Antenatal Care Flashcards
(212 cards)
1
Q
Risk of miscarriage following Amnio or CVS for:
1. Singleton
2. Twin
A
- Singleton - 0.5%
- Twin 1%
2
Q
When is:
1. CVS performed?
2. Amnio performed?
A
- CVS 11+0 - 13+6
- Amnio from 15+0
3
Q
Risks associated with Amnio?
A
- Second sample/rpt procedure - 6%
- Blood stained sample - 0.8%
- Maternal cell contamination - 1-2%
- Rapid test failure - 2%
- Failed cell culture - 0.5-1%
- Severe infection/fetal injury / maternal visceral injury - rare
4
Q
Risks associated with CVS?
A
- Second sample/rpt procedure - 6%
- Confined placental mosaicism - <2%
- Maternal cell contamination - 1-2%
- Rapid test failure - 2%
- Failed cell culture - 0.5-1%
- Severe infection / fetal injury / maternal visceral injury - rare
5
Q
Chickenpox:
1. Incubation period?
2. Infectious period?
A
- Incubation period: 1-3 weeks
- Infectious period: 48 hours before the rash appears and continues to be infectious until vesicles crust over (usually 5 days)
6
Q
Treatment of chickenpox in Pregnancy?
A
- If non immune pregnant woman has significant exposure, she should be offered VZIG as soon as possible (effective when given up to 10 days after contact).
- Oral Aciclovir should be given:
- Within 24 hours of onset of rash
- If over 20/40
- IV Aciclovir should be given to women with severe chickenpox
7
Q
If maternal chicken pox happened in last 4 weeks of pregnancy:
1. What is the plan for delivery?
2. % of babies infected?
3. % of babies that develop clinical varicella?
A
- Avoid planned delivery for 7 days to allow for passive transfer of antibodies
- 50% of babies are infected
- Approx 23% will develop clinical varicella
For babies born to mothers who have had chickenpox within the period 7 days before to 7 days after delivery - the neonate will need VZIG with or without Aciclovir ASAP.
No need to test neonate in these circumstances.
8
Q
Chickenpox infection < 28/40 management?
A
- 1% chance of FVS
- Refer to FMU at 16-20 weeks or 5 weeks after infection
- Amniocentesis to detect varicella DNA may be considered
9
Q
What are the three subgroups of neonatal herpes?
What is the mortality and morbidity of each subgroup?
A
- Disease localised to skin/eye/mouth
- 30% of neonatal herpes infections
- <2% morbidity with appropriate Rx - Local CNS disease (encephalitis)
- 70% of infections
- 6% mortality
- 70% neurological abnormality - Disseminated infection with multi organ involvement
- 70% infections combined with local CNS disease
- 30% mortality from disseminated infection
- 17% long term neurological sequelae
60% will present without skin/eye/mouth infection.
Present late - typically 10 days to 4 weeks
10
Q
Neonatal Herpes:
1. HSV 1
2. HSV 2
A
HSV 1: 50%
HSV 2: 50%
11
Q
TTTS complicates what % of Monochorionic Pregnancies?
A
15%
12
Q
Incidence if TAPS (twin anaemia-polycythaemia sequence) after laser ablation?
A
13%
(2% uncomplicated monochorionic twins)
13
Q
TTTS (Quintero Staging)
A
Associated with 15% Monochorionic Twins.
I - significant discordance in amniotic fluid volume. This is defined as: oligo with DVP < 2cm in donor sac and Poly in the recipient sac (DVP > 8cm before 20/40 and >10cm after 20/40). Donor bladder visible and normal Doppler.
II - Bladder of the donor twin not visible and severe oligo due to anuria. Doppler studies not critically abnormal.
III - Doppler studies are critically abnormal in either the donor or recipient.
IV - Ascites, pericardial effusion, scalp oedema or overt hydrops present usually in the recipient.
V - One or both babies have died (not amenable to therapy)
14
Q
TAPS (twin anaemia- polycythaemia sequence)
1. Incidence
2. Definition
A
2% uncomplicated Monochorionic pregnancies
Up to 13% post laser ablation
Signs of fetal anaemia in the donor and polycythaemia in the recipient without significant oligo/poly being present.
Donor has increased MCA PSV (> 1.5 MoM) and recipient has decreased MCA PSV (< 1.0 MoM)
15
Q
Selective Growth Restriction Monochorionic Twins
- Incidence
- Define
A
- Growth discordance > 20%
- Approx 10-15% monochorionic twins
I - growth discordance but positive diastolic velocities in both fetal and umbilical arteries.
II - Growth discordance with absent or reversed end diastolic velocities in one or both fetuses.
III - growth discordance with cyclical UA diastolic waveforms (iAREDV)
16
Q
Risk of congenital CMV with primary infection during Pregnancy?
A
30-40%
17
Q
Risk of congenital infection with recurrent CMV?
A
1-2%
18
Q
Risk of congenital infection with recurrent CMV?
A
1-2%
19
Q
Incubation period for CMV?
A
3-12 weeks
Diagnosis of fetal CMV is by Amniocentesis.
Amnio should not be performed for at least 6 weeks after maternal infection and not until 21/40.
