Antenatal Flashcards Preview

Fifth Year Medicine > Antenatal > Flashcards

Flashcards in Antenatal Deck (408):
1

What effect does progesterone have in pregnancy?

Relaxes smooth muscle:
uterus
gut- constipation + acid reflux
ureters- hydronephrosis

Raises temperature

2

What effect does oestrogen has in pregnancy?

Breast and nipple growth
Water retention
Protein synthesis

3

Why does vaginal discharge increase in pregnancy?

Cervical ectopy
Cell desquamation
Vasocongested vagina > increased mucus production

4

How much does plasma volume increase to in pregnancy?

3.8 Litres

5

What increases on the FBC are expected in pregnancy?

WCC (10.5)- neutrophilia from invading placenta
ESR (x4)
Cholesterol
b-globulin
Fibrinogen

6

What decreases are expected on the FBC in pregnancy?

Platelets- haemodilution + consumption
Urea
Creatinine

(small degree of hydronephrosis)

7

What happens to the inferior vena cava when pregnant woman lie supine?

From 20 weeks the gravid uterus compresses the ivc reducing venous return

8

How can ivc compression in pregnant women be reduced?

Lying in the left lateral position or wedging her tilted 15 degrees onto the left (restores venous return and thus cardiac output).

9

What effect does progesterone have on the lungs?

Relaxes smooth muscle of the diaphragm causing tidal volume to increase to 700mL

10

Why do pregnant women get breathless?

Maternal PaCO2 is set lower to allow the placenta to offload CO2 so breath more.

11

How soon will a pregnancy test give a positive result?

9 days after ovulation (day 23 of cycle)

12

How long into pregnancy is a pregnancy test positive?

20 weeks

13

How long does the corpus luteum produce progesterone for?

35 days

14

What three factors contribute to high risk pregnancies?

1. Maternal age above 35
2. Previous abnormal baby
3. Family history of genetic condition

15

What does the ultrasound scan at 11-13weeks (+6 days) look for?

Nuchal translucency
Chorionicity- twins

16

When is the second abnormality scan?

18 weeks

17

What kinds of things is the ultrasound screen better or worse at identifying?

Good for:
Structural abnormalities that alter external anatomy
- anencephaly, spina bifida

Bad for:
internal structural abnormality- under 50% pick up
- heart disease, diaphragmatic hernia

18

What is choroid plexus cyst a soft sign for?

Trisomy 21- Down's
Trisomy 18- Edwards

(choroid plexus is blood supply to brain)

19

What is echogenic bowel a soft sign for?

Trisomy 21
Cystic fibrosis- associated wit reduced bowel motility

20

Where is a-fetoprotein synthesised in the fetus?

the GI tract and liver

21

What pathologies can a high a-fetoprotein indicate?

Increased opening to amniotic sac:
Open neural tube defect
Examphalos

Tube Obstruction:
Kidney (post urethral valves) or gut abnormalities
Turner's syndrome (XO)
(NB: not Downs which has low AFP)

22

What is a normal cause of high a-fetoprotein?

Twins

23

What can cause a low a-fetoprotein?

Chromosomal abnormalities- Down's syndrome
Diabetic mother

24

When can amniocentesis be performed?

16 weeks
before then it has a 5% loss rate and may lead to talipes (club foot) or respiratory problems.

25

What is the advantage of amniocentesis over chorionic villus biopsy?

Amniocentesis provides a more accurate a-fetoprotein level to detect neural tube defects.
Chorionic villus biopsy can't detect neural tube defects

26

What is the disadvantage of amniocentesis?

Problems detected late in pregnancy
-done at 16 weeks, cell culture for enzyme and gene probing takes 3 weeks

27

What is the chorionic villus biopsy loss rate?

4%

28

When can chorionic villus biopsies be taken up until?

20 weeks

after that use cordcentesis

29

What type of pregnancy is chorionic villus biopsy not recommended in?

Dichorionic multiple pregnancy
+ After 20 weeks

30

When is fetoscopy carried out and why?

At 18 weeks to find external abnormalities

31

Loss rates of all the invasive procedures for fetal abnormality?

Amniocentesis before 16 weeks- 5%
Amniocentesis after 16 weeks- 1%
Chorionic villus biopsy- 4%
Fetoscopy- 4%

32

What can nuchal translucency be a sign of?

Anomaly of heart and great arteries- leads to oedema in neck
Downs- more hydrophilic collagen in dermis
Turners- lymph obstruction

33

Nuchal translucency has a positive predictive value of 4%, what does this mean?

Out of 100 women with a positive result, 4 will have a chromosomal abnormality

34

What type of twins have a higher rate of false positives with nuchal translucency?

Monochorionic twins

35

What risk of Down's prompts the option of invasive sampling in 1st and 2nd trimester?

1st: 1 in 150
2nd: 1 in 250

36

What does the combined test for Down's entail?

nuchal translucency (high)
b-HCG (high)
pregnancy associated plasma protein (low)
woman's age

37

How is risk assessed with the combined test for dichorionic fetuses?

Risk is done per fetus so use nuchal translucency of each for their own scores

38

What does the integrated test for Down's entail?

Nuchal translucency
Pregnancy associated plasma protein (PrAP-A)

+ Quadruple test (EFGHI):
unconjugated Estriol
maternal a-Fetoprotein
free b-HCG
Inhibin-A

39

What is the advantage and disadvantage of the integrated Down's test over the combined test?

Advantage- better than combined test
Disadvantage- can only do the quadruple test with values from the 2nd trimester

40

What Down's tests can be used in 2nd trimester?

The quadruple test:
Low:
AFP
unconjugated estriol

High: b-HCG
inhibin A

41

When can the quadruple test be used?

Between 15 weeks (+0 days) and 20 weeks (+0 days)

42

When can the combined test be used?

Between 10 weeks (+3 days) and 13 weeks (+6 days)

43

What are the indications for preimplantation genetic diagnosis?

Women who have repeatedly terminated pregnancy due to abnormality
Concurrent infertility
Recurrent miscarriage
+ if objections to terminations

44

In preimplantation genetic diagnosis how are different conditions detected?

Fluorescence in situ hybridisation- chromosomes
PCR- mongenic gene diseases

45

Women with 3 risk factors for thromboembolism should receive what Rx?

LMW heparin (like enoxaparin) fro 28 weeks + labour and 6 weeks after.
With TED stockings given.

46

Lady with BMI above 40 gives birth.
What does she need after birth?

7 days of LMWH

47

After caesarian sections that occur whilst in labour what thromboprophylaxis should woman get?

7 days of LMWH

(elective C-section is just a risk factor, of which 2 are needed to warrant post-birth LWH)

48

What are the risk factors for thromboembolism in pregnancy?

Over 35
BMI >30 in early pregnancy
Parity >= 3
Multiple pregnancy

COAGULATION
Assisted reproduction
Ovarian hyperstimulation

Hyperemesis
Vomiting

PMH:
Thromboembolism
Thrombophilia
Myeloproliferative disorder
Sickle cell

ENDOTHELIAL INJURY
Major infection- pyelonephritis, wound infection
Smoker
SLE
Inflammatory bowel disease

Pre-eclampsia
Nephrotic syndrome (hypertension, oedema, proteinuria)

FLOW
Paraplegia
Immobility for more than 2 days
pubic symphysis dysfunction
Long travel time (>3 hours)

Gross varicose veins

Flow: Labour for more than 24 hours
Coag: Blood loss> 1L
Transfusion >1L
Endo injury: Mid-cavity forceps
Elective caesarian
Postpartum sterilisation

49

How does the LMWH regimen change if a woman has two risk factors rather than 3 in pregnancy?

3- Start LMWH straight away
2- Start LMWH after delivery

50

What factors should delay starting LMWH after birth?

Postpartum haemorrhage
Wait 4 hours after epidural catheter siting or removal
Wait 6 hours after traumatic epidural catheter placement

51

How is enoxaparin (LMWH) dosed according to weight?

For every 40kg give 20mg more SC OD, starting below 50kg.

52

What constitutes very high risk of VTE in pregnancy?
How should they be managed?

Recurrent VTEs
- antiphospholipid syndrome
- antithrombin deficiency
Or on long-term Warfarin

High dose of prophylaxis, giving dose BD instead of OD
or 75% of therapeutic dose (= 1mg/kg/12hrs)

53

What dose of LMWH do you give a pregnant woman who gets a VTE?

1mg/kg SC BD enoxaparin

54

What do you give a woman who gets a VTE post partum?

1.5mg/kg OD SC ENOXAPARIN

55

How should thromboprophylaxis regimen change as a very high risk woman for VTE onsets labour?

Go from giving it BD to OD the day before and the day of induction

56

A pregnant woman had a VTE in the past due to varicose veins that have since been removed. She has no other risk factors. What thromboprophylaxis should she receive?

LMWH for 6 weeks post birth

(any previous VTE)

57

What complications of sickle cell anaemia are commoner in pregnancy?

Painful crises
Prematurity
Fetal growth restriction

58

What factors in pregnancy could precipitate painful sickle cell crises?

