Obstetrics

Question 1

What is the management of Preterm pre-labour Rupture of Membranes (PPRM)?

Answer 1

Admission
Regular Observations
Antenatal corticosteroids Dex to avoid risk of Respiratory Distress Syndrome
delivery should be considered at 34 weeks of gestation
10 days erythromycin should be given to all women with PPROM
consider IV magnesium sulphate for fetal neuroprotection if < 30 weeks and birth is imminent

Question 2

What steroids to be given in case of PPRM?

Answer 2

Dexamethosone

if pooling of fluid is not observed, NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1)

Question 3

What are the reasons to start continuous CTG in labour;

Answer 3

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 - this was a new point added to the guidelines in 2014

Question 4

What is featal tachy and brady in CTG;

Answer 4

Tachy; >160

Brady <100

Question 5

What are the issues with CTPA and V/Q scanning in pregnancy?

Answer 5

CTPA- increase in maternal breast cancer (tissue particularly sensitive during pregnancy)

V/Q; increase in childhood cancer

Question 6

Can you thrombolyse a pregnant woman with PE?

Answer 6

Thrombolysis is contraindicated in pregnancy as it can cause catastrophic haemorrhage of the placenta and the foetus.

Question 7

What are the investigations for a suspected DVT or PE in pregnancy;

Answer 7

Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
PE–> ECG and chest x-ray should be performed in all patients, can also have USS and if needed started on LMWH

Question 8

Pregnancy with raised bile acids, pruritus but no rash

Answer 8

intrahepatic cholestasis of pregnancy

Question 9

When to induce in Intrahepatic cholestasis?

Answer 9

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation

Question 10

Pregnancy with sudden increase in size of abdomen and breathlessness

Answer 10

Twin to twin transfusion syndrome

TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition. After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.

Question 11

What drugs to avoid in breastfeeding

Answer 11

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone

Question 12

What is the most common organism for infection <48hrs after birth, in babies ?

Answer 12

Group B Streptococcus (GBS)

Question 13

What is the most common organism for infection <48hrs after birth, in babies ?

Answer 13

late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.

Question 14

How to manage during delivery a patient that during their pregnancy was treated for GBS?

Answer 14

GBS bacteriuria should therefore be offered intrapartum antibiotics in addition to appropriate treatment at the time of diagnosis

Question 15

What antibiotics for GBS prohypaxis

Answer 15

BenPen

Question 16

What are the risk factors and type for placena accreta

Answer 16

Risk factors

previous caesarean section
placenta praevia

Strictly speaking, there are 3 different types of placenta accreta, depending on the degree of invasion although this is quite small print:

accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium

Question 17

malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.

Answer 17

HELLP syndrome

is a severe form of pre-eclampsia whose features include:

Haemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP)

Question 18

What are the cut-off vallues for anaemia in pregnancies

Answer 18

first trimester Hb less than 110 g/l
second/third trimester Hb less than 105 g/l
postpartum Hb less than 100 g/l

Question 19

When should women be screened for aneamia

Answer 19

the booking visit (often done at 8-10 weeks), and at
28 weeks

Question 20

What is the Management of iron anaemia in pregnancy and duration of treatment

Answer 20

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

Question 21

Name anti-epileptics and potential issues in pregnancies;

Answer 21

sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

Question 22

What is the management of diabetes based on the different cut-offs?

Answer 22

if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Question 23

What type of insulin for gestetional diabetes

Answer 23

Gestational diabetes is treated with short-acting, but not longer-acting SC insulin

Question 24

What is the management for women who have a bg of diabetes;

Answer 24

weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy

Question 25

When should women be tested for diabetes and what test? the oral glucose tolerance test (OGTT) is the test of choice women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs women with any of the other risk factors should be offered an OGTT at 24-28 weeks Pregnant women who have a first degree relative with diabetes should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks

Answer 25

the oral glucose tolerance test (OGTT) is the test of choice women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs women with any of the other risk factors should be offered an OGTT at 24-28 weeks Pregnant women who have a first degree relative with diabetes should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks

Question 26

How can a diagnosis of Gestational diabetes be made;

Answer 26

fasting glucose is >= 5.6 mmol/L, or 2-hour glucose level of >= 7.8 mmol/L '5678

Question 27

Is metformin safe in pregnancy?

Answer 27

yes

Question 28

What is the definition of Post Partum Haemorrhage and main causs

Answer 28

Postpartum haemorrhage is defined as blood loss of 500 ml after a vaginal delivery The causes of PPH are said to be the 4 Ts: Tone (uterine atony): the vast majority of cases- by far most common Trauma (e.g. perineal tear) Tissue (retained placenta) Thrombin (e.g. clotting/bleeding disorder)

Question 29

What is the management of post partum haemorrhage

Answer 29

ABC approach two peripheral cannulae, 14 gauge lie the woman flat bloods including group and save commence warmed crystalloid infusion mechanical palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’) catheterisation to prevent bladder distension and monitor urine output medical IV oxytocin: slow IV injection followed by an IV infusion ergometrine slow IV or IM (unless there is a history of hypertension) carboprost IM (unless there is a history of asthma) misoprostol sublingual there is also interest in the role tranexamic acid may play in PPH surgical: if medical options fail to control the bleeding then surgical options will need to be urgently considered the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Question 30

What is the Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)

Answer 30

if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Question 31

When should antivirals be given in pregnancy when contact

Answer 31

antivirals should be given at day 7 to day 14 after exposure, not immediately

Question 32

How to diagnose rubella in pregnancy?

