PACES obstetrics

Question 1

P-PROM RFs

Answer 1

smokers
STI
previous P-ROM
mutliple pregnancy

Question 2

PACES P-PROM counselling…explain

Answer 2

• need for admission
• risks (infection when can cause damage to the baby)
• risks of prematurity (ideally like to keep baby inside for as long as possible but this has to be balanced with infection risk)
• importance of close monitoring (CTG, maternal infections)
• role of antenatal steroids
• likelihood of delivery

Question 3

Breech RFs

Answer 3

uterine malformation
fibroids
placenta praevia
poly/oligohydramnios
foetal anomaly (chromosomal disorders)
prematurity

Question 4

Breech counselling

Answer 4

• explain what breech means
• offer ECV and explain risks (50% success rate, placental abruption, foetal distress, requiring emergency CS)
• explain benefits of vaginal (if successful, fewest complications, 40% risk of needing emergency CS)
• explain benefits of CS (small reduction in perinatal mortality, implications on future pregnancy = praevia, VBAC, uterine rupture)

Question 5

VBAC PACES couselling

Answer 5

• options: ERCS or VBAC
• VBAC (uterine rupture risk of 1/200, 75% success rate, others need emergency CS)
• ERCS (implications on future pregnancies, uterine rupture/abruption)

Question 6

HIV counselling

Answer 6

• need to be seen at a joint HIV physician and obstetric clinic every 1-2 weeks
• need to monitor viral load every 2-4 weeks, 36 weeks and delivery
• stress important of good compliance with ART
• discuss options for delivery (depending on viral load at 36 weeks)
• advise not to breastfeed
• neonatal treatment with ART for 2-4 weeks and testing for HIV transmission

Question 7

Pre-eclampsia RFs

Answer 7

• previous HTN disease in pregnancy
• mutliple pregnancy
• DM
• kidney disease
• 1st pregnancy
• obseity
• > 35y or <20y
• FH
• PCOS
• IVF

Question 8

Counselling of Pre-eclampsia

Answer 8

• admission is needed (at leas until BP controlled)
• explain early delivery and risks (early delivery, reduced placental function, IUGR, risks to mother)
• treatment = labetalol
• BP monitored closely with regular blood tests (2/ week) and foetal surveillance (every 2 weeks)
• early delivery before 37 weeks may be needed
• 15% risk of recurrence

Question 9

GDM RFs

Answer 9

• age
• FH
• obesity
• multiple pregnancy
• Asian background

Question 10

GDM counselling

Answer 10

• diabetes that occurs in pregnancy because body isn’t able to produce enough insulin to meet demands of carrying a baby
• Maternal risks: HTN disease, traumatic delivery, stillbirth
• Foetal risk: macroscomia, neotnatal hypoglycaemia, congenital abnormalities
• treatment options: CDE, metformin, insulin
• importance of good glycaemia control
• explain to monitor blood glucose using glucometer
• need to be seen at joint diabetes and antenatal clinic within 1 week and every 2 weeks thereafter
• US growth scans every 4 weeks from 28-36 weeks
• medication stopped at delivery but followed by GP

Question 11

OC RFs

Answer 11

• personal/family Hx of OC
• history of liver disease
• multiple pregnancy

Question 12

OC counselling

Answer 12

• explain diagnosis and risks (still birth and premature birth)
• need for early delivery (37 weeks)
• regular monitoring and weekly LFTs
• pay close attention to foetal movements
• symptomatic treatment with ursodeoxycholic acid, emollients, Vit K
• high recurrence rate (up to 90%)

Question 13

Placenta Praevia RFs

Answer 13

previous placenta praevia
multiple pregnancy
previous CS
smoking and drug use
advanced maternal age

Question 14

counselling if placenta praevia presenting with asymptomatic low-lying/placenta

Answer 14

• importance of the finding (increases risk of bleeding)
• 90% of placentas will move away from os
• rescan at 32 weeks and go from there
• advise to avoid having sex

Question 15

counselling if placenta praevia presenting with symptomatic placeta praevia (with bleeding)

Answer 15

• admit until bleeding has stopped and for further 48 hours
• importance of findings and foetus needs to be monitored
• prompt delivery needs to be discussed (based on gestation)
• risks of delivery: major blood loss, may require blood transfusion, may require hysterectomy
• Anti-D

Question 16

important to ask about previous pregnancies

Answer 16

how born and WHY

Question 17

what to do if the situation is an emergency

Answer 17

ABCDE

alert seniors

Question 18

Hyperemesis Gravidarum counselling

Answer 18

• unlikely to harm the baby but if you lose a lot of weight, baby can be smaller than expected
• condition usually resolves after 14 weeks, hopefully treatment we will give you can help reduce symptoms

Question 19

when to do CTG

Answer 19

if come with problems and in third trimester

Question 20

Tests in PROM

Answer 20

• IGF binding protein 1
• placental alpha-microglobulin 1 test
• TVUSS can be used to assess cervical length and determine likelihood of birth in 48 hours

Question 21

what to monitor in eclampsia?