Cold
Hypoxia
Dehydration- vomiting
Over exertion
Stress

59

Pregnant woman has chest pain and a cough
PMH: sickle cell
IHx: infiltrates on CXR

Acute Chest Syndrome
Respiratory symptoms + CXR infiltrates

60

How should acute chest crises in sickle cell patients be treated?

Blood transfusion
+ pneumonia antibiotics

ie Cephalosporin (cefotaxime)
+ Macrolide (Azithromycin)

61

What assessments do sickle cell pregnant women require?

Echocardiography- look for pulmonary hypertension
BP + urinalysis- higher risk of pre-eclampsia
U+E, LFTs- crises can damage liver or kidney function
Retinal screening- Proliferative retinopathy common
Iron levels- may need chelation due to transfusions

62

What prophylaxis and vaccines do hyposplenic patients need?

Daily Penicillin + Erythromycin

Vaccines:
Hepatitis B
Haemophilus influenza B
Meningococcal
H1N1 seasonal influenza
Pneumococcal- every 5 years

63

What drug alterations should be made for sickle cell patients trying to conceive?

Stop ACEi and Angiotensin Receptor blockers
Start 5mg folic acid preconception

64

When can sickle cell prenatal testing be done?

8-10 weeks

65

For what Hb changes would transfusions be considered for sickle cell pregnant women?

If Hb falls to 6
or if Hb falls by 2g/dL from booking

66

What sickle cell complications in pregnancy would need an exchange transfusion?

Acute chest syndrome
Stroke

67

What pain relief should be used or avoided for sickle cell pregnant women with crises?

Use morphine/diamorphine
Avoid pethidine- increases risk of fits

68

What heparin regime should be given to sickle cell women after birth?

Heparin for 7 days if vaginal delivery
or for 6 weeks if caesarian

69

What is the maternal mortality associated with Eisenmenger's syndrome and pulmonary hypertension?

30-50% so advise against pregnancy

Eisenmenger's = right to left shunt

70

What thromboprophylaxis regime can be used for women with prosthetic heart valves?

Heparin IV on weeks 6-12 and 37 to term +7 days
Warfarin at other times

71

Why can't Warfarin be used throughout pregnancy for women with prosthetic heart valves?

Fetal harm

72

What position should be avoided in labour for women with impaired cardiac function?

Avoid lithotomy position- causes dangerous rise in venous return after labour
Semi-sitting is best with short 2nd stage labour- instrumental delivery may be needed

73

In labour what drug should be avoided in mothers with cardiac impairment?

Ergometrine for expulsion of the placenta
use OXYTOCIN if necessary instead

74

Under what circumstances would a caesarian be given for a woman with cardiac impairment?

Only if she develops eclampsia should it be given. shouldn't be done if she is in heart failure unless eclampsia occurs.

75

Rx for pregnant women who develop acute heart failure?

Furosemide 40mg IV slowly
Oxygen
Morphine 10mg IV

Ventilation if no improvement

76

Rx for pregnant woman with palpitations
ECG shows narrow complex tachycardia

Valsalva manoeuvre
Carotid massage

anaesthetise and cardiovert if unstable
IV adenosine if stable

77

What heart sounds can be normal in pregnancy?

Loud S1
an S3 heart sound
Ejection systolic murmur

78

What cardiac signs can be normal in pregnancy?

Pulsating neck veins (not raised JVP)
Oedema
Forceful apex beat

79

What CXR findings can be normal in pregnancy?

Slight cardiomegaly
Distention of pulmonary veins (due to increased plasma volume)

80

What signs are not normal in pregnancy?

A raised JVP in neck
Apex beat more than 2cm lateral to the midclavicular line

81

When is it best to hold off antidepressants until in pregnancy?

2nd trimester

82

Which antidepressants are typically prescribed in pregnancy?

Tricylics- AMITRIPTYLINE
(blocks seratonin reuptake)

83

What is the disadvantage of tricyclics in pregnancy?

Consequences of overdose are worse than SSRIs

84

What withdrawal symptoms of amitriptyline (TCA) are seen in neonates?

Agitation ± respiratory depression
(it's an SNRI and 5-HT is involved in chemoreception at central respiratory centres, increases breathing rate so as conc lowers, so does breathing rate)

85

What withdrawal symptoms of imipramine (TCA) are seen in neonates?

(Imipramine also blocks serotonin uptake)
Colic
Spasms
Hypotension/hypertension (binds a-adrenergic Rs)

86

What withdrawal symptoms do neonates get from clomipramine (TCA) antidepressants?

Convulsions

87

What is the danger of using SSRIs in pregnancy for depression?

Persistent pulmonary hypertension of the newborn if used after 20 weeks gestation

88

Which SSRI in pregnancy is associated with least known risk?

Fluoxetine

89

Why is paroxetine SSRI contraindicated in pregnancy?

1st trimester- associated with cardiac malformations
withdrawal in neonate- convulsions

90

Which antidepressants have the lowest rate of transfer in breastfeeding?

Imipramine (TCA)
Nortriptyline (TCA)
Sertraline (SSRI)

91

Which antidepressants have the highest rate of transfer in breastfeeding?

Citalopram (SSRI)
Fluoxetine (SSRI)

92

What defects in the fetus is lithium therapy associated with?

Teratogenicity: Heart defects
ie Ebsteins abnormality
(displaced tricuspid valve allows back flow of blood into the R atrium)

93

For pregnant women who choose to stay on lithium therapy what investigation should be offered?

Fetal echocardiography at 16 weeks incase of heart defects

94

How should drug levels be monitored in women electing to stay on lithium during pregnancy?

Up to 36 weeks:
Measure 12hours after dose 4x a week

After 36 weeks:
Measure weekly

95

What lithium drug level is aimed for if continuing it in pregnancy?

As low as possible- under 0.4mmol/L

96

Can women taking lithium breastfeed?

No.

97

Can women with schizophrenia continue taking phenothiazines in pregnancy?

Yes = Dopamine 2 Receptor antagonist

98

What can phenothiazine use in pregnancy (for schizophrenia) cause in the newborn?

Phenothiazine = DA 2 R antagonist, causes parkinsonism symptoms in baby:
Hyperreflexia
Hypertonia
Tremor

99

Which antipsychotics can lead to raised prolactin levels and thus infertility?

Atypicals: Amisulpride
Sulpride
Risperidone
dopamine antagonists stop inhibition of prolactin

100

What can Olanzapine (anti-schizophrenic) cause in pregnancy?

Gestational diabetes due to weight gain. Atypicals are known to sometimes trigger metabolic syndrome

101

What side effects can anxiety medication cause in pregnancy?

Benzodiazepines- fetal malformation
Diazepam- floppy baby syndrome when withdrawal
b-blockers- retard fetal growth

102

What are the diagnostic indications for amniocentesis?

Prenatal genetic studies
Assess fetal lung maturity- if possibility of prematurity
Chorioamnionitis or TORCH infection (toxo, rubella, CMV, HSV, HIV)
Blood type, haemoglobinopathies
Neural tube defects

103

What is twin to twin transfusion syndrome?

Occurs with monochorionic pregnancies where placental vascular anastomoses cause disproportionate blood supplies.

One twin becomes anaemic- used too much oxygen
the other twin becomes plethoric and then jaundiced when red cells are destroyed at birth- used to too little oxygen

104

What structures need to be avoided during amniocentesis?

The umbilical cord and its insertion site.
Maternal bowel and bladder

105

What symptoms after amniocentesis are normal and which should be reported?

Expect: Mild cramping
Report: Vaginal bleeding/discharge, severe uterine cramping or fever

Avoid: coitus and anaerobic exercise for a day

106

Why might a genetic abnormality be detected in chorionic villus sampling but not in amniocentesis or fetal blood sampling?

Confined placental mosaicism- only the placenta contains the abnormality.
At inner cell mass stage, a few cells will derive the fetus and a few the placenta.
Could be only the placental precursors don't correctly split the chromosomes (post-zygotic nondisjunction) or there's trisomic rescue in the fetal cells (deletes extra chromosome)

107

What is antepartum haemorrhage defined as?

Bleeding from the genital tract after 24 weeks of pregnancy

108

What can cause antepartum haemorrhage?

Placental abruption- placenta separates from uterus lining
Placental praevia- placenta anchored in the lower uterine segment
Vasa praevia- fetal blood vesse;s running across uterine os
Genital tract source

109

What ares the dangers of anaemia in pregnancy?

Worsens postpartum haemorrhage
Predisposes to infection
Antagonises heart failure
Causes problems with postnatal malaria

110

Risk factors for placenta praevia

Age >40
Babies before (multiparity)
Caesarian/ Previous uterine surgery
Dilatation & cutterage (biopsies)
Endometriosis + deficient Endometrial-manual removal of the placenta
Fibroids
Going smoking

111

What investigation best diagnoses a low lying placenta

Transvaginal ultrasound, not transabdominal

112

What investigation can be combined with ultrasound to diagnose vase praevia or placenta acreta?

3D Doppler USS /MRI

113

What is the most severe form of placenta praevia?

Major/Grade 4
Covers the internal os

114

How is major placenta praevia treated?

Caesarian section for delivery.

