Antenatal Care Flashcards

Question

Management of pre eclampsia - preventative

Answer 1

Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with: A single high-risk factor or Two or more moderate-risk factors All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with: Blood pressure, Symptoms, Urine dipstick for proteinuria

Answer 2

Treating to aim for a blood pressure below 135/85 mmHg Admission for women with a blood pressure above 160/110 mmHg Urine dipstick testing at least weekly Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) Monitoring fetal growth by serial growth scans PlGF testing on one occasion

Answer 3

Treating to aim for a blood pressure below 135/85 mmHg Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S) Blood pressure is monitored closely (at least every 48 hours) Urine dipstick testing is not routinely necessary (the diagnosis is already made) Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

Answer 4

Labetolol is first-line as an antihypertensive Nifedipine (modified-release) is commonly used second-line Methyldopa is used third-line (needs to be stopped within two days of birth) Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Answer 5

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Answer 6

Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

Answer 7

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics: Haemolysis Elevated Liver enzymes Low Platelets

Answer 8

Last menstrual period (LMP) refers to the date of the first day of the most recent menstrual period

Answer 9

Gestational age (GA) refers to the duration of the pregnancy starting from the date of the last menstrual period

Answer 10

Estimated date of delivery (EDD) refers to the estimated date of delivery (40 weeks gestation)

Answer 11

Gravida (G) is the total number of pregnancies a woman has had

Answer 12

Primigravida refers to a patient that is pregnant for the first time

Answer 13

Multigravida refers to a patient that is pregnant for at least the second time

Answer 14

Para (P) refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn

Answer 15

Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation

Answer 16

Primiparous technically refers to a patient that has given birth after 24 weeks gestation once before

Answer 17

Multiparous (“multip”) refers to a patient that has given birth after 24 weeks gestation two or more times

Answer 18

Weeks + Days e.g. 5 + 2 (5 weeks 2 days since first day of LMP)

Answer 19

The first trimester is from the start of pregnancy until 12 weeks gestation.

Answer 20

13 weeks to 26 weeks gestation

Answer 21

The third trimester is from 27 weeks gestation until birth.

Answer 22

Around 20 weeks gestation

Answer 23

Before 10 weeks Offer a baseline assessment and plan the pregnancy

Answer 24

Between 10 and 13 + 6 weeks An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified

Answer 25

16 weeks Discuss results and plan future appointments

Answer 26

Between 18 and 20 + 6 weeks An ultrasound to identify any anomalies, such as heart conditions

Answer 27

Booking scan - before 10 weeks Dating scan - between 10 and 13+6 weeks 16 weeks (Discuss results and plan future appointments) Anomaly scan between 18 and 20+6 weeks 25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks (monitor the pregnancy and discuss future plans)

Answer 28

Additional appointments for higher risk or complicated pregnancies Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks) Anti-D injections in rhesus negative women (at 28 and 34 weeks) Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan Serial growth scans are offered to women at increased risk of fetal growth restriction

Answer 29

Discuss plans for the remainder of the pregnancy and delivery Symphysis–fundal height measurement from 24 weeks onwards Fetal presentation assessment from 36 weeks onwards Urine dipstick for protein for pre-eclampsia Blood pressure for pre-eclampsia Urine for microscopy and culture for asymptomatic bacteriuria

Answer 30

Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter COVID 19

Answer 31

Live vaccines, such as the MMR vaccine, are avoided in pregnancy.

Answer 32

Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects) Take vitamin D supplement (10 mcg or 400 IU daily) Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)

Answer 33

Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses) Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome) Don’t smoke (smoking has a long list of complications, see below) Avoid unpasteurised dairy or blue cheese (risk of listeriosis) Avoid undercooked or raw poultry (risk of salmonella) Continue moderate exercise but avoid contact sports

Answer 34

Sex is safe STIs can be passed on to fetus/baby

Answer 35

Place car seatbelts above and below the bump (not across it)

Answer 36

Alcohol can cross the placenta, enter the fetus, and disrupt fetal development. There is no safe level of alcohol in pregnancy. Pregnant women are encouraged not to drink alcohol at all. Small amounts are less likely to result in lasting effects. The effects are greatest in the first 3 months of pregnancy. Alcohol in early pregnancy can lead to: Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 37

Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 38

First 3 months

Answer 39

Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy

Answer 40

Fetal growth restriction (FGR) Miscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palate Sudden infant death syndrome (SIDS)

Answer 41

Flying increases the risk of venous thromboembolism (VTE) The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to: 37 weeks in a single pregnancy 32 weeks in a twin pregnancy After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well and there are no additional risks.

Answer 42

What to expect at different stages of pregnancy Lifestyle advice in pregnancy (e.g. not smoking) Supplements (e.g. folic acid and vitamin D) Plans for birth Screening tests (e.g. Downs screening) Antenatal classes Breastfeeding classes Discuss mental health Discuss female genital mutilation Discuss domestic violence

Answer 43

Blood group, antibodies and rhesus D status Full blood count for anaemia Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) Patients are also offered screening for infectious diseases, by testing antibodies for: - HIV - Hepatitis B - Syphilis Rubella immunity Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onwards.

Answer 44

Weight, height and BMI Urine for protein and bacteria Blood pressure

Answer 45

Rhesus negative (book anti-D prophylaxis) Gestational diabetes (book oral glucose tolerance test) Fetal growth restriction (book additional growth scans) Venous thromboembolism (provide prophylactic LMWH if high risk) Pre-eclampsia (provide aspirin if high risk)

Answer 46

Downs Syndrome

Answer 47

The screening tests involve taking measurements from the fetus using ultrasound, combining those measurements with the mother’s age and blood results and providing an indication of the risk of Down’s syndrome. Older mothers have a higher risk of Down’s syndrome. All women are offered screening for Down’s syndrome during pregnancy. The purpose of the screening test is to decide which women should receive more invasive tests to establish a definitive diagnosis. It is the choice of the woman whether to go ahead with screening.

Answer 48

11 - 14 weeks

Answer 49

The combined test is the first line and the most accurate screening test.

Answer 50

Ultrasound measures nuchal translucency, which is the thickness of the back of the neck of the fetus. Down’s syndrome is one cause of a nuchal thickness greater than 6mm. Maternal blood tests: Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk

Answer 51

Beta‑human chorionic gonadotrophin (beta-HCG) – a HIGHER result indicates a greater risk

Answer 52

A LOWER result indicates a greater risk

Answer 53

Down’s syndrome is one cause of a nuchal thickness greater than 6mm.

