Antenatal Care

Question 1

Triad of symptoms - vasa praevia

Answer 1

Painless vaginal bleeding
Foetal bradycardia
Rupture of membranes

Question 2

What is vasa praevia and why is it dangerous?

Answer 2

Condition where the feotal blood vessels (not protected by the umbilical cord) run close or across the cervical os.

Rupture of membranes can cause rupture of feotal vessels and subsequent feotal haemorrhage

Question 3

What should be done if a placenta is found to be low lying at the 20 week abnormality scan?

Answer 3

Repeat at 32 and 36 weeks (if still not moved at 32)

Question 4

Social history considerations in pregnancy?

Answer 4

Planned vs unplanned
Safety issues
Home situation
Smoking and alcohol use
Risk factors for mental health problems - perinatal mental health team

Question 5

What would a community midwife risk assess a pregnant patient for?

Answer 5

Small for gestational age
Pre eclampsia
Preterm labour
Gestational diabetes
VTE

Question 6

Within how long is it reccomended a pregnant woman has a booking appointment with a midwife?

Answer 6

10 weeks

Question 7

What might intractable vomiting lead to?

Answer 7

Thiamine deficiency leading to Wernickes encepalopathy leading to feotal death

Question 8

What is pre eclampsia?

Answer 8

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

Question 9

After how many weeks gestation does pre eclampsia occur?

Answer 9

20 weeks

Question 10

What is the basic cause of pre eclampsia?

Answer 10

Spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels

Question 11

Pre-eclampsia is a significant cause of maternal and fetal morbidity and mortality - what can it lead to?

Answer 11

Without treatment, it can lead to maternal organ damage, fetal growth restriction, seizures, early labour and in a small proportion, death.

Question 12

Triad of signs in preeclampsia

Answer 12

Hypertension
Proteinuria
Oedema

Question 13

What is chronic HTN in pregnancy, how does it compare to pre eclampsia?

Answer 13

Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding (Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, occuring after 20 weeks gestation)

This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Question 14

What is pregnancy induced hypertension, how does it compare to pre eclampsia?

Answer 14

Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria (pre eclampsia involves proteinuria)

Question 15

What is eclampsia?

Answer 15

Eclampsia is when seizures occur as a result of pre-eclampsia (HTN oedema and proteinuria occurring from 20 weeks gestation)

Question 16

Pathophysiology of pre eclampsia?

Answer 16

When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium.

It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.

Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile.

The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes).

Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins.

Lacunae form at around 20 weeks gestation.

When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia.

Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta.

This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

Question 17

Pre eclampsia - high risk factors

Answer 17

Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease

Question 18

Pre eclampsia moderate risk factors

Answer 18

Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia

Question 19

Which women are offered aspirin as prophylaxis against pre-eclampsia and from when?

Answer 19

Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Question 20

Symptoms of pre eclampsia

Answer 20

Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema - pitting
Reduced urine output
(Brisk reflexes, HTN>140)

Question 21

How can pre eclampsia be diagnosed?

Answer 21

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg

PLUS any of:

Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Question 22

How is proteinuria quantified?

Answer 22

Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 23

PlGF - pre eclampsia

Answer 23

The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia.

Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels.

In pre-eclampsia, the levels of PlGF are LOW.

NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Question 24

What blood test can rule out pre eclampsia between 20 and 35 weeks?

Answer 24

NICE recommends using PlGF (placental growth factor) between 20 and 35 weeks gestation to rule-out pre-eclampsia (low in pre eclampsia)

Question 25

Management of pre eclampsia - preventative

Answer 25

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

Question 26

When gestational hypertension (without proteinuria) is identified, the general management involves what?

Answer 26

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

Question 27

General management of diagnosed pre eclampsia?

Answer 27

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

Question 28

Medical management of pre eclampsia?

Answer 28

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

Question 29

Role of IV magnesium sulphate in a woman with pre eclampsia?

Answer 29

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

Question 30

What is eclampsia and how is it managed?

Answer 30

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

Question 31

What is HELLP syndrome?

Answer 31

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

Question 32

Define Last menstrual period (LMP)

Answer 32

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

Question 33

Define Gestational age (GA)

Answer 33

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

Question 34

Define Estimated date of delivery (EDD)

Answer 34

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

Question 35

Define Gravida (G)

Answer 35

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

Question 36

Define Primigravida

Answer 36

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

Question 37

Define Multigravida

Answer 37

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

Question 38

Define Para (P)

Answer 38

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

Question 39

Define Nulliparous (“nullip”)

Answer 39

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

Question 40

Define Primiparous

Answer 40

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

Question 41

Define Multiparous

Answer 41

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

Question 42

How is gestational age described?

Answer 42

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

Question 43

When is the first trimester?

Answer 43

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

Question 44

When is the second trimester?

Answer 44

13 weeks to 26 weeks gestation

Question 45

When is the third trimester?