115

What are the different grades of placenta praevia?

1. minor- placenta in lower segment, doesn't extend to cervix
2. minor- placenta extends to cervix, does not cover it
3. major- placenta partially covers cervix
4. major- placenta wholly covers cervix

116

What factors in placenta praevia would suggest caesarian is needed rather than vaginal delivery?

If placenta encroaches within 2cm of internal os
especially if it encroaches posteriorally or is thick

117

Why does placenta praevia predispose to postpartum haemorrhage?

Poor contractility of the uterus in the lower segment, where the placenta is lying.

118

If accreta suspected in a case of placenta praevia, when should the baby be delivered?

36-37 weeks with steroid cover and cross-matched blood available

119

Placenta weighs more than 25% of the baby and baby has proteinuria at birth and is swollen, what does this suggest?

Congenital nephrotic syndrome (HOP)
Common in Finnish population

120

Give 2 reasons why vasa praevia may occur?

1. Velamentous cord insertion- cord inserts into chorioamniotic membranes instead of placenta, vessels are running with the cord
2. Vessels may be joining an accessory lobe of the placenta to the main placental disk.

121

What are the issues of an anterior low-lying placenta?

During the caesarian the placenta may need to be parted to access the baby.
Also more possibility of accreta

122

What abdominal findings can be found with placenta praevia?

Soft uterus
High presenting part

123

25 year old, para 2 presents at 37 weeks
Pain at uterine fundus, fresh vaginal bleeding
Abdomen is hard and tender. Diagnosis?

1. degenerating uterine fibroid
2. pancreatitis
3. placenta praevia
4. torted ovarian cyst
5. placental abruption

Placental abruption

Fundus where placenta normally is

124

What should be avoided with placenta praevia?

1. Pervaginal examinations
2. PV intercourse

125

Why isn't blood loss a good indicator of placental abruption severity?

Blood can collect behind membranes.

126

20 year old woman at 38 weeks gestation
Vaginal bleeding that started as membranes ruptured 20 minutes ago
CTG shows fetal bradycardia
Diagnosis?

Vasa praevia- stretching of os ruptures vessels

127

25 year old primip at 30 weeks
Fresh vaginal bleeding and abdominal pain
EHx: uterus is tender and irritable

Diagnosis?

Placental abruption

128

41 year old para 2 (caesarian sections) at 32 weeks
Heavy vaginal bleeding
Soft non tender uterus

Diagnosis?

Placenta praevia

RFs: age, babies before, caesarians
EHx typical

129

37 year old refugee, HIV positive
2/12 vaginal bleeding with intercourse

Diagnosis?

Cervical carcinoma
HIV increases risk

130

Definition of haemocrit?

Blood cells/Blood volume

131

22 year old primiparous woman
Vaginal spotting at 24 weeks gestation
Vulval itching and vaginal discharge

Diagnosis?

Vulvo-vaginitis (likely candida)

132

MCHC, mean corpuscular haemoglobin concentration

Hb concentration in a given volume of packed red cells

133

How does LMW heparin work?

Increases adhesion of anti-thrombin to factor Xa (10a)

134

What factors are involved in the intrinsic pathway of coagulation?

Factor 12, 11, 9, 8

Contact activation with damaged surface

135

What part of the clotting cascade does APTT measure?

The intrinsic, contact-activated pathway
Involves factors 12, 11, 9, 8

136

How does unfractionated heparin work differently to LMW heparin?

LMWH activates Antithrombin - inhibits factor Xa

UF heparin activates Antithrombin- inhibits factor Xa + thrombin

X > Xa
Prothrombin > Thrombin

137

Which proteins degrade Factor V and where is Factor V involved in the coagulation pathway?

Factor Va combines with Factor X to activate Thrombin

Protein S + Protein C degrade Factor V

Protein C resistance = factor V not degraded

138

Why is the Kleinhauer test used?

To determine how much fetal Hb is in the maternal blood stream and therefore whether fetal haemorrhage is the cause of fetal death

139

How does the Kleinhauer test work?

Acid is added to maternal blood which destroys adult Hb, leaving only the fetal Hb behind to be quantified.

140

Why might TSH be low in the first 20 weeks of pregnancy?

HCG suppresses it

141

What are the factors of hyperemesis gravidarum?

Persistent vomiting leading to:
5% of weight loss from pre-pregnancy weight
Ketosis

142

What are the risk factors for hyperemesis gravidarum?

Youth
Primips

Multiple
Molar pregnancy

PMH: diabetes,
hyperthyroidism,
psych illness,
eating disorder

FHx
SHx: non smokers, working women

143

What is thought to underlie morning sickness?

Steeply rising oestrogens

144

Excessively high levels of what are thought to cause hyperemesis gravidarum?

HCG
(as molar and multiple pregnancy are RFs)

145

If a woman has hyperemesis in one pregnancy, what is the likelihood of reoccurance?

15%
10% if she changes partner

146

How should hyperemesis gravidarum be investigated?

Urine dipstick- look for ketones
For guiding fluids: U+Es + Packed Cell Volume (FBC)
LFTs will be abnormal

TFTs- abnormality corresponds to severity of hyperemesis, indicates likely duration of hospital stay

Fluid chart, weights, BP lying and standing
USS- exclude twins or hydratidiform mole

147

How should Hyperemesis Gravidarum be managed?

Enoxaparin 40mg SC
Thiamine 40mg TDS (prevent Wernicke's encephalopathy)
IV Saline + Potassium
Cyclizine 50mg TDS PO/IM for emesis

148

What things can help with hyperemesis?

Rest
Ginger
Pyridoxine- found in bananas, whole grains, avocados
Dry bland food
Carbonated drinks

149

What antiemetics are D2 antagonists

METOCLOPROMIDE

PROCHLOPERAZINE

CHLORPROMAZINE

DOMPERIDONE

150

Which antiemetic for pregnancy antagonises 5-HT 3 receptors?

ONDANSETRON

(the only one with an S for Seratonin)

151

Which antiemetic for pregnancy acts on antihistamine Rs?

Cyclizine

152

What are the potential side effects of phenothiazines like prochlorperazine or chlorpromazine (used for anti-emesis)?

Drowsiness
Extrapyramidal side effects- dystonia, parkinsonism
Oculogyric crisis- involuntary upwards looking

153

If someone has hyperemesis resistant to anti-emetics, what can be tried?

100mg BD Hydrocortisone

then 40mg Prednisolone OD
tapering down towards 20 weeks gestations

154

What do women taking steroids in pregnancy need to be monitored for?

UTIs
Gestational diabetes

155

What is anaemia in pregnancy defined as?

Hb below 11g/dL

156

How to treat iron deficiency anaemia in pregnancy?

Ferrous Sulphate 200mg OD

157

What can you give to anaemia patients not tolerating iron supplements?
What does it risk?

Parental (IV) iron
Anaphylaxis

158

After iron supplementation how long does it take for Hb levels to improve?

6 weeks

159

When should iron not be given for a microcytic anaemia?

When thalassaemia is suspected, iron levels will already be high.

160

Which thalassaemia is more severe for the fetus to have?

a thalassaemia is worse (as HbF is a2 y2)

b thalassaemia affects adult Hb (a2, b2)

161

How can thalassaemias be identified?

Chorionic villus sampling

162

What reduces risk of HIV transmission in pregnancy and peripuerium?
3 things

1. Antiretroviral use
2. Elective caesarian
3. Bottle feeding

163

What should pregnant women found to be HIV +ve be tested for?

Antibodies against:
Hep B + Hep C
Varicella zoster
measles
toxoplasmosis

Genital tract infections

164

What vaccines should HIV +ve pregnant women be offered?

Vaccines for:
Hep B
Pneumococcus
Influenza

165

What are women with HIV in pregnancy more at risk of?

Infections
and thus, pre-term labour

166

What are women on HAART for HIV more at risk of?

Gestational diabetes

167

HIV +ve women taking prophylaxis against pneumocystis jirovecii (co-trimoxazole) should also take what in early pregnancy?

5mg folic acid

as trimethoprim in cotrimoxazole inhibits folate synthesis

168

For women who are HIV +ve not taking HAART, when should they start taking it in pregnancy?

Zidovudine from 20-28 weeks until delivered

169

What should you do if a HIV +ve woman's membranes rupture earlier than 34 weeks?

Steroids- for lung development
Erythromycin
take normal HAART regime
may need zidovudine IV

170

Which women with HIV could have a vaginal delivery?

If viral load is below 50 copies per mL

or if on HAARt and viral load is below 400/mL

171

What monitoring investigation in labour should be avoided if a woman is HIV +ve?

Fetal blood sampling OBVS

172

What instrumentation is preferred in HIV +ve women?

Low cavity forceps

Appears to cause less fetal trauma than mid-cavity forceps or the ventouse (kiwi)

173

When should HIV women undergoing Caesarian have it?

At 38 weeks

unless viral load is under 50copies/mL, then 39 weeks + is fine

174

Which HIV +ve women should be offered caesarian?

3 reasons

1. If viral load is above 50, or above 400 on HAART
2. If coinfected with Hep C
3. If on zidovudine monotherapy

175

What can be given after birth to suppress lactation in HIV mothers who can't breastfeed?