Answer 54

14-20 weeks

Answer 55

It only involves maternal blood tests: Beta-HCG – a higher result indicates greater risk Alpha-fetoprotein (AFP) – a lower result indicates a greater risk Serum oestriol (female sex hormone) – a lower result indicates a greater risk

Answer 56

It only involves maternal blood tests: Beta-HCG – a higher result indicates greater risk Alpha-fetoprotein (AFP) – a lower result indicates a greater risk Serum oestriol (female sex hormone) – a lower result indicates a greater risk Inhibin-A - A higher inhibin-A indicates a greater risk.

Answer 57

. When the risk of Down’s is greater than 1 in 150 (determined by combined, triple or quadruple assessment), the woman is offered amniocentesis or chorionic villus sampling.

Answer 58

These tests involve taking a sample of the fetal cells to perform karyotyping for a definitive answer about Down’s: Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks). Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.

Answer 59

More amniotic fluid - safer sample

Answer 60

Non-invasive prenatal testing (NIPT) is a relatively new test for detecting abnormalities in the fetus during pregnancy. It involves a simple blood test from the mother. The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA. These fragments can be analysed to detect conditions such as Down’s.

Answer 61

Increased risk of abnormality identified through antenatal screening (risk >1:150) A previous child with chromosomal or genetic abnormality Known carrier status for a genetic condition A family history of a genetic condition Ultrasound scan evidence of fetal abnormalities that are associated with a chromosomal or genetic condition.

Answer 62

Miscarriage: There is an additional risk of 0.5% following chorionic villus sampling. Vaginal bleeding: occurs in around 1 in 10 women (higher in transcervical approach). Other maternal complications include: pain, infection, amniotic fluid leakage and resus sensitisation (give anti-D) There is also a 1% risk of a mosaic result (where both normal and abnormal cells are found). Amniocentesis may then be offered to establish whether the baby has a mosaic karyotype or if mosaicism is just confined to the placenta (confined placental mosaicism). Chorionic Villus Sampling can be performed from 10 weeks’ gestation; however, this is technically challenging.

Answer 63

0.5% risk of miscarriage (RCOG). The risk is higher in a multiple pregnancy False reassurance – a “normal” result may make women feel their baby will be born completely healthy when this may not be the case. Risk of infection, as with most surgical procedures Pain from the procedure Rhesus sensitisation Increased risk of club foot

Answer 64

Miscarriage Anaemia Small for gestational age Pre-eclampsia.

Answer 65

Hypothyroidism is treated with levothyroxine (T4). Levothyroxine can cross the placenta and provide thyroid hormone to the developing fetus. The levothyroxine dose needs to be increased during pregnancy, usually by at least 25 – 50 mcg (30 – 50%). Treatment is titrated based on the TSH level, aiming for a low-normal TSH level.

Answer 66

ACE inhibitors (e.g. ramipril) Angiotensin receptor blockers (e.g. losartan) Thiazide and thiazide-like diuretics (e.g. indapamide)

Answer 67

Labetalol (a beta-blocker – although other beta-blockers may have adverse effects) Calcium channel blockers (e.g. nifedipine) Alpha-blockers (e.g. doxazosin)

Answer 68

400mcg (usually) Ideally start 3 months prior to conception Carry on to 12 weeks gestation

Answer 69

Pregnancy may worsen seizure control due to the additional stress, lack of sleep, hormonal changes and altered medication regimes. Seizures are not known to be harmful to the pregnancy, other than the risk of physical injury.

Answer 70

Sodium valproate is avoided as it causes neural tube defects and developmental delay There are a lot of warnings about the teratogenic effects of sodium valproate, and NICE updated their guidelines in 2018 to reflect this. It must be avoided in girls or women unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant. There is a specific program for this, called Prevent (valproate pregnancy prevention programme).

Answer 71

Phenytoin is avoided as it causes cleft lip and palate

Answer 72

Levetiracetam Lamotrigine Carbamazepine

Answer 73

At least 3 months

Answer 74

Often the symptoms of rheumatoid arthritis will improve during pregnancy, and may flare up after delivery.

Answer 75

Hydroxychloroquine is considered safe during pregnancy and is often the first-line choice Sulfasalazine is considered safe during pregnancy Corticosteroids may be used during flare-ups

Answer 76

Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities

Answer 77

Particularly in third trimester Can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.

Answer 78

They work by blocking prostaglandins. Prostaglandins are important in maintaining the ductus arteriosus in the fetus and neonate. Prostaglandins also soften the cervix and stimulate uterine contractions at the time of delivery.

Answer 79

Fetal growth restriction Hypoglycaemia in the neonate Bradycardia in the neonate

Answer 80

Labetalol is the most frequently used beta-blocker in pregnancy, and is first-line for high blood pressure caused by pre-eclampsia.

Answer 81

Oligohydramnios (reduced amniotic fluid) Miscarriage or fetal death Hypocalvaria (incomplete formation of the skull bones) Renal failure in the neonate Hypotension in the neonate

Answer 82

Medications that block the renin-angiotensin system (ACE inhibitors and ARBs) can cross the placenta and enter the fetus. In the fetus, they mainly affect the kidneys, and reduce the production of urine (and therefore amniotic fluid).

Answer 83

Fetal loss Congenital malformations, particularly craniofacial problems Bleeding during pregnancy Postpartum haemorrhage Fetal haemorrhage Intracranial bleeding

Answer 84

Lithium is particularly avoided in the first trimester, as this is linked with congenital cardiac abnormalities in particular, it is associated with Ebstein’s anomaly When lithium is used, levels need to be monitored closely (NICE says every four weeks, then weekly from 36 weeks). Lithium also enters breast milk and is toxic to the infant, so should be avoided in breastfeeding.

Answer 85

Ebstein’s anomaly, where the tricuspid valve is set lower on the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle.

Answer 86

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants in pregnancy. SSRIs can cross the placenta into the fetus. The risks need to be balanced against the benefits of treatment. The risks associated with untreated depression can be very significant. Women need to be aware of the potential risks of SSRIs in pregnancy:

Answer 87

First-trimester use has a link with congenital heart defects In particular, paroxetine has a stronger link with congenital malformations

Answer 88

Third-trimester use has a link with persistent pulmonary hypertension in the neonate

Answer 89

Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management

Answer 90

Isotretinoin is a retinoid medication (relating to vitamin A) that is used to treat severe acne. It should be prescribed and monitored by a specialist dermatologist. Isotretinoin is highly teratogenic, causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.

