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AKT O&G 2 Flashcards

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1
Q

What is antepartum haemorrhage?

A

Bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Antepartum haemorrhage can indicate various complications during pregnancy.

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2
Q

What are the characteristics of placental abruption?

A
  • Shock out of keeping with visible loss
  • Constant pain
  • Tender, tense uterus
  • Normal lie and presentation
  • Fetal heart: absent/distressed
  • Coagulation problems
  • Beware pre-eclampsia, DIC, anuria

Placental abruption is a serious condition that requires immediate medical attention.

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3
Q

What are the characteristics of placenta praevia?

A
  • Shock in proportion to visible loss
  • No pain
  • Uterus not tender
  • Lie and presentation may be abnormal
  • Fetal heart usually normal
  • Coagulation problems rare
  • Small bleeds before large

Placenta praevia typically poses different risks compared to placental abruption.

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4
Q

True or False: In cases of suspected antepartum haemorrhage, a vaginal examination should be performed in primary care.

A

False

Vaginal examinations can exacerbate bleeding in women with placenta praevia.

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5
Q

Fill in the blank: In placental abruption, the fetal heart may be _______.

A

absent/distressed

This indicates potential fetal distress which may require urgent intervention.

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6
Q

Fill in the blank: In placenta praevia, the uterus is usually _______.

A

not tender

A tender uterus may indicate placental abruption rather than praevia.

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7
Q

What complications should be considered with placental abruption?

A
  • Pre-eclampsia
  • Disseminated intravascular coagulation (DIC)
  • Anuria

These conditions can complicate the clinical picture and management of placental abruption.

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8
Q

What does the shock level indicate in placental praevia?

A

Shock is in proportion to visible loss

This is an important distinguishing feature from placental abruption.

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9
Q

What is a common pattern of bleeding in placenta praevia?

A

Small bleeds before large

This pattern can help in identifying placenta praevia during assessments.

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10
Q

What is antepartum haemorrhage?

A

Bleeding after 24 weeks of pregnancy

Antepartum haemorrhage can indicate serious complications and requires prompt evaluation.

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11
Q

List three causes of bleeding in the 1st trimester of pregnancy.

A
  • Spontaneous abortion
  • Ectopic pregnancy
  • Hydatidiform mole

Each of these conditions presents with different clinical features.

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12
Q

List three causes of bleeding in the 2nd trimester of pregnancy.

A
  • Spontaneous abortion
  • Hydatidiform mole
  • Placental abruption

These conditions can have significant implications for maternal and fetal health.

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13
Q

List four causes of bleeding in the 3rd trimester of pregnancy.

A
  • Bloody show
  • Placental abruption
  • Placenta praevia
  • Vasa praevia

These conditions require immediate medical assessment.

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14
Q

What conditions should be excluded alongside pregnancy-related causes of bleeding?

A
  • Sexually transmitted infections
  • Cervical polyps

These conditions can also cause bleeding and need to be ruled out.

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15
Q

What is a threatened miscarriage?

A

Painless vaginal bleeding typically around 6-9 weeks

It indicates a risk of pregnancy loss but does not always result in miscarriage.

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16
Q

What characterizes a missed (delayed) miscarriage?

A

Light vaginal bleeding and symptoms of pregnancy disappear

This type of miscarriage can go undetected until a routine scan.

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17
Q

What are the features of an inevitable miscarriage?

A

Complete or incomplete depending on whether all fetal and placental tissue has been expelled

It often involves heavier bleeding and cramping.

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18
Q

What are the symptoms of an incomplete miscarriage?

A

Heavy bleeding and crampy, lower abdominal pain

It may require medical intervention to manage bleeding.

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19
Q

What describes a complete miscarriage?

A

Little bleeding

The body has expelled all pregnancy tissue.

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20
Q

What is a common presentation of ectopic pregnancy?

A

History of 6-8 weeks amenorrhoea with unilateral lower abdominal pain and later vaginal bleeding

Shoulder tip pain and cervical excitation may also be present.

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21
Q

What is a hydatidiform mole associated with?

A

Bleeding in first or early second trimester with exaggerated pregnancy symptoms

High serum hCG levels and an enlarged uterus for dates are common.

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22
Q

What are the signs of placental abruption?

A

Constant lower abdominal pain, tender tense uterus, and fetal heart distress

Visible blood loss may not correlate with maternal shock.

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23
Q

What characterizes placenta praevia?

A

Vaginal bleeding without pain and a non-tender uterus

The lie and presentation of the fetus may be abnormal.

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24
Q

What occurs in vasa praevia?

A

Rupture of membranes followed immediately by vaginal bleeding

Fetal bradycardia is classically seen, indicating fetal distress.