20
Q
List features of congenital CMV
A
- Sensorineural hearing loss
- Visual impairment
- Microcephaly
- Low birth weight
- Seizures
- Cerebral palsy
- Hepatosplenomegaly with jaundice
- Thrombocytopenia with petechial rash
21
Q
In women who develop chickenpox within the 4 weeks prior to delivery, what is the risk of varicella infection of the newborn?
A
50% of babies are infected.
23% of babies develop clinical varicella.
22
Q
High risk factors for antenatal Aspirin?
Moderate risk factors for antenatal Aspirin?
A
High Risk Factors:
1. Hypertensive disease during a previous pregnancy
2. CKD
3. Autoimmune disease such as SLE or APLS
4. Type 1 or Type 2 DM
5. Chronic HTN
Moderate Risk Factor:
1. Primip
2. Age > 40
3. Inter pregnancy interval > 10 years
4. BMI > 35
5. FHx PET
6. Multiple Pregnancy
23
Q
Risk of renal transplant injury at LSCS?
A
1.5%
Consider midline skin incision to reduce risk of trauma to allograft.
24
Q
Risk of cephalhaematoma with vacuum?
A
1-12%
25
Risk of facial or scalp lacerations with instrumental delivery? (Vacuum and Forceps)
10%
26
Risk of retinal haemorrhage with instrumental delivery?
17-38%
27
Monochorionic twin pregnancy with single twin demise.
1. Risks?
2. Investigations?
1. Neurological abnormality 26%
Death 15%
2. Fetal MRI of brain 4/52 after co-twin demise
28
MCMA twins comprise what % of monochorionic twin pregnancies?
1%
They carry a very high risk of perinatal loss, most commonly before 24/40.
29
Selective growth restriction in monochorionic twin pregnancies.
1. % cases
2. Staging
Growth discordance of > 20%.
Approx 10-15% monochorionic twins.
Staging:
I - growth discordance but +ve EDF in both fetal UA.
II - growth discordance with absent or reversed EDF in one or both fetuses.
III - growth discordance with cyclical UA diastolic waveforms (+ve followed by absent then reversed EDF in a cyclical pattern over several minutes).
30
Lambda and T sign
1. Monochorionic - T sign (inter twin membrane that inserts into the placenta at a perpendicular plane)
2. Dichorionic - lambda sign (adjacent pelvic masses forming a lambda sign as placental tissue is present where the thick inter twin membrane inserts onto the placenta)
31
Recurrence rate of TTTS following fetoscopic laser ablation?
Up to 14%
Likely due to missed anastamoses at the time of initial laser treatment.
32
% of women that are GBS carriers?
20-40%
33
Incidence of early onset GBS?
0.57/1000
Of these:
1. 22% born prematurely
2. 35% had 1 or more of the following RFs (prev baby affected by GBS, GBS bacteruria, vaginal swab pos for GBS or mat T > 38C in labour)
34
Intrapartum pyrexia and risk of EOGBS?
5.3/1000
(Compared to background risk of 0.6/1000)
35
Risk of EOGBS in preterm infants?
What % of women deliver pre term?
1. 2.3/1000
(Mortality rate from infection is increased at preterm gestation (20-30% vs 2-3% at term)
2. 8.2%
36
Incidence of EOGBS without risk factors?
0.2/1000 cases.
37
Main reason for transfer to an obstetric unit from home/birth unit?
1. Delay in 1st or 2nd stage
(32% from home, 37% birth unit)
2. Meconium
(12.2% from home/Birth unit)
38
IOL for fetal macrosomia vs expectant management
Benefit:
1. Lower rates of SD vs expectant management
Risks:
2. Increased 3rd/4th degree tears
Same:
1. Perinatal death
2. Brachial plexus injury
3. Need for EmLSCS
39
Low risk primip wanting home birth - risks of babies born with serious medical problems vs hospital/MLU?
Home: 9/1000
Hosp/MLU: 5/1000
75%: Neonatal encephalopathy and Meconium aspiration syndrome
13%: Intrapartum SB or death of baby in first week of life
4%: # humerus/clavicle
40
Pre-Labour Rupture of Membranes:
1. Risk of infection
2. Chance of spont labour within 24h
1. Risk of serious neonatal infection 1% rather than 0.5% for women with intact membranes
2. 60% of women with pre labour rupture of membranes will go into labour within 24 hours
41
Maternal cardiac arrest.
1. Incidence
2. Case fatality rate
3. Leading cause
1. 1/36,000
2. 42% case fatality rate
3. 25% secondary to anaesthesia (100% survival from this)
42
Amniotic Fluid Embolism:
1. Incidence
2. Survival
3. Perinatal Mortality
1. Incidence: 1.7/100,000
2. 81% survival (2014)
3. Perinatal mortality: 67/1000 births
43
MOH Incidence?
6/1000
44
Anaphylaxis
1. Incidence
2. Mortality
1. 1-3.5/100,000
2. 1% mortality rate
Mast cell tryptase levels 1-2 hours after onset of symptoms.
45
Risk of dural puncture headache following spinal anaesthetic?
1/500
46
Risk of temporary nerve damage following epidural anaesthesia?
1/1000
47
Risk of significant hypotension following epidural?