Answer 91

Women need very reliable contraception before, during and for one month after taking isotretinoin.

Answer 92

The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth. NAS presents between 3 – 72 hours after birth with: Irritability Tachypnoea (fast breathing) High temperatures Poor feeding

Answer 93

The anterior pituitary gland produces more ACTH in pregnancy. Higher ACTH levels cause a rise in steroid hormones, particularly cortisol and aldosterone. Higher steroid levels lead to an improvement in most autoimmune conditions.

Answer 94

The anterior pituitary gland produces more ACTH in pregnancy. Higher ACTH levels cause a rise in steroid hormones, particularly cortisol and aldosterone. Higher steroid levels lead to a susceptibility to diabetes and infections.

Answer 95

Clotting factors such as fibrinogen and factor VII, VIII and X increase in pregnancy, making women hyper-coagulable.

Answer 96

There is increased red blood cell production in pregnancy, leading to higher iron, folate and B12 requirements.

Answer 97

Plasma volume increases more than red blood cell volume, leading to a lower concentration of red blood cells. High plasma volume means the haemoglobin concentration and red cell concentration (haematocrit) fall in pregnancy, resulting in anaemia.

Answer 98

The mother’s antibodies can transfer across the placenta to the fetus during pregnancy. These antibodies allow the fetus to benefit from the long term immunity of the mother during the pregnancy and shortly after birth. The mother’s antibodies to the herpes virus cross the placenta and protect the baby during labour and delivery, preventing infection during birth. This protection does not occur during an initial episode of genital herpes, as the mother has not yet started producing sufficient antibodies against the herpes virus to offer the fetus protection.

Answer 99

1. Regular periods 2. No hormonal contraception in last 3 months 3. Not lactation EDD=LMP + 9 months and 7 days

Answer 100

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth

Answer 101

NOn invasive prenatal screening test - analyses small DNA fragments that circulate in the blood of a pregnant woman (cell tree fetal DNA, cffDNA) - cffDNA derives from placental cells and is usually identical to fetal DNA - analysis of cffDNA allows for the early detection of certain chromosomal abnormalities - sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities

Answer 102

Down's syndrome Edward's syndrome Neural tube defects

Answer 103

↓ AFP ↓ oestriol ↓ hCG ↔ inhibin A

Answer 104

↑ AFP, ↔ oestriol, ↔ hCG, ↔ inhibin A

Answer 105

small eyes, cleft lip and polydactyly

Answer 106

overlapping fingers and low-set ears

Answer 107

Trace glycosuria is common in pregnancy due to the increased GFR and reduction in tubular reabsorption of filtered glucose

Answer 108

Increased maternal age Smoking in pregnancy Consuming alcohol Recreational drug use High caffeine intake Obesity Infections and food poisoning Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes Medicines, such as ibuprofen, methotrexate and retinoids Unusual shape or structure of womb Cervical incompetence

Answer 109

Heavy lifting Bumping your tummy Having sex Air travel Being stressed

Answer 110

uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation)

Answer 111

Pre eclampsia

Answer 112

A cut-off of 110 g/Lshould be used in the first trimester to determine if iron supplementation should be taken

Answer 113

↓ AFP ↓ oestriol ↑ hCG ↑ inhibin A

Answer 114

Ondansetron during pregnancy is associated with a small increased risk of cleft palate/lip - the MHRA advise that these risks need to be discussed with the pregnant woman before use

Answer 115

5 days, due to risk of extrapyramidal effects

Answer 116

insulin should be added

Answer 117

Fasting 5.3 mmol/L One hour after a meal 7.8 mmol/L Two hours after a meal 6.4 mmol/L

Answer 118

The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.

Answer 119

In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards.

Answer 120

Brisk reflexes

Answer 121

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: - proteinuria - other organ involvement: e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 122

hypertension: typically > 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 123

For patients with uterine fibroids, GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment E.g. Triptorelin

Answer 124

jaundice, mild pyrexia, hepatitic LFTs, raised WBC, coagulopathy and steatosis on imaging Clinically, acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea)

Answer 125

Rescan at 32 weeks to assess

Answer 126

A pregnant woman with abdominal trauma should have Rhesus testing asap because women who are Rhesus-negative should be given anti-D to prevent Rhesus isoimmunization.

Answer 127

Low molecular weight heparin (LMWH) antenatally + 6 weeks postpartum

Answer 128

the local Health Protection Unit

Answer 129

Presenting with low-grade fever, pain and vomiting.

Answer 130

Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash

Answer 131

A Kleihauer test is a test for FMH (fetomaternal haemorrhage) which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.

Answer 132

listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat salmonella: avoid raw or partially cooked eggs and meat, especially poultry

Answer 133

Liver - contains high levels of vitamin A (a teratogen)

Answer 134

Antihistamines e.g. CYCLIZINE are first-line in the management of nausea & vomiting in pregnancy/hyperemesis gravidarum

Answer 135

Ondansetron (a 5-HT3 reception antagonist) and domperidone (dopamine receptor antagonist) are second-line antiemetic.

Answer 136

'Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE).' 'Routine platelet count monitoring should not be carried out.'

Answer 137

18 - 20+6 weeks

Answer 138

10 - 13+6 weeks

Answer 139

Gestational diabetes - insulin should be commenced if fasting glucose level is >= 7 mmol/l insulin at the time of diagnosis

Answer 140

handheld Doppler should be used to confirm fetal heartbeat as a first step (CTG is incorrect in this situation as it is only used to assess reduced foetal movement once viability has been confirmed. The viability must be initially confirmed with a handheld doppler to detect a foetal heartbeat.)