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25
What is one bonding advantage of breastfeeding for the mother?
Bonding with the baby
26
What is a physiological benefit of breastfeeding related to the uterus?
Involution of uterus
27
Breastfeeding offers protection against which types of cancer?
Breast and ovarian cancer
28
What is an economic advantage of breastfeeding?
Cheap, no need to sterilise bottles
29
What contraceptive effect does breastfeeding have?
Contraceptive effect (unreliable)
30
Which immunological component in breast milk protects mucosal surfaces?
IgA
31
What is the role of lysozyme in breast milk?
Bacteriolytic enzyme
32
What does lactoferrin do in breast milk?
Ensures rapid absorption of iron so not available to bacteria
33
Breastfeeding reduces the incidence of which types of infections?
Ear, chest, and gastro-intestinal infections
34
What skin condition is less common in breastfed infants?
Eczema
35
Breastfeeding is associated with a reduced incidence of which chronic condition?
Type 1 diabetes mellitus
36
What syndrome has a reduced incidence in breastfed infants?
Sudden infant death syndrome
37
Who is in control of how much milk it takes during breastfeeding?
The baby
38
What is a disadvantage of breastfeeding related to drug transmission?
Transmission of drugs
39
What infection can be transmitted through breastfeeding?
HIV
40
What nutrient inadequacy may result from prolonged breastfeeding?
Vitamin D deficiency
41
What deficiency can occur in breastfed infants related to vitamin K?
Vitamin K deficiency
42
What condition can arise due to breast milk?
Breast milk jaundice
43
What is a common misconception about frequent feeding in a breastfed infant?
Frequent feeding is not alone a sign of low milk supply.
44
What may cause nipple pain in breastfeeding?
A poor latch may cause nipple pain.
45
What is a blocked duct also known as?
'Milk bleb'.
46
What should be done if experiencing a blocked duct?
Breastfeeding should continue and advice on positioning should be sought.
47
What treatment is recommended for nipple candidiasis while breastfeeding?
Miconazole cream for the mother and nystatin suspension for the baby.
48
What percentage of breastfeeding women are affected by mastitis?
Around 1 in 10 breastfeeding women.
49
When should mastitis be treated according to the BNF?
If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal, or if culture indicates infection.
50
What is the first-line antibiotic for treating mastitis?
Flucloxacillin for 10-14 days.
51
What may develop if mastitis is left untreated?
A breast abscess.
52
What is breast engorgement?
A condition causing breast pain in breastfeeding women, usually occurring in the first few days postpartum.
53
What complications can arise from breast engorgement?
Blocked milk ducts, mastitis, difficulties with breastfeeding, and reduced milk supply.
54
How can discomfort from engorgement be relieved?
Hand expression of milk.
55
What characterizes Raynaud's disease of the nipple?
Intermittent pain during and immediately after feeding, blanching of the nipple followed by cyanosis and/or erythema.
56
What lifestyle changes can help manage Raynaud's disease of the nipple?
* Minimizing exposure to cold * Using heat packs after breastfeeding * Avoiding caffeine * Stopping smoking.
57
What should be done if a breastfed baby loses more than 10% of their weight in the first week?
Consider the breastfeeding problems and examine the infant for underlying issues.
58
What does NICE recommend for monitoring poor infant weight gain?
An 'expert' review of feeding and monitoring weight until gain is satisfactory.
59
What is a non-drug contraindication for breastfeeding?
galactosaemia ## Footnote Galactosaemia is a metabolic disorder that affects the body's ability to process galactose.
60
What is a controversial viral infection regarding breastfeeding?
HIV ## Footnote The controversy arises from the high infant mortality and morbidity associated with bottle feeding in the developing world.
61
Name 3 antibiotic classes drugs that can be given to breastfeeding mothers for infections.
antibiotics ## Footnote Examples include penicillins, cephalosporins, and trimethoprim.
62
Which drug class should be avoided in high doses for breastfeeding mothers?
glucocorticoids can be given in breastfeeding but should be avoided in high doses ## Footnote High doses may pose risks to the breastfeeding infant.
63
Identify a drug used for epilepsy that is safe for breastfeeding mothers.
sodium valproate ## Footnote Another option is carbamazepine.
64
What is a safe asthma medication for breastfeeding mothers?
salbutamol ## Footnote Theophyllines are also considered safe.
65
Which psychiatric drug should be avoided in breastfeeding mothers?
clozapine ## Footnote Clozapine poses risks to breastfeeding infants.
66
Name a type of drug used to treat hypertension that is safe for breastfeeding.
beta-blockers ## Footnote Hydralazine is another safe option.
67
What anticoagulant can be given to breastfeeding mothers?
warfarin ## Footnote Heparin is also considered safe.
68
What is one drug that should be avoided while breastfeeding?
ciprofloxacin ## Footnote Other antibiotics to avoid include tetracycline and chloramphenicol.
69
Which psychiatric drug is contraindicated for breastfeeding mothers?
lithium ## Footnote Benzodiazepines should also be avoided.
70
Fill in the blank: _______ should be avoided during breastfeeding due to potential risks.
aspirin ## Footnote Aspirin can have adverse effects on the breastfeeding infant.
71
Identify a cytotoxic drug that should be avoided while breastfeeding.
methotrexate ## Footnote Other drugs to avoid include carbimazole and sulfonylureas.
72
True or False: Amiodarone is safe for breastfeeding mothers.
False ## Footnote Amiodarone should be avoided due to potential risks to the infant.
73
What are risk factors for breech presentation?
Uterine malformations, fibroids, placenta praevia, polyhydramnios or oligohydramnios, fetal abnormality, prematurity ## Footnote Fetal abnormalities may include CNS malformation and chromosomal disorders.
74
What is more common in breech presentations?
Cord prolapse ## Footnote Cord prolapse can complicate labor and delivery in breech presentations.
75
What happens if a fetus is breech at less than 36 weeks?
Many fetuses will turn spontaneously ## Footnote Spontaneous turning is common before 36 weeks of gestation.
76
What is the NICE recommendation for breech presentation at 36 weeks?
External cephalic version (ECV) with a success rate of around 60% ## Footnote ECV is a procedure to turn the fetus from a breech position to a head-down position.
77
When should ECV be offered to nulliparous women according to RCOG?
From 36 weeks ## Footnote Nulliparous women are those who have never given birth before.
78
When should ECV be offered to multiparous women according to RCOG?
From 37 weeks ## Footnote Multiparous women are those who have given birth before.
79
What are the delivery options if the baby is still breech?
Planned caesarean section or vaginal delivery ## Footnote The choice of delivery method can depend on various factors, including maternal and fetal health.
80
What should women be informed about regarding planned caesarean section for breech presentation?
It carries a reduced perinatal mortality and early neonatal morbidity compared to planned vaginal birth ## Footnote This information is crucial for informed decision-making in childbirth.
81
What evidence exists regarding the long-term health of babies with breech presentation delivered at term?
There is no evidence that it is influenced by how the baby is born ## Footnote This suggests that the mode of delivery may not affect long-term outcomes.
82
What are the absolute contraindications to ECV according to RCOG?
* Where caesarean delivery is required * Antepartum haemorrhage within the last 7 days * Abnormal cardiotocography * Major uterine anomaly * Ruptured membranes * Multiple pregnancy ## Footnote These contraindications ensure the safety of the mother and fetus during ECV.
83
What virus causes chickenpox?
Varicella-zoster virus
84
What condition is caused by the reactivation of dormant varicella-zoster virus?
Shingles
85
What is the risk to the mother associated with chickenpox in pregnancy?
5 times greater risk of pneumonitis
86
What is the risk of fetal varicella syndrome (FVS) following maternal varicella exposure before 20 weeks gestation?
Around 1%
87
List some features of fetal varicella syndrome (FVS).
* Skin scarring * Eye defects (microphthalmia) * Limb hypoplasia * Microcephaly * Learning disabilities
88
What is the risk of shingles in infancy if maternal exposure occurs in the second or third trimester?
1-2%
89
What is the risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth?
Around 20% fatality risk to the newborn
90
What should be checked if there is doubt about a mother's previous chickenpox infection?
Maternal blood should be urgently checked for varicella antibodies
91
What is the first choice of post-exposure prophylaxis (PEP) for pregnant women?
Oral aciclovir (or valaciclovir)
92
When should antivirals be given after exposure to chickenpox in pregnancy?
Day 7 to day 14 after exposure
93
What should be done if a pregnant woman develops chickenpox?
Specialist advice should be sought
94
What do consensus guidelines suggest for pregnant women ≥ 20 weeks presenting within 24 hours of rash onset?
Oral aciclovir should be given
95
How should aciclovir be considered for pregnant women < 20 weeks who develop chickenpox?
Considered with caution
96
What is the standard antenatal test for Down's syndrome?
The combined test ## Footnote The combined test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A) and should be done between 11 - 13+6 weeks.
97
What results suggest Down's syndrome in the combined test?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency ## Footnote Similar results can occur for trisomy 18 (Edward syndrome) and 13 (Patau syndrome), but hCG tends to be lower.
98
When should the quadruple test be offered if women book later in pregnancy?
Between 15 - 20 weeks ## Footnote The quadruple test includes alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin, and inhibin A.
99
What are the possible results of the combined or quadruple tests?
Lower chance or higher chance ## Footnote 'Lower chance' is defined as 1 in 150 chance or more (e.g., 1 in 300) and 'higher chance' is 1 in 150 chance or less (e.g., 1 in 100).
100
What is offered to women with 'higher chance' results?
A second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or CVS) ## Footnote NIPT is likely preferred due to its non-invasive nature and high sensitivity and specificity.
101
What does NIPT analyze?