Answer 45

The third trimester is from 27 weeks gestation until birth.

Question 46

At how many weeks does fetal movement start?

Answer 46

Around 20 weeks gestation

Question 47

When is booking clinic and what is the purpose?

Answer 47

Before 10 weeks

Offer a baseline assessment and plan the pregnancy

Question 48

When does a dating scan occur and what is the purpose?

Answer 48

Between 10 and 13 + 6 weeks

An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified

Question 49

Purpose of 16 week antenatal appointment?

Answer 49

16 weeks

Discuss results and plan future appointments

Question 50

When does the anomaly scan occur and what is the purpose?

Answer 50

Between 18 and 20 + 6 weeks

An ultrasound to identify any anomalies, such as heart conditions

Question 51

At which points during a pregnancy should antenatal appointments be had?

Answer 51

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)

Question 52

What additional antenatal appointments may be required if the mother/pregnancy meet certain criteria?

Answer 52

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

Question 53

Several things are covered at each routine antenatal appointment, including what?

Answer 53

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

Question 54

Symphysis–fundal height measurement from how many weeks onwards?

Answer 54

24 weeks

Question 55

Fetal presentation assessment from how many weeks onwards?

Answer 55

36 weeks

Question 56

What vaccines should be offered to pregnant women?

Answer 56

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

Question 57

What vaccines should be avoided in pregnancy?

Answer 57

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

Question 58

An ultrasound scan should be performed at how many weeks for women with placenta praevia on the anomaly scan?

Answer 58

32 weeks

Question 59

What supplements are recommended in pregnancy?

Answer 59

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)

Question 60

What should pregnant women avoid?

Answer 60

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

Question 61

Advice for sexually active pregnant women?

Answer 61

Sex is safe

STIs can be passed on to fetus/baby

Question 62

Advice for travelling by car for pregnant women

Answer 62

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

Question 63

Implications of drinking alcohol during pregnancy?

Answer 63

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

Question 64

What might alcohol in early pregnancy lead to?

Answer 64

Miscarriage
Small for dates
Preterm delivery
Fetal alcohol syndrome

Question 65

During which part of a pregnancy does drinking alcohol have the greatest effect on the fetus?

Answer 65

First 3 months

Question 66

Features of fetal alcohol syndrome

Answer 66

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

Question 67

What are the risks of smoking during pregnancy?

Answer 67

Fetal growth restriction (FGR)

Miscarriage

Stillbirth

Preterm labour and delivery

Placental abruption

Pre-eclampsia

Cleft lip or palate

Sudden infant death syndrome (SIDS)

Question 68

Flying during pregnancy?

Answer 68

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.

Question 69

What pregnancy related topics are covered in booking clinic?

Answer 69

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

Question 70

What bloods are taken at booking clinic?

Answer 70

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.

Question 71

'’Bedside’’ test and examinations at booking clinic

Answer 71

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

Question 72

At booking clinic women are assessed for risk factors for other conditions, and plans are put in place with additional appointments booked. What risk factors are screened for and what action might be taken?

Answer 72

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)

Question 73

What condition is caused by three copies of chromosome 21, (also called trisomy 21)

Answer 73

Downs Syndrome

Question 74

Downs Syndrome screening in pregnancy?

Answer 74

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.

Question 75

When is the combined test (down syndrome screening performed)?

Answer 75

11 - 14 weeks

Question 76

What is the first line and most accurate screening test for Downs Syndrome?

Answer 76

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

Question 77

How does the combined test screen for Downs Syndrome?

Answer 77

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

Question 78

How does beta-HCG relate to risk of Downs Syndrome?

Answer 78

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

Question 79

How does pregnancy-associated plasma protein-A (PAPPA) relate to risk of Downs Syndrome?

Answer 79

A LOWER result indicates a greater risk

Question 80

How does USS at 11-14 weeks help to indicate risk of Downs Syndrome?

Answer 80

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

Question 81

At what gestation can the triple test or quadruple for Downs Syndrome screening be performed?

Answer 81

14-20 weeks

Question 82

What does the triple test involve?

Answer 82

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

Question 83

What does the quadruple test involve?

Answer 83

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.

Question 84

Which women are offered amniocentesis or chorionic villus sampling for Downs Syndrome?

Answer 84

. 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.

Question 85

What are CVS and amniocentesis (DS syndrome screening)

Answer 85

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.

Question 86

Chorionic villus sampling is the test of choice prior to what gestation?

Answer 86

15 weeks

Question 87

Why is amniocentesis reserved for use later in pregnancy?

Answer 87

More amniotic fluid - safer sample

Question 88

NIPT

Answer 88

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.

Question 89

Indications for Chorionic villus sampling?

Answer 89

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.

Question 90

Chorionic villus sampling limitations and complications

Answer 90

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.