Answer 141

Women who have a first degree relative with diabetes History of a previous macrosomic baby weight of 4.5kg or more BMI above 30 kg/m² Ethnicity with high prevalence of diabetes Previous gestational diabetes

Answer 142

Immediate ultrasound

Answer 143

Pregnant women with GDM should be advised to maintain their CBGs below the following target levels: fasting: 5.3mmol/L AND 1 hour postprandial: 7.8 mmol/L or 2 hours postprandial: 6.4 mmol/L

Answer 144

oral prochlorperazine is an alternative

Answer 145

Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty Previous baby with neonatal encephalopathy Pre-eclampsia requiring preterm birth Placental abruption with adverse outcome Eclampsia Uterine rupture Primary postpartum hemorrhage requiring additional treatment or blood transfusion Retained placenta requiring manual removal in theatre Caesarean section Shoulder dystocia

Answer 146

risk of causing worsening bleeding, which can lead to hypovolaemic shock in severe cases.

Answer 147

Without intervention the vertical transmission rate is around 20%, which increases to 90% if the woman is positive for HBeAg.

Answer 148

≥ 160/110 mmHg

Answer 149

ursodeoxycholic acid

Answer 150

Placental abruption is characterised by constant pain, shock out of keeping with the visible loss, tender and tense uterus

Answer 151

BMI>30 screen for GDM Increased risk PPH INcreased risk of still birth Increased risk of vit D def Increased risk of intra+PP VTE Increased risk of HTN and pre eclampsia SFH less likely to be accurate, BMI > 35 refer for serial fetal growth USS

Answer 152

After 24 weeks you would only expect the fundal height to increase by 1cm a week.

Answer 153

AFP - raised with fetal abdominal wall defects (e.g. omphalocele)

Answer 154

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gestation; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 155

During the first 10 weeks

Answer 156

When mother is infected by rubella virus within first 20 weeks of pregnancy

Answer 157

Women planning to become pregnant should ensure they have had the MMR vaccine. When in doubt, they can be tested for rubella immunity. If they do not have antibodies to rubella, they can be vaccinated with two doses of the MMR, three months apart. Pregnant women should not receive the MMR vaccination, as this is a live vaccine. Non-immune women should be offered the vaccine after giving birth.

Answer 158

Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Answer 159

Chickenpox is caused by the varicella zoster virus (VZV). It is dangerous in pregnancy because it can lead to: More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis Fetal varicella syndrome Severe neonatal varicella infection (if infected around delivery)

Answer 160

Mothers that have previously had chickenpox are immune and safe. When in doubt, IgG levels for VZV can be tested. A positive IgG for VZV indicates immunity. Women that are not immune to varicella may be offered the varicella vaccine before or after pregnancy. Exposure to chickenpox in pregnancy: When the pregnant woman has previously had chickenpox, they are safe When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe. When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.

Answer 161

When the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.

Answer 162

Congenital varicella syndrome occurs in around 1% of cases of chickenpox in pregnancy. It occurs when infection occurs in the first 28 weeks of gestation. The typical features include: Fetal growth restriction Microcephaly, hydrocephalus and learning disability Scars and significant skin changes located in specific dermatomes Limb hypoplasia (underdeveloped limbs) Cataracts and inflammation in the eye (chorioretinitis)

Answer 163

Listeria is an infectious gram-positive bacteria that causes listeriosis. Listeriosis is many times more likely in pregnant women compared with non-pregnant individuals. Infection in the mother may be asymptomatic, cause a flu-like illness, or less commonly cause pneumonia or meningoencephalitis. Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection. Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.

Answer 164

Congenital cytomegalovirus infection occurs due to a cytomegalovirus (CMV) infection in the mother during pregnancy. The virus is mostly spread via the infected saliva or urine of asymptomatic children. Most cases of CMV in pregnancy do not cause congenital CMV.

Answer 165

Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures

Answer 166

Infection with the Toxoplasma gondii parasite is usually asymptomatic. It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy, it can lead to congenital toxoplasmosis. The risk is higher later in the pregnancy.

Answer 167

Intracranial calcification Hydrocephalus Chorioretinitis (inflammation of the choroid and retina in the eye)

Answer 168

Parvovirus B19 infection typically affects children. It is also known as fifth disease, slapped cheek syndrome and erythema infectiosum. It is caused by the parvovirus B19 virus. The illness is self-limiting, and the rash and symptoms usually fade over 1 – 2 weeks. Parvovirus infection starts with non-specific viral symptoms. After 2 – 5 days, the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy. Reticular means net-like. Healthy children and adults have a low risk of any complications, and management is supportive. They are infectious 7 – 10 days before the rash appears. They are not infectious once the rash has appeared. Significant exposure to parvovirus is classed as 15 minutes in the same room, or face-to-face contact, with someone that has the virus. Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters.

Answer 169

First two trimesters

Answer 170

Miscarriage or fetal death Severe fetal anaemia Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome

Answer 171

Fetal anaemia is caused by parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver. These cells produce red blood cells, and the infection causes them to produce faulty red blood cells that have a shorter life span. Less red blood cells results in anaemia. This anaemia leads to heart failure, referred to as hydrops fetalis.

Answer 172

Maternal pre-eclampsia-like syndrome is also known as mirror syndrome. It can be a rare complication of severe fetal heart failure (hydrops fetalis). It involves a triad of hydrops fetalis, placental oedema and oedema in the mother. It also features hypertension and proteinuria.

Answer 173

IgM to parvovirus, which tests for acute infection within the past four weeks IgG to parvovirus, which tests for long term immunity to the virus after a previous infection Rubella antibodies (as a differential diagnosis)

Answer 174

Treatment is supportive. Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations.

Answer 175

The zika virus is spread by host Aedes mosquitos in areas of the world where the virus is prevalent. It can also be spread by sex with someone infected with the virus. It can cause no symptoms, minimal symptoms, or a mild flu-like illness. In pregnancy, it can lead to congenital Zika syndrome,

Answer 176

Microcephaly Fetal growth restriction Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

Answer 177

Pregnant women that may have contracted the Zika virus should be tested with viral PCR and antibodies to the Zika virus. Women with a positive result should be referred to fetal medicine for close monitoring of the pregnancy. There is no treatment for the virus.

Answer 178

Within the rhesus group, many different types of antigens can be present or absent, depending on the person’s blood type. The most relevant antigen within the rhesus blood group system is the rhesus-D antigen. When we refer to someone’s rhesus status in relation to pregnancy (e.g. “she is rhesus-negative”), we are usually referring to whether they have the rhesus-D antigen present on their red blood cell surface.

Answer 179

It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens. Usually, this sensitisation process does not cause problems during the first pregnancy. During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.