Answer 32

IgM antibodies are raised in women that have been recently exposed to the virus Always check for parvovirus B19 serology as there is 30% risk of transplacental infection

Question 33

How to manage Rubella in pregnancy?

Answer 33

Discuss with the local health protection unit Do not offer vaccine in women who are pregnant or trying to get pregnant.

Question 34

MMR vaccine and pregnancy

Answer 34

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)

Question 35

How to calculate Syphysis- fundal height and how to calculate normal values?

Answer 35

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Question 36

What is the definition of HTN in pregnancy?

Answer 36

Hypertension in pregnancy in usually defined as: systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Question 37

What should women who are at high risk of developing pre-eclampsia be given?

Answer 37

Aspirin 75mg od from 12 weeks until the birth of the baby How to defferentialte pregnancy induced HTN from pre-eclampsia ? Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)- No proteinuria, no oedema Pre-eclampsia: Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)

Question 38

What is the management of Pre-eclampsia

Answer 38

oral labetalol is now first-line following the 2010 NICE guidelines oral nifedipine (e.g. if asthmatic) and hydralazine

Question 39

How to supress lactation?

Answer 39

Cabergoline is a dopamine receptor agonist which inhibits prolactin production causing suppression of lactation.

Question 40

What are high risk factors for pre-eclampsia

Answer 40

High; hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension Moderate; first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth ≥ 1 high risk factors ≥ 2 moderate factors

Question 41

What are the RCOG absolute contraindications to ECV:

Answer 41

where caesarean delivery is required antepartum haemorrhage within the last 7 days abnormal cardiotocography major uterine anomaly ruptured membranes multiple pregnancy

Question 42

When to perform ECV:

Answer 42

if still at breech presentation at 36 then NICE recommends ECV (60% success rate)- 36 for nulliparous women and 37 weeks for multiparous women

Question 43

Pt presents with -bleeding in first or early second trimester -exaggerated symptoms of pregnancy e.g. hyperemesis (due to high hCG) -uterus large for dates -very high serum levels of human chorionic gonadotropin (hCG) hypertension and hyperthyroidism* may be seen

Answer 43

Complete hydatidiform mole

Question 44

What is the management of shoulder dystocia:

Answer 44

Senior help should be called as soon as shoulder dystocia is identified and McRoberts' manoeuvre should be performed: this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery. Wood's screw manoeuvre describes the action of putting a hand in the vagina and rotating the foetus 180 degrees in attempt to 'dislodge' the anterior shoulder from the symphysis pubis.

Question 45

What are the possible complications of shoulder dystocia

Answer 45

maternal postpartum haemorrhage perineal tears fetal brachial plexus injury- Erbs palsy- 'waiter's tip', adduction and internal rotation of the arm with pronation of the forearm neonatal death

Question 46

adduction and internal rotation of the right arm after delivery?

Answer 46

Erbs palsy

Question 47

When to take folic acid in pregnancy?

Answer 47

Prevention of neural tube defects (NTD) during pregnancy: all women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

Question 48

When are women considered high risk of pregnancy and thus needing more folic acid ?

Answer 48

women are considered higher risk if any of the following apply: either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more). M- Metabolic disease (diabetes and coeliac) O- Obesity R- Relative or personal Hx of NTD E- Epilepsy (taking anti-epileptics)

Question 49

What daily supplements does the NHS currently advise all women take during pregnancy ?

Answer 49

folic acid 400mcg when trying to conceive through to 12 weeks gestation to reduce the incidence of neural tube defects. A daily supplement of vitamin D 10mcg is also advised throughout pregnancy for bone health, and should be continued for the duration of breastfeeding.

Question 50

Epilepsy and conceiving:

Answer 50

She should be referred to specialist care but as per the National Institute of Health and Care Excellence (NICE) guidance, she should continue to use effective contraception until she has a full assessment by the specialist. he blood films suggests that the cause of the macrocytosis is a megaloblastic anaemia which can occur due to folate or B12 deficiency Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess

Question 51

What is the management of eclampsia?

Answer 51

in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression treatment should continue for 24 hours after last seizure or delivery

Question 52

What to monitor when giving Magnesium sulphate?

Answer 52

reflexes + respiratory rate, urine output

Question 53

how to manage magnesium sulphate induced respiratory depression?

Answer 53

calcium gluconate is the first-line treatment for

Question 54

When is the booking visit?