Small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA) ## Footnote This analysis allows for early detection of certain chromosomal abnormalities.
102
What is the sensitivity and specificity of NIPT for trisomy 21?
>99% ## Footnote NIPT also has similarly high sensitivity and specificity for other chromosomal abnormalities.
103
At what gestational age can private companies offer NIPT screening?
From 10 weeks gestation ## Footnote Companies such as Harmony provide this service.
104
Interpreting the results of quadrapule tests
Downs: Only one with raised inhibin A and HCG. AFP and unconjugated oestriol low Edward’s: (everything low), Inhbin A normal Neural tube defects : AFP raised everything else normal
105
106
What is the general consensus regarding the risks of uncontrolled epilepsy during pregnancy versus the risks of medication to the fetus?
The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus.
107
What should epileptic women thinking about becoming pregnant be advised to take to minimize the risk of neural tube defects?
Folic acid 5mg per day.
108
What percentage of newborns born to non-epileptic mothers have congenital defects?
1-2%.
109
What is the percentage of congenital defects in newborns if the mother takes antiepileptic medication?
3-4%.
110
What is the recommended approach regarding antiepileptic medication during pregnancy?
Aim for monotherapy.
111
Is there an indication to monitor antiepileptic drug levels during pregnancy?
No indication.
112
Which antiepileptic drug is associated with neural tube defects?
Sodium valproate.
113
Which older antiepileptic is often considered the least teratogenic?
Carbamazepine.
114
What congenital defect is phenytoin associated with?
Cleft palate.
115
What does current research suggest about lamotrigine and congenital malformations?
The rate of congenital malformations may be low.
116
What may need to be increased during pregnancy for epileptic women taking lamotrigine?
The dose of lamotrigine.
117
Is breastfeeding considered safe for mothers taking antiepileptics?
Generally safe, with exceptions for barbiturates.
118
What supplement is advised for pregnant women taking phenytoin?
Vitamin K in the last month of pregnancy.
119
What significant risk is associated with maternal use of sodium valproate according to the November 2013 Drug Safety Update?
Significant risk of neurodevelopmental delay in children.
120
What conclusion does the Drug Safety Update reach regarding the use of sodium valproate during pregnancy?
Sodium valproate should not be used during pregnancy unless clearly necessary.
121
What should epileptic women of childbearing age not do without specialist neurological or psychiatric advice?
Start treatment with sodium valproate.
122
123
What is folic acid converted to?
tetrahydrofolate (THF) ## Footnote Folic acid is essential for various biochemical processes in the body.
124
What are good dietary sources of folic acid?
green, leafy vegetables ## Footnote These foods are rich in folate and contribute to overall health.
125
What key role does THF play in the body?
transfer of 1-carbon units for DNA & RNA synthesis ## Footnote 1-carbon units include methyl, methylene, and formyl groups.
126
Name a medication that can cause folic acid deficiency.
phenytoin ## Footnote Phenytoin is an anticonvulsant that can interfere with folate metabolism.
127
What is another medication that can lead to folic acid deficiency?
methotrexate ## Footnote Methotrexate is used in cancer treatment and autoimmune diseases.
128
Which lifestyle factor can contribute to folic acid deficiency?
alcohol excess ## Footnote Excessive alcohol consumption can impair the absorption of folate.
129
What are the consequences of folic acid deficiency?
* macrocytic, megaloblastic anaemia * neural tube defects ## Footnote These conditions can have serious health implications, especially in pregnancy.
130
What is the recommended folic acid intake for all women during pregnancy?
400mcg until the 12th week of pregnancy ## Footnote This recommendation aims to reduce the risk of neural tube defects.
131
What is the folic acid dosage for women at higher risk of conceiving a child with a neural tube defect?
5mg from before conception until the 12th week of pregnancy ## Footnote Higher risk factors include previous NTD-affected pregnancies and certain medical conditions.
132
List one factor that classifies a woman as higher risk for NTD.
* either partner has a NTD * previous pregnancy with NTD * family history of NTD * taking antiepileptic drugs * coeliac disease * diabetes * thalassaemia trait * obesity (BMI of 30 kg/m2 or more) ## Footnote Identifying these risk factors is crucial for preventive health strategies.
133
What is the prevalence of gestational diabetes in pregnancies?
Affects around 4% of pregnancies ## Footnote Gestational diabetes is the second most common medical disorder complicating pregnancy after hypertension.
134
List six risk factors for gestational diabetes.
* BMI of > 30 kg/m² * Previous macrosomic baby weighing 4.5 kg or above * Previous gestational diabetes *first-degree relative with diabetes *family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) *unexplained stillbirth in a previous pregnancy
135
What is the test of choice for screening gestational diabetes?
Oral glucose tolerance test (OGTT) ## Footnote NICE recommends early self-monitoring of blood glucose as an alternative to OGTTs.
136
When should women with risk factors for gestational diabetes be offered an OGTT?
At 24-28 weeks ## Footnote This applies to women with any of the specified risk factors.
137
What are the diagnostic thresholds for fasting glucose to diagnose gestational diabetes?
EITHER OF THE TWO BELOW Fasting glucose is >= 5.6 mmol/L 2hours post challenge >= 7.8 mol/L ## Footnote This is one of the criteria updated by NICE.
138
What should newly diagnosed women with gestational diabetes do within a week?
Be seen in a joint diabetes and antenatal clinic ## Footnote This is part of the management plan.
139
What dietary advice should be given to women with gestational diabetes?
Advice about diet including eating foods with a low glycaemic index ## Footnote This is part of the management strategy.
140
What should be done if fasting plasma glucose is < 7 mmol/L?
A trial of diet and exercise should be offered ## Footnote This is an initial management step.
141
What is the next step if glucose targets are not met within 1-2 weeks of diet/exercise alteration?
Metformin should be started ## Footnote This is part of the stepwise management approach.
142
What type of insulin is used to treat gestational diabetes?
Short-acting insulin ## Footnote Long-acting insulin is not used in this context.
143
When should insulin be started for gestational diabetes?
If the fasting glucose level is >= 7 mmol/L ## Footnote This indicates a need for insulin therapy.
144
What should be offered if plasma glucose levels are between 6-6.9 mmol/L with complications?
Insulin should be offered ## Footnote Complications may include macrosomia or hydramnios.
145
Under what conditions should glibenclamide be offered?
For women who cannot tolerate metformin or those who fail to meet glucose targets with metformin but decline insulin treatment ## Footnote This is a specific management option.
146
What is the recommended weight loss for women with pre-existing diabetes and a BMI of > 27 kg/m²?
Weight loss ## Footnote This is part of the management to improve diabetes control.
147
What should be done for women with pre-existing diabetes regarding insulin?
Stop oral hypoglycaemic agents, apart from metformin, and commence insulin ## Footnote This is necessary for effective diabetes management.
148
What is the recommended dose of folic acid for women with pre-existing diabetes?
5 mg/day from pre-conception to 12 weeks gestation ## Footnote This is to prevent neural tube defects.
149
What type of scan is recommended at 20 weeks for women with pre-existing diabetes?
Detailed anomaly scan including four-chamber view of the heart and outflow tracts ## Footnote This is to check for any fetal anomalies.
150
What does tight glycaemic control reduce in pregnant women with diabetes?
Complication rates ## Footnote Maintaining tight control is crucial for maternal and fetal health.
151
What should be treated in women with pre-existing diabetes as it can worsen during pregnancy?
Retinopathy ## Footnote Monitoring and treatment are important to prevent progression.
152
What is the target fasting blood glucose level for pregnant women with PRE-XISTING diabetes?
5.3 mmol/l ## Footnote This target applies to both pre-existing and gestational diabetes.
153
What is the target blood glucose level 1 hour after meals for pregnant women with PRE-EXISTING diabetes?
7.8 mmol/l ## Footnote This target is crucial for managing blood sugar levels effectively.
154
What is the target blood glucose level 2 hours after meals for pregnant women with PRE-EXISTING diabetes?
6.4 mmol/l ## Footnote Maintaining this level helps prevent complications during pregnancy.
155
156
What are gestational trophoblastic disorders?
A spectrum of disorders originating from the placental trophoblast including: * complete hydatidiform mole * partial hydatidiform mole * choriocarcinoma ## Footnote These disorders arise from abnormal growth of the trophoblastic tissue.
157
Define complete hydatidiform mole.
A benign tumour of trophoblastic material occurring when an empty egg is fertilized by a single sperm that duplicates its DNA, resulting in all chromosomes being of paternal origin. ## Footnote This leads to a complete absence of maternal DNA.
158
List the features of complete hydatidiform mole.
The features include: * bleeding in first or early second trimester * exaggerated symptoms of pregnancy (e.g. hyperemesis) * uterus large for dates * very high serum levels of human chorionic gonadotropin (hCG) * hypertension and hyperthyroidism may be seen ## Footnote Hyperemesis refers to severe nausea and vomiting during pregnancy.
159
What is the management for complete hydatidiform mole?
Urgent referral to a specialist centre for evacuation of the uterus is performed; effective contraception is recommended to avoid pregnancy in the next 12 months. ## Footnote This is crucial to prevent complications and monitor for potential choriocarcinoma development.
160
What percentage of complete hydatidiform moles go on to develop choriocarcinoma?
Around 2-3% go on to develop choriocarcinoma. ## Footnote Choriocarcinoma is a malignant form of trophoblastic disease.
161
Define partial hydatidiform mole.
A condition where a normal haploid egg is fertilized by two sperms or by one sperm with duplication of paternal chromosomes, resulting in DNA of both maternal and paternal origin, usually triploid (e.g. 69 XXX or 69 XXY). ## Footnote Fetal parts may be seen in this condition.