Answer 180

Prevention of sensitisation is the mainstay of management. This involves giving intramuscular anti-D injections to rhesus-D negative women. There is no way to reverse the sensitisation process once it has occurred, which is why prophylaxis is so essential.

Answer 181

28 weeks gestation Birth (if the baby’s blood group is found to be rhesus-positive)

Answer 182

The anti-D medication works by attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen. It acts as a prevention for the mother becoming sensitised to the rhesus-D antigen.

Answer 183

Anti-D injections should also be given at any time where sensitisation may occur, such as: Antepartum haemorrhage Amniocentesis procedures Abdominal trauma

Answer 184

Anti-D is given within 72 hours of a sensitisation event

Answer 185

The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required. The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.

Answer 186

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age.

Answer 187

Estimated fetal weight (EFW) Fetal abdominal circumference (AC)

Answer 188

Customised growth charts are used to assess the size of the fetus, based on the mother’s: Ethnic group Weight Height Parity

Answer 189

Severe SGA is when the fetus is below the 3rd centile for their gestational age

Answer 190

Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)

Answer 191

Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta. Higher risk of morbidity and mortality

Answer 192

Placenta mediated growth restriction Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

Answer 193

Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions

Answer 194

Genetic abnormalities Structural abnormalities Fetal infection Errors of metabolism

Answer 195

SGA Reduced amniotic fluid volume Abnormal Doppler studies Reduced fetal movements Abnormal CTGs

Answer 196

Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia

Answer 197

Cardiovascular disease, particularly hypertension Type 2 diabetes Obesity Mood and behavioural problems

Answer 198

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Answer 199

Low-risk women have monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA. The SFH is plotted on a customised growth chart to assess the appropriate size for the individual woman. If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler. Women are booked for serial growth scans with umbilical artery doppler if they have: Three or more minor risk factors One or more major risk factors Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

Answer 200

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring: Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery Amniotic fluid volume The local guidelines for the initiation and frequency of ultrasound scans may vary. An example regime is a growth scan every four weeks from 28 weeks gestation. Ultrasound frequency is increased where there is reduced growth velocity or problems with umbilical flow.

Answer 201

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring: Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery Amniotic fluid volume The local guidelines for the initiation and frequency of ultrasound scans may vary. An example regime is a growth scan every four weeks from 28 weeks gestation. Ultrasound frequency is increased where there is reduced growth velocity or problems with umbilical flow.

Answer 202

reduced growth velocity or problems with umbilical flow.

Answer 203

During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

Answer 204

Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby

Answer 205

Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare)

Answer 206

Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood

Answer 207

Ultrasound to exclude polyhydramnios and estimate the fetal weight Oral glucose tolerance test for gestational diabetes

Answer 208

The main risk with a large for gestational age baby is shoulder dystocia. The risks at delivery can be reduced by: Delivery on a consultant lead unit Delivery by an experienced midwife or obstetrician Access to an obstetrician and theatre if required Active management of the third stage (delivery of the placenta) Early decision for caesarean section if required Paediatrician attending the birth

Answer 209

Monozygotic: identical twins (from a single zygote)

Answer 210

Dizygotic: non-identical (from two different zygotes)

Answer 211

Monoamniotic: single amniotic sac

Answer 212

Diamniotic: two separate amniotic sacs

Answer 213

Monochorionic: share a single placenta

Answer 214

Dichorionic twins

Answer 215

The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Answer 216

Multiple pregnancy is usually diagnosed on the booking ultrasound scan. Number of placentas (chorionicity) and amniotic sacs (amnionicity)

Answer 217

Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign

Answer 218

Monochorionic diamniotic twins have a membrane between the twins, with a T sign

Answer 219

Monochorionic monoamniotic twins have no membrane separating the twins

Answer 220

The lambda sign, or twin peak sign, refers to a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane. This indicates a dichorionic twin pregnancy (separate placentas).

Answer 221

The T sign refers to where the membrane between the twins abruptly meets the chorion, giving a T appearance. This indicates a monochorionic twin pregnancy (single placenta).

Answer 222

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Answer 223

Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Answer 224

Twin-twin transfusion syndrome occurs when the fetuses share a placenta. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses. When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the fetuses. Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

Answer 225

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Answer 226

Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at: Booking clinic: 20 weeks gestation 28 weeks gestation Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome: 2 weekly scans from 16 weeks for monochorionic twins 4 weekly scans from 20 weeks for dichorionic twins

Answer 227

2 weekly scans from 16 weeks for monochorionic twins

Answer 228

4 weekly scans from 20 weeks for dichorionic twins

Answer 229

32-33+6 weeks

Answer 230

36 and 36+6 weeks

Answer 231

37 and 37+6 weeks

Answer 232

Before 35 + 6 weeks for triplets

Answer 233

Urinary tract infections in pregnant women increase the risk of preterm delivery. They may also increase the risk of other adverse pregnancy outcomes, such as low birth weight and pre-eclampsia.

Answer 234

Asymptomatic bacteriuria refers to bacteria present in the urine, without symptoms of infection. Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth.

Answer 235

Pregnant women are tested for asymptomatic bacteriuria and other abnormalities at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S). Testing for bacteria in the urine of asymptomatic patients is not recommended as it may lead to unnecessary antibiotics. Pregnant women are an exception to this rule, due to the adverse outcomes associated with infection.

Answer 236

Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Increased frequency of urination Urgency Incontinence Haematuria

Answer 237

Fever (more prominent than in lower urinary tract infections) Loin, suprapubic or back pain (this may be bilateral or unilateral) Looking and feeling generally unwell Vomiting Loss of appetite Haematuria Renal angle tenderness on examination

Answer 238

Most common cause of urinary tract infection is Escherichia coli (E. coli). This is a gram-negative, anaerobic, rod-shaped bacteria that is part of the normal lower intestinal microbiome. It is found in faeces, and can easily spread to the bladder. Other causes: Klebsiella pneumoniae (gram-negative anaerobic rod) Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)

Answer 239

Urinary tract infection in pregnancy requires 7 days of antibiotics. The antibiotic options are: Nitrofurantoin (avoid in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin

Answer 240

Trimethoprim needs to be avoided in the first trimester as it is works as a folate antagonist. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.

Answer 241

Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

Answer 242

Booking clinic 28 weeks gestation

Answer 243

During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume. It is important to optimise the treatment of anaemia during pregnancy so that the woman has reasonable reserves, in case there is significant blood loss during delivery.