1/50
48
Risk of epidural providing inadequate pain relief in labour ?
Risk of epidural providing inadequate pain relief for caesarean section necessitating GA?
1. 1/8 ineffective pain relief in labour
2. 1/20 inadequate analgesia for C/S
49
Risk of dural puncture headache?
1. Epidural
2. Spinal
1. 1/100 epidural
2. 1/500 spinal
50
Risk of nerve damage (numb patch on leg or foot, or weak leg) following epidural/spinal.
1. Temporary
2. Permanent
1. 1/1000 temporary
2. 1/13000 permanent
51
Risk of:
1. Epidural abscess
2. Epidural haematoma
1. Epidural abscess: 1/50,000
2. Epidural haematoma: 1/170,000
52
IUD - Mife/Miso regime
Mifepristone 200mg followed 24-48hrs later by:
1. 100mcg Miso 6 hourly before 26+6
2. 25-50mcg 4 Miso 4 hourly at 27+0 or more, up to 24 hours
53
Risk of haemorrhage > 500ml with:
1. Active management of 3rd stage?
2. Physiological 3rd stage?
1. 68/1000 with active management
2. 188/1000 with physiological 3rd stage
54
Risk of haemorrhage > 1000ml
1. Active management
2. Physiological management
1. 13/1000 active management
2. 29/1000 physiological management
55
Need for blood transfusion:
1. Active management 3rd stage
2. Physiological management
Doubles!
1. 13/1000
2. 35/1000
56
Need for further uterotonics in 3rd stage:
1. Active Management
2. Physiological 3rd stage
1. Active mgmt: 47/1000
2. Physiological: 247/1000
57
3rd stage management- what were similar outcomes for both active and physiological management ?
1. Retained placenta > 1hr or need for MROP
2. Antibiotics for bleeding
3. Satisfied with 3rd stage management
4. Felt in control during labour
58
Nausea and vomiting in 3rd stage with:
1. Active management
2. Physiological management
1. 100/1000
2. 50/1000
59
Management of 3rd stage - risk of PP anaemia Hb < 90.
1. Active management
2. Physiological management
1. 30/1000
2. 60/1000
60
When should PET bloods be re checked after delivery for women with PET?
48-72 hrs
Do not repeat again if results are normal.
61
Thrombophilias and risk of PET
1. Hyperhomocystinaemia
2. Anticardiolipin antibodies and prothrombin heterozygosity
2. Methylenetetrahydrofolate reductase gene mutation (MTHFR)
(Antithrombin III, Protein S and Protein C deficiencies, lupus anticoagulants are not associated with PET).
62
IVF and first trimester screening - discuss.
- PAPP-A
- HCG
- MSuE3 (maternal serum conjugated estradiol)
1. Falsely low PAPP-A
2. Elevated free HCG leading to false Pos Downs Syndrome screening results
3. MSuE3 levels are lower
- in IVF pregnancies, the rate of false positive results in 2x as high as in normal controls in the mid trimester.
- PAPP-A was significantly lower in IVF pregnancies compared to spontaneously conceived pregnancies.
- ICSI was associated with a significantly decreased PAPP-A and an increased false positive rate.
IVF pregnancies have significantly lower PAPP-A levels supporting the need to appropriately adjust the cFTS algorithm for IVF conceptions.
- Maternal serum levels of free HCG are elevated in IVF pregnancies causing a high false positive rate on screening for DS.
- MSuE3 levels are lower in IVF pregnancies.
63
When compared to euploid pregnancies at 11-13 weeks, how are maternal PAPP-A levels affected with Down Syndrome?
Reduced by 50%!
Free HCG is about twice as high.
64
T13 is associated with what anomalies?
1. Holprosencephaly
2. Micro-Opthalmia
3. Anopthalmia or cyclopia
4. Cleft lip and palate
5. Clenched fist
6. Single palmar crease/scalp defects
7. Post axial (little finger side) polydactyly
8. Cardiac defects (VSD, PDA, dextrocardia)
9. Abnormal genitalia
10. Renal defects
11. 10% survive beyond the first year; severe developmental delay
65
Carrier rate for CF in general population?
1/20 (Caucasian, no FHx)
66
What time frame will karyotype results be available for:
1. CVS
2. Amnio
1. 48-72h from fetal blood and chorionic villi
2. 2-3 weeks for Amniotic fluid
67
For karyotoype from maternal blood cell division must be..
Arrested in Metaphase by the addiction of colchicine which prevents spindle formation.
68
Choroid plexus cysts are associated with?
Increased risk of T18.
Usually resolve by 22-26/40.
69
Hyperechogenic bowel is associated with ?
1. CF
2. Meconium ileus
3. T21
4. CMV infection
5. IUGR
6. Intra uterine death
‘Subjective assessment. Diagnosis made when the echogenicity of fetal bowel is similar to or greater than that of surrounding bone,’
70
Significance of Cardiac echogenic foci?
Most resolve spontaneously.
Karyotype NOT indicated for isolated cardiac echogenic foci.
71
Definition and significance of Pelvicalyceal dilatation?