Question 91

Amniocentesis limitations and complications

Answer 91

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

Question 92

Untreated or under-treated hypothyroidism in pregnancy can lead to several adverse pregnancy outcomes, including what?

Answer 92

Miscarriage
Anaemia
Small for gestational age
Pre-eclampsia.

Question 93

Treatment of hypothyroidism in pregnancy?

Answer 93

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.

Question 94

What anti-hypertensive agents should be stopped during pregnancy?

Answer 94

ACE inhibitors (e.g. ramipril)

Angiotensin receptor blockers (e.g. losartan)

Thiazide and thiazide-like diuretics (e.g. indapamide)

Question 95

What anti-hypertensive agents are considered safe during pregnancy?

Answer 95

Labetalol (a beta-blocker – although other beta-blockers may have adverse effects)

Calcium channel blockers (e.g. nifedipine)

Alpha-blockers (e.g. doxazosin)

Question 96

Women with epilepsy should take how much folic acid daily from before conception to reduce the risk of neural tube defects?

Answer 96

5mg

Question 97

How much folic acid should be taken during pregnancy and at what dose?

Answer 97

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

Question 98

How do pregnancy and epilepsy affect eachother?

Answer 98

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.

Question 99

Why should sodium valproate be avoided during pregnancy?

Answer 99

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).

Question 100

Why should phenytoin be avoided during pregnancy?

Answer 100

Phenytoin is avoided as it causes cleft lip and palate

Question 101

What anti-epileptic drugs are considered the safe options during pregnancy?

Answer 101

Levetiracetam
Lamotrigine
Carbamazepine

Question 102

Ideally, rheumatoid arthritis should be well controlled for how long before becoming pregnant?

Answer 102

At least 3 months

Question 103

How does pregnancy affect RA?

Answer 103

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

Question 104

What treatments used for autoimmune conditions are considered safe in pregnancy?

Answer 104

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

Question 105

Which DMARD should NOT be used in pregnancy?

Answer 105

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

Question 106

NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis), when in particular and why?

Answer 106

Particularly in third trimester

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

Question 107

Why can NSAIDs cause problems in pregnancy?

Answer 107

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.

Question 108

What problems can beta blockers cause in pregnancy?

Answer 108

Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate

Question 109

What is the most commonly used beta blocker in pregnancy and what is it used for?

Answer 109

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

Question 110

What can ARBs and ACEi cause if used in pregnancy?

Answer 110

Oligohydramnios (reduced amniotic fluid)

Miscarriage or fetal death

Hypocalvaria (incomplete formation of the skull bones)

Renal failure in the neonate

Hypotension in the neonate

Question 111

How can ACEi and ARBs cause Oligohydramnios if used in pregnancy?

Answer 111

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).

Question 112

Warfarin crosses the placenta and is considered teratogenic in pregnancy, therefore it is avoided in pregnant women. What can it cause?

Answer 112

Fetal loss

Congenital malformations, particularly craniofacial problems

Bleeding during pregnancy
Postpartum haemorrhage
Fetal haemorrhage
Intracranial bleeding

Question 113

Lithium is avoided in pregnant women, breastfeeding women, or those planning pregnancy unless other options (i.e. antipsychotics) have failed - why?

Answer 113

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.

Question 114

What congenital abnormality is Lithium particularly associated with in the first trimester of pregnancy?

Answer 114

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.

Question 115

Use of SSRIs in pregnancy

Answer 115

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:

Question 116

What is the risk of first trimester use of SSRIs?

Answer 116

First-trimester use has a link with congenital heart defects

In particular, paroxetine has a stronger link with congenital malformations

Question 117

What is the risk of third trimester use of SSRIs?

Answer 117

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

Question 118

Implications of taking SSRIs during pregnancy on the neonate?

Answer 118

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

Question 119

What common drug used to treat acne is considered dangerous to take during pregnancy?

Answer 119

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.

Question 120

Family planning considerations for women taking isotretinoin?

Answer 120

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

Question 121

What is neonatal abstinence syndrome (NAS) and when and how does it present?

Answer 121

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

Question 122

Why do autoimmune conditions improve during pregnancy?

Answer 122

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.

Question 123

Why does susceptibility to diabetes and infections increase during pregnancy?

Answer 123

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.

Question 124

Why are pregnant women at increased risk of thromboembolism?

Answer 124

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

Question 125

Why do pregnant women have a higher requirement for B12, iron and folate?

Answer 125

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

Question 126

Why might pregnant women become anaemic?

Answer 126

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.

Question 127

Will a pregnant woman with HSV pass protection on to her fetous?

Answer 127

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.

Question 128

Nageles Rule of EDD

Answer 128

1. Regular periods
2. No hormonal contraception in last 3 months
3. Not lactation

EDD=LMP + 9 months and 7 days

Question 129

Women at moderate or high risk pre eclampsia should take what, and when?