Answer 244

Asymptomatic Shortness of breath Fatigue Dizziness Pallor

Answer 245

Low MCV may indicate iron deficiency Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy Raised MCV may indicate B12 or folate deficiency

Answer 246

Women are offered haemoglobinopathy screening at the booking clinic for thalassaemia (all women) and sickle cell disease (women at higher risk). Both are causes of significant anaemia in pregnancy.

Answer 247

Additional investigations are not routinely performed, by may help establish the cause of the anaemia. They may include: Ferritin B12 Folate

Answer 248

IRON Women with anaemia in pregnancy are started on iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron. B12 The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). Advice should be sought from a haematologist regarding further investigations and treatment of low B12 in pregnancy. Treatment options for low B12 are: Intramuscular hydroxocobalamin injections Oral cyanocobalamin tablets FOLATE All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily. THALASSAEMIA AND SICKLE CELL ANAEMIA Women with a haemoglobinopathy will be managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

Answer 249

Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

Answer 250

28 weeks if there are three risk factors First trimester if there are four or more of these risk factors

Answer 251

Hospital admission Surgical procedures Previous VTE Medical conditions such as cancer or arthritis High-risk thrombophilias Ovarian hyperstimulation syndrome

Answer 252

All pregnant women should have a risk assessment for their risk of venous thromboembolism (VTE) at booking. A risk assessment is performed again after birth. Additional risk assessments are necessary at other times, such as if they are admitted to hospital, undergo a procedure or develop significant immobility Each unit will have a policy and protocol for assessing risk and starting prophylaxis in pregnancy.

Answer 253

Women at increased risk of VTE should receive prophylaxis with low molecular weight heparin (LMWH) unless contraindicated. Examples of LMWH are enoxaparin, dalteparin and tinzaparin. Prophylaxis is started as soon as possible in very high risk patients and at 28 weeks in those at high risk. It is continued throughout the antenatal period and for six weeks postnatally. Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals).

Answer 254

Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs Anti-embolic compression stockings

Answer 255

Deep vein thrombosis is almost always unilateral. Bilateral DVTs are rare, and bilateral symptoms are more likely due to an alternative diagnosis such as chronic venous insufficiency or heart failure. DVTs present with: Calf or leg swelling Dilated superficial veins Tenderness to the calf (particularly over the deep veins) Oedema Colour changes to the leg To examine for leg swelling measure the circumference of the calf 10cm below the tibial tuberosity. More than 3cm difference between calves is significant.

Answer 256

Pulmonary embolism can present with subtle signs and symptoms. In patients with potential features of a PE, risk factors for PE, and no other explanation for their symptoms, have a low threshold for suspecting a PE. Presenting features include: Shortness of breath Cough with or without blood (haemoptysis) Pleuritic chest pain Hypoxia Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy) Raised respiratory rate Low-grade fever Haemodynamic instability causing hypotension

Answer 257

Doppler ultrasound is the investigation of choice for patients with suspected deep vein thrombosis. The RCOG guideline (2015) recommends repeating negative ultrasound scans on day 3 and 7 in patients with a high index of suspicion for DVT. Women with suspected pulmonary embolism require: Chest xray ECG There are two main options for establishing a definitive diagnosis: CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan. CT pulmonary angiogram involves a chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots. This is usually the first choice for investigating a pulmonary embolism, as it tends to be more readily available, provides a more definitive assessment and gives information about alternative diagnoses such as pneumonia or malignancy. Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs. First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused. When considering the choice between CTPA and VQ scan: CTPA is the test for choice for patients with an abnormal chest xray CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk) VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk) Patients with a suspected deep vein thrombosis and pulmonary embolism should have a Doppler ultrasound initially, and if a DVT is present, they do not require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.

Answer 258

The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Answer 259

Management of venous thromboembolism in pregnancy is with low molecular weight heparin (LMWH). Examples of LMWH are enoxaparin, dalteparin and tinzaparin. The dose is based on the woman’s weight at the booking clinic, or from early pregnancy. LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis. When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery. An individual risk assessment is performed before stopping anticoagulation, with advice from a haematologist if necessary. Women with a massive PE and haemodynamic compromise need immediate management by an experienced team of medical doctors, obstetricians, radiologists and others. This is a life-threatening scenario. Treatment options are: Unfractionated heparin Thrombolysis Surgical embolectomy

Answer 260

Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.

Answer 261

The most significant immediate complication of gestational diabetes is a large for dates fetus and macrosomia. This has implications for birth, mainly posing a risk of shoulder dystocia. Longer-term, women are at higher risk of developing type 2 diabetes after pregnancy. P

Answer 262

Anyone with risk factors should be screened with an oral glucose tolerance test at 24 – 28 weeks gestation. Women with previous gestational diabetes also have an OGTT soon after the booking clinic.

Answer 263

Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes (first-degree relative)

Answer 264

Large for dates fetus Polyhydramnios (increased amniotic fluid) Glucose on urine dipstick

Answer 265

An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.

Answer 266

Normal results are: Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l Results higher than these values are used to diagnose gestational diabetes. (5 6 7 8]

Answer 267

Patients with gestational diabetes are managed in joint diabetes and antenatal clinics, with input from a dietician. Women need careful explanation about the condition, and to learn how to monitor and track their blood sugar levels. Four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation. The initial management suggested by the NICE guidelines (2015) is: Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin Fasting glucose above 7 mmol/l: start insulin ± metformin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin. Women need to monitor their blood sugar levels several times a day. The NICE (2015) target levels are: Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below

Answer 268

Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.

Answer 269

four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation.

Answer 270

Before becoming pregnant, women with existing diabetes should aim for good glucose control. They should take 5mg folic acid from preconception until 12 weeks gestation. Women with existing type 1 and type 2 diabetes should aim for the same target insulin levels as with gestational diabetes. Women with type 2 diabetes are managed using metformin and insulin, and other oral diabetic medications should be stopped. Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required. NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6). A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes.

Answer 271

Shortly after booking clinic And at 28 weeks gestation

Answer 272

Neonatal hypoglycaemia Polycythaemia (raised haemoglobin) Jaundice (raised bilirubin) Congenital heart disease Cardiomyopathy

Answer 273

Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding. Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

Answer 274

Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby. Obstetric cholestasis is a relatively common complication of pregnancy, occurring in around 1% of pregnant women. It usually develops later in pregnancy (i.e. after 28 weeks)

Answer 275

increased oestrogen and progesterone levels There seems to be a genetic component. It is more common in women of South Asian ethnicity.

