancies per 100 woman-years of use
eg 0.2 is 2 women per 1000
139
how should assymptomatic bacteriuria be managed in pregnant women
immediate 7 day course of abx (nitrofuratonin)
140
what is the cut off for the "chance" result fro Down syndrome testing, that indicates high risk and need for further investigation
chance = 1/150, anything greater than this is high risk
141
If a woman vomits within "x" of taking levonorgestrel or ulipristal acetate, prescribe a second dose of emergency hormonal contraception to be taken as soon as possible.
3 hours
142
pregnant woman develops rash in 2nd trimester
well demarcated erythematous urticated plaques around the abdomen
intensely pruritic
likely diagnosis ?
pemphigoid gestationis
143
what is co-cyprindiol (Dianette) used for
contraception typically used for acne treatment
144
what is the main risk with co-cyprindiol (Dianette) use
increase risk of VTE
145
can you have vaginal birth if u have a previous classic C section scar
no
146
can you have induction of labour if u have had a previous classic C section
no
147
what is the preferable medication for migraine prophylaxis in women of childbearing age
propanolol (preferable to topiramate)
148
how much vitamin D should be taken as supplementation in pregnancy
All pregnant women should take vitamin D 400IU once daily, throughout the pregnancy.
149
how is patent ductus arteriosus (PDA) treated
ibuprofen/indomethacin is given to the neonate in the postnatal period, if the echocardiogram shows PDA one week after delivery
150
what maternal condition can cause Surfactant lung disease aka neonatal respiratory distress syndrome (RDS) in the infant
maternal diabetes mellitus
151
what is the first step when a pregnant woman has been exposed to chickenpox
urgently check varicella antibodies if there is any doubt about mother having previous exposure or not
treat with oral acyclovir from day 7-14 after exposure
152
what sort of pill is Microgynon
COCP
153
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of
amniotic fluid embolism
154
what is the most common cause of umbilical cord prolapse
artificial rupture of membranes
155
what contraception is suitable for a transgender male (female at birth) taking testosterone therapy
intrauterine copper device (copper so it is non hormonal therefore doesn't interact with the pts testosterone)
156
what should be done if pregnant woman has not had MMR vaccine, and has her rubella status checked
result = Rubella IgG Not detected
advise her of risks and keep away from anyone with rubella
(MMR vaccine is C/I in pregnancy)
157
which pregnancy rash spares the umbilicus
Polymorphic Eruption of Pregnancy (PEP)
158
which pregnancy rash is characterised pruritic papules over abdominal striae, that evolve into larger erythematous plaques and may also spread to the buttocks and thighs
Polymorphic Eruption of Pregnancy (PEP)
159
A pregnant woman is found to have tested positive syphilis and is currently 12 weeks pregnant. What is the most appropriate management?
IM benzathine penicillin G
160
when are immunoglobulins given in pregnancy
to provide protection against viral illnesses such as rubella
161
middle aged/elderly women with nipple discharge that is green or blood stains d
diagnosis
duct ectasia
162
when in pregnancy can galactorrhea occur
2nd trimester onwards
163
which medication used for nausea (from chemo/radiotherapy, or from migraines) can cause galactorrhea
metoclopramide
164
abdominal pain + jaundice in pregnancy
most likely diagnosis ?
acute fatty liver of pregnancy
165
pt with rheumatoid arthritis takes methotrexate and hydroxycholorquine and wants to get pregnant
how should her medications change
Stop methotrexate 6 months prior to becoming pregnant
Hydroxychloroquine can be safely used during pregnancy
166
name 4 risk factors in pregnancy for orofacial cleft malformations developing the infant
smoking
benzodiazepine use
anti-epileptic use
rubella infection
167
In surgical management of an ectopic pregnancy "X" should be administered.
n Anti-D immunoglobulin should be administered.
168
what is the direct Coombs test used for
to look for autoimmune haemolytic anaemia
169
what is the indirect Coombs test used for
Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn
170
what is the most common causative organism of meningitis in a newborn
group B strep
171
Soon after birth by normal vaginal delivery, a baby develops fever, tachycardia and respiratory distress. What is the most likely cause?
group B septicaemia
172
who is HIV screening offered to
all pregnant women
173
pregnant woman has group B streptococcus is treated with a short course of oral antibiotics. How should this woman be managed with respect to delivering her baby in a few weeks time?
Intrapartum IV benzylpenecillin
174
All breech babies at or after 36 weeks gestation require ......screening at 6 weeks regardless of mode of delivery
Ultrasound scan for DDH (developmental dysplasia of the hip)
175
ultrasound scan demonstrates polyhydramnios, ascites and fetal skin oedema
What is the most common and likely underlying cause for this presentation?
Parvovirus B19 (causing hydrops fetalis)
176
A 34-year-old pregnant woman comes to see you in clinic today concerned as her brother's son has just been diagnosed with rubella. She is 9 weeks pregnant and is unsure of her rubella status.
What is the most appropriate first step to take at this stage?
discuss immediately with local health protection unit
177
A baby is born at 32 weeks gestation and transferred to the neonatal unit. Over the next few hours, the baby exhibits nasal flaring, chest wall indrawing, and appears to be jaundiced. Observations are a heart rate of 72/min, a respiratory rate of 70/min, and a temperature of 38.1ºC.
Which organism is most commonly responsible for the likely diagnosis?
group B strep
(neonatal sepsis)
178
A mother brings her 6 year-old son to clinic with a widespread rash. You diagnose chickenpox. You know his mother, who is also a patient at the practice, is currently 20 weeks pregnant with her second child. What action should you take, if any, regarding her exposure to chickenpox?
ask about her chickenpox exposure history
(if she's unsure, then can check her antibody levels)
(if she's symptomatic, give oral acyclovir)
179
how is chronic htn (pre-existing and longstanding) managed in pregnancy
Stop ACEi/ARB/TLD
switch to
1) labetolol
2) nifedipine
180
when does gestational htn / pregnancy-induced htn occur
> 20/40
181
how is gestational htn / pregnancy-induced htn defined and diagnosed
Bp >= 140/90
> 20/40 wks
measured 2 times, at leats 4 hrs apart
previously normotensive
no proteinuria/other signs of pre eclampsia
182
when does pre eclampsia occur
> 20/40
183
what is the train of features of pre eclampsia
HOP
Hypertension
Oedema
Proteinuria
184
what is the pathophysiology behind pre eclampsia
spiral arteries of the placenta form abnormally,
leading to high vascular resistance in these vessels
185
definition of pre eclampsia
New hypertension (≥140/90) in pregnancy with end-organ dysfunction,
notably proteinuria
186
how is diagnosis of pre eclampsia made
BP >140/90 plus any of:
proteinuria
organ dysfunction (kidney/liver)
placental dysfunction
187
how is proteinuria detected and confirmed in pre eclampsia diagnosis
1) urine dipstick
if 1+, then confirm via either of:
ACR (>8mg/mol) --> most used
PCR (>30mg/mol)
24 hr urine (>=300mg/24hrs)
188
what is the ACR limit for proteinuria
> 8mg/mol
189
how is organ dysfunction investigated for pre eclampsia diagnosis
FBC
U&Es
LFTs
Fundoscopy
look for:
Thrombocytopenia
Raised creatinine
Elevated liver enzymes
Seizures
190
how is placental dysfunction investigated for pre eclampsia diagnosis
low SFH (symphysis-fundal height) --> foetal growth restriction
abnormal doppler
191
high risk factors for pre eclampsia (5)
pre-existing hypertension
previous hypertension in pregnancy
existing autoimmune conditions (SLE)
diabetes
CKD
192
moderate risk factors for pre eclampsia (6)
age >40
BMI >35
10 years since previous pregnancy
first pregnancy
multiple pregnancy
FH of pre-eclampsia
193
what happens to bp usually in pregnancy
BP falls in first half until 20-24 weeks
then begins to rise to pre-pregnancy levels by term
194
how many risk factors are needed for aspirin prophylaxis for pre eclampsia
1 high risk factor or ≥2 moderate risk factors
195
how much aspirin is given and for how long (pre eclampsia prophylaxis)
aspirin 150mg (low dose)
from 12 weeks gestation until birth
196
sx of pre eclampsia
Headache
Visual disturbance or blurriness
N&V
Upper abdo or epigastric pain
Oedema
Hyperreflexia (clonus)
Oliguria (reduced urine output)
Seizures ---> eclampsia
197
how is pre eclampsia prevented
everyone gets urine dip and bp at every antenatal appt
1 high risk factor / 2 or more moderate --> aspirin
198
How do we manage a pregnant woman with 1+ protein on urine dip without HTN?
Measure the blood pressure & ACR or PCR
Arrange a follow-up appointment in GP to reassess in 1 week
199
How do we manage a pregnant woman with 2+ protein on urine dip without HTN?