Answer 129

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

Question 130

NIPT

Answer 130

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

Question 131

What can the quadruple test suggest risk of?

Answer 131

Down’s
syndrome

Edward’s
syndrome

Neural
tube
defects

Question 132

Edward’s syndrome: quadruple test result

Answer 132

↓ AFP
↓ oestriol
↓ hCG
↔ inhibin A

Question 133

Patau syndrome: quadruple test result

Answer 133

↑ AFP, ↔ oestriol, ↔ hCG, ↔ inhibin A

Question 134

Patau syndrome characteristics

Answer 134

small eyes, cleft lip and polydactyly

Question 135

Edwards syndrome characteristics

Answer 135

overlapping fingers and low-set ears

Question 136

Why is trace glucosuria not usually and concern in pregnancy?

Answer 136

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

Question 137

Factors associated with miscarriage

Answer 137

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

Question 138

Factors commonly mistaken as being associated with miscarriage

Answer 138

Heavy lifting
Bumping your tummy
Having sex
Air travel
Being stressed

Question 139

Risk factors for breech presentation

Answer 139

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

Question 140

Women with autoimmune conditions such as SLE or antiphospholipid syndrome are at high risk of what?

Answer 140

Pre eclampsia

Question 141

When should iron replacement be considered in the first trimester of pregnancy?

Answer 141

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

Question 142

Down’s syndrome quadruple test result

Answer 142

↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A

Question 143

At what gestation would a referral to the maternal fetal medicine unit for a presentation of absence of feotal movements?

Answer 143

24 weeks

Question 144

Risks of ondansetron use in first trimester

Answer 144

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

Question 145

Metoclopramide is an option for nausea and vomiting in pregnancy, but it should not be used for more than a given period? How long is this period and what is the reason!?

Answer 145

5 days, due to risk of extrapyramidal effects

Question 146

What should be done in gestational diabetes, if blood glucose targets are not met with diet/metformin?

Answer 146

insulin should be added

Question 147

Plasma glucose targets in pregnancy?

Answer 147

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

Question 148

Why are pregnant women more susceptible to thyrotoxicosis?

Answer 148

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.

Question 149

Ovarian cysts in pregnancy?

Answer 149

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

Question 150

What sign of pre eclampsia is particularly specific to the condition?

Answer 150

Brisk reflexes

Question 151

Formal definition of pre eclampsia

Answer 151

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

Question 152

Features of severe pre eclampsia

Answer 152

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

Question 153

For patients with intrauterine fibroids, what can be given while surgery is awaited.

Answer 153

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

Question 154

Acute fatty liver of pregnancy typical presentation

Answer 154

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)

Question 155

If low-lying placenta is found at the 20-week scan what should be done?

Answer 155

Rescan at 32 weeks to assess

Question 156

Haemoglobin lower than what is the cut-off level to prescribe iron replacement therapy in women during the second and third trimesters?

Answer 156

105 g/L

Question 157

What should be done for all pregnant women regardless of station following abdominal trauma?

Answer 157

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.

Question 158

Managing pregnant women at high risk of VTE

Answer 158

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

Question 159

Suspected cases of rubella in pregnancy should be discussed with who?

Answer 159

the local Health Protection Unit

Question 160

Fibroid degeneration may develop during pregnancy, presenting how?

Answer 160

Presenting with low-grade fever, pain and vomiting.

Question 161

Pregnant women > 20 weeks presenting with symptoms of chicken pox

Answer 161

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

Question 162

What is a Kleihauer test and when is it required?

Answer 162

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.

Question 163

What food acquired infections should pregnant women be warned about?

Answer 163

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

Question 164

What food should be avoided due to concerns re teratogenicity?

Answer 164

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

Question 165

First line management of NVP/hyperemesis gravidarum?

Answer 165

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

Question 166

Second line management of NVP/hyperemesis gravidarum?

Answer 166

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

Question 167

RCOG guidance on monitoring of women on LMWH for treatment of acute VTE in pregnancy

Answer 167

‘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.’

Question 168

First dose of anti-D prophylaxis to rhesus negative women should be given when

Answer 168

28 weeks

Question 169

When should the anomaly scan occur

Answer 169

18 - 20+6 weeks

Question 170

When should the dating scan occur

Answer 170

10 - 13+6 weeks

Question 171

When gestation diabetes is diagnosed, when should insulin be commenced immediately?

Answer 171

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

Question 172

If a pregnant woman reports reduced fetal movements what is the first line investigation?

Answer 172

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.)

Question 173

Which pregnant women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks?

Answer 173

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

Question 174

If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then what should be offered

Answer 174

Immediate ultrasound

Question 175

GDM blood sugar targets

Answer 175

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

Question 176

Alternatives to antihistamines as first line to treat NVP/hyperemesis gravidarum

Answer 176

oral prochlorperazine is an alternative

Question 177

Previous pregnancy Risk factors for consultant lead care

Answer 177

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

Question 178

Why should bimanual examination be avoided in women with placenta praevia

Answer 178

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

Question 179

Risk of vertical transmission in pregnant women with hep B

Answer 179

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

Question 180

Pregnant women with blood pressure above what are likely to be admitted and observed, regardLess of symptoms of proteinuria?