1mg Cabergoline within 24 hours.

(Dopamine agonist, acts on pituitary to suppress prolactin)

176

What HAART regimen should new borns recieve after delivery if mum is HIV +ve?

Zidovudine BD for 4 weeks

HAART if mum is untreated/high risk

177

For babies at high risk of HIV transmission, what other medication should be given aside from HAART?

Co-trimoxazole to protect against pneumocystis jirovecii

178

What CD4 count is a contraindication for HIV +ve women to receive an MMR vaccine?

below 200/mL
as MMR is a live vaccine

179

What HbA1C is the aim for diabetic women before they conceive?

Below 6.1%

Avoid conception is above 10%

180

What supplement should diabetic women take before conception?

5mg folic acid

181

What diabetic medications should be stopped before pregnancy?

Oral hypoglycaemics- except metformin
Statins
ACEi/ A2R blockers

182

What are the maternal risks of diabetes?

Unawareness of hypoglycaemia
Hydramnios-(could be due to fetal polyuria)
Preterm labour
Stillbirth

183

What are the risks of diabetes to the fetus?

CVS + CNS malformation
Macrosomia- more glucose not taken up by cells
Growth restriction

Rarely sacral agenesis (no sacrum bones, bad bad)

184

What are the risks to the neonate when the mother is diabetic?

name 4 things

Hypoglycaemia- persistent high insulin levels with sudden loss of glucose

Low Ca2+ or Mg2+- due to low maternal levels with polyuria

Respiratory distress syndrome- high insulin interferes with steroid maturation of lungs perhaps

Polycythaemia (jaundice)- high insulin increases metabolic rate, increasing oxygen requirements and predisposing to hypoxia

185

What is the fasting sugar level at which you would diagnose gestational diabetes?

5.6mmol or over

186

What is the 2 hour glucose level that suggests gestational diabetes?

7.8mmol/L or over

187

What values would prompt referral of diabetic mother to nephrologist?

Creatinine above 120micromol/L

or protein excretion more than 2g/24 hours

188

What diabetic medication is used in pregnancy?

Metformin
Insulin

189

Why should maternal hyperglycaemia be avoided during labour in diabetic mothers?

High glucose leads to high insulin levels
predisposes the baby to hypoglycaemia when the glucose source suddenly dissappears

190

What should be aimed for in the labour of diabetic mothers?

Deliver at 38 weeks
Vaginally
Give insulin to prevent hyperglycaemia
Aim for under 12hours

191

What complication is increased in delivery of diabetic mother's babies?

Shoulder dystocia

192

What insulin and glucose can be given to mothers electively giving birth who have diabetes?

Night before- normal insulin
On day-
1L 5% Dextrose /8 hours IV
1-2U Insulin/ hour via pump

Aim: 4.5-5.5mmol/L check hourly

193

How is the timing of cord clamping related to polycythaemia risk?

The cord transfers the placental reservoir of RBCs to the newborn after birth, 75% are transferred in the first minute so depending when it is clamped, more or less RBCs will be recieved by the fetus.

194

Which diabetic medications are allowed when breastfeeding?

Metformin- increases insulin sensitivity
Glibenclamide- acts on Katp channels in pancreatic b cells

195

How is gestational diabetes defined?

>7.8mmol/L glucose on the Oral Glucose Tolerance Test

196

What proportion of gestational diabetics become diabetic after pregnancy?

50%

197

What hyperthyroid treatment is contraindicated in pregnancy?

radioactive iodine

198

What thyroid drug is recommended for hyperthyroidism in pregnancy and breastfeeding?

Propylthiouracil
inhibits conversion of iodide into iodine for hormone production
preferred to carbimazole, less concentrated in breast milk too

199

What can be done for hyperthyroidism in pregnancy if drugs don't work?
and when?

Partial thyroidectomy in 2nd trimester

200

At onset of labour woman starts to become feverish, tachycardic, agitated, psychotic.
DHx propythiouracil

Whats the diagnosis?

Thyroid storm

201

What consequences can occur from fetuses having TSH-receptor antibodies?

Fetal hyperthyroidism- premature delivery
Craniosynostosis (skull sutures are fixed) - intellectual impairment
Goitre- polyhydramnios as fetus doesn't swallow enough amniotic fluid

202

How much should levothyroxine be increased by when a woman finds out she is pregnant?

30%

203

What TSH should a woman with hypothyroidism aim for in pregnancy?

below 2.5mu/L

204

For women with gestational diabetes, how long should you trial diet and exercise before switching them onto oral hypoglycaemics?

1-2 weeks

205

How to Rx postpartum thyrotoxicosis?

b- blockers (symptomatic)
antithyroid drugs don't work as the gland is releasing more due to it being attacked not because it is synthesising more

monitor for permanant hypothyroidism

206

What proportion of women giving birth undergo thyrotoxicosis for 4 months, which eventually resolves?

5%

90% have antiperoxidase Abs. Hyperthyroidism then hypothyroidism
5% develop permanent hypothyroidism

207

Mother has had Grave's disease in past
At 37 weeks fetus' heart rate is 170/min

Diagnosis + Rx?

Neonatal thyrotoxicosis
Mother's TSH-R stimulating Abs cross placenta

Test thyroid function in baby
May need antithyroid drugs

208

What are the different antibodies associated with thyroid disease?

TSH R-stimulating antibodies: Graves' disease
Antiperoxidase antibodies: thyroiditis
Thyroid antibodies: can occur in pregnancy

209

What tests should you do for a pregnant woman with jaundice?

Urine test for bile- obstructive cholestasis (alk phos high)
Serology- hepatitis
LFTs- hepatitis (massive AST, ALT increase)
Ultrasound- obstruction, fibrosis

210

Woman in third trimester, intractable itching. Gravida 2 para 1
Previous pregnancy, lots of itching too.
ALT 250 iU/L, AST 250iU/L, Bilirubin 3.1, yGTP= normal
Serum bile acids- 10x normal level

R upper quadrant USS= normal
Viral serology= normal
Diagnosis?

Intrahepatic (obstructive) cholestasis
Bile can't get out of the hepatocyte

No abdo pain or fever making choledocolithiasis unlikely
No dilatation of bile duct making cholangitis unlikely
Normal yGTP- making primary biliary cirrhosis unlikely
Serology- not hepatits

211

What Rx can you offer a pregnant woman with intrahepatic cholestasis?

Cholestasis- bile can't get out of hepatocyte cells

Vitamin K to woman and baby at birth
Ursodeoxycholic acid reduces pruritis and abnormal LFTs

212

When should pregnancy associated- obstructive cholestasis resolve?

Within days of delivery

213

When do pregnant women get obstructive cholestasis?

Third trimester when levels of oestrogen are highest- exact mechanism unknown

214

What type of contraception should women who have had pregnancy-related intrahepatic cholestasis avoid?

Oestrogen containing contraaceptive pills because it is the high levels of oestrogens thought to prompt the cholestasis in pregnancy.

215

Pregnant woman gravida 1 para 0 comes in with jaundice, vomiting and abdo pain.
BP is mildly raised
AST + ALT 300iU/L, WCC raised, Prothrombin Time increased
Urinanalysis- trace protein

What is diagnosis and differential?

Acute Fatty Liver of Pregnancy (1 in 10000)
Micro-droplets of fat in liver cells

Normalish BP and urinalysis make HELLP and Atypical Pre-eclampsia less likely
Coagulopathy (^PT time) + jaundice make Fatty Liver more likely
Abdo pain makes fatty liver more likely than cholestasis

216

What symptoms or test findings make fatty liver more likely than HELLP or atypical pre-eclampsia?

Hypoglycaemia (as liver fails to break down glycogen)
Encephalopathy
Coagulopathy
Not very raised BP or urine protein

217

What Rx should be offered to women with Acute Fatty Liver of Pregnancy?

Treat hypoglycaemia vigorously (protect from neonatal hypoglycaemia)

Correct clotting disorders (in preparation of birth)
Fresh frozen plasma, cryoprecipitate, RBCs, platelets PRN

Supportive treatment for liver and renal failure- fluids

218

Which viral hepatitis is associated with high mortality rates in pregnancy?

Hepatitis E

219

Under what circumstances would you offer a pregnant woman with viral hepatitis a caesarian section?

If she has HIV also

220

When should you check a baby for Hep C RNA if the mother is Hep C +ve?

after 2/3 months and again at 12 months

anti HCV Abs at 12-18 months

221

Why might someone with pre-eclampsia get jaundice?

DIC- tissue factor from high BP damage to endothelium
HELLP
Fatty liver (rare)

222

Causes of jaundice in pregnancy:

Pregnancy specific:
intrahepatic cholestasis (itchy)
acute fatty liver (low BM, clotting abnormal)
hyperemesis gravidarum- 1st trimester (ketones)
pre-eclampsia (BP, ketones)
HELLP- haemolysis, elevated LFTs, low platelets

Viral hepatitis (serology)

223

What does HELLP stand for?