Refer for same day assessment
200
how is pre eclampsia monitored
222 rule
BP every 2 days
Bloods 2x/week (FBC, LFT, U&Es)
US foetal surveillance every 2 weeks
^ checks for:
growth
liquor → assessing amniotic fluid volume
UA blood flow
201
1st, 2nd, 3rd line tx for pre eclampsia
1) labetolol
2) nifedipine
3) methyldopa
202
in which individuals should labetolol for pre eclampsia be avoided
asthmatics - give 2nd line (nifedipine) instead
203
target bp for individuals with pre eclampsia
<135/85
204
indications for admission in pre eclampsia / HTN in pregnancy
Severe HTN (>=160/110)
Symptoms of severe late stage disease - such as
Headache
Visual disturbance
Epigastric pain
Oedema
Hyperreflexia
Deranged LFTs or U&Es
Low platelets
Suspected foetal compromise
Urine dip 1+ protein
205
in pre eclampsia pt, when is delivery planned for
37 weeks
206
if delivery in pre eclampsia pt occurs before 34 weeks, what is given during partum
IV mgso4 + corticosteroids
(for 24 hrs after delivery/last seizure - whichever comes later)
207
what should be monitored when giving Iv mgso4
Do the ROUR
Reflexes
O2 sats
Urine output
Resp rate
208
why are reflexes monitored on IV mgso4
hyperreflexia indicates cerebral involvement - seizures
209
why are O2 sats monitored on IV mgs04
can cause respiratory depression
210
what is given if IV mgso4 causes respiratory depression
calcium gluconate
211
if delivery in pre eclampsia pt occurs between 34-36 weeks, what is given during partum
consider corticosteroids
212
what mode of delivery is preferred in pre eclampsia
elective C section or IoL
213
what should be given and avoided if pre eclampsia pt opts for IoL delivery
give epidural - lowers bp
avoid ergometrine - can raise bp
214
what should be done once baby is born to mother w pre eclampsia
monitor them both for 24 hrs
215
what follow ups are arranged for motehr w pre eclampsia after delivery and discharge
BP should be checked every other day by community midwife until targets achieved
GP follow up at 2, then 6-8 weeks for medication reviews ad confirming resolution of HTN
216
eclampsia acute tx
IV bolus of magnesium sulphate
→ 4g over 5-10 minutes followed by an infusion of 1g/hour
217
what syndrome is a complication of pre eclampsia
HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
218
sx of HELLP syndrome
Headache
N&V
Epigastric pain
Blurred vision
Peripheral oedema
219
32 weeks pregnant pt presents with bp 190/95, ALT 260, and schistocytes on blood film
diagnosis?
HELLP syndrome
220
"x" is first-line for pregnancy-induced hypertension
labetolol
221
what are age most important 2 things to monitor in a pt on IV magnesium sulphate
reflexes + respiratory rate
222
3rd trimester, lower abdo pain, bleeding, pinpoint pupils, risk reflexes
placental abruption due to cocaine abuse
223
when in pregnancy does gestational diabetes occur
24-28 weeks gestation
224
What are women with GDM more at risk of
developing T2DM after birth
225
RF for gestational diabetes (6)
previous GDM
FHx of DM (1st degree relative)
BMI > 30
south asian ethnicity
previous acrostic baby (>=4.5kg)
previous unexplained stillbirth
226
effects of diabetes on pregnancy (9)
Increased risk of
miscarriage
congenital malformation (spina bifida)
macrosomia
-->Shoulder dystocia
pre-eclampsia
stillbirth
infection
polyhydramnios
IUGR (intrauterine growth restriction) → smaller foetus than expected
Increased operative delivery rate
227
next step if
glycosuria on urien dipstick
immediate 2 hour 75g OGTT
228
next step if
previous GDM
immediate 2 hour 75g OGTT
and if normal
Do it again at 24-28 weeks
229
next step if
RF for GDM present
2 hour 75g OGTT at 24-28 weeks
230
fasting glucose and 2 hr OGTT cut offs for GDM diagnosis
"5 6 7 8"
Fasting plasma glucose ≥5.6 mmol/L
or
2-hour OGTT ≥7.8 mmol/L
231
targets for blood glucose in pregnant women with pre existing diabetes or gestational diabetes
(fasting, 1 hr and 2 hrs post meal)
fasting: 5.3mmol/l
1 hour post-meal: 7.8mmol/l
2 hours post-meal: 6.4mmol/l
232
where do women with gestational diabetes need to be reviewed and how soon after their diagnosis
joint diabetes and antenatal clinic
within 1 week of their diagnosis
233
what do women with new gestational diabetes dx need to be taught
self monitoring of glucose
234
wo often do women with new diagnosis of gestational diabetes need to be scanned and during which weeks of gestation
Serial growth scans every 4 weeks from 28-36 weeks gestation
235
how is medication managed for women with pre existing DM that become pregnant
stop oral hypoglycaemic agents, apart from metformin, and commence insulin if need be
236
what supplements should women take with pre existing DM that become pregnant
folic acid 5mg/day from pre conception to 12 weeks gestation
237
what advice should be given to women with pre existing DM that become pregnant
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
238
gestational diabetes
fasting glucose <7
first, second and third line management
1st) 2 week trial of changing diet and exercise
if targets not met:
2nd) metformin
if targets not met:
3rd) SHORT acting insulin
239
gestational diabetes
fasting glucose >7
management
Go straight to insulin treatment (SHORT ACTING) and review in 1 week
240
what type of insulin is used in diabetes in pregnancy
short acting
241
gestational diabetes
fasting glucose 6-6.9
management
offer insulin if evidence of complications such as macrosomia or hydramnios
if not do lifestyle changes / metformin
242
for which gestational diabetes pts is glibenclamide offered
women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
243
when should gestational diabetes pts give birth
no later than 40+6 weeks
(increased risk of stillbrith) - if need be, induce before this point
244
if gestational diabetes patient is not already on insulin, what should be given during labour
Variable-rate insulin infusion
245
for gestational diabetes, how should diabetes meds be managed after birth
immediately stop meds after birth
246
for pre-existing diabetes, how should diabetes meds be managed after birth
Immediately reduce insulin and monitor blood glucose to establish appropriate dose to avoid risk of hypoglycaemia post-partum
247
what should baby be monitored for if mother had pre existing or gestational diabetes
neonatal hypoglycaemia
248
management of asymptomatic baby of a mother with pre existing or gestational diabetes
encourage normal feeds
monitor glucose for neonatal hypoglycaemia
249
management of symptomatic baby of a mother with pre existing or gestational diabetes
neonatal hypoglycaemia
--> Admit to neonatal ward
--> give 10% IV dextrose
250
what follow up is needed after brith for women with gestational diabetes and why
GP follow-up in 6 weeks to test fasting glucose because 50% chance of developing subsequent T2DM
251
risks to mother of large for gestational age baby (6)
Failure to progress
Perineal tears
Instrumental delivery or caesarean
PPH
Uterine rupture
Shoulder dystocia
252
what is shoulder dystocia impact between
anterior foetal shoulder on the maternal pubic symphysis
so inability to delivery age foetal body using gentle traction, and head has already been delivered
253
2 risks to baby with shoulder dystocia
Erb’s palsy (brachial plexus injury)
Clavicle/humerus fracture
254
how is herbs palsy in a newborn managed
phsyiotherapy
255
3 risks to mother with shoulder dystocia
PPH
Perineal tears
Uterine rupture
256
how to manage shoulder dystocia (steps)
HELPERR
H --> call for help
E --> evaluate need for episiotomy (can u fit ur hand in for manoeuvres)
L --> legs in McRoberts position
P --> suprapubic pressure
E --> tenter manœuvres (rubans, woods screw)
R --> removal of posterior arm
R --> roll pt on all 4s and try to report manoeuvres or see if position moves the foetus
call for help
257
what last resort options can u try if the HELPERR steps don't resolve shoulder dystocia
symphysiotomy
(dividing the mother’s pubic symphysis)
cleidotomy
(dividing the foetal clavicles)
Zavenelli manoeuvres
(pushing the foetal head back into the vagina in anticipation of a C section)
(if in theatre then do zavenelli, but these are all rarely done)
258
what is the McRoberts position
lie on back with hips flexed and abducted
259
what are the Rubins and woods screw manoeuvres
Rubin’s manoeuvre
(press on the posterior shoulder to allow the anterior shoulder extra room)
Woods’ Screw
(putting a hand in the vagina and rotating the foetus 180 degrees in attempt to 'dislodge' the anterior shoulder from the symphysis pubis)
woman needs to be in mcRoberts position for these manoeuvres
260
what is the risk of delivering the posterior arm
(tug posterior arm, risk of humeral fracture
261
4 risks to baby of being LGA
Birth injury
Neonatal hypoglycaemia
Obesity in childhood and later in life
T2DM in adulthood
262
What 3 tools can diagnose large for age prenatally?