Answer 180

≥ 160/110 mmHg

Question 181

Definitive treatment for obstetric cholestasis

Answer 181

ursodeoxycholic acid

Question 182

How is placental abruptiom characterised

Answer 182

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

Question 183

Increased BMI implications on pregnancy and birth

Answer 183

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

Question 184

Normal fundal height increase after 24 weeks

Answer 184

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

Question 185

Raised AFP in pregnancy

Answer 185

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

Question 186

Risk factors for placental abruption

Answer 186

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)

Question 187

In which stage of pregnancy is rubella most harmful to the fetus

Answer 187

During the first 10 weeks

Question 188

When can congenital rubella syndrome occur

Answer 188

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

Question 189

Pregnancy and MMR vaccine

Answer 189

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.

Question 190

What are the features of congenital rubella syndrome

Answer 190

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

Question 191

Why is chickenpox dangerous in pregnancy?

Answer 191

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)

Question 192

Chicken pox exposure during pregnancy?

Answer 192

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.

Question 193

If a woman who is pregnant develops a chickenpox rash during pregnancy, when can she be treated?

Answer 193

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.

Question 194

What is congenital varicella syndrome

Answer 194

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)

Question 195

What is listeria and why is it a concern in pregnancy?

Answer 195

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.

Question 196

Congenital cytomegalovirus infection

Answer 196

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.

Question 197

What are the features of congenital cytomegalovirus infection

Answer 197

Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures

Question 198

Toxoplasmosis in pregnancy

Answer 198

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.

Question 199

Triad of features of toxoplasmosis

Answer 199

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

Question 200

Fifth disease in pregnancy

Answer 200

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.

Question 201

When is parvovirus 19 most dangerous in pregnancy

Answer 201

First two trimesters

Question 202

Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters, such as what?

Answer 202

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

Question 203

How can maternal parvovirus 19 infection cause fetal anaemia +/- hydrops fetalis?

Answer 203

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.

Question 204

What is maternal pre-eclampsia-like syndrome and what are the features

Answer 204

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.

Question 205

Suspected parvovirus infection in pregnancy

Answer 205

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)

Question 206

Management of parvovirus 19 in pregnancy?

Answer 206

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

Question 207

What is Zika virus and why is it a concern in pregnancy

Answer 207

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,

Question 208

Features of congenital zika syndrome

Answer 208

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

Question 209

Management of suspected Zika virus in pregnancy

Answer 209

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.

Question 210

What is meant by rhesus negative/positive

Answer 210

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.

Question 211

When a woman that is rhesus-D negative becomes pregnant, we have to consider the possibility that her child will be rhesus positive - why?

Answer 211

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.

Question 212

What is the mainstay of rhesus-D negative management during pregnancy and why is it important

Answer 212

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.

Question 213

When is anti d given in pregnancy

Answer 213

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

Question 214

How does anti D work to prevent sensitisation

Answer 214

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.

Question 215

Other than at 28 weeks gestation and at birth, when should rhesus negative women be given anti-D

Answer 215

Anti-D injections should also be given at any time where sensitisation may occur, such as:

Antepartum haemorrhage
Amniocentesis procedures
Abdominal trauma

Question 216

Within what time period should anti D be given after a sensitisation event has occured

Answer 216

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

Question 217

What is The Kleihauer test and when is it done?

Answer 217

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.

Question 218

What is small for gestational age defined as?

Answer 218

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

Question 219

What measurements on USS are used to measure fetal size?

Answer 219

Estimated fetal weight (EFW)

Fetal abdominal circumference (AC)

Question 220

Customised growth charts are used to assess the size of the fetus, based on what?

Answer 220

Customised growth charts are used to assess the size of the fetus, based on the mother’s:

Ethnic group
Weight
Height
Parity

Question 221

What is severe SGA

Answer 221

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

Question 222

What are the two categories of causes of SGA

Answer 222

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)

Question 223

What is FGR

Answer 223

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

Question 224

What are the two categories of FGR

Answer 224

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

Question 225

Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta, such as what?

Answer 225

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

Question 226

Non-placenta medicated growth restriction refers to pathology of the fetus, such as?

Answer 226

Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism

Question 227

Signs of FGR

Answer 227

SGA

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

Question 228

Short term complications of FGA?

Answer 228

Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

Question 229

What are babies with growth restriction at increased risk of long term?

Answer 229

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

Question 230

Risk factors for SGA

Answer 230

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

Question 231

At the booking clinic, women are assessed for risk factors for SGA. How are low risk women subsequently monitored?