Answer 21

urine output
reflexes
RR
Oxygen sat
LFTs and plt

Question 22

pathophysiology of GD

Answer 22

• placenta produces substaicnes that have anti-oestrogen effect
  = increased insulin resistance = hyperglycaemia
• maternal glucose crosses placenta = foetal hyperglycaemia
• foetal pancreas starts producing high levels of insulin = foetal hypoglycaemia

Question 23

target levels for glucose in GDM

Answer 23

fasting < 5.3

2 hour post meal < 6.4

Question 24

chance of successful VBAC after 1 previous CS

Answer 24

70%

Question 25

what is the multiple pregnancy support group>

Answer 25

TAMBA (twin and multiple birth association)

Question 26

MCDA sign and when split

Answer 26

T-sign | conceptus split 4-8 days

Question 27

OC features of history and care

Answer 27

jaundice ask about urine and poo consultant led care F/U after delivery to ensure LFTs returned to normal

Question 28

physiological skin changes

Answer 28

linea nigra striae gravidarum striae albicans

Question 29

SGA PACES counselling

Answer 29

- may be a sign your placenta is getting a little bit tired and not being able to feed the baby as well as it did before - we would like to keep an eye on growth of baby by scanning your regularly now - serial growth scans, CTG and doppler US every 2 weeks - ask mum to pay attention to foetal movements

Question 30

important question to ask in ROM

Answer 30

fever

Question 31

if discharging with ROM, what safety net?

Answer 31

call midwife if: - raised temp - any fluid discharge/bleeding from vagina - reduction in foetal movements

Question 32

Couselling features in PPROM

Answer 32

balancing risks of prematurity with risks of infection early delivery likely to be necessary come in x2/ week for CTG and obs consider delivery at 34 weeks

Question 33

questions to ask in pre-eclampsia

Answer 33

- headaches - epigastric pain - visual disturbances - oedema (feel more swollen recently) - N/V - previous BP before and during pregnancy - previous urine dipstick results

Question 34

investigations to do in pre-eclampsia

Answer 34

- full CV and abdo exam - examine legs and reflexes - feel for liquor volume, SFH - FBC, U&Es, uric acid, LFTs, Albumin, clotting screen - USS

Question 35

antenatal management plan for patient with pre-eclampsia

Answer 35

- keep inpt - BP every 4 hours - urinalysis daily - 3x week FBC, U&Es, LFTs - FUSS and CTG regularly - Labetaolol

Question 36

intrapartum management of pre-eclampsia

Answer 36

IV labetaolol | continous fetal monitoring on CTG

Question 37

postnatal management

Answer 37

discharged to primary care if no symptoms of pre-eclampsia BP 149/99 or lower blood tests stable and improving individual care plan, GP to check BP in community

Question 38

how to manage woman at risk of pre-eclampsia?

Answer 38

- healthy lifestyle - refer for consultant led care at booking - aspirin 75mg daily from 12 weeks - urine and BP at every visit - safety net to seek urgent help if signs of pre-eclampsia

Question 39

explaining pre-eclampsia to a patient

Answer 39

Pre-eclampsia is a complication of pregnancy that causes you to have high blood pressure and protein in your urine. It can make you unwell and can affect your baby’s growth and wellbeing.

Question 40

prolonged first stage of labour management

Answer 40

* As membranes are not ruptured, offer ARM * Consider augmentation with oxytocin * Ongoing obstetric review every 15-30 mins * Consider instrumental delivery (if criteria for instrumental delivery are met) * Diligent observation of the CTG trace in case emergency C-section is ne

Question 41

causes of prolonged labour

Answer 41

Malposition Epidural analgesia Obstructed labour (e.g. CPD)

Question 42

propess vs prostin

Answer 42

Propess (24 hours) | Prostin (can be given 6 hourly)