Symphysis-fundal height (SFH)
Abdominal circumference (AC)
Estimated foetal weight (EFW)
263
after ... weeks, fundal height is expected to increase by 1cm a week
24/40
264
once SFH / AC / EFW show possible LGA, what further investigation should be done and why
USS
to exclude polyhydramnios (the increased SFH for example could be due to excess fluid, so need to exclude this before determining its the baby that is LGA)
USS can also be used to estimate foetal weight although often inaccurate
265
What BMI is classified as obesity in pregnancy?
30 kg/m2
266
what advice should be given to obese pregnant women with regards to weight loss management
risk to them and their unborn child should be explained
but
they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy
267
what advice should you give a pregnant obese woman with regards to supplements
take 5mg folic acid rather than 400mcg
268
what advice should you give a pregnant obese woman with regards to gestational diabetes screening
should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
269
what adjustments should be made to birth plan for obese pregnant women with a BMI >= 35
should give birth in a consultant-led obstetric unit
270
what adjustments should be made to birth plan for obese pregnant women with a BMI >= 40
should have an antenatal consultation with an obstetric anaesthetist and a plan made
271
when does obstetric cholestasis occur
later in pregnancy (>28/40)
272
what does obstetric cholestasis increase risk of
stillbirth
273
what is the most common liver disease in pregnancy
obstetric cholestasis
274
what are the main features of obstetric cholestasis
pruritus (palms, soles)
no rash (may be excoriation marks from scratching tho)
raised bilirubin
signs of outflow obstruction in bile ducts
^ fatigue, dark urine, pale stools, jaundice
275
What investigation do we do with pregnant women presenting with pruritus and how often?
LFTs and bile acids
weekly until delivery
doppler and TCG
2x per week
276
non drug management for obstetric cholestasis
Wear cool/loose clothing
Soak in cool bath
Apply ice packs to affected areas
Topical emollients
277
drug management for obstetric cholestasis and what benefit does it provide
Ursodeoxycholic acid
(resolves pruritic and stabilises LFTs, but doesn't protect against risk of stillbirth)
278
what benefit can sedating antihistamines eg chllorphenamines provide for pts with obstetric cholestasis
helps with sleep but not pruritus
279
when do we give vit K to obstetric cholestasis pts
if clotting (PT) is deranged
280
how should delivery be carried out for obstetric cholestasis pts
indiction of labour - around 37 weeks
281
what followup is needed for obstetric cholestasis pts after delivery
Measure LFTs 6 weeks postnatally to ensure resolution
282
what is the main complication, other tank stillbirth, with obstetric cholestasis
high recurrence rate (90%)
283
what is acute fatty liver of pregnancy caused by
Autosomal recessive mitochondrial disorder
--> Long chain 3-hydroxylacyl-CoA dehydrogenase (LCHAD) deficiency
this enzyme is important in fatty acid oxidation
so foetus is unable to break down fatty acids
fatty acids travel into maternal blood and accumulate in maternal liver
284
when does acute fatty liver of pregnancy occur
3rd trimester
but its rare
285
sx of acute fatty liver of pregnancy
Malaise + fatigue
N&V
Jaundice
RUQ abdo pain
Lack of appetite
Ascites
Hypoglycaemia
Coagulopathy
No pruritus
286
what is the main thing to look out for in bloods for acute fatty liver of pregnancy
ALT is typically elevated e.g. 500 u/l
287
what are LFT levels and clotting times in acute fatty liver of pregnancy
Raised ALT and AST
Prolonged PT
Raised bilirubin
288
what do u see on imaging in acute fatty liver of pregnancy
Steatosis
289
how is acute fatty liver of pregnancy managed
emergency
supportive care
delivery is only definite management
290
N&V
jaundice
no pruritus
3rd trimester
dx ?
acute fatty liver of pregnancy
291
A 24-year-old woman attends her booking scan and finds out that she is pregnant with monochorionic twins. Her general practitioner asks her specifically to report any sudden increases in the size of her abdomen and/or any breathlessness. What complication of monochorionic multiple pregnancy is the GP describing the symptoms of?
Twin-to-twin transfusion syndrome
292
A 27-year-old nulliparous woman is diagnosed with gestational diabetes during her current pregnancy via an oral glucose tolerance test (OGTT). She asks whether her diagnosis will impact future pregnancies.
What is the most appropriate approach to screen for gestational diabetes in future pregnancies?
OGTT immediately after booking a
and subsequently at 24-28 weeks
293
baby of 4.5kg is born with adduction and internal rotation of the right arm
diagnosis?
Erbs palsy
(shoulder dystocia causing damage to upper brachial plexus. This results in waiters tip sign)
294
what is the definitive tx for obstetric cholestatis
induction of labour at 37 weeks
(ursodeoxycholic acid is only symptomatic relief for pruritus)
295
what additional measure can aid the effectiveness of McRobert's manoeuvre?
applying suprapubic pressure
296
in which 2 situations would you do an OGTT immediately after the booking appointment, rather tan at 24-28 weeks
glycosuria on urine dipstick
or
previous GDM
297
A 34-year-old pregnant woman presents at 30 weeks gestation for a routine check. On examination she has a symphysis-fundal height of 25 cm. What is the next most important investigation to confirm the examination findings?
Ultrasound
- to confirm whether or not the foetus is small for gestational age
298
at what week should labour be induced for women with obestetric cholestasis
37
299
if metformin has not worked for normalising glucose levels in a woman with gestational diabetes, do you add short acting insulin to the metformin, or stop metformin and commence insulin
add insulin to tx regime with metformin (don't stop the metformin)
300
can fundal pressure be used in shoulder dystocia
never
use suprapubic pressure instead
301
what effect does giving steroids have on insulin tx
monitor BM closely and adjust pump accordingly
302
what does high fetal fibronectin indicate
early labour
303
which diabetic meds should be avoided in breastfeeding due to theoretical risk of neonatal hypoglycaemia
Sulfonylureas (gliclazide)
304
which diabetic medication is safe in breastfeeding
metformin
305
A 26-year-old pregnant woman with type 1 diabetes asks you how often she should test blood glucose levels throughout her pregnancy?
daily fasting, pre meal, 1 hour post meal and bedtime
306
how can the thyroid be affected in pregnancy (which levels are affected and which are not)
Increase in thyroxine-binding globulin (TBG) levels
which increases levels of total thyroxine
--> but free thyroxine level remains normal
307
When do we check TFTs at booking? (4)
Current thyroid disease
Previous thyroid disease
1st degree FHx thyroid disease
Any autoimmune conditions
308
when are TFTs checked in pregnant women with thyroid issues
every trimester and 6-8 weeks postnatally
309
what level should TSH be at for pregnant women with hypo or hyper thryoidism
hypo
TSH < 4 mmol/L
hyper
TSH > 4 mmol/L
310
is thyroxine safe in pregnancy
yes
311
is thyroxine safe in breastfeeding
yes
312
how should levothyroxine be adjusted for pregnant women with hypothyroidism
can be continued as safe in pregnancy
but dose should be increased by 25-50ug / upto 50%
313
How do we treat postpartum thyroiditis depending on the phase? (2)
Thyrotoxic phase
→ propranolol
Hypothyroid phase
→ levothyroxine
314
what medical tx should be used for hyperthyroidism in the 1st trimester vs later pregnancy
1st trimester: propylthiouracil
rest of pregnancy:
carbimazole
315
what are the possible side effects of propylthiouracil
severe hepatic injury to mother
fetal hypothyroidism
birth defects
316
what are the possible side effects of carbimazole
agranulocytosis
317
what two treatments for hyperthyroidism are C/I in pregnancy
radioactive iodine
and
block + replace regimes
318
what should be done to reduce the risk of fetal hypothyroidism in pregnant women with hyperthyroidism
maternal free thyroxine levels should be kept in the upper third of the normal reference
319
how do dosages of medication differ in pregnancy for hypo and hyper thyroidism
hypo:
pt requires higher doses
hyper:
pt requires lower doses
320
what should be checked at 30-36 weeks in pzeganntwomen with hyperthyroidism, to determine risk of neonatal thyroid problems
thyrotrophin receptor stimulating antibodies
321
Untreated thyrotoxicosis in pregnancy increases the risk of ...(3)
fetal loss
maternal heart failure
premature labour
322
... is the most common cause of thyrotoxicosis in pregnancy
graves disease
323
what is transient gestational hyperthyroidism
activation of the TSH receptor by HCG
(usually in first trimester, as hcg levels fall in 2nd and 3rd trimesters)
324
Where does amniotic fluid come from?