Answer 231

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)

Question 232

At the booking clinic, women are assessed for risk factors for SGA. How are high risk women subsequently monitored?

Answer 232

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.

Question 233

At the booking clinic, women are assessed for risk factors for SGA. How are low risk women subsequently monitored?

Answer 233

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.

Question 234

What does increased ultrasound frequency suggest?

Answer 234

reduced growth velocity or problems with umbilical flow.

Question 235

What is large for gestation age

Answer 235

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

Question 236

Causes of macrosomia

Answer 236

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

Question 237

Macrosomia risks to the baby

Answer 237

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

Question 238

Macrosomia - risk to the baby

Answer 238

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

Question 239

Investigations for LGA

Answer 239

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

Question 240

The main risk with a large for gestational age baby is shoulder dystocia.
The risks at delivery can be reduced how?

Answer 240

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

Question 241

Monozygotic twins

Answer 241

Monozygotic: identical twins (from a single zygote)

Question 242

Dizygotic twins

Answer 242

Dizygotic: non-identical (from two different zygotes)

Question 243

Monoamniotic twins

Answer 243

Monoamniotic: single amniotic sac

Question 244

Diamniotic twins

Answer 244

Diamniotic: two separate amniotic sacs

Question 245

Monochorionic twins

Answer 245

Monochorionic: share a single placenta

Question 246

Dichorionic: two separate placentas

Answer 246

Dichorionic twins

Question 247

What types of twins have the best outcomes and why

Answer 247

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

Question 248

When is multiple pregnancy diagnosed

Answer 248

Multiple pregnancy is usually diagnosed on the booking ultrasound scan.

Number of placentas (chorionicity) and amniotic sacs (amnionicity)

Question 249

Dichorionic diamniotic twins USS

Answer 249

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

Question 250

Monochorionic diamniotic twins USS

Answer 250

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

Question 251

Monochorionic monoamniotic twins USS

Answer 251

Monochorionic monoamniotic twins have no membrane separating the twins

Question 252

What is the lambda sign on USS

Answer 252

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).

Question 253

What is the T sign on USS

Answer 253

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).

Question 254

Multiple pregnancies - risks to mother

Answer 254

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

Question 255

Multiple pregnancies - risk to fetuses/neonates

Answer 255

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

Question 256

What is twin to twin transfusion syndrome

Answer 256

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.

Question 257

What is twin anaemia polycythaemia sequence

Answer 257

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).

Question 258

Monitoring in twin pregnancies

Answer 258

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

Question 259

What type of twins require 2 weekly scans and from when

Answer 259

2 weekly scans from 16 weeks for monochorionic twins

Question 260

What type of twins require 4 weekly scans and from when

Answer 260

4 weekly scans from 20 weeks for dichorionic twins

Question 261

Planned birth is offered when for uncomplicated monochorionic monoamniotic twins

Answer 261

32-33+6 weeks

Question 262

Planned birth is offered when for uncomplicated monochorionic diamniotic twins

Answer 262

36 and 36+6 weeks

Question 263

Planned birth is offered when for uncomplicated dichorionic diamniotic twins

Answer 263

37 and 37+6 weeks

Question 264

Planned birth is offered when for triplets

Answer 264

Before 35 + 6 weeks for triplets

Question 265

Pregnant women are at higher risk of developing lower urinary tract infections (cystitis) and pyelonephritis (infection of kidneys). Why is this a problem?

Answer 265

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.

Question 266

What is asymptomatic bacterium in and why is it a problem in pregnancy?

Answer 266

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.

Question 267

Monitoring of urine in pregnancy

Answer 267

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.

Question 268

How might a lower urinary tract infection present

Answer 268

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

Question 269

How might an upper urinary tract infection (pyelonephritis) present

Answer 269

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

Question 270

Causative organisms of UTI

Answer 270

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)

Question 271

Managing uti in pregnancy

Answer 271

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

Question 272

Which antibiotic used to treat UTIs must be avoided in the first trimester and why

Answer 272

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.

Question 273

What antibiotic may be used to treat UTI IN pregnancy but must be avoided in the third trimester and why

Answer 273

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

Question 274

When are women routinely tested for anaemia in pregnancy

Answer 274

Booking clinic
28 weeks gestation

Question 275

Why does pregnancy increase the risk of anaemia and why is this significant

Answer 275

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.

Question 276

How might pregnant women with anaemia present

Answer 276

Asymptomatic
Shortness of breath
Fatigue
Dizziness
Pallor

Question 277

The mean cell volume (MCV) can indicate the cause of the anaemia - how?

Answer 277

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

Question 278

What haematological screening is performed at booking clinic

Answer 278

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.

Question 279

What additional investigations other than MCV may help establish the cause of anaemia

Answer 279

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

Ferritin
B12
Folate

Question 280

Management of anaemia in pregnancy

Answer 280

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.