Haemolysis, elevated LFTs, low platelets

in 16% of cases it coincides with pre-eclampsia

224

28 weeks pregnant woman, gravida 1 para 0 with twins
was hypertensive, prescribed methyldopa and has progressively increasing aminotransferases.
platelets are normal, urine dip: 1+ protein
hepatitis serology- autoimmune and viral is normal

differential + management?

Severe pre-eclampsia, toxicity to methyldopa, acute fatty liver.

Switch methyldopa to labetalol for her HTN
Give corticosteroids incase early delivery is needed
Monitor LFTs in hospital

225

28 week pregnant woman with a history of mild hypertension, urine dip: 1+ protein, raised serum aminotransferases was admitted to hospital.
platelets were normal, hepatitis serology normal.
36 hours later thrombocytopenia has arisen, BP has steadily risen and headache onset. Her ALTs + ASTs continue to climb

Diagnosis and management?

HELLP syndrome
Elevated LFTs + Low platelets

Deliver asap
Try to give steroids for lung maturation if she hasn't already had.

226

What kind of ALT's would you expect in jaundice caused by hyperemesis gravidarum in pregnant women?

Below 200iU/L

227

Pregnant woman presents with fever and sweating
she recently went to visit family in Malawi

Possible diagnosis and investigations?

Malaria

Thick and thin blood films

228

Pregnant woman with malaria is found to be unconscious
She was started on quinine a few days ago

What could have happened?
Investigations?

Hypoglycaemia or cerebral malaria

Check blood glucose, as quinine and malaria both cause low glucose.

229

Rx for pregnant woman with severe Falciparum malaria?

ARTESUNATE 2.4mg/kg IV
then ARTESUNATE + CLINDAMYCIN PO when possible

or
QUININE in 5% glucose

230

What are the possible complications to the mother of malaria in pregnancy?

HA SPR

Hypoglycaemia- especially if on quinine
Anaemia- may need packed red cells + furosemide 20mg

Sepsis
Pulmonary oedema
Renal failure

231

How should uncomplicated Falciparum malaria be treated in pregnancy?

Quinine 600mg
+ Clindamycin 450mg TDS

232

How should non-resistant vivax + ovale malaria be treated during pregnancy?

Chloroquine PO 3 days
then weekly to prevent reoccurence

3 months after delivery give
PRIMAQUINE

233

If mother had malaria during pregnancy, what should you do after birth to see if the baby got it?

Send placenta for histology
and bloods from the cord, placenta and baby 4x a week

234

Pregnant woman going to a malarial area, what should she take?
Any additional medications?

Chloroquine + Proguanil if Falciparum is sensitive
+ 5mg folic acid with Proguanil

Mefloquine if malaria is resistent

235

In which trimester is malarial prophylaxis an issue?

1st trimester

236

What is the benefit on pregnant women who live in malaria endemic areas of giving them chemoprophylaxis?

What chemoprophylaxis can you give?

Better neonate birthweight
Higher red cell mass in mum

Sulfadoxine-pyrimethamine
but increasing resistance and rarely cases of Steven Johnson syndrome occur.

237

What creatinine and urea values in pregnancy would prompt investigation of renal function?

Creatinine above 75umol/L
Urea above 4.5mmol/L

238

Pregnant woman has no symptoms
Urine dip + WCC, + nitrites on two mid-stream urines

Rx?

Asymptomatic bacteruria

Amoxicillin 250mg TDS with high fluid intake

Check for cure in 1-2 weeks

239

Why are pregnant women screened for asymptomatic bacteruria?

High risk of developing pyelonephritis as ureters and calyces are dilated.

240

Rx for pyelonephritis during pregnancy

Fluids + bed rest
Blood + urine culture then

AMPICILLIN 500mg QDS IV
for 2-3 weeks, G +ve and G-ve cover

241

Once a woman has had pyelonephritis in pregnancy what monitoring should be undertaken?

Mid-stream urine every 2 weeks
Ultrasound at 16 weeks postpartum can be considered if renal tract abnormality suspected

242

Pregnant woman has had repeated urinary tract infections, Rx?

Nitrofurantoin 100mg PO OD with food

attacks bacterial ribosomes

243

When is the antibiotic nitrofurantoin (for recurrent UTIs) not a good idea? In pregnancy

When GFR is below 50mL/min
(nephrotoxic)

SEs: vomiting, peripheral neuropathy, liver damage

244

What complications need to be looked for in pregnant women with chronic renal failure on dialysis?

Fluid overload
Hypertension
Pre-eclampsia
Polyhydramnios

245

Where pregnant women get acute tubular necrosis and need to be catheterised, what urine output should be the aim?

30mL/hour

246

What complications can arise in pregnancy for those with epilepsy?

3rd trimester vaginal bleeding- possibly related to folate deficiency from antiepileptic medications

1% convulse in labour

247

What do anti-epileptic drugs put foetuses at risk of?

Enzyme inducers- haemorrhagic disease of newborn
Malformation with valproate,carbamazepine or lamotrigine
depends on dose and how many anticonvulsants used

248

What are the features of fetal valproate syndrome?

L SOAS

L SOAS

Long thin upper lip

Small ears + nose + jaw
Organ anomalies
Autism
Shallow philtrum

249

Which epileptic drugs are associated with cleft lips In newborns?

Phenytoin
Phenobarbital

(also congenital heart disease)

250

Which epileptic drugs are associated with neural tube defects?

Valproate
Carbamazepine

screen for them

251

What is the antiepileptic of choice in pregnancy?

Carbamazepine

still associated with congenital malformation + neural tube defect

252

What non-epileptic related medication should a pregnant woman with epilepsy take?

5mg folic acid OD

20mg Vitamin K from 36 weeks if taking enzyme inducers
(carbamazepine, phenytoin, phenobarbital)

253

Which epileptic drug can cause drowsiness of baby if taking it whilst breastfeeding?

Phenobarbital

254

Rx of rheumatoid arthritis in pregnancy?

Give sulfasalazine + extra folate

255

Which rheumatoid arthritis drugs are not recommended for pregnancy?

Methotrexate is contraindicated

Azathioprine can cause growth restriction- impact on immune system, may affect spiral artery conversion

Penicillamine may weaken fetal collagen

256

When can NSAIDs be taken in pregnancy for rheumatoid arthritis?

Why?

1st and 2nd trimester

In 3rd trimester impact on prostaglandin levels may cause premature closure of ductus arteriosis and renal impairment

257

When is it feasible for women with SLE to consider pregnancy?

After 6 months of stable disease status without using cytotoxic drugs.

258

What drugs to treat women with SLE on during pregnancy?

azathioprine (even though it's avoided in RA)
hydroxychloroquine

aspirin 75mg for pre-eclampsia risk

259

What risks does the foetus face if the mother has SLE?

Sunlight-sensitive rash (which doesn't require treatment)

Anti-Ro/anti-La may damage heart conduction causing congenital heart block= requires a pacemaker

260

Mother with SLE is taking 7.5mg PREDNISOLONE daily in 2 weeks before birth. What medication does she require in labour?

Hydrocortisone 100mg per 6 hours IV

to mimic physiology of birth with rise in cortisol now that endogenous steroid production is reduced

261

What test findings and PMH are defining features of antiphospholipid syndrome?

lupus anticoagulant
or anticardiolipin antibodies
on 2 tests taken 8 weeks apart

± past arterial thrombosis
venous thrombosis
recurrent pregnancy loss

262

What is the likelihood of a live birth for women with untreated antiphospholipid syndrome?

under 20%
thromboses in the placenta lead to 1st trimester loss due to placental insufficiency and growth restriction

263

How can women with antiphospholipid syndrome be treated in pregnancy to reduce fetal loss?

75mg aspirin- from conception

High dose LMWH if previous VTE
Low dose LMWH if no VTE
(from when fetal heart is seen at 6weeks ish to 34 weeks)

264

What is the difference between chronic and gestational hypertension and pre-eclampsia?

Chronic HTN- predates pregnancy or 20 weeks gestation

Gestational HTN- comes on after 20 weeks, no proteinuria

Pre-eclampsia- HTN + proteinuria

265

What antihypertensives should be changed pre-conception for those considering pregnancy

STOP
ACE inhibitors- ramipril
Angiotensin 2 Receptor blockers- losartan
Chlorothiazide- thiazide

266

Which antihypertensives are okay in pregnancy?

b blockers: Atenolol + Labetalol + Metoprolol
Methyldopa

267

What BP should be aimed for in pregnant women with chronic hypertension without end organ damage?

BP under 150/90

268

What BP should be aimed for in pregnant women with chronic hypertension with end organ damage?

Under 140/90

+ diastolic above 80

269

When should pregnant women with chronic hypertension start aspirin?

From 12 weeks until the baby is born

270

How regularly should women have their blood pressure checked in labour if they have PMH of chronic hypertension?

hourly if BP is below 159/109
continuously if BP is above 160/100 mmHg

271

How does active management of the third stage of labour change if a woman has a history of hypertension?

Oxytocin is given alone
No ergotamines

272

When should a woman have her BP checked if shes just given birth and has a PMH of chronic hypertension

Day 1 + 2 + 3/4/5

273

What antihypertensive should be changed after delivery in women with chronic hypertension?

