Day 8 Obstetrics Flashcards
1
Q
A pregnant woman has serum alpha feto-protein levels measured.
- *Which one of the following is associated with a low alpha-feto protein level?
(2) **
A
AFP
- raised in neural tubes defects
- decreased in Down’s syndrome
2
Q
A 46-year-old woman has come into her GP.
She is planning on becoming pregnant, and would like advice about simple lifestyle changes and medications she should be taking, and the GP mentions that the woman should be taking the high dose (5 mg) folic acid.
What are the reasons for taking high dose folic acid?
A
Women are considered higher risk if any of the following apply:
- either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
- the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
3
Q
Which changes would you expect to see in a healthy pregnant patient as compared to before pregnancy?
A
Normal laboratory findings in pregnancy:
- reduced urea
- reduced creatinine
- increased urinary protein loss
4
Q
A 32-year-old gravid 3, para 2 at 24 weeks gestation attends an antenatal clinic and wishes to discuss delivery options for her pregnancy.
On history, you find that her previous pregnancies were delivered by vaginal and elective caesarean section respectively.
What is an absolute contraindication for vaginal delivery following a previous cesarean section?
(2)
A
Vertical (classic) caesarean scar
previous episodes of uterine rupture
5
Q
A 23-year-old woman has come to the emergency department.
She is 37 weeks pregnant, and is complaining of a temperature and feeling generally unwell.
She is seen by the emergency department doctors and sent to the obstetric unit.
There, she is found to have a fever of 38ºC and to be tachycardic at 110 bpm.
The fetus is found to be tachycardic as well.
She says she has had no other symptoms, except having an episode of what she said describes as urinary incontinence 3 weeks ago, and some discharge afterwards.
What is the most likely cause of her presenting complaint?
A
Chorioamnionitis
You should think chorioamnionitis in women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
6
Q
A 19-year-old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding.
Her ultrasound scan confirms a viable intrauterine pregnancy.
However, the high vaginal swab has isolated group B streptococcus (GBS).
How should she be managed?
A
Intrapartum intravenous benzylpenicillin only.
GBS is a vaginal commensal isolated in many women. It is known to be the most frequent cause of severe early-onset infection in the newborn and can cause significant morbidity and mortality.
7
Q
A 28-year-old woman self-presents to the Emergency Department, extremely concerned regarding her pregnancy.
She is 33 weeks pregnant and thus far, the pregnancy has been uncomplicated.
However, several hours ago whilst out shopping, she felt a sudden gush of fluid from her vagina and a subsequent wetness of her underwear.
Her observations have already been taken by one of the triage nurses and are stable, within normal ranges.
Given the likely diagnosis, what is the first-line investigation?
(2)
A
Speculum examination is first line
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
Ultrasound may also be useful to show oligohydramnios.
8
Q
Preterm prelabour rupture of the membranes management
(5)
A
Management
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
9
Q
A mother brings her 6 year-old son to clinic with a widespread rash.
You diagnose chickenpox.
You know his mother, who is also a patient at the practice, is currently 20 weeks pregnant with her second child.
What action should you take, if any, regarding her exposure to chickenpox?
A
You should ask pregnant women exposed to chickenpox if they have had the infection before. If they say no or are unsure, varicella antibodies should be checked.
If it is confirmed they are not immune, varicella immunoglobulin should be considered. It can be given at any point in pregnancy and is effective up to 10 days after exposure.
10
Q
A 27 year old woman attends her GP with breast pain.
She is 2 weeks postpartum and is exclusively breastfeeding.
She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing.
On examination, she appears well, her temperature is 38ºC.
There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
What would be the most appropriate management?
(2)
A
The first-line antibiotic is oral flucloxacillin for 10-14 days.
Breastfeeding or expressing should continue during treatment.
11
Q
A woman has a vaginal delivery of her first child.
Although the birth was uncomplicated, she suffers a tear which extends from the vaginal mucosa into the submucosal tissue, but not into the external anal sphincter.
Which degree tear is this classed as?
A
- 1st degree = tear within vaginal mucosa only
- *- 2nd degree = tear into subcutaneous tissue**
- 3rd degree = laceration extends into external anal sphincter
- 4th degree = laceration extends through external anal sphincter into rectal mucosa
12
Q
Sarah is a 29-year-old woman who comes to see you for a follow-up visit. You initially saw her 1 month ago for low mood and referred her for counselling. She states she is still feeling low and her feelings of anxiety are worsening. She is keen to try medication to help.
Sarah has a 4-month-old baby and is breastfeeding.
Which are the most appropriate medications for Sarah to commence?
(2)
A
Sertraline or paroxetine are the SSRIs of choice in breastfeeding women
Sertraline or paroxetine are the SSRIs of choice in breastfeeding women as whilst they are secreted in low levels in the breast milk it is not thought to be harmful to the infant.
13
Q
A 28-year-old woman is admitted to the labour ward at 38+4 weeks gestation.
This is her first pregnancy and she tells you that contractions started around 10 hours ago.
On examination, her cervix is positioned anteriorly, is soft, and is effaced at around 60-70%.
Cervical dilatation is estimated at around 3-4cm and the fetal head is located at the level of the ischial spines.
She has had no interventions performed as of yet.
What intervention should be performed?
A
She has a bishop score of 10
No interventions required
A Bishop’s score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
14
Q
What is a bishop score?
A
Interpretation
a score of < 5 indicates that labour is unlikely to start without induction
a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
15
Q
When is Vaginal prostaglandin E2 used?
(2)
A
- Vaginal prostaglandin E2 is the preferred method of induction of labour but as this patient is only 10 hours into the first stage of labour
and
- she has a bishop score of 10
16
Q
When is Maternal oxytocin infusion used?