Question 281

What risk factors increase the risk of VTE in pregnancy

Answer 281

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

Question 282

When do the RCOG reccomend VTE prophylaxis be started in pregnancy

Answer 282

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

Question 283

Scenarios where VTE prophylaxis may be indicated in pregnancy despite lack of the risk factors given by RCOG

Answer 283

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

Question 284

When are pregnant women assessed for risk of VTE

Answer 284

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.

Question 285

What prophylaxis is given against VTE in pregnancy

Answer 285

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).

Question 286

Mechanical prophylaxis may be considered in women with contraindications to LMWH. The options for mechanical prophylaxis are what?

Answer 286

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

Question 287

DVT presentation

Answer 287

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.

Question 288

PE PRESENTATION

Answer 288

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

Question 289

Diagnosing DVT/PE in pregnancy

Answer 289

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.

Question 290

What tests/screening associated with VTE are not used in pregnant women

Answer 290

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.

Question 291

Management of VTE in pregnancy

Answer 291

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

Question 292

Why does gestational diabetes occur

Answer 292

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

Question 293

Complications of gestation diabetes?

Answer 293

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

Question 294

Screening for gestational diabetes

Answer 294

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.

Question 295

Risk factors that warrant testing for gestational diabetes

Answer 295

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)

Question 296

Features other than maternal risk factors that may be suggestive of gestational diabetes that therefore warrant OGGT

Answer 296

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

Question 297

How should an OGTT be performed

Answer 297

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.

Question 298

OGGT results

Answer 298

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]

Question 299

Management of gestational diabetes

Answer 299

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

Question 300

What is a suggested option for women with gestational diabetes who decline insulin and cannot tolerate metformin

Answer 300

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

Question 301

Gestational diabetes - monitoring for fetal growth and amniotic fluid volume

Answer 301

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

Question 302

Pregnancy with pre existing diabetes

Answer 302

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.

Question 303

When should women with pre existing diabetes have retinopathy screening

Answer 303

Shortly after booking clinic

And at 28 weeks gestation

Question 304

Maternal diabetes risks to baby

Answer 304

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

Question 305

Blood glucose in babies born to mothers with GD or DM

Answer 305

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.

Question 306

What is obstetric choleostasis and when does it usualy develop

Answer 306

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)

Question 307

Why is obstetric cholestasis thought to occur and who is most at risk?

Answer 307

increased oestrogen and progesterone levels

There seems to be a genetic component. It is more common in women of South Asian ethnicity.

Question 308

What happens in obstetric cholestasis

Answer 308

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).

Question 309

What is obstetric cholestasis associated with an increased risk of?

Answer 309

Still birth

Question 310

Presentation of obstetric cholestasis

Answer 310

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

Question 311

Importantly, there is no rash associated with obstetric cholestasis. If a rash is present, an alternative diagnosis should be considered, such as what?

Answer 311

polymorphic eruption of pregnancy or pemphigoid gestationis

Question 312

Causes of pruritus and deranged LFTs in pregnancy

Answer 312

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

Question 313

Investigating obstetric cholestasis (+what bloods show)

Answer 313

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.)

Question 314

Management of obstetric cholestasis

Answer 314

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.

Question 315

What is acute fatty liver of pregnancy, when does it occur and what are the implications

Answer 315

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.

Question 316

Pathophysiology of acute fatty liver of pregnancy

Answer 316

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.

Question 317

Presentation of acute fatty liver of pregnancy

Answer 317

The presentation is with vague symptoms associated with hepatitis :

General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites

Question 318

Bloods in acute fatty liver of pregnancy

Answer 318

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.

Question 319

Management of acute fatty liver of pregnancy

Answer 319

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.

Question 320

Polymorphic eruption of pregnancy presentation

Answer 320

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)

Question 321

Answer 321

Polymorphic eruption of pregnancy

Question 322

The condition will get better towards the end of pregnancy and after delivery. Management is to control the symptoms, what can be used?

Answer 322

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

Question 323

What is atopic eruption of pregnancy and what are the two types?

Answer 323

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.

Question 324

Atopic eruption of pregnancy will usually get better following delivery. How can symptoms be managed

Answer 324

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

Question 325

What is melasama and why does it occur

Answer 325

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.

Question 326

Management of melasama

Answer 326

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)

Question 327

What is pyogenic granuloma and when might they occur

Answer 327

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.

Question 328

Presentation of pyogenic granuloma

Answer 328

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.

Question 329

Management of pyogenic granuloma

Answer 329

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.

Question 330

What is phemigoid gestationis and why does it occur

Answer 330

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).

Question 331

Presentation of phemigoid gestationis

Answer 331

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.