1. AP diameter of the renal pelvis >4mm before 33/40 and >7mm thereafter.
2. Association with aneuploidy very small and karyotype not indicated.
3. Postnatal urological follow up (renal scan 1 week of age + prophylactic Abx)
72
Downs Syndrome;
1. Chromosomal pattern?
2. Incidence
1. a) 95% due to trisomy 21
b) 4% due to translocation of chromosome 21
c) 1% mosaic
Extra chromosome 21 of maternal origin in 90% of cases - non dysjunction in first meiotic division.
2. Incidence: 1/700 live births
73
Downs Syndrome structural anomalies?
55% have structural anomaly.
1. AV canal defects
2. GI - duodenal atresia
3. Urinary tract
4. Limb defects
5. Congenital cataract
74
Edwards Syndrome features:
1. Early onset IUGR
2. Rocker bottom feet
3. Clenched fists
4. Overlapping fingers
5. Choroid plexus cysts
6. 2 vessel cord
7. Increased NT
8. Oligo or Poly
Associated with a low:
1. Maternal AFP
2. Maternal unconjugated estradiol
3. Maternal free HCG
75
Edwards Syndrome Incidence?
1/8000 live births
95% spontaneously miscarry
10% live births survive first year with profound developmental delay
76
Fragile X syndrome
1. Inheritance pattern
2. Features
1. X linked dominant
Fragile site at Xq27
2. Enlarged testes
Degree of learning disability is present in 20-30% of carrier females.
77
Turners Syndrome;
1. Incidence
2. Inheritance
3. Ultrasound features
45XO
1. 1/2000 live born female infants
2. In patients with a single X chromosome, the chromosome is of maternal origin in 2/3 cases
3. Associated with:
- increased NT
- coarctation of aorta
- ASD
- cystic hygroma
- fetal hydrops
78
NIPT - risk of unsuccessful test?
5-10%
1/10 - 1/20
Means no fetal DNA obtained.
Women should be offered a repeat test free of charge.
79
NIPT:
1. High risk result
2. Low risk result
1. 1/2
2. < 1/10,000
80
Prader Willi Syndrome:
1. Incidence
2. Characterised by
1. Complex genetic condition presenting in infancy and affecting 1/10,000 to 1/30,000 people
2. Characterised by:
a) Hypotonia
b) Feeding difficulties
c) Poor growth with short stature
d) Delayed development with mild to mod learning disability
e) Insatiable appetite - obesity + T2DM
f) Sleep abnormalities
g) Narrow forehead, almond shaped eyes, triangular mouth
h) fair skin and light coloured hair
I) underdeveloped genitals with delayed or incomplete puberty/infertility
81
Incidence of Downs Syndrome
1. Age < 30
2. Age 35
3. Age 40
4. Age 45
1. < 1/1000
2. 1/400
3. 1/105
4. Age 44: 1/35, Age 46: 1/20
82
Combined Test monochorionic twins:
1. Gestation
2. Sensitivity
3. False Post Rate - singleton, twin
1. 11+0 - 13+6 (CRL 45-84mm)
2. Sensitivity 90%
3. False positive rate - up to 10% (monochorionic twins)
- FPR singleton 2.5%
- FPR DCDA 5%
83
From what gestation can NIPT be performed?
10/40
84
Integrated Test + Serum Integrated Test
1. What is tested?
2. Detection rate and false positive rate?
1. Integrated Test
NT and PAPP-A at 10/40 + AFP + free B HCG + uE3 + inhibin A at 14-20/40
Most effective screening test
Detection rate: 85%
FPR: 1.2%
2. Serum Integrated Test
Integrated test without NT
Second most effective test
Detection rate: 85%
FPR: 2.7%
85
Combined test + quadruple test
1. What is tested?
2. Detection rate and FPR?
1. Combined Test:
NT, free BHCG and PAPP-A at 10/40
Detection rate: 85%
FPR: 6.1%
2. Quadruple Test
AFP, UE3, free BHCG, Inhibin A at 14-20/40
Detection rate: 85%
FPR: 6.2%
86
Fetal head diameters:
1. Suboccipitobregmatic (vertex, flexed)
2. Occipitofrontal (vertex, natural flexion)
3. Submentobregmatic (face)
4. Verticomental (brow)
1. 9.5cm
2. 11cm
3. 9.5cm
4. 13.5cm
87
PTB < 27/40. Survivors that will have severe impairment at the following gestations:
1. 22+0 - 22+6
2. 23+0 - 23+6
3. 24+0 - 25+6
4. 26+0 - 26+0
And definite severe impairment.
Severe Impairment;
1. Severe cognitive impairment with IQ < 55
2. Severe cerebral palsy - gross motor classification system grade 3
3. Blindness or severe hearing impairment
22+0 - 22+6 -> 1/3
23+0 - 23+6 -> 1/4
24+0 - 25+6 -> 1/7
26+0 - 26+6 -> 1/10
88
Death rates for babies born between 22-26/40.
1. 22/40
2. 23/40
3. 24/40
4. 25/40
5. 26/40
1. 22/40 - 7/10 die
2. 23/40 - 6/10 die
3. 24/40 - 4/10 die
4. 25/60 - 3/10 die
5. 26/40 - 2/10 die
89
Definite OUTLET assisted vaginal delivery?