Methyldopa- predisposes to postnatal depression

274

Which classes of hypertensives are okay or not when breastfeeding?

b-blockers and ACEi = okay
diuretics = avoid

275

What tests need to be performed with gestational hypertension (comes on after 20 weeks gestation)?

Urine dip- proteinuria
Protein creatinine ratio

276

Pregnant woman at week 23 has a BP of 145/95mmHg
How should she be managed?

Weekly urine dips and BP

277

Pregnant woman at 25 weeks has blood pressure of 155/105
no history of hypertension before

management?

IHx: BP and urine dips twice weekly
As BP is above 150/100 give
LABETOLOL

278

What blood pressure with gestational hypertension would provoke admission to hospital?

A blood pressure above 160/110

279

Woman has gestational hypertension, BP of 161/110
Management?

Admit to hospital
IHx: BP 4x a day
Daily urine
Weekly FBC, U+Es, AST/ALT, bilirubin
Fortnightly ultrasound

280

In pregnancy how does hypertension affect mode of delivery?
Should there be any change to medication?

Maintain antihypertensives during labour
Monitor BP hourly or continuously (if above 169/110)
If above 160/110 consider c-section

281

What are the soft ultrasound signs for Downs?

Fetal nasal bone appearance
Doppler velocity wave form in:
the ductus venosus
tricuspid regurgitation
Nuchal thickening
Chorioid plexus cysts
Echogenic bowel

282

What material is analysed in preimplantation genetic diagnosis?

1st polar body of the egg
2nd extruded polar body of zygote
Blastomeres from embryos at day 5-6

283

Pregnant woman comes in, she's 31 weeks pregnant
PC: sudden onset breathlessness, chest pain
Obs: T of 38 degree
CXR normal

Tests?
Any precautions regarding tests?

Could be pulmonary embolism
ABG: reduced PaO2 and PaCO2
Scan legs for venous thrombi

if none found:
V/Q scan (increases risk of cancer to fetus)
CTPA (increases risk of breast cancer in mum and fetal hypothyroidism)
fetal hypothyroidism due to iodinated contrast used.

284

If pregnant woman with signs of PE is found to have thrombi in legs on scanning, does she need any other tests before treatment?

No further imaging needed (VQ scan or CTPA)
but should do:
FBC
U+Es- check hydration status (RF)
coagulation screen
LFTs- incase of liver failure

Rx: small- LWMH, massive- unfractionated heparin + thrombolysis

285

How might a massive Pulmonary Embolism present in a pregnant woman?

PC + EHx

PC: Collapse, cyanosis, chest pain
EHx: raised JVP (pulmonary hypertension
third heart sound
parasternal heave (R ventricle enlargement)

286

What management can be used for massive pulmonary embolism in pregnant women?

Prolonged cardiac massage
Percutaneous catheter thrombus fragmentation
Thrombolysis
Pulmonary embolectomy- clot removal (often last resort)

287

Pregnant woman has massive pulmonary embolism, is treated with percutaneous catheter thrombus fragmentation.
What medication should she be given after?

Post-thrombolysis- continuous IV unfractionated heparin

No thrombolysis- STAT dose first as loading dose

then LWMH

288

Once unfractionated heparin is given for a massive pulmonary embolism in a pregnant woman, how should it be monitored?

What is the aim value?

APTT:
(activated partial prothrombin time)

at 6 hours from loading dose
after dose changes
at 24 hours

Target APTT: 1.5-2.5

289

What side effects are associated with unfractionated heparin in pregnancy given at high doses to treat VTE?

maternal osteopenia (reversible)
thrombocytopenia- monitor platelets every 2 days from day 4
alopecia

290

How should small pulmonary emboli be treated in pregnancy.
When should it be stopped?

Enoxaparin 1mg/kg BD SC (based on early pregnancy weight)

Stop at onset of labour or 24 hours before planned delivery

291

Conradi-Hünermann Syndrome
what is it
what's it caused by?

caused by Warfarin in 1st trimester pregnancy

Cataracts
Optic atrophy
Nasal hypoplasia
Reduced IQ
A bit small

292

After a small pulmonary embolism in pregnancy, how long should treatment be given?

Throughout pregnancy
and for 6 weeks post partum
and at least 3 months after the emboli

293

Pregnant woman has discomfort in L leg and some swelling. What tests?

Deep vein thrombosis
FBC: raised WCC
Compression duplex ultrasound

294

What findings in a suspected deep vein thrombosis would suggest it's a iliac vein thrombosis and how would this effect management?

Back pain or entire limb swollen

changes:
IHx: MRI or contrast venography
Rx: inferior vena cava filter

295

If a pregnant woman is on LMWH, how long do you have to wait before giving regional anaesthesia- like a epidural?

24 hours- risk of spinal haematoma?

296

After a DVT and enoxaparin Rx, how soon can Rx be restarted after birth?

3 hours in caesarian
or 4 hours after epidural siting

297

How does therapeutic enoxaparin regimen change before and after birth?

(therapeutic = given for DVT or PE)

1mg/kg BD before birth

1.5mg/kg OD after birth

298

If a woman who has just given birth would prefer to have her clotting risk managed after a DVT with Warfarin, how long should you wait before commencing and is it safe to breastfeed on it?

Start warfarin 3 days postpartum
Warfarin and heparin are safe to breast feed with

299

If a pregnant woman has a PE/DVT during pregnancy, how long should she wear compression stockings for?

2 years

halves relative risk of post-thrombotic syndrome

300

What is Factor V Leiden?

What risk does it pose

Factor V is needed to combine with Factor Xa to convert
prothrombin to thrombin

= protein C resistance where factor V isn't broken down by protein C
in 4% of population

heterozygotes have 7x risk of VTE
homozygotes have 25x risk of VTE

301

What impact does protein C and protein S deficiency have?

=thrombophilia

protein C and S break down factor V

Factor Va + Factor Xa turn prothrombin into thrombin

302

How does antithrombin deficiency have an impact?
(mechanism)

Thrombophilia

Antithrombin breaks down Factor Xa and Thrombin

303

What is acquired thrombophilia?
what are the risks?

Lupus anticoagulant ± anticardiolipin antibody

Risk of arterial and venous thrombosis, particularly in portal veins or arms

304

What pregnancy complications would prompt a screen for thrombophilia defects?

second trimester pregnancy loss
severe/recurrent pre-eclampsia
intrauterine growth restriction

305

Which thrombophilias pose an increased risk of pre-eclampsia and should be started on 75mg Aspirin from 12 weeks?

Factor V Leiden
Protein C deficiency
Protein S deficiency
Cardiolipin antibody (acquired thrombophilia)

306

Maculopapular rash in pregnant woman.
What do you want to rule out?

Rubella
Parvovirus B19
Measles

307

Mother gets measles 6 days before birth or 6 days after birth, what Rx for the baby?

Human immune globulin 0.6mL/kg (up to 5mL) to prevent infection

308

Pregnant mother gets itchy chicken pox rash at week 21, Rx?

After 20 weeks, give:
oral aciclovir- if already having the rash it's too late for IV Ig

309

In what circumstances of a pregnant mother getting chicken pox would you hospitalize for IV aciclovir rather than oral?

If immunosupressed, dense or haemorrhagic lesions, neuro/resp symptoms- IV aciclovir

If in contact with chickenpox, no rash yet and no varicella Ig- give IV Ig
If 20 weeks pregnant, within 24 hours of rash onset: PO aciclovir

310

What constitutes 'contact' when determining if a pregnant mother has been 'in contact' with someone with a rash

15 minutes around them
live in same household
face-to-face contact- conversation

311

Pregnant woman had a conversation with someone who turned out to have a rash, what tests should be done?

When is test not needed?

Parvovirus B19 serology
Rubella serology

Don't test if mother has :
2 rubella Ab levels above 10iU/mL
2 rubella vaccinations
1 vaccination + 1 high Ab level

312

Pregnant mother has a child who contracts chicken pox, she is not sure if she has had it before.
Management?

Urgent blood test to check for VZV antibodies

if negative >
Varicella zoster immune globulin within 10 days of exposure

'see your GP if you develop a rash'

313

When does rubella pose the greatest risk to the fetus?

What is the risk of fetus being affected?

1st trimester worst

55% affected in 1st trimester
5% affected in 2nd trimester infection

314

If suspect pregnant woman has been in contact with rubella, how is it investigated?

Look for increase in IgG antibody levels 10 days apart

and IgM antibodies 4 weeks from contact

315

Which infection causes more congenital retardation if contracted during pregnancy?

Cytomegalovirus

(moreso than rubella)

316

What effects can CMV have on fetal development?

ears and eyes and nose and mouth

chorioidoretinitis
deafness
microcephaly, cerebral calcification (low IQ)
hydrops (fluid in compartments ie ascites)

317

How can CMV transmission be determined in the fetus?

and in the baby?

Amniocentesis at 20 weeks + viral culture

Post birth:
Throat swab
urine culture
baby's serum.

318

How can reactivation of CMV in pregnancy (benign) be distinguished from new infection (dangerous)?