(2)
A
Maternal oxytocin infusion can be used if labour is not progressing and other methods of induction have been tried but wouldn’t be appropriate in this scenario at this stage.
Oxytocin infusion carries the risk of uterine hyperstimulation.
17
Q
When is an amniotomy performed?
(2)
A
Amniotomy is the artificial rupturing of membranes and can be performed if other methods have failed to induce labour or if vaginal prostaglandin E2 is contra-indicated.
Amniotomy carries the risk of infection, umbilical cord prolapse and baby moving into breech position if the fetal head is not engaged.
18
Q
A woman who is at 12 weeks gestation presents to her antenatal appointment for her combined screening test.
She consents to, and undergoes, the standard screening test involving blood tests being taken and an ultrasound scan.
She is subsequently informed that her results may indicate Down’s syndrome, and is invited to discuss this further.
What results would be expected in this instance?
(3)
A
Down’s syndrome is suggested by
raised HCG
low PAPP-A
thickened nuchal translucency
19
Q
A 29-year-old woman with her first pregnancy presents to you at 30-weeks gestation with itchiness.
There is no rash on examination and after referral to an obstetrician, she is confirmed to be suffering from intrahepatic cholestasis of pregnancy.
What should she be treated with?
The patient mentions her obstetrician said something about her labour but she was not sure.
What needs to be planned regarding this patient’s labour?
A
She should initially be treated with ursodeoxycholic acid.
Induction of labour at 37-38 weeks gestation
20
Q
A 36-year-old woman who is currently 32 weeks pregnant has been monitoring her capillary blood glucose (CBG) at home following a diagnosis of gestational diabetes mellitus (GDM) 4 weeks ago.
She has been given appropriate dietary and exercise advice, as well as review by a dietitian.
She has also been taking metformin and has been on the maximum dose for the past 2 weeks.
Fetal growth scans have been normal with no signs of macrosomia or polyhydramnios.
She has brought her CBG diary today, which shows that her mean pre-meal CBG is 5.9 mmol/L and mean 1-hour postprandial CBG is 8.3 mmol/L.
What is the most appropriate management?
A
In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added
21
Q
You are a male FY1 working in obstetrics. A 33-year-old female is on the ward in labour, 10 minutes ago she suffered a placental abruption and is in need of emergency care.
Her midwife comes to see you, informing you that she is requesting to only be seen and cared for by females.
What do you say?
A
Ask the midwife to immediately summon senior medical support, regardless of gender
While patients do have a right to choose their own doctor, this doesn’t apply in emergency situations where treatment is needed to save the life of the patient.
22
Q
Hepatitis B and pregnancy
(4)
A
Basics
all pregnant women are offered screening for hepatitis B
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
there is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
23
Q
A 36-year-old nulliparous woman is admitted in labour at 37 weeks gestation.
On examination, the cervix is 7 cm dilated, the head is direct Occipito-Anterior, the foetal station is at -1 and the head is 2/5ths palpable per abdomen.
The cardiotocogram shows late decelerations and a foetal heart rate of 100 beats/min which continue for 15 minutes.
How should this situation be managed?
(4)
A
The cardiotocogram is very concerning (the late decelerations which are a worrying sign especially in the context of foetal bradycardia) and indicates that the baby needs to be delivered immediately.
Instrumental delivery is not possible because the cervix is not fully dilated and the head of the baby is high.
Oxytocin and vaginal prostaglandin are contraindicated due to foetal distress.
Therefore the safest approach in this case is an emergency caesarian section.
24
Q
A 28-year-old woman rings up the surgery for the results of her oral glucose tolerance test. She is 25 weeks pregnant and had a glucose tolerance test as she has a body mass index of 34kg/m².
Her results are as below:
Fasting glucose = 5.4 mmol/L
2-hour glucose = 7.8 mmol/L
What is the single best description of these results?
A
Gestational diabetes due to a raised 2-hour glucose
Gestational diabetes can be diagnosed by either a:
- fasting glucose is >= 5.6 mmol/L, or
- 2-hour glucose level of >= 7.8 mmol/L
- ‘5678’
25
Risk factors for gestational diabetes
| (5)
* BMI of \> 30 kg/m²
* previous macrosomic baby weighing 4.5 kg or above
* previous gestational diabetes
* first-degree relative with diabetes
* family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
26
A 25-year-old primigravida presents to her General Practitioner at 25-week gestation following a referral from her midwife who found glucose present during a routine urinalysis. The following results are noted:
Blood pressure = 129/89 mmHg
Fundal height = 25.5 cm
Fasting plasma glucose = 6.8 mmol/L
**What intervention should be offered to this patient?**
**(2)**
**if the fasting plasma glucose is \< 7 mmol/l**
then
**a trial of diet and exercise should be offered for 1-2 weeks**
* This patient is presenting with elevated fasting plasma glucose (6.8 mmol/L) and may have gestational diabetes.*
* The most appropriate management for this is a trial of diet and exercise to attempt to control blood glucose without pharmacological intervention.*
* The patient should be advised to eat a high fibre diet with minimal foods containing refined sugars.*
* During this period, the patient will be asked to check their blood glucose regularly as there are significant risks to the foetus with gestational diabetes and the patient should contact their team if ongoing elevated readings despite lifestyle interventions.*
27
A 28-year-old pregnant woman with pre-eclampsia suffered an eclamptic seizure at 11 am yesterday.
She was started on magnesium, the baby was delivered an hour later at midday, but she had another eclamptic seizure at 2 pm.
She has been well since then, as is the baby.