1. Fetal scalp visible without parting labia
2. Fetal skull has reached the perineum
3. Rotation does not exceed 45 degrees
90
Define LOW assisted vaginal delivery?
1. Fetal skull at station +2cm but not on the perineum
2. Subdivisions:
a) Non Rotational < 45 degrees
b) Rotational > 45 degrees
91
Define MID CAVITY assisted vaginal delivery?
1. Fetal head no more than 1/5 palpable abdominally
2. Leading point of the skull 0 -> +1cm
3. Subdivisions:
a) Non rotational < 45 degrees
b) Rotational > 45 degrees
92
Maternal indications for assisted vaginal birth.
1. Nulliparous patients
2. Multiparous patients
1. NULLIPAROUS
- Lack of continuing progress after 3 hours (active + passive) with regional anaesthesia
- OR 2 hours without regional anaesthesia
2. MULTIPAROUS
- lack of continuing progress after 2 hours (active and passive) with regional anaesthesia
- OR 1 hour without regional anaesthesia
93
Maternal outcomes following AVB - vacuum vs forceps.
1. Episiotomy
2. Significant vulvovaginal tear
3. OASI
4. PPH
5. Urinary or bowel incontinence
1. Episiotomy
V: 50-60%
F: > or equal to 90%
2. Significant vulvovaginal tear
V: 10%
F: 20%
3. OASI
V: 1-4%
F: 8-12%
4. PPH
V + F: 10 - 40%
5. Urinary or bowel incontinence
Common at 6 weeks, improves over time
94
Perinatal outcomes with AVB - vacuum vs forceps
1. Cephalhaematoma
2. Facial or scalp lacerations
3. Retinal haemorrhage
4. Jaundice or hyperbilirubinaemia
5. Subgaleal haemorrhage
6. Intracranial haemorrhage
1. Cephalhaematoma
Predominantly vacuum, 1-12%
2. Facial or scalp lac.
V + F: 10%
3. Retinal haemorrhage
V > F, variable 17-38%
4. Jaundice or hyperbilirubinaemia
V + F: 5-15%
5. Subgaleal haemorrhage
Predominantly vacuum, 3-6/1000
6. Intracranial haemorrhage
V + F: 5-15/10,000
95
Risk factors for shoulder dystocia:
1. Pre labour
2. Intrapartum
1. Pre Labour
- Diabetes Mellitus
- BMI > 30
- Induction of labour
- Previous shoulder dystocia
- EFW > 4.5kg
2. Intrapartum
- Delay in 1st stage
- secondary arrest
- prolonged 2nd stage
- oxytocin augmentation
- assisted vaginal delivery
96
Incidence of SD?
0.58 - 0.70%
97
Recurrence rate of SD if previous SD?
10 times higher than the rate in the general population.
Reported recurrence rate between 1-25% (could be underreported owing to selection bias as LSCS may have been advocated)
98
Maternal complications of Shoulder Dystocia:
1. PPH
2. OASI
1. PPH - 11%
2. OASI - 3.8%
Other reported complications include vaginal lacerations, cervical tears, bladder rupture, uterine rupture.
99
Incidence of BPI following shoulder dystocia?
2.3-16%
90% make full recovery.
10% left with permanent injury.
100
Incidence of umbilical cord prolapse?
0.1 - 0.6%
Increases to 1% with Breech presentation.
101
Perinatal Mortality associated with cord prolapse?
91/1000
Prematurity and congenital malformations account for the majority of adverse outcomes.
102
2020 MBBRACE, risk of Maternal death:
1. White Women
2. Black women
3. Mixed ethnicity
4. Asian Women
1. White women - 8/100,000
2. Black women - 34/100,000 (4x higher)
3. Mixed Ethnicity - 25/100,000 (3x higher)
4. Asian Women - 15/100,000 (2x higher)
103
PPH management:
1. FFP
2. Cryo
1. FFP:
1. If PT or APTT is prolonged and haemorrhage is ongoing, administer 12-15mg/kg of FFP.
2. If haemorrhage continues after 4u PRC and haemostatic tests are not available, give 4u FFP.
Cryo:
1. Administer 2 pools of Cryo if haemorrhage ongoing and Fribrinogen <2.
104
Therapeutic goals of massive blood loss from PPH is maintaining:
1. HB
2. Plt count
3. Prothrombin time
4. APTT
5. Fibrinogen
1. Hb > 80
2. Plt count > 50
3. PT < 1.5 x normal
4. APTT < 1.5 x normal
5. Fibrinogen > 2
105
PPH management, in order:
1. Fundal rub
2. Catheter in bladder
3. Oxytocin 5units IV
4. ergometrine 0.5mg IM
5. Oxy infusion
6. Carboprost 0.25mg IM (can be repeated 15 minutely up to 8 doses)
7. Misoprostol 800mcg Sublingual
106
Risk of uterine perforation with postnatal ERPC?
1.5%
107
Incidence of OASI
1. Overall
2. Primip
3. Multip
1. 2.9%
2. 6.1%
3. 1.7%
108
Prognosis following EAS repair?
60-80% of women are asymptomatic 12 months following EAS repair.
109
Risk of sustaining a further 3rd or 4th degree tear after subsequent delivery?