162
Fill in the blank: In complete hydatidiform mole, all chromosomes are of _______ origin.
paternal ## Footnote This results from the fertilization of an empty egg.
163
True or False: Hypertension and hyperthyroidism are commonly associated with complete hydatidiform mole.
True ## Footnote These conditions can be secondary effects due to elevated hCG levels.
164
What can human chorionic gonadotropin (hCG) mimic?
Thyroid-stimulating hormone (TSH) ## Footnote This mimicry can lead to confusion in diagnosing thyroid conditions.
165
What is Group B Streptococcus (GBS)?
GBS is the most common cause of early-onset severe infection in the neonatal period.
166
What percentage of mothers are thought to carry GBS?
20-40% of mothers have GBS present in their bowel flora.
167
How can infants be exposed to GBS?
Infants may be exposed to maternal GBS during labour.
168
List risk factors for Group B Streptococcus (GBS) infection.
* Prematurity * Prolonged rupture of membranes * Previous sibling GBS infection * Maternal pyrexia (e.g., secondary to chorioamnionitis)
169
What organization published guidelines on GBS in 2017?
The Royal College of Obstetricians and Gynaecologists (RCOG).
170
Should universal screening for GBS be offered to all women?
No, universal screening for GBS should not be offered to all women.
171
Is a maternal request an indication for GBS screening?
No, a maternal request is not an indication for screening.
172
What should women with a previous GBS detection be informed about?
They should be informed that their risk of maternal GBS carriage in this pregnancy is 50%.
173
What should be offered to women with a previous baby with early- or late-onset GBS disease?
Intrapartum antibiotic prophylaxis (IAP).
174
When should swabs for GBS be offered?
Swabs for GBS should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date.
175
Who should receive IAP regardless of GBS status?
Women in preterm labour.
176
What should be given to women with pyrexia during labour?
Intrapartum antibiotic prophylaxis (IAP).
177
What is the antibiotic of choice for GBS prophylaxis?
Benzylpenicillin.
178
What is offered to all pregnant women regarding hepatitis B?
Screening for hepatitis B ## Footnote Early detection can help manage the health of both the mother and the baby.
179
What should babies born to mothers who are chronically infected with hepatitis B receive?
A complete course of vaccination and hepatitis B immunoglobulin ## Footnote This is crucial for preventing hepatitis B infection in newborns.
180
What is currently being evaluated for use in the latter part of pregnancy for hepatitis B?
Oral antiviral treatment (e.g. Lamivudine) ## Footnote This could potentially improve outcomes for mothers and infants.
181
Does caesarean section reduce vertical transmission rates of hepatitis B?
Little evidence suggests it does ## Footnote Management strategies may focus more on vaccination than delivery method.
182
Can hepatitis B be transmitted via breastfeeding?
No ## Footnote This is an important distinction from HIV, which can be transmitted through breast milk.
183
What factors reduce vertical transmission of HIV from 25-30% to 2%?
* maternal antiretroviral therapy * mode of delivery (caesarean section) * neonatal antiretroviral therapy * infant feeding (bottle feeding) ## Footnote These factors significantly lower the risk of HIV transmission from mother to child during pregnancy and delivery.
184
What do NICE guidelines recommend regarding HIV screening in pregnant women?
Offering HIV screening to all pregnant women ## Footnote This recommendation aims to identify and manage HIV in pregnant women to reduce transmission risks.
185
Should all pregnant women be offered antiretroviral therapy?
Yes, regardless of previous treatment status ## Footnote Antiretroviral therapy is crucial for managing HIV during pregnancy.
186
What is the recommended mode of delivery for pregnant women with a viral load less than 50 copies/ml at 36 weeks?
Vaginal delivery ## Footnote If the viral load is higher, a caesarean section is recommended to minimize transmission risk.
187
What should be done before a caesarean section for a pregnant woman with HIV?
Start a zidovudine infusion four hours before the procedure ## Footnote This is to ensure that the infant has some level of protection against HIV during delivery.
188
What is the recommended neonatal antiretroviral therapy if maternal viral load is <50 copies/ml?
Zidovudine administered orally ## Footnote If the maternal viral load is higher, triple ART should be used instead.
189
How long should neonatal antiretroviral therapy be continued?
For 4-6 weeks ## Footnote This duration is essential for effective management of the infant's exposure to HIV.
190
What infant feeding practice is advised for women in the UK with HIV?
Not to breastfeed ## Footnote This recommendation is to prevent potential HIV transmission through breast milk.
191
What happens to blood pressure during the first trimester of normal pregnancy?
Blood pressure usually falls, particularly the diastolic, and continues to fall until 20-24 weeks.
192
What occurs to blood pressure after 20-24 weeks of pregnancy?
Blood pressure usually increases to pre-pregnancy levels by term.
193
What did NICE publish in 2010 regarding hypertension in pregnancy?
Guidance on the management of hypertension in pregnancy.
194
What should women at high risk of developing pre-eclampsia take from 12 weeks until birth?
Aspirin 75 mg od.
195
How is hypertension in pregnancy usually defined?
Systolic > 140 mmHg or diastolic > 90 mmHg, or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic.
196
What is pre-existing hypertension?
A history of hypertension before pregnancy or elevated blood pressure > 140/90 mmHg before 20 weeks gestation.
197
What characterizes pre-existing hypertension in pregnancy?
No proteinuria, no oedema, occurs in 3-5% of pregnancies, more common in older women.
198
What should be done if a pregnant woman is taking an ACE inhibitor or ARB for pre-existing hypertension?
These should be stopped immediately, and alternative antihypertensives should be started.
199
What is pregnancy-induced hypertension (PIH)?
Hypertension occurring in the second half of pregnancy, with no proteinuria or oedema.
200
What percentage of pregnancies does pregnancy-induced hypertension occur in?
Around 5-7%.
201
What is the typical resolution timeframe for pregnancy-induced hypertension after birth?
Typically resolves after one month.
202
What is the risk for women who have pregnancy-induced hypertension?
Increased risk of future pre-eclampsia or hypertension later in life.
203
What characterizes pre-eclampsia?
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours).
204
How common is pre-eclampsia in pregnancies?
Occurs in around 5% of pregnancies.
205
What is the first-line management for hypertension in pregnancy according to the 2010 NICE guidelines?
Oral labetalol.
206
What alternative medications may be used for managing hypertension in pregnancy?
Oral nifedipine and hydralazine.
207
What is intrahepatic cholestasis of pregnancy also known as?
Obstetric cholestasis
208
What percentage of pregnancies in the UK are affected by intrahepatic cholestasis of pregnancy?
Around 1%
209
What is the associated risk with intrahepatic cholestasis of pregnancy?
Increased risk of premature birth
210
What is a common symptom of intrahepatic cholestasis of pregnancy?
Pruritus
211
Where is pruritus typically worse in patients with intrahepatic cholestasis of pregnancy?
Palms, soles, and abdomen
212
What percentage of patients with intrahepatic cholestasis of pregnancy experience clinically detectable jaundice?
Around 20%
213
In what percentage of cases is raised bilirubin seen in intrahepatic cholestasis of pregnancy?
> 90%
214
What is a common management practice for intrahepatic cholestasis of pregnancy?
Induction of labour at 37-38 weeks
215
Is the management practice of inducing labour at 37-38 weeks evidence-based?
No, may not be evidence based
216
What medication is widely used in the management of intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid
217
Is the evidence base for ursodeoxycholic acid clear?
No, evidence base not clear
218
What supplementation is recommended in the management of intrahepatic cholestasis of pregnancy?
Vitamin K supplementation
219
What is the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
45-90%
220
What does Gravida (G) refer to?
The number of times a woman has been pregnant, regardless of the outcome. ## Footnote Gravida counts all pregnancies, including those that ended in miscarriage or abortion.
221
What does Para (P) refer to?
The number of pregnancies that have resulted in the birth of potentially viable offspring, typically around 24 weeks of gestation. ## Footnote Viability may vary based on local standards.
222
How is a pregnancy with twins counted in Gravida and Para?
The pregnancy is counted as one gestational event for Gravida and as one for Para regardless of the number of viable offspring. ## Footnote For example, twins would result in G1P1.
223
If a woman gives birth to twins in her first pregnancy, what is her Gravida and Para designation?
G1P1. ## Footnote The Para count is incremented by one for each pregnancy that results in a birth, not by the number of babies born.
224
True or False: Para is counted by the number of babies born.
False. ## Footnote Para is counted by the number of pregnancies that result in a birth.
225
What does placenta praevia describe?
A placenta lying wholly or partly in the lower uterine segment ## Footnote This condition can lead to complications during pregnancy and delivery.
226
What percentage of women will have a low-lying placenta when scanned at 16-20 weeks gestation?
5% ## Footnote Most low-lying placentas resolve as the pregnancy progresses.
227
What is the incidence of placenta praevia at delivery?
0.5% ## Footnote This indicates that most placentas rise away from the cervix by the time of delivery.
228
Name three associated factors of placenta praevia.
* Multiparity * Multiple pregnancy * Lower segment scar from previous caesarean section ## Footnote These factors increase the likelihood of abnormal placental implantation.
229
What are the clinical features of placenta praevia?
* Shock in proportion to visible loss * No pain * Uterus not tender * Abnormal lie and presentation * Usually normal fetal heart * Rare coagulation problems * Small bleeds before large ## Footnote These features help in assessing the condition of the mother and fetus.
230
Why should a digital vaginal examination be avoided before an ultrasound in cases of suspected placenta praevia?