**When should the magnesium infusion be stopped?**
Magnesium treatment should continue for 24 hours after delivery or after last seizure
28
A 35-year-old woman comes to see you, her GP, because she feels tearful and low since the birth of her son 1 month ago and she isn't sleeping well.
She says she thinks the baby hates her and feels they aren't bonding, though she is still breast feeding.
She has a good family network, including the baby's father and has never suffered with depression in the past.
She does not feel suicidal and has not been abusing any substances, you do not feel the baby is at risk.
**What is the most appropriate management?**
(2)
Cognitive behavioural therapy may be beneficial.
Certain SSRIs such as sertraline and paroxetine\* may be used if symptoms are severe\*\* - whilst they are secreted in breast milk it is not thought to be harmful to the infant
29
A 25-year-old para 1+0 presents at 36 weeks with painless vaginal bleeding.
She reports that she has had intermittent spotting over the last 4 weeks, but they have increased in volume and frequency.
Her blood pressure is 125/80mmHg and her heart rate is 85bpm.
On examination, her abdomen is soft and non-tender, and the fetal head is not engaged and high.
**What examination should you perform to confirm your initial working diagnosis?**
* Transvaginal ultrasound
* The findings, in this case, are classical of placenta praevia.
**_Investigations for placenta praevia_**
placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
30
Acute viral hepatitis screen is negative. Urgent US doppler liver demonstrates steatosis with patent hepatic and portal vessels. What is the most likely diagnosis?
The most likely diagnosis is **acute fatty liver of pregnancy** as demonstrated by:
* jaundice
* mild pyrexia
* hepatitic LFTs
* raised WBC
* coagulopathy
* steatosis on imaging
31
A 32-year-old woman has given birth to a healthy baby 2 weeks ago with no known complications. She enquires about iron supplementation. Her blood tests show:
## Footnote
Hb = 107 g/L
*Female: (115 - 160)*
**What haemoglobin cut-off should be used in order to commence treatment in this patient?**
**How should she be manged?**
**(3)**
* 100g/L
**Management**
* oral ferrous sulfate or ferrous fumarate
* treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
32
**Pregnancy: anaemia management (2)**
**Management**
* oral ferrous sulfate or ferrous fumarate
* treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
33
Is short or long-acting insulin used to treat gestational diabetes?
Gestational diabetes is treated with short-acting, but not longer-acting SC insulin
34
You are seeing a woman for her 6-week follow up appointment following a normal vaginal delivery.
She wishes to cease breastfeeding as her baby requires specialised formula feeds.
Which medication can be used to suppress lactation in this case?
**Cabergoline** is the medication of choice in suppressing lactation when breastfeeding cessation is indicated
35
A 27-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
The patient is at 34 weeks gestation and gravida 2, para 1. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient's pad is partially soaked but there is no active bleeding noted on a quick inspection.
What would the most appropriate first course of action be in this scenario?
Administer corticosteroids and arrange admission to the ward
Management of placental abruption when the fetus is alive, \<36 weeks and not showing signs of distress is to admit and administer steroids
36
A 28-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child one week prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the left breast at the three o'clock position, 4cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 88, resp rate: 12, blood pressure: 110/70mmHg, Oxygen saturation: 98%, Temperature: 37.4 Cº.
What is the likely diagnosis, and what is the most appropriate next step in investigation?
Galactocele, no further investigation necessary
37
A 22-year-old female, gravidity 1 and parity 0 at 10 weeks' gestation is involved in a high speed vehicle collision and her abdomen hits the steering wheel.
Maternal vital signs are stable.
No uterine contractions are present, and there is no vaginal bleeding.
U/S shows an intact placenta.
**Which is the most appropriate next step?**
**(2)**
**Blood type and Rhesus testing**
Important points:
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.
38
Katie a 38-year-old woman who is G1P0 who is 15 weeks pregnant, comes to you to discuss her 12 weeks combined screening test results.
* HCG = raised
* PAPP-A = lower
* Nuchal translucencyThickened
Katie has googled the results and is concerned that her child has Down's syndrome. She is very distressed. This is her first time becoming pregnant after 2 years of trying, and she is concerned she will not be able to conceive again on account of her age. However, Katie is unsure if she wants to continue with the pregnancy and is considering having a termination.
**What is the best advice to give to Katie?**
**(3)**
**An amniocentesis test would give a more accurate result**
* An amniocentesis is a diagnostic test that will show the fetal karyotype and will give a more accurate result than the combined test.
* Amniocentesis is usually performed from week 15 onwards, and so Katie should be booked for an amniocentesis to confirm the presence or absence of trisomy 21.
39
A 25-year-old woman who is 35 weeks pregnant attends the Emergency Department with fever, abdominal pain and anxiety. She says that she has been waking at night with soaked bed sheets for the past few days. She has been sexually active throughout pregnancy. She reports a history of uterine fibroids.
On examination there is marked uterine tenderness and an offensive brown vaginal discharge is noted. Blood pressure is 134/93 mmHg and the maternal heart rate is 110 beats per minute. Blood results are significant for a white cell count of 18.5 \* 109/l. The baseline fetal heart rate is 170 beats per minute.
(3)
What is the most likely diagnosis?
**_Chorioamnionitis_**
* Chorioamnionitis is a clinical diagnosis and is suggested by uterine tenderness and foul-smelling discharge.
* Baseline fetal tachycardia supports the diagnosis.
* The aetiology in this case is likely to involve prolonged premature rupture of membranes.
The mention of previous uterine fibroids is a distractor - fibroids may undergo red degeneration during pregnancy, which can present with fever, pain and vomiting, but usually in the first or second trimester.
40
You have a telephone consultation with a 26-year-old female who wants to start trying to conceive.
She has a history of epilepsy and takes levetiracetam 250mg twice daily.