5 - 7%
110
3rd / 4th degree tear repair consent:
Frequent risks:
1. Difficulty/ discomfort passing stool In the immediate PN period (common)
2. Migration of suture material (common)
3. Granulation tissue (common)
4. Faecal urgency 26/100
5. Perineal pain and dyspareunia 9/100
6. Wound infection 8/100
Serious Risks:
1. Inability to control bowel movement or flatus (common)
2. LSCS in subsequent pregnancy
3. Haematoma (rare)
4. Fistula (very rare)
111
Classification of maternal death?
1. Early vs Late
2. Direct vs Indirect
1. Early - before 6 weeks
Late - after 6 weeks
2. Direct cause - directly linked to pregnancy
Indirect cause - if death occurs of a pre existing medical condition
112
Dose of adrenaline for anaphylaxis?
0.5mg (0.5ml 1:1000)
113
What cardiac biomarker is most reliable for diagnosing acute MI during labour and delivery ?
Troponin I
(Unaffected by labour, anaesthesia or delivery)
114
Max dose lidocaine 1% without epinephrine?
3mg/kg
115
Max dose of lidocaine 1% (without adrenaline)
7mg/kg
116
Risk of the following complications in those with raised BMI vs normal BMI.
1. VTE
2. Gestational Diabetes
3. Hypertensive Disease
4. Caesarean Section
5. Stillbirth
6. PPH
1. VTE - 9x higher
2. Gestational Diabetes - 3x higher
3. Hypertensive disease - 2-3x higher
4. Caesarean Section - 2x higher
5. Stillbirth - 2x higher
6. PPH - 2x higher
117
What is the most consistent indicator of uterine rupture?
Abnormal CTG is the most consistent finding in dehiscence.
55-87% of cases!
118
Most common cause of acute MI in Pregnant women without cardiovascular risk factors?
Coronary Artery Dissection
It is thought that this results from changes in the vessel wall related to high progesterone levels.
The most common cause is atherosclerosis - diabetes and smoking are significant RF’s.
119
How often should lithium levels be checked in pregnancy?
Every 4 weeks until 36/40 then weekly until delivery.
Lithium levels should be checked again within 24 hours of delivery and the dose adjusted to maintain a level in the lower part of the therapeutic range.
120
Incidence of Gestational Thrombocytopaenia?
5%
1/20 pregnancies!
121
What is the most appropriate advice for a T1 diabetic wishing to breastfeed regarding postnatal insulin dose?
Reduce pre pregnancy dose by 25%.
Once women with T1DM are eating normally, subcut insulin should be recommenced at a 25% lower dose of her pre pregnancy dose if she intends to BF. BF is associated with increased energy expenditure.
122
Haemophilia A - Risk of being a carrier
1/20,000
50% of newly diagnosed patients have no family history.
123
OC - which contraceptives to avoid?
Estrogen containing contraceptives should be avoided.
124
What is the strongest predisposing RF for developing placenta praevia?
Maternal age > 40 - associated with a nine fold increase risk of placenta praevia
125
Factor IX deficiency
Haemophilia B
X linked recessive inheritance
126
Risk of ureteric injury at caesarean section?
3/10,000
127
Associations with low PAPP-A
1. Spontaneous miscarriage
2. Gest HTN
3. PET
4. Low birth weight
5. Pre term delivery
128
Associations with low BHCG:
1. Spontaneous miscarriage
2. Low birth weight
129
Associations with raised AFP:
1. FGR 2.
2. Placental abruption
3. Fetal demise after 24/40
4. Pre term delivery
5. Spontaneous miscarriage
130
Associations with raised inhibin A:
1. PTB
2. Gest HTN
3. PET
4. Fetal demise after 24/40
5. FGR
131
Associations with a raised BHCG (screening):
1. Pre term delivery
2. Gestational HTN
3. PET
4. Fetal demise after 24/40
5. FGR
132
Risk of placenta praevia and number of previous caesarean sections ?
1. No previous - 0.25%
2. 1 previous - 0.6%
3. 2 previous - 1.6%
4. 3 previous - 3.3%
5. 4 previous - 10%
133
Incidence of cord prolapse in Breech presentation?
1%
134
Risk of nerve entrapment following Pfsnnenstiel incision?
What nerve is involved?
Management?
3.7% (ilioinguinal, iliohypogastric)
Offer Amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain.
Ilioinguinal nerve block may be offered if resistant to initial treatment.
135
Placental Abruption:
1. Risk of recurrence following 1
2. Risk of recurrence following 2
1. 4.4%
2. 19-25% with 2 previous pregnancies complicated by abruption
136
Red cell antibodies:
1. Detected in what % of pregnancies
2. Prevalence of clinically significant antibodies
1. Detected 1.2% of pregnancies (1/80)
2. 0.4% are clinically significant (1/300)
137
What benefit does Zinc supplementation have on pregnancy outcome?
Reduced risk of PTB.
138
Acute Pancreatitis in Pregnancy:
1. Incidence
2. Rates of maternal mortality
1. 3/10,000
2. High rates of PTB and maternal mortality rates up to 3%
139
Causes of acute pancreatitis in Pregnancy?