Largely from foetal urine from 2nd trimester onwards
325
definition of oligohydramnios
less than 500ml at 32-36 weeks
amniotic fluid index (AFI) < 5th percentile
326
causes of oligohydramnios (4) and examples
Reduced urine production
- placental insufficiency
- pre eclampsia
- IUGR
Reduced urine output from kidneys
- maternal meds eg NSAIDs, ACEi
- renal agenesis --> potter's sequence
Loss of fluid
- PROM (premature rupture of membranes)
- post term pregnancy (>42/20)
- TTTS in donor baby
Chromosomal abnormalities
327
what is renal agenesis and what can in result in for the foetus
failure of kidney development in foetus
can result in potters sequence:
pulmonary hypoplasia + potters facies + clubfoot/joint contractures
--> death in utero
328
what are the features of potters facies
flattened nose
low set ears
small jaw
329
2 features on abdo exam for pt with oligohydramnios
Decreased fundal height
Foetal parts easily palpable
330
what amniotic fluid index is seen in oligohydramnios
< 5cm
(<5th percentile)
331
how to manage oligohydramnios
if at term --> delivery
if preterm --> close monitoring, ensure hydration, early delivery if necessary
332
definition of polyhydramnios
Increased volume of amniotic fluid (>95th centile for gestational age)
333
Amniotic Fluid Index in polyhdramnios
>25cm
334
what level of fluid in litres in seen in polyhdramnios
2-3L
335
causes of polyhydramnios (3) and examples
Increased foetal urine production
- GDM
-TTTS in recipient baby in multiple pregnancy
-Foetal anaemia
→ increased cardiac output so increased urine production
Reduced foetal swallowing
- Duodenal/oesophageal atresia
- Bowel malformation
- Cleft lip (impairs foetus ability to swallow)
- Neurological issue
- Chromosomal abnormality
Congenital infections
336
why can foetal anaemia cause polyhydramnios
increased cardiac output so increased urine production
337
2 features on abdo exam for pt with polyhydramnios
Increased fundal height
Impalpable foetal parts
338
two options for managing polyhydramnios
Amnioreduction (procedure to reduce amniotic fluid amount)
or
COX inhibitors (decreases foetal urine output) e.g. indomethacin
339
how does TTTS cause polydramnios in the recipient twin
the extra blood flow it receives leads to increased urine production
340
how does TTTS cause oligodramnios in the donor twin
blood flow goes from donor to recipient twin
so donor twin has less blood (hypovolaemia)
therefore also reduced urine output
341
What do UTIs increase risk of in pregnant women?
preterm delivery
342
Most common bacterial cause of UTI?
E coli
343
what type of urinary tract infection is renal angle tenderness a sign of
pyelonephritis (upper UTI)
344
what 2 things do you look for on urine dip for urine infection
Nitrites
→ produced by gram -ve bacteria like E coli
- more accurate indication of infection than leukocytes
Leukocytes
→ WBC suggest infection
345
what on a urine dip is the most indicative of urine infection
nitrites
346
what screening is done for urinary tract infections in pregnancy
Women tested for asymptomatic bacteriuria and routinely through pregnancy via urine sample sent for MC&S, starting at booking appt
347
How do we manage UTI in pregnancy (or asymptomatic bacteriuria)?
Nitrofurantoin
348
2nd line for UTI in pregnancy
amoxicillin or cephalexin
349
when is nitrafuratonin avoided for UTI in pregnancy and why
Close to term due to risk of neonatal haemolysis
350
4 RF for group b strep infection in foetus
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
351
what is used fro GBS treatment / prophylaxis
IV benzylpenicillin
352
for which women is IAP (intrapartum antibacterial prophylaxis) for GBS given
previous pregnancy with GBS
previous baby with early or late onset GBS
women in preterm labour
women with pyrexia (>38) during labour
353
what 2 things should be offered to women who've had GBS detected in a previous pregnancy
intrapartum antibiotic prophylaxis (IAP)
OR
testing in late pregnancy and then antibiotics if still positive
354
at what point in pregnancy is GBS testing performed
35-37 weeks or 3-5 weeks prior to the anticipated delivery date
355
for women who have had GBS in a previous pregnancy, what is there chance of having GBS in their current pregnancy
50%
356
what is vasa praevia
Foetal vessels run close to the internal cervical os and vessels at risk of rupture when membranes rupture
357
what are the 2 possible causes of vasa praevia
Velamentous cord insertion
Umbilical cord inserts into foetal membranes (amniotic sac) instead of middle of
placenta, then travels with the membranes of the placenta
Accessory placental lobes (succenturiate lobe)
(Placenta having ≥1 smaller separate lobes to main placenta)
358
name 3 RF for vasa praaevia
History of placenta praevia in 2nd trimester
Multiple pregnancies
IVF
359
what is the classic triad of vasa praevia
Membrane rupture
followed by painless PV bleeding
+ foetal bradycardia (or resulting in foetal death)
360
what is the main investigation for vasa praaevia
Doppler USS
361
how is vasa praaevia managed
emergency C section
362
prognosis of vasa praaevia
50% foetal death (increases to 75% if membranes ruptured)
363
what is the most common area affected by a cerebral venous sinus thrombosis, precipitated by pregnancy
sagittal sinus
364
2 main symptoms of a cerebral venous sinus thrombosis
severe headache
blurred vision
365
when is the most common time of onset of a cerebral venous sinus thrombosis, precipitated by pregnancy
post partum (more common than in during pregnancy)
366
Ix for cerebral venous sinus thrombosis (initial and gold standard)
CT used acutely to rule out intracranial bleeds etc
diagnostic = MRI
367
management of cerebral venous sinus thrombosis
LMWH and catheter guided thrombolysis
then anticoagulation (warfarin/DOAC) for 3-6 months
368
what investigation is used for DVT in pregnancy
compression duplex USS (if scan cannot be done within 4 hours, start anticoagulation)
369
what do you do if compression duplex USS is -ve in suspected DVT
(stop anticoagulation if you already started it)
then repeat USS on days 3 and 7
370
initial 2 Ix for suspected PE
ECG and CXR
371
after ECG and CXR what is done for investigating suspected PE
assess for signs of DVT
372
after ECG and CXR what is done for investigating suspected PE, if there are positive signs of DVT
compression duplex USS, if this comes back as confirmed DVT, no further Ix are needed
373
after ECG and CXR what is done for investigating suspected PE, if there are negative signs of DVT
CTPA or V/Q --> RCOG recommends V/Q
374
what is the risk posed with CTPA and with V/Q scans
CTPA --> increased risk of maternal breast cancer
V/Q --> increased risk of childhood cancer
375
what can be given as thromboembolism prophylaxis in pregnancy
LMWH (enoxaparin)
compression stockings
376
What do we do if mother is on LMWH for thromboembolism but she is at extremes of body weight (<50kg/>90kg) or has renal impairment/recurrent DVTs?
Monitor anti-Xa levels to see activity of LMWH
377
how to manage LMWH therapy in delivery (2)
Temporarily stop LMWH 24 hours before delivery to decrease risk of PPH
Epidural not given until at least ≥24 hours after last LMWH dose
378
What thromboembolism drugs to avoid in pregnancy? (2)
DOACs and warfarin
379
what is preferred in pregnancy, IV heparin or LMWH
LMWH (less bleeding and thrombocytopenia)
380
3 reasons why body becomes more hypercoagulable in pregnancy
increase in factors VII, VIII, X and fibrinogen
decrease in protein S
uterus presses on IVC causing venous stasis in legs
381
what infection can erythema multiform be linked to
HSV
382
what do target lesions suggest
erythema multiforme
383
can erythema multiforme be normal in pregnancy
yes
384
what do painful red bumps on shins suggest
erythema nodosum
385
what are the causes of erythema nodosum
NO (idiopathic)
D (drugs - penicillin sulphonamides)
O (oral contraceptive pill/pregnancy)
S (sarcoidosis/TB)
U (ulcerative colitis/crohns/behcets disease)
M (microbiology - strep, mycoplasma, EBC etc)
386
what is the most common pregnancy rash
atopic eruption of pregnancy
387
describe atopic eruption of pregnancy
eczematous pruritic rash
usually 1st/2nd trimester
388
management of atopic eruption of pregnancy
no specific tx needed
can use emollients / bath additives
389
describe the appearance and development pattern of pemphigoid gestationis
rare autoimmune blistering lesions
starts on abdomen and moves to torso/arms
spares the face
390
when does pemphigoid gestationis appear in pregnancy
2nd or 3rd trimester
391
tx for pemphigoid gestationis
potent topical steroids or oral prednisolone
392
describe the appearance and development pattern of polymorphic eruption of pregnancy
pruritic papules
seen over abdominal striae
spare umbilicus
start on abdomen then spread to buttocks/thighs
393
when does polymorphic eruption of pregnancy appear in pregnancy
3rd trimester
394
tx for polymorphic eruption of pregnancy
emollients + steroids (topical or oral if widespread)
395
which pregnancy rash can be described as
"pruritic papules which develop into erythematous plaques"
polymorphic eruption of pregnancy
396
describe the appearance and location of prurigo of pregnancy
excoriated papules
extensor limbs / abdomen / shoulder
397
when in pregnancy can prurigo happen
3rd trimester
398
what investigation should be done before a diagnosis of prurigo of pregnancy
LFTs to exclude obstetric cholestasis
399
tx for prurigo of pregnancy
symptomatic Tx + topical steroids + emollients
400
what is pruritus folliculitis
itchy inflammation of hair follicles
401
tx for pruritus folliculitis in pregnancy
topical steroids
402
which pregnancy rash is associated with blisters
pemphigoid gestationis
403
which pregnancy rash happens earlier in pregnancy than the others (around 1st trimester)
atopic eruption of pregnancy
404
what test can be done to assess how much foetal blood has past into maternal blood when assessing dose of anti D required to give after a sensitising event
Kleihauer Test
405
the Kleihauer Test can be used after any sensitising event after ... weeks
20 weeks
406
what test is done for all rhesus negative mothers at booking
test for anti D IgG
407
if a rhesus negative pregnant woman has been found to not have anti D IgG (ie is not sensitised) what prophylaxis can be given
IM anti D IgG
1 dose of 1500 IU at 28 weeks
or
2 doses of 500 IU each at 28 and 34 weeks
408
how does giving anti D IgG work
Anti-D med attaches itself to rhesus-D antigens on foetal RBCs in mother’s circulation and destroys them
This prevents mother’s immune system from recognising the antigen and creating its own antibodies to it
409
anti D can be given to a rhesus negative pregnant woman within ... hours of sensitisation
within 72 hours
410
how much anti D can be given within 72 hrs of sensitisation if < 20/40
250 IU
411
how much anti D can be given within 72 hrs of sensitisation if >=20/40, and what else needs to be done
kleihauer test + 500 IU
412
give 8 examples of sensitising events where anti D IgG should be given
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
413
What do we do if baby found to be Rh+ at birth (via cord sample)?