Which of the following would be most important to advise?
**Take folic acid 5 mg once daily from before conception until 12 weeks of pregnancy**
Women on antiepileptics, who try to conceive, should receive folic acid 5mg instead of 400mcg OD
41
A new mother who is 4 weeks post-partum presents for review.
She has developed a warm, red tender patch to on the right breast just lateral to the areola.
This has been getting worse for the past three days and feeding is now painful.
She saw the midwife yesterday who helped with positioning but this has not improved matters.
On examination she has mastitis of the right breast with no obvious abscess.
What is the most appropriate management?
Flucloxacillin, continue breast feeding
42
A 28-year-old woman who is 34 weeks pregnant presents to her GP with pruritus in the soles of her hands and feet which is worse at night and affecting her sleep.
She is later referred to the obstetric team in view of deranged liver function tests (LFTs).
She is provided with some medication by the obstetric team which significantly improves her pruritic symptoms.
What medication has most likely been provided to this patient given the history above?
The first-line medical treatment for intrahepatic cholestasis of pregnancy is ursodeoxycholic acid
43
A 37 year old woman who is 32 weeks pregnant presents with malaise, headaches and vomiting. She is admitted to the obstetrics ward after a routine blood pressure measurement was 190/95mmHg. Examination reveals right upper quadrant abdominal pain and brisk tendon reflexes.
The following blood tests are shown:
Hb = 85 g/l
WBC =6 \* 109/l
Platelets = 89 \* 109/l
Bilirubin = 2.8 µmol/l
ALP =215 u/l
ALT = 260 u/l
γGT = 72 u/l
LDH = 846 u/I
A peripheral blood film is also taken which shows polychromasia and schistocytes.
What is the most likely diagnosis?
HELLP syndrome is a severe form of pre-eclampsia whose features include:
* Haemolysis (H)
* elevated liver enzymes (EL)
* and low platelets (LP)
A typical patient might present with malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.
44
A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes.
There have been no complications of the pregnancy so far and the woman is normally fit and well.
**How is she best managed?**
(3)
**Admit her for at least 48 hours and prescribe antibiotics and steroids**
This woman is only 32 weeks gestation and it could be that she is going into labour with the rupture of the membranes. You therefore want to admit her and treat her with steroids to promote lung maturation of the baby.
Because of the risk of sepsis and post-natal infection you would want to treat with antibiotics, currently erythromycin is recommended, but always consult your hospital guidelines.
45
A 27-year-old female presents to the labour ward ready to deliver.
She is 38-weeks pregnant and her pregnancy was uncomplicated. Her first child, who is now 1-year-old had neonatal sepsis caused by Group B Streptococcus (GBS).
She is otherwise well with no relevant past medical history.
Which one of the following is the most appropriate regarding the management of the GBS risk?
**Prescribe intrapartum intravenous benzylpenicillin**
Maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
46
A 34-year-old pregnant woman presents at 30 weeks gestation for a routine check.
On examination, she has a symphysis-fundal height of 25 cm.
**What is the next most important investigation to confirm the examination findings?**
**How is SFH measured?**
Ultrasound
The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres
47
A 36-year-old woman gives birth to healthy twin girls.
Which agent is most likely to be used after the birth to facilitate delivery of the placenta and to prevent postpartum haemorrhage?
Oxytocin / ergometrine
48
A 31-year-old female (P0 G1) is 30 weeks pregnant.
She has recently been informed that her baby is in the breech position.
A consultant has discussed the possible options with her, which include the external cephalic version (ECV).
**She wants to know when is the earliest time she can be offered ECV.**
(**2**)
In nulliparous women, like the lady in question, ECV should be offered from **36 weeks** if the baby is still breech.
*If the lady was multiparous ECV would be offered from 37 weeks.*
49
A 28-year-old woman, para 2+ 0, has delivered a healthy baby. The third stage of labour was actively managed with Syntocinon, cord clamping, and controlled cord traction.
The placenta was examined by the midwives and it appeared complete.
She continues to bleed post-delivery and has lost an estimated 1,500 ml of blood.
She does not have any past medical history.
**What is the management to arrest the bleeding?**
**(6)**
This patient meets the criteria for post-partum haemorrhage (PPH).
Initially non-pharmacological methods are used such as bimanual uterine compression should be employed and a catheter inserted to ensure an empty bladder.
**RCOG guidelines then suggest to initially use Syntocinon 5 Units by slow IV injection.**
**This should then be followed by ergometrine (contraindicated in hypertension) and then a Syntocinon infusion.**
**Carboprost (contraindicated in asthma) and then misoprostol 1000 micrograms rectally are then recommended.**
If pharmacological management fails then surgical haemostasis should be initiated.
50
A 34-year-old female who is 16 weeks pregnant is found to have a raised serum alpha-feto-protein (AFP) and is concerned as to what may be the cause of this.
**Which of the following may cause this patient to have a raised AFP?**
**AFP - raised with fetal abdominal wall defects**
(e.g. omphalocele)
51
**_Causes of increased AFP_**
(3)
**_Causes of decreased AFP_**
**(3)**
**_Causes of increased AFP_**
* Neural tube defects (meningocele, myelomeningocele and anencephaly)
* Abdominal wall defects (omphalocele and gastroschisis)
* Multiple pregnancy
**_Causes of decreased AFP_**
* Down's syndrome
* Trisomy 18
* Maternal diabetes mellitus
52
A 27-year-old G2P1 woman is admitted to the maternity ward following the onset of regular contractions.
The midwife performs a vaginal examination and confirms that the mother is in the first stage of labour.
At what point does this stage of labour finish?
10 cm cervical dilation
1st stage of labour: from the onset of true labour to when the cervix is fully dilated
53
When does the second stage of labour end?