1. Gallstones (65%) - weight gain and hormonal change predispose to biliary sludge + GS formation
2. Alcohol (5-10%)
3. Hypertriglyceridaemia (4-6%)
Levels of triglycerides rise 3 fold in the 3rd trimester.
4. Rare - hyperemesis, AFLP
140
Fetal exposure to radiation from Abdo CT in pregnancy?
Abdo CT exposes fetus to 1.3 - 35.0 mGy, with levels of <50mGy considered acceptable in Pregnancy.
141
What is the most prevalent HDFN-causing alloantibody?
Anti E!
142
When can you perform Cell free fetal DNA testing for red cell antigens?
16/40 - Rh D, c, C, e
20/40 - Kell
143
Dose of Anti D sufficient to treat FMH of 4ml?
How are Additional Anti D doses calculated?
1. 500 IU sufficient to treat FMH of 4ml
2. Additional 125IU Anti D Ig/ml fetal red cells
144
When to perform VQ vs CTPA when querying PE?
Normal CXR - V/Q scan
Abnormal CXR - CTPA
145
Following blood (rather than platelet) transfusion there are 2 thresholds for Anti D administration:
1. > 15ml
2. > 1 unit
1. >15ml: 1500 or 2500 IU anti D
2. > 1 unit: Red cell exchange transfusion
146
Detection rate of the quadruple test in monochorionic twin pregnancies ?
80%
147
Incidence of PEP or PUPP in Pregnancy?
1 in 200
148
First line treatment of thrush in Pregnancy ?
Clotrimazole 500mg vaginal pessaries daily for 7 days
90% cure rate.
149
Offer a choice of either prophylactic vaginal progesterone or prophylactic cerclage to women?
1. With a history of spontaneous preterm birth or mid-trimester loss between 16+0 and 34+0 weeks of pregnancy
And
2. In whom a TVUS had been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of 25mm or less
150
When does WCC return to normal after steroids?
3 days
151
Erythromycin for PPROM has been shown to reduce?
1. Chorioamnionitis
2. Reduces number of babies born between 48 hours and 7 days
Neonatal infection, use of surfactant, oxygen therapy and abnormal cerebral US prior to discharge was also reduced.
152
Incidence of cerebral palsy in term infants?
0.1%
153
In women presenting with pre term labour, TVUS measurement of cervical length is positive Ic cervical length is?
< 15mm - moderately or very useful positive negative likelihood ratio to diagnose women with pre term delivery at 48 hours.
154
Incidence of puerperal genital haematomas?
RFs?
1/700
Risk factors: prolonged 2nd stage, instrumental birth, baby > 4kg, genital tract varicositoes, maternal age > 30, Nulliparity
155
Risk of fetus reverting to Breech following successful ECV?
3%
156
Cephalhaematoma vs Subgaleal
Cephalhaematoma:
- incidence 1%, beneath periosteum, swelling does NOT cross suture lines
- associated with Jaundice
- May not appear until 2nd day of life and may take several weeks to finally disappear
Subgaleal:
- rare bleed beneath aponeurosis, crosses midline
- associated with shock/anaemia and neonatal death
- increased incidence with ventouse delivery
157
Following rubella vaccination, how long should pregnancy be avoided for?
1 month
158
Incidence of shoulder dystocia?
6/1000
159
Risk of haemorrhage requiring blood transfusion following active mgmt of 3rd stage of labour ?
13/1000
160
Angelman Syndrome
1. Chromosomal pattern
2. Features
1. Inactivation/deletion of the maternally inherited copy of the gene UBE3A on chromosome 15q11-13
70% caused by deletion
10% caused by mutation
Both copies of this gene are active in most tissues except parts of the brain where only the maternal copy is active.
Severe developmental delay
Epilepsy
Severe speech impairment
Fascination with water
161
When is the most suitable time to take Kleihaur test for additional anti-D Ig?
KH should be performed within 2 hours of delivery to identity women with large FMH who require additional Anti D.
162
% increase in blood volume to the neonate by delayed cord clamping?
30%
163
% increase in blood volume to the neonate by delayed cord clamping?
30%
164
Risk of DIC within 4 weeks from date of fetal death?
10%
165
When should women be recommended LSCS following OASI?
1. EAS defect degrees
2. Incremental squeeze pressure
1. > 30 degrees
2. < 20mmHg incremental squeeze pressure
166
Catheter removal post LSCS?
Not sooner than 12 hours for removal (NICE)
167
After LSCS, what % of women suffer from SUI?
4%
168
Upper weight limit for which vag Breech can be undertaken?
3.8kg
169
What % of women attempting vag Breech will need LSCS?
40%
170
Erb’s palsy - injury associated with what likely method of delivery?
Downward traction following delivery of the fetal head
171
Define steroid dependant?
5mg pred OD or more for > 3 weeks
172
What proportion of twin pregnancies attempting vaginal delivery end up with CS for second twin?
1/3
173
Selective twin growth restriction
1. Type
2. Mortality rate
3. When to deliver
Type I - 10% - deliver 34-36 weeks
Type II - 29% - deliver 32 weeks
Type III - 10-20% - deliver 32 weeks
174
Aciclovir for chicken pox - treatment vs prophylactic dose ?