Give mother 500 IU anti-D within 72 hours
414
what are the signs of a foetus affected by haemolytic disease of the newborn
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
415
what 2 things are done for foetuses affected by haemolytic disease of the newborn
transfusions
UV phototherapy
416
how do you manage a suspected PE in pregnant women with a confirmed DVT (via duplex USS)
treat with LMWH first then investigate to rule in/out (via V/Q or CTPA)
417
if a woman had a PE and was started on apixaban, then became pregnant 2 months later, what should be done
need to be on anticoagulation for at leats 3 months
but DOACS and warfarin are C/I in pregnancy
LMWH is what is used in pregnancy
so change apixaban to a LMWH eg enoxaparin
418
is renal agenesis a cause of oligo or poly hydramnios
oligohydramnios
(reduced foetal urien output)
419
what should be used to treat the hyperthyroid ie thyrotoxic phase of postpartum thyroiditis
propanolol
420
what medication is APTT used in the monitoring for
unfractionated heparin
421
what medication is anti-Xa used in the monitoring for
LMWH
422
if suspect DVT or PE, what management approach should be taken
treat immediately with LMWH until diagnosis is excluded by objective testing
423
is duodenal atresia a cause of oligo or poly hydramnios
polyhydramnios - foetus cannot swallow amniotic fluid
424
is fetal anaemia a cause of oligo or poly hydramnios
polyhydramnios - high output heart failure
425
is trisomy 21 a cause of oligo or poly hydramnios
polyhydramnios - trisomy 21 is often associated with duodenal or oesophageal atresia --> trouble swallowing amniotic fluid
426
if a woman has had a previous DVT and is now pregnant, what tx should she have and for how long
LMWH throughout pregnancy and until 6 weeks postpartum
427
what two factors in pregnancy can increase risk of developmental dysplasia of the hip
breech presentation
oligohydramnios - foetus less able to move around
428
what tx should be given if a pregnant woman has 4 or more DVT/PE RF
LMWH
throughout entire antenatal period
+ 6 weeks postnatally
429
what tx should be given if a pregnant woman has 3 DVT/PE RF
LMWH
from 28/40
+ 6 weeks postnatally
430
what tx should be given if a woman has a DVT/PE during pregnancy
LMWH
until at least 3 months postnatally
431
name some RF for DVT/PE in pregnancy
Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy
432
define placenta praevia
low lying placenta
- or covers internal os
433
RF for placenta praevia
smoking
IVF
increasing maternal age
previous placenta praevia
multiple pregnancy
previous uterine surgery
434
grades 1 - 4 of placenta praevia
I (low-lying)
placenta reaches lower segment but not the internal os
II (marginal)
placenta reaches internal os but doesn't cover it
III (partial)
placenta covers the internal os before dilation but not when dilated
IV ('major'/complete)
placenta completely covers the internal os
435
what ix diagnoses placenta praevia
TVUSS
436
on a TVUSS, how far from internal os should placenta be for a placenta praevia diagnosis
20mm
437
which Ix is C/I in placenta praevia
bimanual
438
which Ix can be done initially if someone comes in w bleeding and you suspect placenta praevia
speculum
can be done to assess source of bleeding
(then would do TVUSS for diagnosis)
439
how does placenta praevia present ( if picked up symptomatically, not on scan)
painless vaginal bleeding
no uterus tenderness
440
when is placenta praevia usually picked up
at 20 week appt
441
what proportion of placenta praevias picked ups at 20 weeks resolve by term
90%
442
if placenta praevia is picked up at 20 weeks what advice should be given
no sex
avoid activities which could increase risk of bleed eg heavy exertion/exercise
443
if placenta praevia is picked up at 20 weeks, what follow ups should be done (all the way until term)
scan again at 32 weeks
if still unresolved, scan again at 36 weeks
if still unresolved, plan elective C section at 36/37 weeks
444
how is delivery amended for placenta praevia pts and why
need to have elective C section at 36/37 weeks, before natural indiction of labour to avoid PPH
(grade 1 can trial vaginal delivery)
445
if pt presents with antenatal bleeding, which approach should always be taken, even if bleeding stopped
admit for 48 hrs
446
if placenta praevia pt presents with bleeding and is stable and not at term, what do you do
admit for 48 hrs
447
if placenta praevia pt presents with bleeding and is unstable and not at term, what do you do
emergency C section
448
if placenta praevia pt presents with bleeding and is at term, even if stable, what do you do
emergency C section
449
what should be done if a placenta praevia pt gets into labour prior to her elective C section
emergency c section
450
what is the biggest risk with placenta praevia
can cause PPH
451
shock out of keeping with visible blood loss
likely diagnosis
placental abruption
452
shock in keeping with visible blood loss
likely diagnosis
placenta praevia
453
what is placental abruption
placenta separates from the uterine wall during pregnancy resulting in maternal haemorrhage into intervening space
454
2 types of placental abruption
Concealed (20%)
→ cervical os remains closed so bleeding remains in uterine cavity
- vaginal bleeding is therefore disproportionate to uterine bleeding
Revealed (80%)
455
RF for placental abruption (9)
ABRUPTION
Abruption previously
Blood pressure → hypertension or pre-eclampsia
Ruptured membranes, either premature or prolonged
Uterine injury → trauma to the abdomen (consider domestic abuse)
Polyhydramnios
Twins (multiple pregnancy)
Infection in uterus (esp chorioamnionitis) or IUGR
Older age → aged over 35 years old
Narcotic use → cocaine, amphetamines, smoking
456
sx of placental abruption
Sudden onset constant severe abdo pain
vaginal bleeding (can be very little or a lot depending on type of placental abruption)
shock
can be shock not in keeping with visible blood loss if concealed abruption
457
what is the uterus like on palpation in placental abruption
wood hard uterus (indicates large heamorrhage)
458
what Ix should be done in suspected placental abruption to rule anything else out
TVUSS - to rule out placenta praevia
459
what needs to be given when bleeding happens in placental abruption
anti-D immunoglobulin within 72 hrs
Kleihauer test
460
placental abruption management:
foetus alive
< 36 weeks
foetal distress/maternal instability
immediate C section
461
placental abruption management:
foetus alive
< 36 weeks
no foetal distress/maternal stability
observe, steroids, when bleeding settles can discharge home with weekly serial growth scans
462
placental abruption management:
foetus alive
>= 36 weeks
foetal distress/maternal instability
immediate c section
463
placental abruption management:
foetus alive
>= 36 weeks
no foetal distress/maternal stability
vaginal delivery
464
what is C/I in placental abruption that happens preterm
tocolysis
465
what is the definition in ml of PPP in vaginal vs c section deliveries
>500 mL at vaginal delivery
>1000 mL at C section
466
what is the definition of antepartum haemorrhage
Blood loss after 24/40 prior to delivery of foetus
467
two main causes of antepartum haemorrhage
Placenta praevia
Placental abruption
468
define primary vs secondary PPH
primary: within 24 hrs
secondary: 24 hrs - 12 weeks
469
define minor vs major primary PPH
minor = (500-1000ml) + no shock
major = (>1000ml) or shock
470
2 main causes of secondary PPH
endometritis
retained placental tissue
471
if placenta is completely not out, what do u do
controlled cord traction
472
if placenta is out but incomplete, what do u do
transfer to theatre for manual evacuation
473
4 causes of PPH
4 T's
Tone (uterine atony)
→ uterus fails to contract after birth - most common
Trauma
→ damage to genital structures e.g. perineal tear, lacerations, episiotomy
Tissue
→ retained placental fragments in uterine cavity
Thrombin
→ underlying clotting disorder
474
most common cause of PPH
uterine atony
475
define placenta accreta
placenta attached to myometrium
476
define placenta increta
chorionic villi invade into the myometrium
477
define placenta percreta
chorionic villi invade through the perimetrium
478
rank placenta accreta, increta and percreta in order of severity and how common they are
1) accreta - least severe, although still v dangerous, and most common of the 3
2) increta
3) percreta
479
main risk factors for placenta accreta
previous c section
low lying placenta (placenta uraemia)
and less common: asherman's syndrome (damage to endometrium after surgery, so placenta grows onto myometrium instead)
480
definitive tx for placenta accreta
hysterectomy
481
what prophylactic uetrotonics are given in labor and for which women
given for ALL women in 3rd stage of labour to prevent PPH
IV oxytocin
482
how to manage PPH due to uterine atony
(technically, medically and surgically)
tranexamic acid and massage the uterine fundus (to stimulate contractions)
drain bladder via catheter (full bladder can obstruct contractions)
bimanual compression (until help comes)
medical:
1) IV oxytocin/syntocinon - if not already on it, and can give for long infusion