Answer 276

Bile acids are produced in the liver from the breakdown of cholesterol. Bile acids flow from liver to the hepatic ducts, past the gallbladder and out of the bile duct to the intestines. In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis).

Answer 277

Still birth

Answer 278

Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester. Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet. Other symptoms are related to cholestasis and outflow obstruction in the bile ducts: Fatigue Dark urine Pale, greasy stools Jaundice Importantly, there is no rash associated with obstetric cholestasis

Answer 279

polymorphic eruption of pregnancy or pemphigoid gestationis

Answer 280

Obstetric cholestasis/intrahepatic cholestasis of pregnancy Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis

Answer 281

Women presenting with pruritus should have liver function tests and bile acids checked. Obstetric cholestasis will cause: Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids (It is normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.)

Answer 282

Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms. Symptoms of itching can be managed with: Emollients (i.e. calamine lotion) to soothe the skin Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching) Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged. Vitamin K is a fat-soluble vitamin. Bile acids are important in the absorption of fat-soluble vitamins in the intestines. A lack of bile acids can lead to vitamin K deficiency. Vitamin K is an important part of the clotting system, and deficiency can lead to impaired clotting of blood. Monitor of LFTs is required during pregnancy (weekly) and after delivery (after at least ten days), to ensure the condition does not worsen and resolves after birth. Planned delivery after 37 weeks may be considered, particularly when the LFTs and bile acids are severely deranged. Stillbirth in obstetric cholestasis is difficult to predict, and early delivery aims to reduce the risk.

Answer 283

Acute fatty liver of pregnancy is a rare condition that occurs in the third trimester of pregnancy. There is a rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. There is a high risk of liver failure and mortality, for both the mother and fetus.

Answer 284

Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. This is the result of a genetic condition in the fetus that impairs fatty acid metabolism. The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition. This mode of inheritance means the mother will also have one defective copy of the gene. Th LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. The fetus and placenta are unable to break down fatty acids. These fatty acids enter the maternal circulation, and accumulate in the liver. The mother’s defective copy of the gene may also contribute to the accumulation of fatty acids. The accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure.

Answer 285

The presentation is with vague symptoms associated with hepatitis : General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) Ascites

Answer 286

Liver function tests will show elevated liver enzymes (ALT and AST). Other bloods may be deranged, with: Raised bilirubin Raised WBC count Deranged clotting (raised prothrombin time and INR) Low platelets NOTE elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.

Answer 287

Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery. Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Answer 288

Polymorphic eruption of pregnancy is also known as pruritic and urticarial papules and plaques of pregnancy. It is an itchy rash that tends to start in the third trimester. It usually begins on the abdomen, particularly associated with stretch marks (striae). It is characterised by: Urticarial papules (raised itchy lumps) Wheals (raised itchy areas of skin) Plaques (larger inflamed areas of skin)

Answer 289

Polymorphic eruption of pregnancy

Answer 290

Topical emollients Topical steroids Oral antihistamines Oral steroids may be used in severe cases

Answer 291

Atopic eruption of pregnancy essentially refers to eczema that flares up during pregnancy. This includes both women that have never suffered with eczema and those with pre-existing eczema. Atopic eruption of pregnancy presents in the first and second trimester of pregnancy. There are two types: E-type, or eczema-type: with eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest. P-type, or prurigo-type: with intensely itchy papules (spots) typically affecting the abdomen, back and limbs.

Answer 292

Topical emollients Topical steroids Phototherapy with ultraviolet light (UVB) may be used in severe cases Oral steroids may be used in severe cases

Answer 293

Melasma is also known as mask of pregnancy. It is characterised by increased pigmentation to patches of the skin on the face. This is usually symmetrical and flat, affecting sun-exposed areas. Melasma is thought to be partly related to the increased female sex hormones associated with pregnancy. It can also occur with the combined contraceptive pill and hormone replacement therapy. It is also associated with sun exposure, thyroid disease and family history.

Answer 294

No active treatment is required if the appearance is acceptable to the woman. Management is with: Avoiding sun exposure and using suncream Makeup (camouflage) Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care Procedures such as chemical peels or laser treatment (not usually on the NHS)

Answer 295

Pyogenic granuloma is also known as lobular capillary haemangioma. This is a benign, rapidly growing tumour of capillaries. It present as a discrete lump with a red or dark appearance. They occur more often in pregnancy, and can also be associated with hormonal contraceptives. They can also be triggered by minor trauma or infection.

Answer 296

Pyogenic granuloma present with a rapidly growing lump that develops over days up to 1-2 cm in size, (but can be larger). They often occur on fingers, or on the upper chest, back, neck or head. They may cause profuse bleeding and ulceration if injured.

Answer 297

Other differentials, such as malignancy, need to be excluded (particularly nodular melanoma). When they occur in pregnancy, they usually resolve without treatment after delivery. Treatment is with surgical removal with histology to confirm the diagnosis.

Answer 298

Pemphigoid gestationis is a rare autoimmune skin condition that occurs in pregnancy. Autoantibodies are created that damage the connection between the epidermis and the dermis. The pregnant woman’s immune system may produce these antibodies in response to placental tissue. This causes the epidermis and dermis to separate, creating a space that can fill with fluid, resulting in large fluid-filled blisters (bullae).

Answer 299

Pemphigoid gestationis usually occurs in the second or third trimester. The typical presentation is initially with an itchy red papular or blistering rash around the umbilicus, that then spreads to other parts of the body. Over several weeks, large fluid-filled blisters form.

Answer 300

Phemigoid gestationis

Answer 301

The rash usually resolves without treatment after delivery. It may go through stages of improvement and worsening during pregnancy and after birth. The blisters heal without scarring. Treatment is with: Topical emollients Topical steroids Oral steroids may be required in severe cases Immunosuppressants may be required where steroids are inadequate Antibiotics may be necessary if infection occurs

Answer 302

Fetal growth restriction Preterm delivery Blistering rash after delivery (as the maternal antibodies pass to the baby)

Answer 303

The Resuscitation Council UK list the reversible causes of adult cardiac arrest as the 4 Ts and 4 Hs: 4 Ts: Thrombosis (i.e. PE or MI) Tension pneumothorax Toxins Tamponade (cardiac) 4 Hs: Hypoxia Hypovolaemia Hypothermia Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities The RCOG guideline advises adding to the list: Eclampsia Intracranial haemorrhage

Answer 304

Obstetric haemorrhage Pulmonary embolism Sepsis leading to metabolic acidosis and septic shock

Answer 305

Ectopic pregnancy (early pregnancy) Placental abruption (including concealed haemorrhage) Placenta praevia Placenta accreta Uterine rupture

Answer 306

Aortocaval compression Increased oxygen requirements Splinting of the diaphragm by the pregnant abdomen Difficulty with intubation Increased risk of aspiration Ongoing obstetric haemorrhage

Answer 307

After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). This reduces the cardiac output, leading to hypotension. In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest. The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.