It may provoke a severe haemorrhage ## Footnote Ultrasound is the preferred method for diagnosis.
231
When is placenta praevia often detected?
During the routine 20 week abdominal ultrasound ## Footnote This routine screening is crucial for early identification.
232
What does the RCOG recommend for the diagnosis of placenta praevia?
The use of transvaginal ultrasound ## Footnote This method improves the accuracy of placental localization and is considered safe.
233
What is the classical grading of placenta praevia?
* I - placenta reaches lower segment but not the internal os * II - placenta reaches internal os but doesn't cover it * III - placenta covers the internal os before dilation but not when dilated * IV ('major') - placenta completely covers the internal os ## Footnote This grading system helps assess the severity of the condition.
234
What is placental abruption?
Separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space.
235
What is the approximate incidence of placental abruption in pregnancies?
Occurs in approximately 1/200 pregnancies.
236
What are some associated factors for placental abruption?
* Proteinuric hypertension * Cocaine use * Multiparity * Maternal trauma * Increasing maternal age
237
What are the clinical features of placental abruption?
* Shock out of keeping with visible loss * Constant pain * Tender, tense uterus * Normal lie and presentation * Fetal heart: absent/distressed * Coagulation problems * Beware pre-eclampsia, DIC, anuria
238
True or False: The cause of placental abruption is well known.
False
239
Fill in the blank: Placental abruption results in maternal _______ into the intervening space.
haemorrhage
240
What clinical sign indicates a serious condition in placental abruption?
Shock out of keeping with visible loss.
241
What does a tender, tense uterus indicate in the context of placental abruption?
It is one of the clinical features of placental abruption.
242
What should be monitored in patients suspected of placental abruption?
* Fetal heart * Coagulation problems * Signs of pre-eclampsia * DIC * Anuria
243
What is postpartum haemorrhage (PPH)?
Blood loss of > 500 ml after a vaginal delivery ## Footnote PPH may be primary or secondary.
244
What is primary postpartum haemorrhage?
Occurs within 24 hours after delivery ## Footnote Affects around 5-7% of deliveries.
245
What are the 4 Ts that cause primary PPH?
* Tone (uterine atony) * Trauma (e.g. perineal tear) * Tissue (retained placenta) * Thrombin (e.g. clotting/bleeding disorder) ## Footnote The vast majority of cases are due to uterine atony.
246
List some risk factors for primary PPH.
* Previous PPH * Prolonged labour * Pre-eclampsia * Increased maternal age * Polyhydramnios * Emergency Caesarean section * Placenta praevia * Placenta accreta * Macrosomia * Nulliparity ## Footnote The effect of parity on the risk of PPH is complicated.
247
What is the ABC approach in managing PPH?
* Two peripheral cannulae, 14 gauge * Lie the woman flat * Bloods including group and save * Commence warmed crystalloid infusion ## Footnote This approach is essential in life-threatening emergencies.
248
What is one mechanical management technique for PPH?
Palpate the uterine fundus and rub it to stimulate contractions ## Footnote This technique is referred to as 'rubbing up the fundus'.
249
What are some medical management options for PPH?
* IV oxytocin * Ergometrine IV or IM (unless history of hypertension) * Carboprost IM (unless history of asthma) * Misoprostol sublingual ## Footnote There is interest in the role of tranexamic acid for PPH.
250
What should be done if medical options fail in PPH management?
Urgently consider surgical options ## Footnote The RCOG states intrauterine balloon tamponade is a first-line intervention for uterine atony.
251
What are some surgical options for PPH?
* B-Lynch suture * Ligation of the uterine arteries * Ligation of internal iliac arteries * Hysterectomy (in severe cases) ## Footnote Hysterectomy may be a life-saving procedure.
252
What is secondary postpartum haemorrhage?
Occurs between 24 hours to 12 weeks after delivery ## Footnote Typically due to retained placental tissue or endometritis.
253
What is the Edinburgh Postnatal Depression Scale?
A 10-item questionnaire used to screen for depression with a maximum score of 30 ## Footnote It indicates how the mother has felt over the previous week, with a score > 13 suggesting a depressive illness of varying severity.
254
What score on the Edinburgh Postnatal Depression Scale indicates depressive illness?
Score > 13 ## Footnote This score indicates a depressive illness of varying severity.
255
What is the sensitivity and specificity of the Edinburgh Postnatal Depression Scale?
Both > 90% ## Footnote This high sensitivity and specificity make it a reliable screening tool.
256
What are the characteristics of 'baby-blues'?
Anxiety, tearfulness, and irritability ## Footnote Seen in around 60-70% of women, typically occurring 3-7 days following birth, more common in primips.
257
What is the typical onset period for baby-blues?
3-7 days following birth ## Footnote More common in first-time mothers (primips).
258
What is the recommended support for mothers experiencing baby-blues?
Reassurance and support from health visitors ## Footnote Health visitors play a key role in providing support.
259
What percentage of women are affected by postnatal depression?
Around 10% ## Footnote Most cases start within a month and peak at 3 months.
260
When do most cases of postnatal depression start?
Within a month after birth ## Footnote Typically peaks at 3 months.
261
What treatments may be beneficial for postnatal depression?
Cognitive behavioural therapy, certain SSRIs such as sertraline and paroxetine ## Footnote These medications are not thought to be harmful to the infant when secreted in breast milk.
262
What is puerperal psychosis and its prevalence?
A severe mental illness affecting approximately 0.2% of women ## Footnote Onset usually within the first 2-3 weeks following birth.
263
What are the features of puerperal psychosis?
Severe mood swings and disordered perception (e.g. auditory hallucinations) ## Footnote Similar to bipolar disorder; often requires hospital admission.
264
What is the risk of recurrence for puerperal psychosis in future pregnancies?
25-50% risk of recurrence ## Footnote This highlights the importance of monitoring in subsequent pregnancies.
265
True or False: Postnatal depression and baby-blues have similar features.
True ## Footnote Both conditions require reassurance and support.
266
What are the three stages of postpartum thyroiditis?
1. Thyrotoxicosis 2. Hypothyroidism 3. Normal thyroid function (but high recurrence rate in future pregnancies) ## Footnote Recurrence rates can be significant in subsequent pregnancies.
267
In what percentage of patients are thyroid peroxidase antibodies found in postpartum thyroiditis?
90% ## Footnote This high prevalence indicates an autoimmune component in postpartum thyroiditis.
268
What is the typical management for the thyrotoxic phase of postpartum thyroiditis?
Propranolol is typically used for symptom control ## Footnote Anti-thyroid drugs are not usually used as the thyroid is not overactive.
269
How is the hypothyroid phase of postpartum thyroiditis usually treated?
Usually treated with thyroxine ## Footnote Thyroxine replacement helps manage hypothyroidism effectively.
270
True or False: Anti-thyroid drugs are typically used in the thyrotoxic phase of postpartum thyroiditis.
False ## Footnote The thyroid is not overactive, hence anti-thyroid drugs are not indicated.
271
What does pre-eclampsia describe?
The emergence of high blood pressure during pregnancy that may precede eclampsia and other complications
272
What are the three classical components of pre-eclampsia?
* New-onset hypertension * Proteinuria * Oedema
273
What is the formal definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: proteinuria, other organ involvement
274
What are examples of organ involvement in pre-eclampsia?
* Renal insufficiency (creatinine ≥ 90 umol/L) * Liver * Neurological * Haematological * Uteroplacental dysfunction
275
What are potential consequences of pre-eclampsia?
* Eclampsia * Altered mental status * Blindness * Stroke * Clonus * Severe headaches * Persistent visual scotomata * Intrauterine growth retardation * Prematurity * Liver involvement (elevated transaminases) * Haemorrhage (placental abruption, intra-abdominal, intra-cerebral) * Cardiac failure
276
What defines severe pre-eclampsia?
* Hypertension typically > 160/110 mmHg * Proteinuria: dipstick ++/+++ * Headache * Visual disturbance * Papilloedema * RUQ/epigastric pain * Hyperreflexia * Platelet count < 100 * 106/l * Abnormal liver enzymes or HELLP syndrome
277
What are high-risk factors for pre-eclampsia according to NICE?
* Hypertensive disease in a previous pregnancy * Chronic kidney disease * Autoimmune disease (e.g., systemic lupus erythematosus) * Type 1 or type 2 diabetes * Chronic hypertension
278
List moderate risk factors for pre-eclampsia.
* First pregnancy * Age 40 years or older * Pregnancy interval of more than 10 years * BMI of 35 kg/m² or more at first visit * Family history of pre-eclampsia * Multiple pregnancy
279
What should women with high and moderate risk factors take to reduce hypertensive disorders in pregnancy?
If >=1 high risk factor or >=2 moderate risk factor then Aspirin 75-150mg daily from 12 weeks gestation until birth
280
What is the initial management step for suspected pre-eclampsia?
Arrange emergency secondary care assessment
281
What blood pressure reading typically results in admission for suspected pre-eclampsia?
Blood pressure ≥ 160/110 mmHg
282
What is the first-line medication for managing pre-eclampsia according to 2010 NICE guidelines?
Oral labetalol
283
What are alternative medications to labetalol for managing pre-eclampsia?
* Nifedipine * Hydralazine
284
What is the most important and definitive management step for pre-eclampsia?
Delivery of the baby
285
The timing of delivery in pre-eclampsia depends on what?
The individual clinical scenario
286
287
When are pregnant women screened for anaemia?
At the booking visit (often done at 8-10 weeks) and at 28 weeks ## Footnote Screening is essential for early detection and management of anaemia in pregnancy.
288
What is the NICE cut-off for oral iron therapy in the first trimester?
< 110 g/L ## Footnote This cut-off is used to identify pregnant women who may need treatment for anaemia.
289
What is the NICE cut-off for oral iron therapy in the second and third trimester?
< 105 g/L ## Footnote This threshold helps in monitoring anaemia in later stages of pregnancy.
290
What is the NICE cut-off for postpartum oral iron therapy?