The **birth of the foetus** defines the end of the second stage of labour
54
A 29-year-old woman vaginally delivers a large female child following an uneventful pregnancy.
Which of the following best describes a third-degree tear of the perineum?
Injury to the perineum involving the anal sphincter
55
A 32-week pregnant primiparous woman attends your practice for a routine check up.
Her pregnancy has been complicated by a diagnosis of intrahepatic cholestasis, for which she is currently taking ursodeoxycholic acid and being regularly monitored by her maternity unit.
She asks you regarding what the plan for her delivery is most likely to be.
Induction of labour will be offered at 37-38 weeks
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
56
A 32-year-old woman has a telephone consultation with her GP. She is 23 weeks pregnant, with no complications so far. She is now concerned, as last week she met with her sister and nephew. Several days after, her sister informed her that the child has since developed a rash, which she suspects to be chickenpox. The patient herself was unsure of whether or not she had chickenpox as a child, but she said her lack of symptoms reassured her. However, in the past 12 hours, she has developed a rash and is now worried for the health of her baby. Aside from the rash, she feels well in herself.
**What would be the most appropriate management at this stage?**
## Footnote
**(2)**
**Oral** aciclovir
*\*Intravenous aciclovir would be used with severe chickenpox, but given that the patient is otherwise well, this would not be indicated here.*
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
57
When is the second screen for anaemia and atypical red cell alloantibodies?
28 weeks
58
When does the nuchal scan take place?
11 - 13+6 weeks
59
When does the **Urine culture to detect asymptomatic bacteriuria** take place?
8 - 12 weeks
60
A 35-year-old woman is found at her dating ultrasound scan *(8-14 weeks)* to be pregnant with **monochorionic** **twins**.
Her midwife explains that she will need regular scans throughout her pregnancy.
For this pregnancy, what is the main pathology that ultrasound monitoring performed between **16 and 24 weeks gestation** aims to detect?
Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of **monochorionic** **twin** **pregnancies**.
The two fetuses **share a single placenta**, meaning that blood can flow between the twins.
**In TTTS, one fetus, the 'donor' receives a lesser share of the placenta's blood flow than the other twin, the 'recipient'.**
This is due to abnormalities in the network of placental blood vessels.
The recipient may become fluid-overloaded whilst the donor can become anaemic.
One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems.
In severe cases, TTTS can be fatal for one or both fetuses.
61
A 32-year-old women para 1+0 is 37+1 weeks pregnant and is being monitored and treated for pre-eclampsia.
Her current treatment is with labetalol and her blood pressure has been well controlled.
She attends the antenatal clinic complaining of a severe headache, one episode of vomiting, and blurred vision.
Her blood pressure is currently 156/100 mmHg.
On examination she has papilloedema.
She is admitted to hospital.
* *What is the appropriate management?
(3) **
**IV magnesium sulphate**
and
**plan immediate delivery**
*NICE guidelines recommend delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks.*
**(IM) beclometasone is not required as the woman is past 36 weeks.**
**IV calcium gluconate is used to treat magnesium toxicity and is not indicated.**
62
What is the gestational requirement for steroid treatment?
36 weeks
63
What is IV calcium gluconate used to treat?
IV calcium gluconate is used to treat magnesium toxicity and is not indicated.
64
A 31-year-old woman presents with a positive urine pregnancy test. Blood tests are organised and lifestyle advice is given. She has no significant medical history.
On examination, the following observations are noted:
* Heart rate 94 beats per minute
* Blood pressure 124/77 mmHg
* Oxygen saturation 99% on room air
* Temperature 36.5ºC
* Respiratory rate 15 breaths per minute
* BMI 31 kg/m²
What supplementation should be recommended for this woman?
**Folic acid 5mg daily**
Pregnant obese women (BMI \>30 kg/m2), should be given high dose 5mg folic acid
65
A 39 year-old woman presents to her general practitioner with a grape-sized breast lump that she noticed one week ago whilst in the bath. It is firm and non-tender, with no surrounding skin changes. She feels well in herself with no temperatures, and has no history of breast disease. She stopped breastfeeding one month ago. An ultrasound scan shows a well-circumscribed lesion and aspiration yields a white fluid. What is the likely diagnosis?
**Galactocele**
The ultrasound findings and aspiration results make fibrocystic change, breast cancer and fat necrosis unlikely.
66
A Cardiotocogram (CTG) is performed on a 34-year-old female at 40 weeks gestation who has attended labour ward in spontaneous labour.
The CTG shows a fetal heart rate of 150bpm. There is good variability in fetal heart rate, and it is a low risk pregnancy.
The midwife rings you concerned that there are late decelerations present on the CTG trace.
**Which is the most appropriate next step in management?**
Fetal blood sampling
Late decelerations on CTG are a pathological finding and urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis
67
You are a GP in a local surgery and the next patient is a 23-year-old type 1 diabetic who is keen to get pregnant.
She stopped using the combined oral contraceptive pill (Microgynon) one month ago.
Her body mass index is 22 kg/m²and her only medication is her insulin.
Which of the following should you also advise her?
In women at risk of neural tube defects, folic acid should be started before conception
68
Which drugs are contra-indicated whilst breast feeding?
(7)
The following drugs should be avoided:
* antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
* psychiatric drugs: lithium, benzodiazepines
* aspirin
* carbimazole
* methotrexate
* sulfonylureas
* cytotoxic drugs
* amiodarone
69
A 28-year-old gravida 1 para 0 lady has been in labour for eleven hours; she progressed through the first stage without any issues.
However, the midwife has noted CTG abnormalities, and was able to palpate the umbilical cord.