Answer 54

8 - 12 weeks (ideally < 10 weeks)

Question 55

When is the early scan to confirm dates and multuple pregnancies?

Answer 55

10 - 13+6 weeks

Question 56

When is the down syndrome screening with nuchal scan

Answer 56

11 - 13+6 weeks

Question 57

When is the anomaly scan?

Answer 57

18 - 20+6 weeks

Question 58

What are the causes of oligohydraminos What amount is considered low

Answer 58

anything bellow 500ml Causes premature rupture of membranes Potter sequence bilateral renal agenesis + pulmonary hypoplasia intrauterine growth restriction post-term gestation pre-eclampsia

Question 59

What anti-depressants for post natal issues in breastfeeding women?

Answer 59

Sertaline or Paroxitine is the drug of choice in breastfeeding women.

Question 60

What is the onset of Baby Blues, Post natal depression and Puerperal Psychosis ?

Answer 60

Baby-blues: typically seen within 3-7 days (anxious, tearful and irritable) Post-natal depression: starts within a month and peaks at 3 months Puerperal Psychosis: onset is within the first 2-3 weeks following birth (admission in mommy and baby unit)

Question 61

When to administer anti-D

Answer 61

NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks

Question 62

When should Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) ?

Answer 62

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) ECV antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling abdominal trauma

Question 63

What are risks factors for placenta previa;

Answer 63

multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section

Question 64

How to diagnose placenta previa ?

Answer 64

digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage placenta praevia is often picked up on the routine 20 week abdominal ultrasound the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Question 65

What are the cut-offs for Bishop score?

Answer 65

a score of < 5 indicates that labour is unlikely to start without induction a score of > 8 indicates that the cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour NICE guidelines if the Bishop score is < 6 vaginal prostaglandins or oral misoprostol mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean if the Bishop score is > 6 amniotomy and an intravenous oxytocin infusion

Question 66

What are the possible methods to help with induction of labour;

Answer 66

membrane sweep involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping vaginal prostaglandin E2 (PGE2) also known as dinoprostone oral prostaglandin E1 also known as misoprostol maternal oxytocin infusion amniotomy ('breaking of waters') cervical ripening balloon passed through the endocervical canal and gently inflated to dilate the cervix

Question 67

What is the Management of Pre-eclampsia, when to admit?

Answer 67

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected women with blood pressure a BP of 160/110 mmHg are likely to be admitted and observed

Question 68

What is the management of Intrahepatic cholestasis

Answer 68

Induction of labour at 37-38 weeks is common practice but may not be evidence based, due to increase in still birth ursodeoxycholic acid - again widely used but evidence base not clear vitamin K supplementation

Question 69

Can you have sulfasalazine and hydroxychloroquine for RA in pregnancy ?

Answer 69

YES

Question 70

What is used for RA during pregnancy?

Answer 70

low-dose corticosteroids

Question 71

Can NSAID's be used in RA and preganncy?

Answer 71

NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus

Question 72

Methotrexate and pregnancy?

Answer 72

women: not safe in pregnancy and needs to be stopped at least 6 months before conception

Question 73

deafness, congenital cataracts and cardiac complications

Answer 73

Rubbela

Question 74

rudimentary digits, limb hypoplasia and microcephaly

Answer 74

Varicella Zoster

Question 75

When to refer if person is not feeling the baby kick

Answer 75

If fetal movements have not yet been felt by** 24 weeks**, referral should be made to a maternal fetal medicine unit

Question 76

What are the different degrees of a perineal tear? -

Answer 76

- 1st degree = tear within vaginal mucosa only - 2nd degree = tear into subcutaneous tissue - 3rd degree = laceration extends into external anal sphincter - 4th degree = laceration extends through external anal sphincter into rectal mucosa

Question 77

What are the risk factors for placental abruption

Answer 77

proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age

Question 78

how to manage pregnant women ≥ 20 weeks who develop chickenpox if they present within 24 hours of the rash

Answer 78

are generally treated with oral aciclovir

Question 79

First dose of anti-D prophylaxis to rhesus negative women

Answer 79

28 weeks

Question 80

How to manage an infected nipple

Answer 80

an infected nipple fissure, symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive. If antibiotics are indicated, first line would be flucloxacillin for 10-14 days or erythromycin or clarithromycin if penicillin allergic.

Question 81

how to treat nipple candidiasis

Answer 81

treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby

Question 82

how to manage Raynaud's disease ?

Answer 82

advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Question 83

What is the most common cause ofumbilical cord prolapse?

Answer 83

artificial rupture of membranes others; prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie

Question 84

how to manage cord prolapse

Answer 84

obstetric emergency the presenting part of the fetus may be p**ushed back into the uterus **to avoid compression if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm the patient is asked to go on **'all fours'** until preparations for an immediate caesarian section have been carried out the left lateral position is an alternative **tocolytics** may be used to **reduce uterine contractions**

Question 85

role of bladder in cord prolapse

Answer 85

retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part