< 100 g/L ## Footnote This measurement is critical for postpartum women to ensure recovery from potential anaemia.
291
What is the recommended management for anaemia in pregnant women?
Oral ferrous sulfate or ferrous fumarate ## Footnote These are common forms of iron supplements used to treat anaemia.
292
How long should treatment for anaemia continue after iron deficiency is corrected?
For 3 months ## Footnote Continuing treatment helps to replenish iron stores in the body.
293
What is the percentage of polyhydramnios in maternal complications during pregnancy with diabetes?
25% ## Footnote Polyhydramnios may occur due to fetal polyuria.
294
What is the association between preterm labour and polyhydramnios in pregnant women with diabetes?
15% of preterm labour cases are associated with polyhydramnios.
295
What is macrosomia in the context of neonatal complications from maternal diabetes?
Macrosomia refers to larger than average babies, although diabetes may also cause small for gestational age babies.
296
What causes neonatal hypoglycaemia in infants born to diabetic mothers?
It is secondary to beta cell hyperplasia.
297
What is respiratory distress syndrome in newborns related to maternal diabetes?
Surfactant production is delayed.
298
What complication increases the risk of neonatal jaundice in infants of diabetic mothers?
Polycythaemia.
299
How much do malformation rates increase for infants born to diabetic mothers?
3-4 fold.
300
What types of malformations are associated with diabetes in pregnancy?
Examples include sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy).
301
What is a serious risk for infants born to diabetic mothers that can lead to infant mortality?
Stillbirth.
302
What are two mineral deficiencies that can occur in newborns of diabetic mothers?
* Hypomagnesaemia * Hypocalcaemia
303
What is shoulder dystocia and its potential consequence for infants of diabetic mothers?
It may cause Erb's palsy.
304
What is acute fatty liver of pregnancy?
A rare complication that may occur in the third trimester or the period immediately following delivery. ## Footnote It is characterized by liver dysfunction during pregnancy.
305
List the features of acute fatty liver of pregnancy.
* Abdominal pain * Nausea & vomiting * Headache * Jaundice * Hypoglycaemia * Severe disease may result in pre-eclampsia ## Footnote These symptoms can indicate liver distress and require careful monitoring.
306
What is the typical elevation of ALT in acute fatty liver of pregnancy?
Typically elevated to around 500 u/l. ## Footnote ALT (alanine aminotransferase) is an enzyme that indicates liver health.
307
What is the management approach for acute fatty liver of pregnancy?
* Support care * Delivery is the definitive management once stabilised ## Footnote Immediate delivery may be necessary if the mother's condition worsens.
308
True or False: Gilbert's and Dubin-Johnson syndrome may be exacerbated during pregnancy.
True ## Footnote These conditions can lead to increased bilirubin levels, which may complicate pregnancy.
309
What does HELLP stand for?
Haemolysis, Elevated Liver enzymes, Low Platelets ## Footnote HELLP syndrome is a severe form of pre-eclampsia and requires immediate medical attention.
310
What is the definition of obesity in the context of pregnancy?
Body mass index (BMI) >= 30 kg/m² at the first antenatal visit.
311
List three maternal risks associated with obesity during pregnancy.
* Miscarriage * Gestational diabetes * Pre-eclampsia *venous thromboembolism *dysfunctional labour, induced labour *postpartum haemorrhage *wound infections There is also a higher caesarean section rate.
312
What is a common complication related to delivery for obese women?
Higher caesarean section rate.
313
List 7 fetal risks associated with maternal obesity.
* Congenital anomaly * Prematurity *prematurity *macrosomia *stillbirth *increased risk of developing obesity and metabolic disorders in childhood *neonatal death
314
What increased risk do children of obese mothers face?
Increased risk of developing obesity and metabolic disorders in childhood.
315
True or False: Women with a BMI of 30 or more should try to reduce their weight through dieting during pregnancy.
False.
316
What dosage of folic acid should obese women take during pregnancy?
5mg, rather than 400mcg.
317
At what weeks should all obese women be screened for gestational diabetes?
24-28 weeks.
318
If a woman's BMI is >= 35 kg/m², where should she give birth?
In a consultant-led obstetric unit.
319
What should women with a BMI >= 40 kg/m² have before childbirth?
An antenatal consultation with an obstetric anaesthetist and a plan made.
320
List two maternal complications of obesity during pregnancy.
* Venous thromboembolism * Postpartum haemorrhage
321
What is one risk factor for neonatal death associated with maternal obesity?
Stillbirth.
322
Fill in the blank: Women with a BMI of 30 or more should be informed about the risks to their health and the health of the unborn child during the _______.
booking appointment.
323
324
What is puerperal pyrexia?
A temperature of > 38ºC in the first 14 days following delivery ## Footnote Puerperal pyrexia indicates a febrile condition after childbirth.
325
What is the most common cause of puerperal pyrexia?
Endometritis ## Footnote Endometritis is an infection of the uterine lining commonly occurring after delivery.
326
Name two other causes of puerperal pyrexia.
* Urinary tract infection * Wound infections (perineal tears + caesarean section) * Mastitis * Venous thromboembolism ## Footnote These are additional potential sources of fever postpartum.
327
What should be suspected if puerperal pyrexia occurs?
Endometritis ## Footnote Endometritis requires immediate attention as it can lead to serious complications.
328
What is the recommended management if endometritis is suspected?
Refer the patient to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours) ## Footnote This treatment protocol aims to address the infection effectively.
329
Fill in the blank: Puerperal pyrexia is defined as a temperature of _______ in the first 14 days following delivery.
> 38ºC
330
True or False: Mastitis is a common cause of puerperal pyrexia.
True
331
Fill in the blank: The management of suspected endometritis includes _______ until the patient is afebrile for greater than 24 hours.
intravenous antibiotics (clindamycin and gentamicin)
332
What can reduced fetal movements indicate?
Fetal distress and chronic hypoxia ## Footnote Reduced fetal movements can reflect risk of stillbirth and fetal growth restriction.
333
What is quickening in relation to fetal movements?
The first onset of recognized fetal movements, occurring between 18-20 weeks gestation ## Footnote Multiparous women may experience quickening as early as 16-18 weeks.
334
At what gestational week does the frequency of fetal movements typically plateau?
32 weeks gestation
335
How does the RCOG define reduced fetal movements (RFM) after 28 weeks gestation?
Less than 10 movements within 2 hours
336
What percentage of pregnancies are affected by reduced fetal movements?
Up to 15%
337
What are some risk factors for reduced fetal movements?
* Posture * Distraction * Placental position * Medication * Fetal position * Body habitus * Amniotic fluid volume * Fetal size
338
How does posture affect awareness of fetal movements?
More prominent during lying down and less when sitting or standing
339
What types of medications can temporarily reduce fetal movements?
* Alcohol * Sedative medications (opiates or benzodiazepines)
340
What is the significance of fetal size in relation to RFM?
Up to 29% of women presenting with RFM have a SGA fetus
341
What is the first step in investigating reduced fetal movements past 28 weeks gestation?
Use handheld Doppler to confirm fetal heartbeat
342
What should be done if no fetal heartbeat is detected?
Immediate ultrasound should be offered
343
What does CTG stand for and what is its purpose?
Cardiotocography; to monitor fetal heart rate
344
What is the recommended action if concern remains despite a normal CTG?
Urgent ultrasound within 24 hours
345
What should be assessed in an ultrasound if concerns about RFM exist?
* Abdominal circumference * Estimated fetal weight * Amniotic fluid volume
346
What should be done if fetal movements have not been felt by 24 weeks gestation?
Onward referral to a maternal fetal medicine unit
347
What percentage of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis?
40-55%
348
What is the prognosis for pregnancies with a single episode of reduced fetal movement?
70% have no onward complication
349
How long should CTG be carried out for reduced fatal movements >28w after heartbeat present on Doppler?
If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.
350
351
What is the most important antigen of the rhesus system?
The D antigen ## Footnote The D antigen is crucial for determining Rh status in pregnancy.
352
What percentage of mothers are rhesus negative (Rh -ve)?
Around 15% ## Footnote This statistic highlights the prevalence of Rh -ve mothers.
353
What happens if a Rh -ve mother delivers a Rh +ve child?
A leak of fetal red blood cells may occur ## Footnote This can lead to the formation of anti-D IgG antibodies in the mother.
354
What do anti-D IgG antibodies do in later pregnancies?
They can cross the placenta and cause haemolysis in the fetus ## Footnote This can lead to serious complications for the fetus.
355
Can sensitization occur during the first pregnancy?
Yes, due to leaks ## Footnote Sensitization can happen even if the mother has not had prior pregnancies.
356
What does NICE (2008) advise for non-sensitised Rh -ve mothers?
Giving anti-D at 28 and 34 weeks ## Footnote This is a preventive measure against sensitization.
357
What is the difference in efficacy between single-dose and double-dose regimes of anti-D?
Little difference ## Footnote RCOG in 2011 advised that either regime could be used based on local factors.
358
What is the nature of anti-D immunoglobulin treatment?
It is prophylaxis ## Footnote Once sensitization has occurred, it is irreversible.
359
What should be done if an event occurs in the 2nd/3rd trimester?
Give a large dose of anti-D and perform a Kleihauer test ## Footnote This test determines the proportion of fetal RBCs present.
360
When should anti-D immunoglobulin be given within 72 hours?
In the following situations: * Delivery of a Rh +ve infant, whether live or stillborn * Any termination of pregnancy * Miscarriage if gestation is > 12 weeks * Ectopic pregnancy (surgically managed) * External cephalic version * Antepartum haemorrhage * Amniocentesis, chorionic villus sampling, fetal blood sampling * Abdominal trauma ## Footnote These situations are critical for preventing sensitization.