She immediately calls the obstetric registrar who checks the cardiotocograph (CTG), which shows variable decelerations.
**What is the initial definitive management for the cause of these decelerations?**
Place hand into vagina to elevate presenting part
get patient on all fours
70
You are a junior doctor working in obstetrics and gynaecology. While helping to care for a patient during a vaginal delivery the delivery is suddenly complicated by shoulder dystocia.
After immediately calling for senior help you decide to perform McRobert's manoeuvre, by moving the mother onto her back and hyper flexing and abducting her hips, bringing her thighs towards her abdomen.
Which additional measure can aid the effectiveness of the manoeuvre?
**Suprapubic** **pressure**
The Royal College of Obstetrics and Gynaecology suggest that '**suprapubic** **pressure** should be used to improve the effectiveness of the McRoberts manoeuvre' in their shoulder dystocia guidelines.
71
A 24-year-old woman presents to her GP 8 days after giving birth.
She complains of a persistent pink vaginal discharge which is 'smelly'.
On examination her pulse is 90 / min, temperature 38.2ºC and she has diffuse suprapubic tenderness.
On vaginal examination the uterus feels generally tender.
Examination of her breasts is unremarkable.
Urine dipstick shows blood ++.
**What is the diagnosis? (2)**
**What is the most appropriate management? (2)**
**Puerperal** P**yrexia**
* This woman by definition has **puerperal** **pyrexia**, likely secondary to endometritis.
* Puerperal pyrexia may be defined as a temperature of \> 38ºC in the first 14 days following delivery.
**Management**
* **She needs to be admitted for intravenous antibiotics.**
* (clindamycin and gentamicin until afebrile for greater than 24 hours)
72
A 27-year-old primiparous female is at 39 weeks gestation. A midwife examines the patient and determines her Bishop score to be 4. What does this mean?
Labour is unlikely to start spontaneously
The Bishop scoring system is used to assess the need for induction. It takes into account cervical characteristics (position, consistency, effacement and dilatation) and foetal station. A Bishop score less than 5 generally means induction will likely be necessary. A score above 9 indicates labour will likely occur spontaneously.
73
A 31-year-old pregnant woman presents for her 42-week antenatal visit.
It had been agreed in a previous antenatal visit that she would be induced at 42 weeks if she hadn't gone into labour naturally by this point.
She reports normal foetal movements and denies recent illness. This is her first pregnancy and she has no relevant past medical history.
On examination, her abdomen is soft with a palpable uterus and a fundal height of 40cm.
What is the most important to be assessed in this woman?
**The Bishop Score should be assessed prior to induction of labour**
The Bishop score should be assessed in all women prior to induction of labour. It has the following components:
* Cervical position (posterior/intermediate/anterior)
* Cervical consistency (firm/intermediate/soft)
* Cervical effacement (0-30%/40-50%/60-70%/80%)
* Cervical dilation (\<1 cm/1-2 cm/3-4 cm/\>5 cm)
* Foetal station (-3/-2/-1, 0/+1,+2)
74
A 36-year-old woman presents for a routine antenatal review. She is now 15 weeks pregnant.
Her blood pressure in clinic is 154/94 mmHg.
This is confirmed with ambulatory blood pressure monitoring.
On reviewing the notes it appears her blood pressure four weeks ago was 146/88 mmHg.
A urine dipstick is normal.
There is no significant past medical history of note.
**What is the most likely diagnosis?**
**(2)**
**Pre-existing hypertension**
## Footnote
This lady has pre-existing hypertension. **Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) do not occur before 20 weeks**. The raised ambulatory blood pressure readings exclude a diagnosis of white-coat hypertension.
75
A 36-year-old multiparous patient has an uncomplicated delivery at 39 weeks gestation.
One hour following delivery, the patient develops severe post partum haemorrhage which is acutely managed in the labour ward.
Seven weeks later, the patient presents with difficulty breastfeeding due to a lack of milk production.
Which of the following conditions is most likely to explain this history?
This clinical history suggests **Sheehan's** **syndrome**. Sheehan's syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan's syndrome is a lack of postpartum milk production and amenorrhoea following delivery. Diagnosis of Sheehan's is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
76
A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group = A Rhesus negative
**What is the most appropriate management regarding her rhesus status?**
**(2)**
in Rhesus negative woman -
**anti-D** at **28 + 34 weeks**
77
A 23-year-old G2P1 woman is seen by her midwife at 12 weeks gestation. Her urine dipstick is normal and her blood pressure is 124/68 mmHg. She had no issues during her first pregnancy. Her only medical history is type 1 diabetes mellitus, which is well controlled, and there is a family history of pre-eclampsia.
What is the correct advice regarding her risk of pre-eclampsia?
A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth
78
A woman who is 39 weeks pregnant has come in to hospital in labour. The midwife notices she has a temperature of 38.5ºC, and so suggests that the woman should get some antibiotic treatment. The woman has no drug allergies, and has has a normal and uneventful pregnancy so far.
## Footnote
* *Which antibiotic should the woman get as Group B Streptococcus prophylaxis?
(3) **
## Footnote
Women with pyrexia \>38 degrees
during labour
should get benzylpenicillin as GBS prophylaxis
79
A 28-year-old patient who is currently 25 weeks pregnant attends your GP surgery with an itchy rash on her abdomen and torso, which started the previous night. She had recently been babysitting her niece who was then diagnosed with chickenpox. She does not know for sure if she has had chickenpox in the past. One examination, there are red spots vesicles on her arms, torso and abdomen. She is otherwise well and all vital signs within normal range.
What should your next step be?
Commence an oral course of aciclovir
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
80
At which week should you refer to an obstetrician for lack of fetal movements?