Question 332

Answer 332

Phemigoid gestationis

Question 333

Management of phemigoid gestationis

Answer 333

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

Question 334

What are the risks to the baby in maternal phemigoid gestationis

Answer 334

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

Question 335

Causes of cardiac arrest during pregnancy

Answer 335

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

Question 336

What are the three major causes of cardiac arrest in pregnancy

Answer 336

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

Question 337

What are the causes of massive obstetric haemorrhage

Answer 337

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

Question 338

Why is resuscitation more complicated in pregnancy

Answer 338

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

Question 339

What is aortocaval compression and why does it occur. How can it be relieved?

Answer 339

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.

Question 340

Resuscitation in pregnancy follows the same principles as standard adult life support, except for what?

Answer 340

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

Question 341

How should a pregnant woman be positioned in CPR and why

Answer 341

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

Question 342

In a cardiac arrest when should delivery happen

Answer 342

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

Question 343

What is meant by placenta praevia

Answer 343

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

Question 344

Low lying placenta vs placenta praevia

Answer 344

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

Question 345

Causes of antepartum haemorrhage

Answer 345

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.

Question 346

Placenta praevia is associated with increased morbidity and mortality for the mother and fetus. The risks include what?

Answer 346

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

Question 347

Grading placenta praevia

Answer 347

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.

Question 348

What are the risk factors for placenta praevia

Answer 348

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

Question 349

Presentation and diagnosis of placenta praevia

Answer 349

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).

Question 350

For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), when is repeat TVUSS reccomended

Answer 350

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

Question 351

Given the risk of preterm delivery what is done towards the end of pregnancy in women with placenta praevia

Answer 351

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

Question 352

What is the main complication of placenta praevia and what is done if this occurs

Answer 352

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

Question 353

Vasa praevia pathophysiology

Answer 353

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.

Question 354

Vasa praevia types

Answer 354

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

Question 355

What is vasa praevia

Answer 355

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.

Question 356

Vasa praevia risk factors

Answer 356

Low lying placenta
IVF pregnancy
Multiple pregnancy

Question 357

How might vasa praaevia present

Answer 357

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.

Question 358

Management of vasa praevia

Answer 358

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.

Question 359

What is placental abruption

Answer 359

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.

Question 360

Risk factors for placental abruption

Answer 360

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

Question 361

Presentation of placental abruption

Answer 361

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

Question 362

Severity of antepartum haemorrhage

Answer 362

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

Question 363

What is concealed placental abruption

Answer 363

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.

Question 364

Management of placental abruption

Answer 364

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.

Question 365

What is placenta accreta

Answer 365

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.

Question 366

Why might placenta accreta occur

Answer 366

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).

Question 367

Further definitions of placenta accreta

Answer 367

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

Question 368

Risk factors for placenta accreta

Answer 368

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

Question 369

Superficial placenta accreta

Answer 369

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

Question 370

Placenta increta

Answer 370

is where the placenta attaches deeply into the myometrium

Question 371

Placenta percreta

Answer 371

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

Question 372

Presentation of placenta accreta

Answer 372

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.

Question 373

Diagnosis of placenta accerta

Answer 373

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.

Question 374

A specialist MDT should manage women with placenta accreta. Patients may require additional management at birth due to the risk of bleeding and difficulty separating the placenta. This may include what?

Answer 374

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

Question 375

Diagnosis of intrauterine death

Answer 375

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.

Question 376

What can be used to classsify the severity of vomiting in pregnancy

Answer 376

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

Question 377

At what stage does colostrum formations start

Answer 377

16 weeks gestation

Question 378

What supplements should be taken through pregnancy and for how long?

Answer 378

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

Question 379

Screening for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome is offered when?

Answer 379

between 10 and 14 weeks of pregnancy.

Question 380

What is placenta accreta and what problems can it causw

Answer 380

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.

Question 381

How often should a pregnant women with T1DM check her blood sugar

Answer 381

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

Question 382

Bleeding in pregnancy - first trimester

Answer 382

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

Question 383

Bleeding in pregnancy - second trimester

Answer 383

Spontaneous abortion
Hydatidiform mole
Placental abruption

Question 384

Bleeding in pregnancy - third trimester

Answer 384

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

Question 385

Placenta accreta vs increta vs percreta

Answer 385

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

Question 386

Urine culture to detect asymptomatic bacteriuria should be performed when?

Answer 386

8-12 weeks

Question 387

Dextrose solutions for fluid replacement should be avoided in hyperemesis gravidarum - why?

Answer 387

They can precipitate Wernicke’s encephalopathy

Question 388

Where will the uterine fundus be at 12 weeks gestation?

Answer 388

pubic symphisis

Question 389

Where will the uterine fundus be at 20 weeks gestation?

Answer 389

umbilicus

Question 390

Where will the uterine fundus be at 36 weeks gestation?

Answer 390

The xiphoid process of the sternum

Question 391

What are the 3 types of fetal lie?

Answer 391

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.

Question 392

SFH after 20 weeks

Answer 392

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

Question 393

What type of insulin is used in gestational diabetes?

Answer 393

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