361
Is anti-D required for medically managed ectopic pregnancy with methotrexate?
No ## Footnote Anti-D is not required in cases managed medically.
362
What is rubella also known as?
German measles
363
What type of virus causes rubella?
Togavirus
364
What is the risk of congenital rubella syndrome if rubella is contracted during pregnancy?
High risk
365
What is the incubation period for rubella?
14-21 days
366
How long are individuals infectious with rubella?
From 7 days before symptoms to 4 days after rash onset
367
During which weeks of pregnancy is the risk of damage to the fetus from rubella as high as 90%?
First 8-10 weeks
368
Is damage from rubella common after 16 weeks of pregnancy?
No, damage is rare after 16 weeks
369
What are some features of congenital rubella syndrome? (List at least three)
* Sensorineural deafness * Congenital cataracts * Congenital heart disease * Growth retardation * Hepatosplenomegaly * Purpuric skin lesions * 'Salt and pepper' chorioretinitis * Microphthalmia * Cerebral palsy
370
What should suspected cases of rubella in pregnancy be discussed with?
The local Health Protection Unit (HPU)
371
What type of antibodies are raised in women recently exposed to rubella?
IgM antibodies
372
What is the risk of transplacental infection with parvovirus B19?
30%
373
What is the fetal loss risk associated with parvovirus B19?
5-10%
374
Since when has rubella immunity no longer been routinely checked at the booking visit?
2016
375
What should non-immune mothers be offered after delivery?
MMR vaccination
376
Should MMR vaccines be administered to women known to be pregnant?
No
377
Fill in the blank: The risk of congenital rubella syndrome is highest during the first _____ weeks of pregnancy.
8-10
378
True or False: Congenital heart disease is a feature of congenital rubella syndrome.
True
379
What is a common clinical challenge when diagnosing rubella?
It is difficult to distinguish from parvovirus B19
380
What is the symphysis-fundal height (SFH)?
Measured from the top of the pubic bone to the top of the uterus in centimetres
381
What should the symphysis-fundal height (SFH) match after 20 weeks?
The gestational age in weeks to within 2 cm
382
What is the normal SFH range for a gestational age of 24 weeks?
22 to 26 cm
383
Fill in the blank: The SFH should match the gestational age in weeks to within _______ cm after 20 weeks.
2
384
True or False: The SFH measurement can be more than 2 cm off from the gestational age after 20 weeks.
False
385
What is a nuchal scan?
A nuchal scan is performed at 11-13 weeks.
386
What are the causes of increased nuchal translucency?
* Down's syndrome * congenital heart defects * abdominal wall defects
387
What are the causes of hyperechogenic bowel?
* cystic fibrosis * Down's syndrome * cytomegalovirus infection
388
What is the purpose of the National Clinical Guideline for Stroke published in 2023?
It is a partial update of the 2016 Royal College of Physicians (RCP) guidelines.
389
What parameters should be maintained within normal limits in the management of acute stroke?
* Blood glucose * Hydration * Oxygen saturation * Temperature
390
Should blood pressure be lowered in the acute phase of ischaemic stroke?
No, unless there are complications or they are being considered for thrombolysis.
391
What is the recommended blood pressure control for patients presenting with acute ischaemic stroke?
Considered if systolic blood pressure > 150 mmHg within 6 hours.
392
What should be administered as soon as possible if a haemorrhagic stroke has been excluded?
Aspirin 300mg orally or rectally.
393
When should anticoagulants be started for patients with atrial fibrillation after an ischaemic stroke?
Not until brain imaging has excluded haemorrhage, usually not until 14 days after onset.
394
What is the recommended treatment for patients with cholesterol > 3.5 mmol/l after an ischaemic stroke?
Commence on a statin, often delayed until after 48 hours due to risk of haemorrhagic transformation.
395
What percentage of patients in the UK receive thrombolysis for acute ischaemic stroke?
Around 10%.
396
What is the time frame for administering thrombolysis with alteplase or tenecteplase?
Within 4.5 hours of onset of stroke symptoms.
397
What broadened inclusion criteria for thrombolysis were introduced in the 2023 guidelines?
Patients with an acute ischaemic stroke, regardless of age/severity, last known well > 4.5 hours earlier.
398
What imaging evidence is required for thrombolysis eligibility?
* Core-perfusion mismatch from CT/MR perfusion * DWI-FLAIR mismatch from MRI
399
What is the required blood pressure before thrombolysis?
Lowered to 185/110 mmHg.
400
Name three absolute contraindications to thrombolysis.
* Previous intracranial haemorrhage * Seizure at onset of stroke * Suspected subarachnoid haemorrhage
401
What is a relative contraindication to thrombolysis?
Pregnancy.
402
What is the time frame for offering mechanical thrombectomy after symptom onset?
As soon as possible and within 6 hours.
403
What pre-stroke functional status is recommended for thrombectomy candidates?
Less than 3 on the modified Rankin scale.
404
What imaging is required to confirm occlusion for thrombectomy?
* Computed tomographic angiography (CTA) * Magnetic resonance angiography (MRA)
405
What is recommended for people last known to be well between 6 hours and 24 hours previously?
Thrombectomy if there is potential to salvage brain tissue.
406
What is the new recommendation regarding clopidogrel for secondary prevention?
Clopidogrel is recommended ahead of aspirin plus modified-release dipyridamole.
407
What is the indication for carotid endarterectomy?
If there is stenosis > 50% and patient is not severely disabled after a stroke or TIA.
408
What is the score used for assessment of suspected stroke in the Emergency Department?
Rosier score.
409
What is the point allocation for new, acute onset of asymmetric facial weakness in the Rosier score?
1 point.
410
A stroke is likely if the Rosier score is greater than what value?
> 0.
411
What is a transient ischaemic attack (TIA)?
A brief period of neurological deficit due to a vascular cause, typically lasting less than an hour.
412
What updated recommendation was made in the National Clinical Guideline for Stroke published in 2023?
The use of dual antiplatelet therapy (DAPT) for TIA.
413
Is dual antiplatelet therapy (DAPT) recommended for major ischaemic stroke?
No, due to the high risk of haemorrhagic transformation.
414
What was the original definition of a TIA?
A sudden onset of a focal neurologic symptom lasting less than 24 hours due to a transient decrease in blood flow.
415
What is the new 'tissue-based' definition of a TIA?
A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
416
What term do patients often use to refer to TIAs?
Mini-stroke.
417
What are some clinical features of a TIA?
* Unilateral weakness or sensory loss * Aphasia or dysarthria * Ataxia, vertigo, or loss of balance * Visual problems * Sudden transient loss of vision in one eye (amaurosis fugax) * Diplopia * Homonymous hemianopia
418
What should be administered to patients with suspected TIA immediately?
Aspirin 300 mg unless contraindicated.
419
What is the recommended timeframe for urgent assessment of suspected TIA by a stroke specialist?
Within 24 hours.
420
What are some examples of TIA mimics that require exclusion?
* Hypoglycaemia * Intracranial haemorrhage
421
What should happen if a patient presents more than 7 days after symptoms?
They should be seen by a stroke specialist clinician as soon as possible within 7 days.
422
Is the ABCD2 prognostic score still recommended for risk stratification in suspected TIA?
No, it is no longer recommended due to poor performance.
423
What type of brain imaging is preferred for suspected TIA?
MRI (including diffusion-weighted and blood-sensitive sequences).
424
What is the risk level for patients who have had a TIA regarding further vascular events?
High risk, particularly in the first few days.
425
What immediate antithrombotic therapy should be given to patients with TIA or minor ischaemic stroke?
Antiplatelet therapy unless contraindicated or high risk of bleeding.
426
What is the recommended DAPT regimen for patients with TIA or minor ischaemic stroke within 24 hours?
* Clopidogrel (300 mg initial dose, then 75 mg od) + Aspirin (300 mg initial dose, then 75 mg od for 21 days) * Followed by monotherapy with Clopidogrel 75 mg od.
427
What is the alternative DAPT regimen to clopidogrel and aspirin?
Ticagrelor + Clopidogrel.
428
What should be considered for patients on DAPT?
Proton pump inhibitor therapy.
429
What is the medication regimen during the different phases of TIA management?
* Resolved TIA symptoms, awaiting specialist review: Aspirin * Reviewed by specialist, initial 21 days at high risk: Aspirin + Clopidogrel * Long-term secondary prevention after 21 days: Clopidogrel.
430
What should be initiated for patients with atrial fibrillation after excluding intracranial haemorrhage?
Anticoagulation.
431
What is the aim of high-intensity statin therapy in TIA patients?
To reduce non-HDL cholesterol by more than 40%.
432
What type of imaging should be performed for carotid assessment in TIA patients?
* Carotid duplex ultrasound * CT angiography * MR angiography.
433
What is the recommendation for carotid endarterectomy in TIA patients?
It is recommended if the patient has suffered a stroke or TIA in the carotid territory and stenosis > 50%.
434
What are the timeframes for performing carotid endarterectomy after assessment?
As soon as possible within 7 days.
435
What is Alzheimer's disease?
A progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK
436
What does NICE recommend for non-pharmacological management of Alzheimer's disease?
Offering a range of activities to promote wellbeing tailored to the person's preference
437
What type of therapy does NICE recommend for patients with mild and moderate dementia?
Group cognitive stimulation therapy
438
Name two other non-pharmacological options for managing Alzheimer's disease.
* Group reminiscence therapy * Cognitive rehabilitation
439
When were the dementia guidelines updated by NICE?
2018
440
What are the three acetylcholinesterase inhibitors recommended for managing mild to moderate Alzheimer's disease?
* Donepezil * Galantamine * Rivastigmine
441
What is memantine and when is it used?
An NMDA receptor antagonist used as a second-line treatment for Alzheimer's
442
In what situations is memantine recommended according to NICE?
* For patients with moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors * As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's * Monotherapy in severe Alzheimer's
443
Does NICE recommend antidepressants for mild to moderate depression in patients with dementia?