2) IM ergometrine / syntometrin
3) PR/SL misoprostol
4) IM carboprost or IV carbetocin --> if have reached this stage TRANSFER TO THEATRE IMMEDIATELY
surgical:
1) bakri catheter (intrauterine ballon tamponade)
2) B-lynch sutures
3) if still unresolved, can do ligation of uterine/internal iliac arteries, but best to just go for hysterectomy at this point
483
in which pts is ergometrine or syntometrin C/I
pts with HTN
484
in which its is IM carboprost C/I
asthmatics
485
what is a syndrome which is a consequence of PPH
Sheehans
486
if qs mentions painless vaginal bleeding after membrane rupture, what should be ur top differential diagnosis
vasa praevia (rather than placenta praevia)
487
For a woman pregnant with twins, what is the main pathology that needs to be looked for with USS monitoring between weeks 16 and 24 gestation ?
TTTS
488
contrast the onset of PPH due to atony vs retained placental tissue
atony - immediately after delivery (usually primary PPH)
placental tissue - bleeding can happen soon or later (can be primary or secondary PPH)
489
A 25-year-old woman (G1P1) undergoes a vaginal delivery at 39 weeks gestation, followed by a physiological third stage of labour. In the hours following, she has some brown mucousy vaginal discharge with blood in it, producing approximately 100ml of blood.
On examination, the patient has a GCS of 15, a soft but tender abdomen. Her blood pressure is 132/83 mmHg, her pulse is 86 bpm, her temperature is 36.5C.
What is the most appropriate next step in her management?
give her sanitary pads
(is <500ml so is not a PPH)
490
if not picked up on a scan, when does placenta accreta symptomatically present
at birth - as PPH (this is what make sit different in presentation to placenta praevia, which presents as bleeding before birth)
--> placenta acretta is usually low lying but doesn't always cover the internal os, therefore can not cause bleeding until labour
491
can multiparty or nulliparity be a risk factor for placental abruption
multiparity
492
Human chorionic gonadotrophin (HCG) is secreted by "x" into the maternal bloodstream, where is acts to maintain the production of "x" by the corpus luteum in early pregnancy
secreted by syncytiotrophoblasts
maintain production of progesterone
493
HCG can be detected in the maternal blood as early as day "x" after conception
day 8
494
how does the blood colour differ in placenta praevia and abruption
praevia - brigh tred
abruption - dark red
495
other than downs syndrome, what defect can cause increased nuchal translucency
congenital heart defects
496
You are a male FY1 working in obstetrics. A 33-year-old female is on the ward in labour, 10 minutes ago she suffered a placental abruption and is in need of emergency care. Her midwife comes to see you, informing you that she is requesting to only be seen and cared for by females. What do you say?
ask midwife to immediately call for senior medical support, regardless of gender
(While patients do have a right to choose their own doctor, this doesn't apply in emergency situations where treatment is needed to save the life of the patient)
497
A 36-year-old woman gives birth to healthy twin girls. Which agent is most likely to be used after the birth to facilitate delivery of the placenta and to prevent postpartum haemorrhage?
oxytocin / ergometrine
498
what role can prostaglandin E2 play in labour
initiating labour
499
what role can indomethacin and salbutamol play in labour
tocolytics
500
how should a woman be positioned in a PPH
lying flat on her back
501
how should a pregnant women be positioned if she is haemodynamicaly compromised and why
on her left lateral side
will relieve the pressure of the uterus on the inferior vena cava, increase venous return and improve circulation
(irrelevant step for a woman who has already delivered her baby as the uterus is no longer compressing the inferior vena cava)
502
A 36-year-old multiparous patient has an uncomplicated delivery at 39 weeks gestation. One hour following delivery, the patient develops severe post partum haemorrhage which is acutely managed in the labour ward. Seven weeks later, the patient presents with difficulty breastfeeding due to a lack of milk production. Which of the following conditions is most likely to explain this history?
Sheehans syndrome
503
most important risk factor for placenta acretta
previous c sections
504
if scanned at 20 weeks and found placneta praevia, when is the next scan done
32 weeks
(then 38)
505
what is the initial surgical intervention doers for PPH due to atony, if medical management has failed
intrauterine balloon tamponade (bakri catheter)
506
if placenta is found to be adherent to the bladder what condition best describes this
placenta percreta --> invade through the perimetrium
507
most common cause of PPH
atony
508
how many units of IV syntocinon/oxytocin should be given in PPH
5 units
509
how many mg of IM ergometrine should be given in PPH
0.5 mg
510
contrast PROM to PPROM
both are Spontaneous rupture of membranes prior to onset of labour
PROM is > 37 weeks
PPROM is < 37 weeks
511
what is the cause of PROM
Natural physiological mechanisms
→ Braxton Hicks contractions and cervical ripening lead to weakening of the membrane
512
what is the cause of PPROM
Weakening of the membranes strongly linked to an infective cause e.g. E coli or GBS
513
sx of PROM/PPROM
Sudden gush of fluid PV
Contractions
Chorioamnionitis
514
what are the 3 main features of chorioamnionitis
Maternal pyrexia + maternal tachycardia + foetal tachycardia
515
1st line ix in PROM/PPROM
speculum
516
what is a speculum looking for in PROM/PPROM
pooling of amniotic fluid in the posterior vaginal vault
517
what should b done if no pooling of fluid can be seen in PROPM/PPROM on speculum
Test the fluid for
placental alpha microglobulin-1 protein (PAMG-1)
or
insulin-like growth factor binding protein-1 (IGFBP-1)
PAM likes insulin but can’t see the pool
518
what ix is C/I in PROM/PPROM
bimanual
519
what's the benefit of doing USS as an addition ix in PROM/PPROM
to look for oilgohydramnios - indicates the membranes have ruptured
520
what is the first step in managing PROM and what monitoring should be done
Admit to antenatal ward for speculum
4 hourly temp measurements
24 hour foetal monitoring
521
after examination/investigations, how should PROM be managed if the amniotic fluid is clear liquor
expectant management for 24 hours (60% will deliver) and if nothing happens at 24 hours then induce labour
522
after examination/investigations, how should PROM be managed if the amniotic fluid is meconium stained
indie labour ASAP
523
how is PPROM initially managed and why's observation very important
Admit to antenatal ward
to ensure chorioamnionitis (infection of placenta and amniotic fluid) isn’t developing
524
which 2 medications are always prescribed in PPROM and for how long
oral erthromycin (for 10 days or until labour, whichever is first)
corticosteroids (2 x 12mg IM betamethasone 24 hours apart)
525
why is oral erythromycin prescribed in PPROM
Shown to improve outcomes for the baby
526
why are corticosteroids prescribed in PPROM
reduce risk of respiratory distress syndrome
527
in which circumstance is IV mgso4 prescribed in PPROM and why
if <30/40 and birth is expected within 24 hours
provides neuroprotection to foetus
528
when is delivery recommended in PPROM
37/40
if there are no indictions for earlier delivery su ch as chorioamnionitis or foetal compromise
529
abx for chorioamnionitis
IV ampicillin + gentamicin
if c section:
add Clindamycin or metronidazol to the above
530
what type(s) of monozygotic pregnancies can you have
MCMA (mono chorionic, mono amniotic)
MCDA (mono chorionic, di amniotic)
531
what type(s) of dizygotic pregnancies can you have
DCDA (Dichorionic diamniotic)
532
what is more common, mono or di zygotic twins
dizygotic (80%)
533
what is the biggest risk with monochorionc twins
TTTS
534
TTTS: What happens to recipient? (3)
Fluid overload
Heart failure
Polyhydramnios
535
TTTS: What happens to donor? (3)
Growth restriction
Anaemia
Oligohydramnios
536
what procedure can be done for TTTS
Laser ablation to destroy connection between blood supplies
537
what chorionicity and amnionicity presents when the zygote divides < day 4
DCDA
538
what chorionicity and amnionicity presents when the zygote divides day 4-8
MCDA
539
what chorionicity and amnionicity presents when the zygote divides day 8-12
MCMA
540
what chorionicity and amnionicity presents when the zygote divides day 13+
conjoined twins
541
at which week should air travel be avoided in single vs multiple pregnancies
single >37/40
multiple > 32/40
542
which symptom is often heightened in a multiple pregnancy
N&V --> hyperemesis gravidarum in 1st trimester
543
which conception method increases risk of multiple pregnancy
IVF
544
which ethnicity is at higher risk of DCDA twins
afro-caribbean
545
when is multiple pregnancy picked up
1st trimester dating scan (10-13+6/40)
546
how is gestational age determined in multiple pregnancy
using largest baby
547
"membrane between the twins, with a lambda sign"
what amnionicity and chorionicity is this twin pregnancy ?