Treatment - Aciclovir 800mg 5x day for 7 days
PEP - Aciclovir 800mg 4x day
175
In event of hypotension and or lactate > 4, what vol of IV fluids do you want to administer ?
30ml/kg crystalloid within 3 hours
176
Fetal anaemia - define?
> 70g/L below the mean for gestation!
Hydrops more likely if HB < 40 at 18/40 and < 80 at term.
177
Antibody titres requiring FMU referral:
1. Anti D
2. Anti c
3. Anti K
4. Anti E
1. Anti D > 4
2. Anti c > 7.5
3. Anti K any titre
4. Anti E > 32 or at any titre in presence of anti c
178
Topirimate increased risk of what congenital anomaly?
Oral clefts
179
Obesity increases risk of what congenital anomaly ?
Spina bifida
180
Incidence of recurrent UTI in pregnancy ?
8%
181
Hysterectomy rate after B lynch?
Suture material used?
Hysterectomy rate 25%
Use unbraided absorbable suture with high tensile strength - Monocryl first
182
ketones are the breakdown products of?
fat metabolism
183
By which gestation must a woman stop smoking to reduce risk of pre term birth?
15/40
184
Which immune suppressant drug is associated with maternal diabetes mellitus?
Cyclosporine
185
Risk of blood transfusion at caesarean section?
1-2%
186
When should MCDA twin pregnancies complicated by TTTS be delivered?
34-36 weeks
187
What proportion of smokers will stop in the first trimester of Pregnancy?
27-47%
188
What is the maximum number of courses of antenatal corticosteroids a fetus should receive?
3
189
Most commonly used tocolytic for insertion of cervical cerclage?
Indomethacin
190
In a supine position, the gravis uterus, after 20 weeks reduces cardiac output by how much?
30-40%
191
Quoted rate of uterine rupture in women who undergo IOL with dinoprostone having had 1 prev LSCS?
1.2%
192
What proportion of neonates, born to opioid dependant mothers will experience seizures?
5%
193
What % of women in the UK enter pregnancy underweight?
3-4%
194
What proportion of women develop itching in Pregnancy?
25%
195
Incidence of UTI and pyelonephritis in Pregnancy ?
UTI - 8%
Pyelo - 2%
196
What proportion of women experience frequency of micturition?
41%
197
What is the fetal loss rate if a fetus becomes infected with syphilis during pregnancy ?
30-40%
Spirochete bacteria cross the placenta from 14 weeks gestation.
198
Antenatal Care for women with high risk endometriosis?
- CLC
- Inc BP monitoring
- consider Aspirin
- endometrioma surveillance - 1 scan in each trimester, can mimic malignancy (MRI without gadolinium contrast if concerns)
- growth scans
199
What is the most common type of Breech presentation?
Extended/frank (2/3rds)
Buttocks present with hips fully flexed, knees extended, feet by the head.
200
What % of pregnancies does constipation effect?
11-38%
201
Management of Constipation in Pregnancy? Examples of:
1. Bulk forming agents
2. Osmotic laxatives
3. Stimulant laxatives
4. Suppositories
1. Bull forming laxatives: bran, isphagula, methyl cellulose
2. Osmotic Laxatives: lactulose, sorbitol, polyethylene glycol
3. Stimulant laxatives: bisacodyl, senna
4. Suppositories: glycerol suppositories
202
Incidence of dural puncture with epidural?
If dural puncture, what % will suffer post dural puncture headache?
Blood patch cure rate?
1. 0.5 - 2.5%
2. 70-80% will suffer with headache
3. Blood patch 60-90% cure rate
203
Incidence of cerebral palsy and gestational age?
1. 22-27 weeks
2. 28-31 weeks
3. 32-36 weeks
4. Term
1. 14.6%
2. 6.2%
3. 0.7%
4. 0.1%
204
Trauma imaging in pregnancy and radiation exposure:
1. CT head and neck
2. CT chest
3. CT abdo
4. CT pelvis
1. 0.001 - 0.01
2. 0.01 - 0.66
3. 1.3 - 3.5
4. 10 - 50
205
False Pos rate of T21 in:
1. 1st trimester combined test
2. Cell free DNA test
1. CFTS: 5%
2. Cell free DNA test: 0.1%
206
Causes of false +ve NIPT?
1. Low fetal DNA fraction
2. Vanishing twin
3. Placental mosaicism
4. Maternal cancers and maternal copy variants
207
Caesarean Section.
NNT to prevent one case of fecal incontinence ?
167
208
Caesarean Section.
NNT to prevent one case of fecal incontinence ?
167
209
Caesarean Section.
NNT in Breech birth to prevent one case:
1. Adverse outcome
2. Perinatal death
1. Adverse outcome - 29
2. Perinatal death - 175-400
210
Elective induction of labour at 40 weeks compared with expectant management.
NNT to prevent once case of perinatal mortality?
1040
211
What us chance of transfer to an obstetric unit for low risk nulliparous women opting for planned home birth?
45%
212
Di George Syndrome
1. Inheritance /gene
2. Features
CATCH 22
22q11.2 deletion
Congenital heart defect (truncus arteriosus)
Abnormal facies
Thymus - absent
Cleft palate
Hypocalcaemia