Answer 308

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

Answer 309

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta

Answer 310

Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

Answer 311

Placenta praevia is where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.

Answer 312

Low-lying placenta is used when the placenta is within 20mm of the internal cervical os Placenta praevia is used only when the placenta is over the internal cervical os

Answer 313

The three causes of antepartum haemorrhage to remember are placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality. Causes of spotting or minor bleeding in pregnancy include cervical ectropion, infection and vaginal abrasions from intercourse or procedures.

Answer 314

Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth

Answer 315

Traditionally, there are four grades of placenta praevia: Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os Partial praevia, or grade III – the placenta is partially covering the internal cervical os Complete praevia, or grade IV – the placenta is completely covering the internal cervical os The RCOG guidelines (2018) recommend against using this grading system, as it is considered outdated. The two descriptions used are low-lying placenta and placenta praevia.

Answer 316

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 317

The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia. Many women with placenta praevia are asymptomatic. It may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage). Bleeding usually occurs later in pregnancy (around or after 36 weeks).

Answer 318

32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)

Answer 319

Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.

Answer 320

The main complication of placenta praevia is haemorrhage before, during and after delivery. When this occurs, urgent management is required and may involve: Emergency caesarean section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy

Answer 321

Under normal circumstances, the umbilical cord containing the fetal vessels (umbilical arteries and vein) inserts directly into the placenta. The fetal vessels are always protected, either by the umbilical cord or by the placenta. The umbilical cord contains Wharton’s jelly. Wharton’s jelly is a layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection. There are two instances when the fetal vessels can be exposed, outside the protection of the umbilical cord or placenta: Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes. In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.

Answer 322

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 323

Vasa praevia is a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os. The fetal membranes surround the amniotic cavity and developing fetus. The fetal vessels consist of the two umbilical arteries and single umbilical vein.

Answer 324

Low lying placenta IVF pregnancy Multiple pregnancy

Answer 325

Vasa praevia may be diagnosed by ultrasound during pregnancy. This is the ideal scenario, as it allows a planned caesarean section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally. It may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy. It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.

Answer 326

For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend: Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs. After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.

Answer 327

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Answer 328

Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (consider domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use

Answer 329

Sudden onset severe abdominal pain that is continuous Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating fetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Answer 330

Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Answer 331

Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage. Concealed abruption is opposed to revealed abruption, where the blood loss is observed via the vagina.

Answer 332

There are no reliable tests for diagnosing placental abruption. It is a clinical diagnosis based on the presentation. Placental abruption is an obstetric emergency. The urgency depends on the amount of placental separation, extent of bleeding, haemodynamic stability of the mother and condition of the fetus. It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding. The initial steps with major or massive haemorrhage are: Urgent involvement of a senior obstetrician, midwife and anaesthetist 2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption. Antenatal steroids are offered between 24 and 34 + 6 weeks gestation to mature the fetal lungs in anticipation of preterm delivery. Rhesus-D negative women require anti-D prophylaxis when bleeding occurs. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required. Emergency caesarean section may be required where the mother is unstable, or there is fetal distress. There is an increased risk of postpartum haemorrhage after delivery in women with placental abruption. Active management of the third stage is recommended.

Answer 333

Placenta accreta refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby. It is referred to as placenta accreta spectrum, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.

Answer 334

With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond. This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as a caesarean section or curettage procedure. The deep implantation makes it very difficult for the placenta to separate during delivery, leading to extensive bleeding (postpartum haemorrhage).

Answer 335

Depending on depth of insertion Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond Placenta increta is where the placenta attaches deeply into the myometrium Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 336

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 337

is where the placenta implants in the surface of the myometrium, but not beyond

Answer 338

is where the placenta attaches deeply into the myometrium

Answer 339

is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 340

Placenta accreta does not typically cause any symptoms during pregnancy. It can present with bleeding (antepartum haemorrhage) in the third trimester. It may be diagnosed on antenatal ultrasound scans, and particular attention is given to women with a previous placenta accreta or caesarean during scanning. It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.

Answer 341

Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth. MRI scans may be used to assess the depth and width of the invasion.

Answer 342

Complex uterine surgery Blood transfusions Intensive care for the mother Neonatal intensive care

Answer 343

Ultrasound scan is the investigation of choice for diagnosing intrauterine fetal death (IUFD). It is used to visualise the fetal heartbeat to confirm the fetus is still alive. Passive fetal movements are possible after IUFD, and a repeat scan is offered to confirm the situation.

Answer 344

The Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of nausea and vomiting in pregnancy

Answer 345

16 weeks gestation

Answer 346

Vitamin D 400IU daily throughout the pregnancy, and folic acid 4-5mg (depending on risk factors) daily for the first 12 weeks of pregnancy

Answer 347

between 10 and 14 weeks of pregnancy.

Answer 348

Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage.

Answer 349

Daily fasting, pre-meal, 1-hour post-meal and bedtime tests.

Answer 350

Spontaneous abortion Ectopic pregnancy Hydatidiform mole

Answer 351

Spontaneous abortion Hydatidiform mole Placental abruption

Answer 352

Bloody show Placental abruption Placenta praevia Vasa praevia

Answer 353

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

Answer 354

8-12 weeks

Answer 355

They can precipitate Wernicke’s encephalopathy

Answer 356

pubic symphisis

Answer 357

The xiphoid process of the sternum

Answer 358

Longitudinal lie: the head and buttocks are palpable at each end of the uterus. Oblique lie: the head and buttocks are palpable in one of the iliac fossae. Transverse lie: the fetus is lying directly across the uterus.

Answer 359

It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Answer 360

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

Antenatal Care Flashcards

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