No
444
When should antipsychotics be used in patients with Alzheimer's disease?
Only for patients at risk of harming themselves or others, or when agitation, hallucinations, or delusions cause severe distress
445
What is a contraindication for using Donepezil?
Bradycardia
446
What is a common adverse effect of Donepezil?
Insomnia
447
448
What is Lewy body dementia?
An increasingly recognised cause of dementia, accounting for up to 20% of cases ## Footnote Characterised by alpha-synuclein cytoplasmic inclusions (Lewy bodies) in specific brain areas
449
What are the characteristic pathological features of Lewy body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas ## Footnote These inclusions are key to diagnosing the condition
450
What is the relationship between Parkinson's disease and Lewy body dementia?
Complicated; dementia often seen in Parkinson's disease, and up to 40% of Alzheimer's patients have Lewy bodies ## Footnote Both conditions can share overlapping symptoms
451
What are the key features of Lewy body dementia?
* Progressive cognitive impairment * Typically occurs before parkinsonism * Fluctuating cognition * Early impairments in attention and executive function * Parkinsonism * Visual hallucinations ## Footnote Other features may include delusions and non-visual hallucinations
452
How does the onset of symptoms in Lewy body dementia differ from Parkinson's disease?
Cognitive symptoms typically occur within a year of motor symptoms, unlike in Parkinson's disease, where motor symptoms present at least one year before cognitive symptoms ## Footnote This timing is crucial for differential diagnosis
453
How is Lewy body dementia diagnosed?
Usually clinical; single-photon emission computed tomography (SPECT) is increasingly used ## Footnote Known commercially as DaTscan, using 123-I FP-CIT as the radioisotope
454
What is the sensitivity and specificity of SPECT in diagnosing Lewy body dementia?
Sensitivity of around 90% and specificity of 100% ## Footnote High specificity makes SPECT a reliable diagnostic tool
455
What management strategies are recommended for Lewy body dementia?
* Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) * Memantine ## Footnote NICE has made detailed recommendations for drug use at various stages
456
What should be avoided in the management of Lewy body dementia?
Neuroleptics should be avoided due to extreme sensitivity and risk of irreversible parkinsonism ## Footnote Patients may deteriorate following the introduction of antipsychotic agents
457
Fill in the blank: The characteristic inclusion in Lewy body dementia is _______.
alpha-synuclein cytoplasmic inclusions
458
True or False: Visual hallucinations are a common feature of Lewy body dementia.
True
459
What is frontotemporal lobar degeneration (FTLD)?
The third most common type of cortical dementia after Alzheimer's and Lewy body dementia. ## Footnote FTLD encompasses various forms of dementia that primarily affect the frontal and temporal lobes of the brain.
460
What are the three recognized types of FTLD?
* Frontotemporal dementia (Pick's disease) * Progressive non fluent aphasia (chronic progressive aphasia, CPA) * Semantic dementia ## Footnote Each type has distinct features and symptoms.
461
What are common features of frontotemporal lobar dementias?
* Onset before 65 * Insidious onset * Relatively preserved memory and visuospatial skills * Personality change and social conduct problems ## Footnote These features help differentiate FTLD from other types of dementia.
462
What characterizes Pick's disease?
* Personality change * Impaired social conduct * Hyperorality * Disinhibition * Increased appetite * Perseveration behaviours ## Footnote Pick's disease is the most common type of FTLD.
463
What is a characteristic macroscopic change seen in Pick's disease?
Atrophy of the frontal and temporal lobes. ## Footnote This atrophy contributes to the symptoms observed in patients.
464
What defines the microscopic changes in Pick's disease?
* Pick bodies - spherical aggregations of tau protein (silver-staining) * Gliosis * Neurofibrillary tangles * Senile plaques ## Footnote These changes are important for diagnosis and understanding the disease pathology.
465
What does NICE recommend regarding the management of frontotemporal dementia?
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia. ## Footnote This guidance is based on the lack of evidence for efficacy in this specific type of dementia.
466
What is the chief factor in progressive non fluent aphasia (CPA)?
Non fluent speech. ## Footnote Patients often make short utterances that are agrammatic.
467
How does comprehension differ in CPA compared to speech production?
Comprehension is relatively preserved. ## Footnote This is a key feature that distinguishes CPA from other types of aphasia.
468
What characterizes semantic dementia?
Fluent progressive aphasia with speech that is fluent but empty and conveys little meaning. ## Footnote Unlike in Alzheimer's, memory is better for recent events rather than remote ones.
469
What is atrial fibrillation (AF)?
The most common sustained cardiac arrhythmia present in around 5% of patients over aged 70-75 years and 10% of patients aged 80-85 years. ## Footnote AF can lead to symptomatic palpitations and inefficient cardiac function, with a significant risk of stroke.
470
What are the classifications of atrial fibrillation?
1. First detected episode 2. Paroxysmal AF 3. Persistent AF 4. Permanent AF ## Footnote Paroxysmal AF lasts less than 7 days, persistent AF lasts greater than 7 days, and permanent AF cannot be cardioverted.
471
What characterizes paroxysmal atrial fibrillation?
Episodes of AF that terminate spontaneously and last less than 7 days, typically < 24 hours. ## Footnote Recurrent episodes are defined as having 2 or more episodes of AF.
472
What are the symptoms of atrial fibrillation?
* Palpitations * Dyspnoea * Chest pain ## Footnote Symptoms can vary in intensity and may not always be present.
473
What is a key sign of atrial fibrillation?
An irregularly irregular pulse. ## Footnote This sign helps differentiate AF from other conditions that can cause an irregular pulse.
474
What investigation is essential for diagnosing atrial fibrillation?
An ECG (electrocardiogram). ## Footnote Other conditions like ventricular ectopics or sinus arrhythmia can mimic AF's irregular pulse.
475
What are the two key parts of managing patients with AF?
* Rate/rhythm control * Reducing stroke risk ## Footnote Effective management focuses on both controlling the arrhythmia and minimizing complications.
476
What is the difference between rate control and rhythm control in AF management?
* Rate control: Slow the heart rate to avoid negative effects on cardiac function. * Rhythm control: Attempt to restore and maintain normal sinus rhythm (cardioversion). ## Footnote Cardioversion can be achieved using pharmacological methods or electrical shocks.
477
What is the first-line medication for rate control in AF?
A beta-blocker or a rate-limiting calcium channel blocker (e.g., diltiazem). ## Footnote These medications help manage heart rate effectively in AF patients.
478
If one drug does not control the rate adequately in AF, what does NICE recommend?
Combination therapy with any 2 of the following: * A beta-blocker * Diltiazem * Digoxin ## Footnote This approach is used to achieve better rate control when monotherapy is insufficient.
479
True or False: The predominant approach to managing AF has always been to maintain sinus rhythm.
False. The approach changed in the early 2000s to favor a rate control strategy for most patients. ## Footnote Specific situations may still warrant rhythm control.
480
What are the updated guidelines for managing atrial fibrillation (AF) according to NICE in 2021?
Based on the joint AHA, ACC, and ESC guidelines from 2012.
481
What should be done for patients with signs of haemodynamic instability presenting with AF?
They should be electrically cardioverted.
482
What is the management strategy for haemodynamically stable patients with AF for less than 48 hours?
Rate or rhythm control.
483
What is the management strategy for haemodynamically stable patients with AF for 48 hours or uncertain onset?
Rate control.
484
What is the minimum duration for maintaining therapeutic anticoagulation before considering cardioversion for long-term rhythm control?
3 weeks.
485
What is required for all patients with new-onset AF?
Anticoagulation.
486
On what basis is long-term anticoagulation determined?
CHA2DS2-VASc score.
487
What is the first-line treatment strategy for atrial fibrillation?
Rate control.
488
In which situations is rate control not the first-line treatment for AF?
* Reversible cause of AF * Heart failure primarily caused by AF * New-onset AF (< 48 hours) * Atrial flutter suitable for ablation * Clinical judgement favors rhythm-control.
489
What are the agents used for rate control in patients with AF?
* Beta-blockers * Calcium channel blockers * Digoxin.
490
What is a common contraindication for using beta-blockers?
Asthma.
491
Why is digoxin not considered first-line for rate control anymore?
Less effective at controlling heart rate during exercise.
492
What are the agents used to maintain sinus rhythm in AF patients?
* Beta-blockers * Dronedarone * Amiodarone.
493
What does NICE recommend for patients with AF who have not responded to antiarrhythmic medication?
Catheter ablation.
494
What is the aim of catheter ablation in AF treatment?
To ablate faulty electrical pathways causing AF.
495
How is catheter ablation typically performed?
Percutaneously, typically via the groin.
496
What methods can be used for ablation during catheter ablation?
* Radiofrequency * Cryotherapy.
497
What is the anticoagulation protocol before and during catheter ablation?
4 weeks before and during the procedure.
498
Why is anticoagulation still required post-catheter ablation?
It does not reduce the stroke risk even if patients remain in sinus rhythm.
499
What is the recommended anticoagulation duration if the CHA2DS2-VASc score is 0?
2 months.
500
What is the recommended anticoagulation duration if the CHA2DS2-VASc score is greater than 1?
Long-term anticoagulation.
501
What are notable complications of catheter ablation?
* Cardiac tamponade * Stroke * Pulmonary vein stenosis.
502
What is the early recurrence rate of AF within 3 months after catheter ablation?
Around 50%.
503
What percentage of patients remains in sinus rhythm after 3 years following a single catheter ablation procedure?
Around 55%.
504
What percentage of patients remains in sinus rhythm after multiple catheter ablation procedures?
Around 80%.

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