Serology pre-pregnancy
IgG avidity indicates recent infection or previous pretty well.

319

Pregnant woman has high temperature, very sore throat and swollen glands.
She also has a cat.
What are you worried about?
How to test?

Toxoplasmosis
gives an glandular fever-like presentation

IHx: IgG and IgM

320

Toxoplasmosis Rx in pregnancyif mother is affected?

Spiramycin 1.5mg BD (macrolide)

321

Toxoplasmosis Rx for mum in pregnancy if fetus is affected?

Loading: Pyrimethamine 50mg BD on day 1

Ongoing until delivery:
Pyrimethamine 1mg/kg OD
+ Sulfadiazine 50mg/kg BD
+ Calcium Folinate 15mg twice weekly

Pyrimethamine interferes with dihydrofolate reductase

322

How to treat a neonate who has toxoplasmosis?

4-weekly course of:
pyrimethamine
sulfadiazine
calcium folinate

then 4 weeks of: spiramycin macrolide

+ Prednisolone until CNS inflammation or choroidretinitis abated

323

If pregnant mother found to have syphilis, what Rx can reduce chance of fetus being still born?

Procaine Penicillin 600mg OD IM for 10 days

324

What tests suggest a newborn has been affected by syphilis?

Nasal discharge exam: spirochetes
Xrays: perichondritis (affects cartilage)
CSF: raised monocytes and protein, serology +ve

325

Rx of neonate with syphilis?

Procaine penicillin 37mg/kg OD IM for 3 weeks

326

What foods may transmit Listeria to pregnant mothers?

Milk
Paté
Soft cheeses

327

Pregnant woman has had unexplained fever for 48 hours, how can Listeria be tested for?
What are the other possible PCs?

Blood culture
As commensal, swabs and serology don't help

Myalgia
Headache
Sore throat, cough
Vomiting, diarrhoea
Vaginitis

328

What may be the complications of a neonate who gets Listeria?

QRS

Q- convulsions, conjuctivitis
R- respiratory distress due to pneumonia, rash
S- spleen/liver is big, small WCC

329

How can neonatal Listeria be tested for?

Blood, CSF, meconium and placental culture

330

Rx for neonate with listeria?

Gram-positive anaerobe

Ampicillin 50mg/kg QDS (gram +ve and gram -ve)
Gentamycin 3mg/kg BD

for 1 week after fever subsides

331

What does TORCH stand for?

Screen in pregnancy:

Toxoplasmosis
Other (syphilis, cocksackie, chicken pox, leptospira, Q fever, lyme disease, malaria)
Rubella
CMV
Herpes, HIV

332

When do most neonatal transmissions of Hep B occur?

During birth
(although in the East it may be transplacental, hence failure of the vaccination attempts)

333

Mother of baby is found to be HBsAg +ve during pregnancy, how should baby be managed post-birth?

Immunoglobulin 200U IM
Hep B vaccination

334

Baby is born to Hep B +ve mum, given IM Ig and vaccination. What signs at three months would indicate that the virus has been cleared?

HBV DNA cleared
anti-core antibodies present
anti-HBe antibodies
HBeAg and ABsAg decline at 3 months

335

What test should be done on a HepB exposed baby to demonstrate the child is protected after vaccination and Ig?

Serology at 12-15 months:
HBsAg -ve
anti-HBs +ve

336

What is the progression of HepE in pregnant women prior to death?
When do they tend to die?

After birth:
Hepatic failure
Coma
Massive post-partum haemorrhage

337

What can Herpes Simplex cause in the neonate?

blindness
low IQ, epilepsy
DIC, jaundice
respiratory distress
death

338

What are the high risk groups that should take 75mg Aspirin to prevent pre-eclampsia in pregnancy?

gestational hypertension
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus

339

If a mother contracted Herpes Simplex for the first time in pregnancy, what Rx would you offer?
(note it depends on the trimester it was contracted in)

If primary infection + third trimester that she's become infected:

Oral aciclovir/vanciclovir
± elective caesarian (if birth is in the 6 weeks after infection)

340

Pregnant mother ruptured membranes 4 hours before, midwife has noticed some warts around vagina.
No PMH of herpes reported
How should delivery be managed?

Caesarian section

(vaginal transmission of HSV to baby is 40%)

341

Mother with vaginal warts is adamant that she wants a vaginal delivery, despite risk of transmitting Herpes Simplex to baby. How should she be managed?

IV aciclovir in labour
try to avoid:
fetal blood sampling
instrumental delivery
scalp electrodes

high dose aciclovir to baby once born
- do PCR of baby at birth

342

How does a neonatal present with herpes simplex infection?

Vesicles around site of trauma or presenting part
Periocular lesions
Conjunctival lesions

343

Pregnant woman comes into contact with person with chicken pox, she doesn't think she's ever had it before?
Test and Rx?

Test: varicella antibodies

Rx: Varicella Zoster Ig
'notify doctor if you develop a rash'

344

Pregnant woman exposed to chicken pox develops a rash.
Rx?

After 20 weeks gestation

Oral aciclovir 5x day
for 7 days

345

Mother gets chicken pox in first trimester, not thought to have been infected with it before.
How should she be followed up to see if Fetal Varicella Syndrome has occurred?

Infection between 3-28 weeks requires:
detailed ultrasound at 16-20 weeks
or 5 weeks post-infection

346

Neonate develops conjunctivitis on day 10 post-partum
Mother is known to have chlamydia

Rx for baby?
Rx for parents?

Baby- eye cleansing + Erythromycin 12.5mg/kg QDS

Parents- Erythromycin or Azithromycin 1g PO one dose.

347

How does chlamydial and gonococcal conjunctivitis present differently in the neonate?

Chlamydia: minimal inflammation, slight purulent discharge
PC on day 5-14

Gonococcal: purulent discharge, lid swelling ± corneal rupture/hazing
PC on day 4

348

Rx + prophylaxic Rx for neonatal gonococcal conjunctivitis?

Active infection of newborn:
Benzylpenicillin
Chloramphenical eye drops every 3 horus for 7 days

Prophylaxis if mum has active infection:
Cefotaxime 100mg/kg STAT IM
Chloramphenicol eye drops within 1hour of birth

349

Neonate under 21 days has purulent discharge coming from the eye, what is the differential?

Opthalmia neonatorum:

viral: Chlamydiae
Herpes virus
bacterial: Staphylococci
Streptococci
Pneumococci
Gonococci
E Coli

350

What are the indications regarding group B strep for giving a woman IV antibiotics in labour?

+ve Group B Strep swab (at 35-37 weeks)
previous baby had Group B Strep
Cultured GBS on urinalysis during pregnancy
Intrapartum fever
Culture GBS unknown + membranes ruptured longer than 18 hours

351

Which babies should receive a BCG after birth?

If they:
are born into households with TB
have mothers from endemic areas
will travel to TB endemic areas

(0.05mL intradermal at the deltoids)

352

Mother had cough, fever and not much weight gain during pregnancy, has just given birth and is found to have active TB.

How long must mum be isolated for?
Rx for baby?
Rx for mum?

Separate mum from baby whilst giving her RIPE:
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol

after 2 weeks and sputum -ve, may be reunited.

Baby Rx:
BCG vaccination
+ Isoniazid until +ve skin reaction

353

Woman 30 weeks pregnant:
PC: Abdominal pain, vaginal bleeding
EHx: rigid tender uterus

1. diagnosis?
2. differential?
2. management?
3. complications?

1. placental abruption

2. rectus sheath haemotoma- ultrasound to decide

3. try to deliver baby

4. if 50% of placenta affected- likely fetal demise
DIC
postpartum haemorrhage

354

Woman 34 weeks pregnant

PC: abdominal pain, hasn't peed in hours
PMH: fibroids
EHx: tense uterus, difficulty catheterising

diagnosis

Uterine Torsion- very rare

often diagnosed by laparotomy
deliver with caesarian

355

What are the risks of appendicitis in pregnancy?

Higher mortality
Perforation
Fetal mortality (1% of time, 30% of perforations)

356

Similarities and differences between presentation of appendicitis in pregnancy Vs normal individual?

Similarities:
Right low quadrant pain commonest
Need to Rx with surgery- often laparoscopy in both cases

Differences:
can be subcostal or para-umbilical in pregnancy
Tenderness + guarding less obvious in pregnancy
- instead uterus becomes rigid and woody-hard
obstetrician performs surgery
patient is tilted 30 degrees to left

357

Why is cholecystitis more common in pregnancy?

Gallstones form with
increased biliary stasis (progesterone relaxes muscles)
and increased cholesterol in bile

(cystitis= inflammation of cystic duct containing bile)

358

Pregnant woman has subcostal pain, nausea and vomiting.

Tests?
Management?

Differential: appendicitis or cholecystitis

IHx: ultrasound- gallstones or appendicitis
if inconclusive- MRI
if can't exclude appendicitis- laparoscopy

Rx: appendicitis- surgery
cholecystitis- conservative

if complicated and non-resolving cholecystitis- laparoscopic surgery

359

How is pancreatitis in pregnancy tested for in first trimester?