If fetal movements have not yet been felt by **24 weeks**, referral should be made to a maternal fetal medicine unit
81
A 30-year-old woman, para 2+0, is in the second stage of labour and has just delivered the anterior shoulder.
She has opted for active management during the third stage of her labour.
She had mild gestational hypertension during pregnancy with a recent blood pressure recording of 142/91 mmHg.
**What drug should now be administered? (1)**
**Which other active measures should be employed? (3)**
Oxytocin
*Active management of this stage is recommended in order to reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery.*
**Active management lasts less than 30 minutes and involves the following:**
* Uterotonic drugs
* Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
* Controlled cord traction after signs of placental separation
82
When does the third stage of labour begin/end?
The third stage of labour is measured from the birth of the baby
to
the expulsion of the placenta and membranes.
83
A 24 year-old woman, who is 35 weeks pregnant is found to have a blood pressure of 165/108 mmHg at a routine GP appointment. She is otherwise well. Her only regular medication is 200mg labetalol.
Urinalysis reveals 2+ proteinuria. Cardiotocography is normal.
**Blood tests are as follows:**
Hb = 140 g/l
Platelets = 270 \* 109/l
WBC = 5.6 \* 109/l
Na+ = 140 mmol/l
K+ = 3.9 mmol/l
Urea = 2.4 mmol/l
Creatinine = 21 µmol/l
**What is the most appropriate step in her management?**
**Admit the patient to hospital as an emergency**
## Footnote
Even though the patient is asymptomatic, she has a raised blood pressure above 160/100 mmHg combined with the significant proteinuria.
Furthermore, this is despite receiving labetalol treatment.
She will need emergency admission for monitoring and management of the hypertension in a controlled environment, with delivery being an option if there is no improvement.
84
A 24 year-old lady with type 1 diabetes presents to the maternity department at 25+3 weeks gestation with tightenings and a thin watery discharge.
Her pregnancy so far has been uncomplicated and all scans have been normal.
She has well controlled diabetes by using an insulin pump.
A speculum examination is performed and no fluid is noted, the cervical os is closed.
A fetal fibronectin (fFN) test is performed which comes back as 300 (positive).
**What is Fetal fibronectin? (1)
What does the elevation mean? (2)**
**What is the most appropriate management? (2)**
Fetal fibronectin (fFN) is a protein that is released from the gestational sac.
Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc.
Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN
**_Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly_**
85
CTG tracings
## Footnote
**_Definition of baseline bradycardia_**
**_(1)_**
**_Causes of baseline bradycardia_**
**_(2)_**
**_Definition of baseline bradycardia_**
* Heart rate \< 100 /min
**_Causes of baseline bradycardia_**
* Increased fetal vagal tone (activity of the vagus nerve)
* maternal beta-blocker use
86
CTG tracings
## Footnote
**_Definition of Baseline tachycardia_**
**_(1)_**
**_Causes of Baseline tachycardia_**
**_(4)_**
CTG tracings
**_Definition of Baseline tachycardia_**
* Heart rate \> 160 /min
**_Causes of Baseline tachycardia_**
* Maternal pyrexia
* chorioamnionitis
* hypoxia
* prematurity
87
CTG tracings
## Footnote
Definition of **Loss of baseline variability**
(1)
Causes of **Loss of baseline variability**
(2)
**_Definition of Loss of baseline variability_**
* \< 5 beats / min
**_Causes of Loss of baseline variability_**
* Prematurity
* hypoxia
88
CTG tracings
## Footnote
**_Definition of Early deceleration_**
**_(1)_**
**_Causes of Early deceleration_**
**_(1)_**
**_Definition of Early deceleration_**
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
**_Causes of Early deceleration_**
Usually an innocuous feature and indicates head compression
89
**_CTG tracings_**
## Footnote
**_Definition of Late decelerations_**
**_(1)_**
**_Causes of Late decelerations_**
**_(2)_**
**_Definition of Late deceleration_**
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
**_Causes of Late deceleration_**
* Indicates fetal distress
* asphyxia or placental insufficiency
90
CTG tracings
## Footnote
**_Definition of Variable decelerations_**
**_(1)_**
**_Causes of Variable decelerations_**
**_(1)_**
**_Definition of Variable decelerations_**
decelerations which are independent of contractions
**_Causes of Variable decelerations_**
May indicate cord compression
91
A 29-year-old G3P2 woman at 33 weeks gestation presents to the emergency department with severe, sudden-onset lower abdominal pain which began 30 minutes ago. She reports a small volume of vaginal bleeding but that her baby remains active, however movements are slightly less than normal.
Her pregnancy to date has been uncomplicated, with up-to-date antenatal care, and her past medical history is unremarkable. Both of her previous children are healthy, aged 3 and 5, born by vaginal delivery. She is a current smoker with a 9 pack-year history.
The mother is alert and oriented but in significant pain. Her vitals include a blood pressure of 148/91mmHg and heart rate of 115 beats per minute, with other values within normal limits. A cardiotocograph is reported as normal, with a non-concerning baseline fetal heart rate, as well as appropriate accelerations and no decelerations.
**What is the most likely diagnosis?**
## Footnote
**(1)**
**What is the next most appropriate step in management?**
**(2)**
Management of **placental** **abruption** when the fetus is alive,
\<36 weeks and not showing signs of distress is to **admit** and **administer steroids**
92
A 27-year-old woman who is 40-weeks pregnant arrives in the labour suite with irregular contractions.
Earlier today she noticed a mucous plug in her pants at home.
On examination, she is breathing hard and obviously in some discomfort.
The cardiotocography is normal and progressing well.
On vaginal examination, her cervix is estimated to be 2cm dilated.