DCDA
548
"membrane between the twins, with a T sign"
what amnionicity and chorionicity is this twin pregnancy ?
MCDA
549
"no membrane separating the twins"
what amnionicity and chorionicity is this twin pregnancy ?
MCMA
550
at which appts are FBCs done in normal single pregnancy
at booking (<10/40)
and at 28/40
551
at which appts are FBCs done in multiple pregnancy
at booking (<10/40)
at 20/40
and at 28/40
552
why do serial growth scans and doppler USS need to be done in multiple pregnancy
Monitoring for IUGR and TTTS
553
How many scans needed for monochorionic twin pregnancies
Scans every 2 weeks from 16/40 ⇒ delivery
554
in monochorionic twin pregnancies, what are the scans between 16-24/40 used to detect
TTTS
555
in monochorionic twin pregnancies, what are the scans from 24/40 onwards used to detect
IUGR
556
How many scans needed for dichorionic twin pregnancies?
Scans every 4 weeks from 20/40 ⇒ delivery
557
how are monoamniotic twins delivered
elective C section
558
how are diamniotic twins delivered
if presenting (1st baby) is cephalic:
1st baby vaginal delivery
assess 2nd baby's lie
--> stable lie: also vaginal delivery
--> unstable lie: C section
if presenting baby is not cephalic:
both via C section
559
when does birth usually happen in DCDA twins
37/40
560
when does birth usually happen in MCDA twins
36/40
561
when does birth usually happen in MCMA twins
32/40
562
An ultrasound is indicated if lochia persists beyond "x" weeks
6
563
when does puerperal pyrexia occur
first 14 days following delivery
564
what is the most common cause of puerperal pyrexia
endometritis
565
what should be done if endometritis is expected
admit to hospital asap
IV abx: (clindamycin and gentamicin until afebrile for greater than 24 hours)
566
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then ...... should be offered
an immediate ultrasound
567
If a pregnant woman reports reduced fetal movements then "x" should be used to confirm fetal heartbeat as a first step
handheld Doppler
568
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler, what sort of ultrasound should be done immediately
transabdominal
569
which antibiotic can be used as prophylaxis in pre term labour to prevent early onset infection before birth
benzylpenicillin
570
all women should take ... folic acid from ... until ....
all women should take 400mcg of folic acid from start until the 12th week of pregnancy
571
women at higher risk of conceiving a child with a NTD should take ... of folic acid from .... until .....
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
572
AFP is raised in .. (3)
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
573
AFP is low in ... (3)
Down syndrome
trisomy 18
maternal DM
574
causes of increased nuchal translucency on USS ... (3)
Down's syndrome
congenital heart defects
abdominal wall defects
575
Causes of hyperechogenic bowel on USS ... (3)
cystic fibrosis
Down's syndrome
cytomegalovirus infection
576
symphisis fundal height should match the gestational age in weeks to within .... cm after ... weeks
within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
577
what is loch and how long after childbirth can it last
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
578
when in pregnancy do hCG levels peak
8-10 weeks
579
in first few weeks of pregnancy, how much should hCG be increasing by
levels should double every 48 hrs
580
what tx is needed fro genital gerpoes and how should delivery be managed
oral acyclovir 400mg ads until delivery
delivery via C section
581
what is the most likely cause of jaundice in baby first 24 hrs after birth from a mother of whom this is the 2nd pregnancy
rhesus haemolytic disease of the newborn
582
what position should pt be in umbilical cord prolapse
all 4s
583
management of umbilical cord prolapse
definitive = c section emergency
until theatres are ready: push foetal head/presenting part back into uterus, and get pt n all 4s so gravity helps with this
584
how many sutures come from the anterior fontanelle
4
585
how many sutures come from the posterior fontanelle
3
586
A 26-year-old primigravida woman presents for an ultrasound scan at 34 weeks gestation. It is discovered that her baby is in the breech position.
What is the most appropriate course of action?
offer external cephalic version if the foetus is breech at 36 weeks
587
what is an omphalocele
at type of foetal abdominal wall defect
588
how does false labour present
in last 4 weeks of pregnancy
irregular contractions felt in the lower abdomen every 20 minutes
Progressive cervical changes are absent.
589
"x" is the medication of choice in suppressing lactation when breastfeeding cessation is indicated
Cabergoline
590
what new sign during a cardiac examination on a pre ant woman prompts urgent referral
pulmonary oedema
(third heart sound / peripheral oedema / ejection styptic murmur / forceful apex beat are all normal)
591
when is the earliest a pregnant nulliparous woman can be offered ECV
36 weeks
592
when is the earliest a pregnant multiparous woman can be offered ECV
37 weeks
593
why is aspirin C/I in pregnancy
associated with Reyes syndrome in the infant developing later in life
594
Women with uncomplicated, multiple pregnancies should avoid travel by air once at "x" weeks
32
595
Women with uncomplicated, single pregnancies should avoid travel by air once at "x" weeks
37
596
initial management of puerperal mastitis
continue breastfeeding / expressing milk
warm compress
only antibiotics (oral flucloxacillin if signs of infectious mastitis - worsening sx, nipple fissure, positive bacterial culture)
597
what type of medication is cabergoline
dopamine receptor agonist
598
what precautions should be taken by pregnant women when using air travel (esp long haul flights ie > 4 hrs)
wear compression stockings
do in-seat exercises every 30 minutes
599
if a pregnant woman has other risk factors for DVT what should she have before using air travel
heparin injection
600
infective mastitis tx
flucloxacillin and continue breastfeeding
601
what is the most common causative organism of infective mastitis
staph aureus
602
If fetal movements have not yet been felt by "x" weeks, referral should be made to a maternal fetal medicine unit
24
603
If a breastfed baby loses > 10% of birth weight in the first week of life then what referral should be made
referral to a midwife-led breast feeding clinic
604
what is the preferred method of smoking cessation in pregnant women
NRT
605
Category 1 caesarean sections should occur within "x" minutes of making the decision
30
606
which medication is a cause of folic acid deficiency
phenytoin
607
what is pethidine
strong opioid painkiller
608
when in pregnancy is anti D prophylaxis given to rhesus negative women
28 and 34 weeks
608
what medication can be prescribed during umbilical cord prolapse whilst waiting for C section
terbutaline - Tocolytics may be useful in umbilical cord prolapse to reduce uterine contractions
609
what position should a woman with cord prolapse be in, whilst waiting for C section
should be on all 4s (on knees and elbows)
610
when in antenatal care pathway is the first screen for anaemia and atypical red cell alloantibodies
8-12 weeks
611
at which week is the appointment where ECV can be offered
36 weeks
612
what is a galactocele
a benign milk-filled cyst that typically occurs during lactation or shortly after cessation of breastfeeding
613
what is the most risky form of breech
footling prolapse --> higher risk of cord prolapse
614
8 - 12 weeks (ideally < 10 weeks)
purpose?
Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
615
10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy
616
11 - 13+6 weeks
Down's syndrome screening including nuchal scan
617
16 weeks
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
618
18 - 20+6 weeks
Anomaly scan
619
28 weeks
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
620
34 weeks
Routine care: BP, urine dipstick, SFH
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
621
36 weeks
Routine care: BP, urine dipstick, SFH
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, 'baby-blues'
622
38 weeks
Routine care: BP, urine dipstick, SFH
623
41 weeks
Routine care: BP, urine dipstick, SFH
Discuss labour plans and possibility of induction
624
what are the 2 extra antenatal appts for primip women
25 weeks (only if primip)
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
40 weeks (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
625
at which antenatal appts is anti D prophylaxis given
28 weeks
34 weeks
626
supplementation of which vitamin could be teratogenic
vit A
627
which pregnant women should take vitamin D
all pregnant women
628
how much vit D per day should pregnant women take
10 mcg
629
what is used for smoking cessation in pregnancy
NRT
630
which 2 smoking cessation drugs are C/I in pregnancy
varenicline
bupropion
631
pregnant women should avoid unpasteurised mill and ripened soft cheese (camembert/brie/blue) to prevent ... infection
listeriosis
632
women > x weeks with singleton pregnancy and no additional risk factors should avoid air travel
37
633
women with uncomplicated, multiple pregnancies should avoid travel by air once > x weeks
32
634
1st line meds for N&V in pregnancy
antihistamines - promethazine
634
what 2 conservative options can be used for N&V in pregnancy
natural remedies containing ginger
acupuncture on the p6 point (by the wrist)
635
in eclampsia an MgSO4 IV bolus of ...g over....minutes should be given followed by an infusion of ...g / hour
in eclampsia an MgSO4 IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
636
how should a blocked duct (milk bleb) when breastfeeding be managed
Breastfeeding should continue.
Advice should be sought regarding the positioning of the baby.
Breast massage may also be tried
637
what tx can be given to mother and to baby in. nipple candidacies in a breastfeeding mother
miconazole cream for the mother
nystatin suspension for the baby
638
tx for mastitis that doesn't have signs of infection
continue expressing milk / breastfeeding
warm compresses
639
what are the signs of mastitis being infective
systemically unwell
nipple fissure present
symptoms do not improve after 12-24 hours of effective milk removal
culture indicates infection
640
tx for infective mastitis
oral flucloxacillin for 10-14 days
continue breastfeeding / expressing milk throughout
641
pain in both breasts
in first few days after birth
worse just before a feed
breast may appear red
diagnosis ?
engorgement
642
engorgement management
hand expression of milk
frequent feeding
643
intermittent pain in nipple, during and after feeding
Blanching of the nipple may be followed by cyanosis and/or erythema
diagnosis
raynauds of nipple
644
management of raynauds of nipple
heat packs following a breastfeed
avoid caffeine
stop smoking
oral nifedipine
645
which condition in the infant contraindicates breastfeeding
galactosaemia
646
which medication can be used to stop breastfeeding
cabergoline
647
cystic lesion in breast after recently stopping breastfeeding
painless
no signs of infection
diagnosis?
galactocele
648
which abx are allowed in breastfeeding
penicillins, cephalosporins, trimethoprim
649
which abx are C/I in breastfeeding
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
650
which psychiatric drugs are C/I in rfegnancy
lithium
benzodiazepine
clozapine
651
RF for umbilical cord prolapse
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
652
2 possible situations which allow diagnosis of umbilical cord prolapse
fetal heart rate becomes abnormal and the cord is palpable vaginally,
or if the cord is visible beyond the level of the introitus.
653
what 2 positions can the mother be placed in in umbilical cord prolapse
on all 4s (most preferable)
or
left lateral position
654
what can be prescribed in umbilical cord prolapse to reduce uterine contractions
tocolytics
655
other than medication, or positioning can be done in umbilical cord prolapse to help elevate the presenting part until delivery via c section
retrofilling the bladder with 500-700ml of saline
656
3 types of Breech
Frank breech (most common)
→ hips flexed and knees extended so legs reach shoulders
Complete breech
→ both hips and knees flexed
Footling breech (most risky)
→ feet born first inside of pelvis
657
which type of breech is most common
frank
658
which type of breech is most risky
footling
659
biggest risk factor for cord prolapse
ARM
660
RF for malpresentation eg breech or unstable/transverse lie
foetal factors that limit foetal movement
- oligo/polyhydramnios
- prematurity
- foetal abnormality
maternal factors that limit foetal movement
- fibroids
- previous uterine surgery
- placenta praevia
661
clinical features of breech baby
Palpable, hard and ballotable head at fundus
Soft breech (baby bottom) at pelvis
662
when is ECV offered for breech babies in nulliparous vs multiparous women
Nulliparous → 36/40
Multiparous → 37/40
663
C/I of ECV
antepartum haemorrhage in last 7 days
abnormal CTG
ruptured membranes
multiple pregnancy
major uterine abnormality
other reason for caesarean section
664
what medication is given to a woman undergoing ECG (2)
Anti-D if woman is Rh-
Tocolytic agent with beta-mimetic effect (e.g. beta-2 receptor agonists like terbutaline/ritodrine/salbutamol) to improve success rate as they relax uterine muscles
665
what is done for breech baby if ECH fails
C section
666
what is the most safe option for delivery of the baby if it is breech
C section
more risk to mother, less risk to baby
667
What kind of breech is an absolute contraindication to vaginal breech delivery?
footling breech
668
3 types of lie
longitudinal lie (99.7% of foetuses at term)
transverse lie (<0.3% of foetuses at term)
oblique (<0.1% of foetuses at term)
669
which is easier to correct, oblique or transverse
oblique
670
2 types of transverse lie and which is most common
scapulo-anterior (most common)
scapula-posterior
671
after how many weeks gestation is an ECV offered for transverse / unstable lie
36 weeks
672
if ECV fails in transverse/unstable baby what is done
elective C section
673
pain in late pregnancy
pain is over the pubic symphysis and radiates to the groin / medial aspects of thighs
waddling gait
diagnosis
symphysis pubis dysfunction
674
antepartum haemorrhage is after ... weeks
24
675
which substance abuse can cause damage to the umbilical cord
smoking
676
describe foetal alcohol syndrome (4)
learning difficulties
characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
IUGR & postnatal restricted growth
677
what type of drinking pattern is a major risk factor for FAS (foetal alcohol syndrome)
binge drinking
678
what is neonatal abstinence syndrome
Opiate exposure in utero triggers postnatal withdrawal syndrome in baby
Irritability
Hypertonia
Seizures
Feeding difficulties
Respiratory distress
Tremors
Loose stools
679
which substance abuse can cause neonatal abstinence syndrome
cocaine
heroin
680
In which condition do you see platelet count that falls as pregnancy progresses
gestational thrombocytopenia
681
is gestational thrombocytopenia dangerous to the neonate
no
682
why can gestational thrombocytopenia occur
dilution, deceased production and increased destruction of platelets (due to increased work of maternal spleen --> mild sequestration)
683
what is quickening and when does it happen
first onset of recognised foetal movements
18-20 wks
684
how do foetal movement frequency change in pregnancy
increases from quickening (18-20 wks) until plates at 32 wks
685
what is RCOG advice for further investigation for reduced foetal movements
investigate further if > 28 weeks and <10 movements over 2 hrs
686
by which weeks should you have established foetal movements
24
687
how can posture affect foetal movements
There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
688
how can placental position affect foetal movements
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
689
how can foetal position affect foetal movements
Anterior fetal position means movements are less noticeable
690
how can maternal body habitus affect foetal movements
Obese patients are less likely to feel prominent fetal movements
691
how to investigate reduced foetal movements > 28 wks
do a hand held doppler
if foetal heart beat detectable:
CTG monitoring (monitor HR)
if still concerned can do USS (check amniotic fluid volume, circumference, foetal weight)
if foetal heart beat undetectable:
urgent USS (check amniotic fluid volume, circumference, foetal weight)
692
how to investigate reduced foetal movements 24 - 28 wks
hand held doppler
693
how to investigate reduced foetal movements < 24 weeks if foetal movements have been previously felt
hand held doppler
694
how to investigate reduced foetal movements < 24 weeks if foetal movements have not been previously felt
refer to foetal maternal medicine unit
(should feel foetal movement by 24 wks )
695
what to do if reduced foetal movement are recurrent, and what could it suggest
refer to foetal maternal medicine unit
structural or genetic fetal abnormalities
696
are pregnant women offered a whooping cough / pertussis vaccine
yes
697
Dania Khunda year 5
flashcards
Decks in class (19)
# Cards
-
Gynaecology676
-
extra from passmed39
-
Obstetrics699
-
Contraception109
-
Paeds endo62
-
Paeds MSK41
-
Paeds Neuro125
-
Psychiatry10
-
Paeds renal/urology65
-
Paeds respiratory142
-
Paeds gastro89
-
Paeds cardio63
-
Paeds infections95
-
Paeds haem43
-
Paeds derm54
-
Paeds malignancy25
-
paeds extra97
-
Psychiatry248
-
microbiology (path)2