Urinary diastase
(amylase may be low)

360

How is postmaturity defined in obstetrics?

Pregnancy exceeding 42 weeks

361

What are the possible issues for neonates of being born after 42 weeks?

Placental insufficiency

Larger fetus
Skull more ossified and less mouldable for labour
Increased meconium passage in labour
Increased fetal distress in labour

362

What options can be offered to a woman at 41 weeks gestation in pregnancy to prompt initiation of labour?

1. membrane sweep
2. induction (vaginal prostaglandin, then oxytocin)
3. if the above is declined, twice weekly CTG + USS

363

Mother has genital herpes during pregnancy, how does the timing of this determine whether she should be routinely offered a caesarian section or not?

Herpes in 3rd trimester- offer
Recurrent herpes at term- don't offer

364

Which antibiotics should be avoided with breastfeeding?

Ciprofloxacin
Chloramphenicol
Tetracycline
Sulphonamides

365

What dose of folic acid should be taken as standard in pregnancy?

400micrograms

366

Neonate born prematurely, xray shows bilateral ground glass appearance of lungs. Diagnosis?

Respiratory distress syndrome

367

Abdo xray signs is baby has bowel perforation?

Air in peritoneal cavity:
Look for football sign, air under diaphragm, visible ligament of liver demarcated by air either side

368

Kernicterus is the build up of unconjugated or conjugated bilirubin?

Unconjugated (fat-soluble)
it's insoluble and can cross the blood brain barrier to be deposited in the basal ganglia

369

How is low, very low and extremely low birth weight defined?

LBW

369

Why is nitrofurantoin avoided close to delivery?

May cause haemolysis of fetus

370

How does the fasting glucose level in recently-diagnosed gestational diabetes in pregnant woman determine initial treatment approach?

Fasting glucose 6.9 straight onto insulin

371

Who gets high dose folate? (5mg rather than 400 micrograms)

Obese >30 BMI

Previous neural tube defect

PMH: diabetic, sickle cell
DHx: HIV mum on co-trimoxazole or anti-epileptics

372

When would you give IV glucose to a neonate?

If symptomatically hypoglycaemic
If 2 blood glucose readings are under 2mmol

373

If a woman giving birth has a BMI over 40, what is always indicated post birth?

7 days heparin
TED stocking

374

What is Naegele's rule for determining estimated due date in pregnancy?

LMP + 1year + 7 days -3 months

If irregular period +/- days difference from 28 days

375

How is screening different for someone with previous gestational diabetes compared to someone at high risk (FHx, BMI >30, previous baby >45kg, asian)?

Previous diabetes: OGTT at 18 ± 28 weeks
High risk: OGTT at 24 weeks

376

Women with what BMI should take vit D supplements in pregnancy?

Above 30

377

When is 500U of anti-D unlikely to be sufficient for a rhesus -ve mother?

500U is enough for 8mL of fetal blood (=4ml of fetal red cells) may be more transplacental haemorrhage in:
Manual removal or placenta
C-section

Hence Kleihauer test needed to quantify

378

A miscarriage after how many weeks warrants anti-D prophylaxis for a rhesus -ve mother?

12 weeks

379

Which diseases are associated with hyperemesis gravidarum?

Pre-existing diabetes
Hyperthyroidism
Previous eating disorders

380

For miscarriages and terminations, sometimes anti-D isn't given if it is before 12 weeks, which circumstances does this not apply for?

ALWAYS give anti-D (even if pre-12 weeks) if:
Terminations with medical or surgical management
Spontaneous miscarriage with medical or surgical management

If spontaneous or threatened miscarriage with no intervention before 12 weeks, no anti-D needed

381

Why ask about peripheral sensation in those with hyperemesis gravidarum?

May get a polyneuritis due to low B vitamins

382

Which trimester is it worse to take Lithium in?

1st trimester- increased chance of heart defects (ebstein's abnormality)

383

How may atypical antipsychotics impact fertility? (The mechanism)

DA antagonist = hyperprolactinaemia = infertility

384

Which regions are associated with a high prevelance of thalassaemia?

Mediterranean
Indian
South East Asian regions

385

How long does it take Hb to rise once iron supplementation is given?

6 weeks
If very anaemic late in pregnancy then blood transfusion may be needed as iron will more work in time

386

35 weeks pregnant, found to have Hb of 60 from iron-deficiency anaemia, due Caesarian
Rx?

Blood transfusion
Too late for Fe supplementation (takes 6 weeks to work)

387

How do you decide whether a woman needs HAART from 28 weeks or all the way through pregnancy?

If she needs HAART for her own health (low CD4, AIDS illnesses) = all the way through

If CD4 high, viral load low = take from 28 weeks

388

Mum is taking propylthiouracil but doesn't know why and doesn't speak much english. What abnormalities might the fetus have?

Mum has hyperthyroidism (likely Grave's disease)
Can cause fetal hyperthyroidism as antibodies cross placenta:
Premature delivery
Craniosynostosis
Goitre (= polyhydramnios)
Tachycardia

389

Mother has Dubin-Johnson syndrome, what is likely to happen in pregnancy?

Inability to secrete conjugated bilirubin in liver due to a protein transporter defect (autosomal recessive)

Likely to become jaundiced, fairly benign

391

What is the difference between acute fatty liver of pregnancy and intra-hepatic cholestatsis of pregnancy?

In both: jaundice and after 2nd trimester

Cholestasis- itchy, mild AST + ALT rise
Acute fatty liver- pain, headache, vomiting, low BM/clotting disorder/ other liver dysfunction

391

Why don't you want to give methylodopa after birth in women with hypertension?

Predisposes to post-natal depression

392

Jaundice in pregnancy, what conditions tend to have an abnormal ALT

A. Hyperemesis gravidarum complication
B. Intrahepatic cholestasis
C. Pre-eclampsia + HELLP

High- hepatitis

393

Pregnant woman comes in breathless and with pleuritic chest pain, what would make you think it was due to a pneumonia over a thromboembolism?

High fever
Purulent sputum

394

A pregnant woman with VTE has a CTPA, what needs to be checked in the fetus afterwards?

Neonatal hypothyroidism as iodinated contrast is used

(Sleepy, poor tone, jaundice, low body temperature)

396

What is considered a high risk thrombophilia in pregnancy and a low risk thrombophilia when determining appropriate thromboprophylaxis regime For those who have not had a VTE before?

High risk (>10x worse than general population):
antithrombin deficiency
homozygotes factor V leiden
homozygotes G20210A
Two compounding thrombophilias

Require antenatal LMWH
Low risk thrombophilia just counts as a RF like obesity etc

397

Primary infection of chickenpox before how many weeks predisposes a fetus to varicella zoster syndrome?

20 weeks
(Skin scarring, eye cataracts and retinitis, small head low IQ)

398

Which infections in pregnancy do you give IV Ig to the babies at birth for?

Measles (if get it 6 days before birth)
Chicken pox (if get it 7 days before birth)
Hepatits B (if mum is carrier)

399

Which infections in pregnancy would you give mum aciclovir for?

Chicken pox (if primary infection, after 20 weeks and within 24 hours of a rash)
Herpes simplex (3rd trimester PO, IV if vaginal delivery- recommend C-section)

400

Which infections in pregnancy warrant a penicillin derivative for mum?

Syphilis- procaine pen IM
Listeria- ampicillin (+ gentamycin)
Clostridium perfringins endometritis- Benzylpenicillin
Group B Strep- penicillin (prophylaxis)

401

Which infections in pregnancy warrant a macrolide for mum?

Toxoplasmosis- spiramycin (+sulfadiazine, pyrimethamine + ca folinate if fetus becomes infected)
Sheep-borne infections- erythromycin
Chlamydia trachomatis- erythromycin

402

Imaging to differentiate cholecystitis and appendicitis in pregnancy?

USS- Stones in gallbladder = cholecystitis
Appendix is displaced upwards in pregnancy so pain is localised to RUQ often.

Laproscopy 2nd line if can't be sure.

403

What number of accelerations would you expect on a CTG?

2 in 20 minutes, of an amplitude of 15bpm (unless sleeping)

404

How can amniotic fluid levels indicate chronic asphyxia of the fetus?

Chronic hypoxia in IUGR may lead to shunting of blood to vital organs rather than the fluid producing organs (of kidney and lungs) leading to less amniotic fluid.

If the largest pocket of fluid is less than 1cm this suggests chronic asphyxia

405

You suspect there is IUGR of a fetus, how can the fetal growth be monitored?

Regular scans measuring the abdominal: skull circumference ratio

406

In pre-eclampsia what can be tested for in blood that rises before women start getting proteinuria?

Urate (uric acid)

>0.29 at 28 weeks
>0.34 at 32 weeks
>0.39 at 36 weeks

407

When would you admit someone for suspected pre-eclampsia?

>160/100
>140/90 + proteinuria
BP rise of >30/20 mmHg
Growth restriction

408

How does Rx for the mum change if she is infected by toxoplasmosis depending on whether amniocentesis shows the baby is also infected or not?

Baby not infected: mum takes spiramycin
Baby infected: mum takes sulfadiazine, pyrimethamine, calcium folinate