**What stage of labour is she in?**
Latent 1st stage
**1st stage of labour**
* latent phase = 0-3 cm dilation
* active phase = 3-10 cm dilation
93
A Cardiotocogram (CTG) is performed on a 28-year-old female at 36 weeks gestation who has attended labour ward in spontaneous labour.
The CTG shows a foetal heart rate of 120bpm and variable decelerations and accelerations are present.
There are no late decelerations.
However, the midwife notices a 20 minute period where the foetal heart rate only varies by 3-4bpm.
The mum is concerned as she has not felt her baby move much for about 20 mins and would like to know what the likely cause is.
She starts crying when she tells you that she took some paracetamol earlier as she was in so much pain from the contractions and is worried this has harmed her baby.
**Which of the following is the most likely cause of this decreased variability? (1)**
**What about if she'd not felt movement in \>40 minutes? (4)**
**The most common explanation for short episodes (\< 40 minutes) of decreased variability on CTG is that the foetus is asleep.**
Other causes of decreased variability in foetal heart rate on CTG are due to:
* maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol),
* foetal acidosis (usually due to hypoxia)
* prematurity (\< 28 weeks, which is not the case here)
* foetal tachycardia (\> 140 bpm, again not the case here)
* congenital heart abnormalities
94
You are the obstetrics FY2 doctor checking through the list of patients currently on the labour ward.
**Which findings in one of the patients would prompt you to start continuous CTG tracing while in labour?**
(5)
As per NICE guidelines; the following would warrant continuous CTG monitoring if any of the following are present or arise during labour;
* suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
* severe hypertension 160/110 mmHg or above
* oxytocin use
* the presence of significant meconium
* fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
95
A patient 18/40 gestation makes a telephone consultation to your surgery.
This is her first pregnancy.
She is concerned about not feeling any foetal movements yet.
You reassure her that foetal movements can occur between 18-20 weeks gestation in first pregnancies.
**At what gestation is further investigation required if there are not foetal movements felt by this time?**
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
96
A 40+5 week gestation primigravida presents to the maternity assessment unit for assessment following a membrane sweep 2 days ago attempting to induce labour.
She has had an uncomplicated pregnancy and has attended all prenatal appointments.
Her most recent scan showed a posterior high placenta and cephalic presentation.
She has no past medical or surgical history and takes no regular medication.
Cardiotocography is recorded as reassuring.
She has a vaginal examination performed which shows a Bishop score of 7.
**What is the most appropriate management choice to attempt to induce labour in this patient?**
**Vaginal Prostaglandin E2 (PGE2) is the preferred method of induction of labour**
This patient has a Bishop score which shows good favourability for vaginal delivery (a score of 7 or more is considered 'favourable' and the likelihood of vaginal delivery with induction is similar to spontaneous labour).
NICE guidelines advise that vaginal PGE2 is the induction method of choice irrespective of cervical status and parity. It is available as a tablet, gel or pessary.
This patient has no contraindications for the usage of these drugs such as acute inflammatory pelvic disease, active renal, hepatic, pulmonary or cardiac disease, foetal distress where delivery is not imminent, vaginal bleeding during pregnancy, marked cephalopelvic disproportion.
**Amniotomy with an amnio hook is only appropriate if the cervix is favourable for this intervention (it is ripe and slightly dilated) and if there are specific contraindications to the use of vaginal prostaglandins.**
97
A 32-year-old lady presents to the booking clinic.
She is approximately 8 weeks pregnant.
During the consultation, it comes to light that she has had two deep vein thromboses in the past.
**Which of the following will she require given her history of previous VTEs?**
(3)
* Low molecular weight heparin,
* starting immediately until 6 weeks postnatal
*Pregnant woman with a previous VTE history: LMWH throughout pregnancy until 6 weeks postnatal*
98
A 35-year-old lady on the labour ward developed a primary postpartum haemorrhage (PPH) 4 hours after giving birth.
After appropriate resuscitation, she was examined and uterine atony was identified as the cause.
Pharmacological management was thus commenced, but without success.
**What is the diagnosis? (1)**
**What is the most appropriate initial surgical intervention?**
(4)
A primary postpartum haemorrhage (**PPH**) is the loss of \>500mL of blood \<24 hours after delivery.
* **Intrauterine balloon tamponade**
other options include:
* **B-Lynch suture**
* **ligation of the uterine arteries**
* **internal iliac arteries**
*if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure*
99
**Secondary PPH**
When does it occur? (1)
What causes it? (2)
**Secondary PPH**
* occurs between 24 hours - 12 weeks\*\*
* due to retained placental tissue or endometritis
100
Jane is a 29-year-old woman who is known to have epilepsy. She was diagnosed with this 5 years ago and she remains stable on carbamazepine.
She had recently been pregnant and has just given birth to a baby girl.
While in hospital, Jane has approached you as she is unsure about breastfeeding.
Jane is afraid that the baby will be affected is she continues to breastfeed while on carbamazepine.
**What advice would you provide Jane with regards to her antiepileptic and breastfeeding?**
**(3)**
## Footnote
Continue carbamazepine, continue breastfeeding
Breastfeeding is acceptable with nearly all anti-epileptic drugs \*except barbituates
101
A woman who gave birth 5 days ago presents for review as she is concerned about her mood.
She is having difficulty sleeping and feels generally anxious and tearful.
Since giving birth she has also found herself snapping at her husband.
This is her first pregnancy, she is not breast feeding and there is no history of mental health disorders in the past.
**What is the diagnosis?**
**What is the most appropriate management?**
**Explanation and reassurance**
## Footnote
This woman has the baby-blues which is seen in around two-thirds of women.
Whilst poor sleeping can be a sign of depression it is to be expected with a new baby!
