Day 9 Obstetrics Flashcards
1
Q
A 31-year-old female presents to the antenatal clinic for a booking appointment.
What are the risk factors for pre-eclampsia?
(9)
A
- Aged 40 years or older
- Nulliparity
- Pregnancy interval of more than 10 years
- Family history of pre-eclampsia
- Previous history of pre-eclampsia
- Body mass index of 30kg/m^2 or above
- Pre-existing vascular disease such as hypertension
- Pre-existing renal disease
- Multiple pregnancy
2
Q
A 26-year-old woman presents to her GP with a 5 week history of worsening dull pelvic pain and smelly discharge.
She has had a hormonal intrauterine device in situ for one year and does not menstruate with this.
She has had the human papilloma virus vaccine but has not yet had any smear tests.
What is the most likely diagnosis?
How should she be managed?
A
Pelvic inflammatory disease is the most likely diagnosis in this patient.
Her pain has developed over a long duration, and she has presented to her GP suggesting that the pain is not severe.
She also complains of smelly discharge that may be a sign of a sexually transmitted infection.
This patient has an intrauterine device suggesting that there may be no barrier method in use to prevent sexually transmitted infections.
Abnormal bleeding (post-coital, inter-menstrual, menorrhagia) may be also present.
High vaginal swabs should be taken, and antibiotics prescribed if appropriate. A smear test can be taken opportunistically in this patient.
3
Q
A woman who is 8 weeks pregnant presents with abdominal pain and vaginal bleeding.
On examination she is tender in the right iliac fossa and suprapubic region.
Speculum examination shows an open cervical os.
Ultrasound confirms an intrauterine pregnancy.
What is the most likely diagnosis?
A
This lady is likely to be having an inevitable miscarriage.
4
Q
A woman who is 22 weeks pregnant presents with abdominal pain on the right side of her abdomen.
On examination she has abdominal tenderness on the right side and urine dipstick is normal.
White blood cells are raised at 18.5 * 109/l
A
The correct answer is: Appendicitis
5
Q
A woman who is 33 weeks pregnant presents with vaginal bleeding, which she describes as being like a period.
She also has constant, lower abdominal pain. On assessment, her blood pressure is 90/60 mmHg and her pulse is 110/min
What is the likely diagnosis?
A
Placental abruption
*Placental praevia would not usually present with abdominal pain.
6
Q
A 28-year-old pregnant woman wishes to receive the measles, mumps and rubella (MMR) vaccination.
She has never received any MMR vaccination and is worried that her baby may be infected as a result.
She is currently 12-weeks pregnant and there are no sick contacts around her.
Which of the following is the correct response in this scenario?
A
Refrain from giving her any MMR vaccination now and at any stage of her pregnancy
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant; to avoid becoming pregnant for 28 days after receipt of MMR vaccine (CDC 2013)
7
Q
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
A
The bleeding associated with placenta praevia is painless and usually bright red.
Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red.
The pattern of previous bleeding also favours placenta praevia. Though vasa praevia can also present with painless vaginal bleeding other expected features would include fetal bradycardia and membrane rupture.
8
Q
A 32-year-old woman presents to the obstetric clinic at 30 weeks gestation.
She has been diagnosed with gestational diabetes and was started on metformin two weeks previously.
Despite a well controlled diet and maximum dose metformin, her blood glucose levels remain too high.
What is the next most appropriate step to control blood glucose in this woman?
(2)
What are the potential complications? (3)
A
Add on insulin therapy
In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added
This woman has gestational diabetes and hyperglycaemia associated with this can result
- macrosomia
- premature birth
- stillbirth
9
Q
A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy.
Her baby is known to currently lie in a breech presentation.
What is the most appropriate management?
A
Refer for external cephalic version
*if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
10
Q
A 23-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents after fainting and has severe abdominal pain.
Blood pressure = 92/58 mmHg and heart rate = 132/min.
On examination she is cold and her fundal height is 37 cm; the cervical os is closed and there is no vaginal bleeding.
Which is the most appropriate diagnosis?
(4)
A
Placental abruption
- Presents with sudden abdominal pain in the third trimester.
- On examination the mother can be seen to be in extreme pain and cold to touch.
- Bleeding is present in 80% of cases - absence of visible bleeding does not rule out this diagnosis.
Risk factors include: maternal hypertension (common), cocaine, trauma, uterine overdistension, tobacco and previous placental abruption
11
Q
A pregnant woman is brought to the Emergency department with nausea, severe itching and lethargy.
She is 37 weeks pregnant and this is her second pregnancy.
On examination she is clinically jaundiced but observations are normal.
Her blood tests are as follows:
Hb = 121 g/l
Platelets = 189 * 109/l
WBC = 8.7 * 109/l
Bilirubin = 90 µmol/l
ALP = 540 u/l
ALT = 120 u/l
γGT = 130 u/l
Albumin = 35 g/l
INR = 1.0
Acute viral hepatitis screen is negative. What is the most likely diagnosis?
A
Cholestasis of pregnancy
Clinically, cholestasis of pregnancy is characterised by severe pruritis,
whereas
acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea).
12
Q
When does the foetal anomaly scan occur?
A
18 - 20+6 weeks
13
Q
When is the first dose of anti-D prophylaxis to rhesus negative women?
A
28 weeks
14
Q
When is the “early scan” to confirm dates?
A
10 - 13+6 weeks
15
Q
A 32-year-old female presents at 28 weeks gestation in her third pregnancy.
An ultrasound scan at 12 weeks had confirmed a dichorionic diamniotic twin pregnancy.
She was admitted complaining of bleeding per vaginum.
The bleeding was bright red in nature and painless.
She has a history of two previous caesarian sections.
What is the most likely diagnosis? (1)
What is the key clinical feature? (1)
What are the risk factors? (4)
A
Placenta praevia is a complication of pregnancy where the placenta is attached to the lower part of the uterus.
The key clinical feature is painless bleeding after 24 weeks of gestation.
Risk factors include:
- previous placenta praevia
- previous caesarean section
- endometrium damage
- multiple pregnancies
Placenta praevia is often associated with a high presenting part or abnormal lie as a direct consequence of the low lying placenta.
16
Q
A 29-year-old woman presents with dysuria and frequency four weeks after giving birth. The antenatal period and delivery were unremarkable. She is exclusively breastfeeding her child at the current time. Abdominal examination is unremarkable and she is apyrexial. A urine dipstick shows blood +, protein +, leucocytes +++ and nitrites positive.
What is the most appropriate management?
(3)
A
Trimethoprim in breastfeeding is considered safe to use
penicillins, cephalosporins, trimethoprim are SAFE to use in breastfeeding
17
Q
A 26-year-old pregnant woman with type 1 diabetes asks you how often she should test blood glucose levels throughout her pregnancy?
(4)
A
- Daily fasting
- pre-meal
- 1-hour post-meal
- bedtime tests
18
Q
A woman gives birth via normal vaginal delivery. The midwife notices the baby has an umbilical hernia, a large, protruding tongue, flattened face, and low muscle tone.
Which of the following results is most likely to have been those of this woman’s combined screening test at 12-weeks-pregnant with this child?
A
increased HCG
decreased PAPP-A
thickened nuchal translucency
19
Q
According to guidelines on shoulder dystocia management:
(5)
A
According to guidelines on shoulder dystocia management:
Immediately after shoulder dystocia is recognised, additional help should be called.
Fundal pressure should not be used.
An episiotomy is not always necessary.
Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes.
McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases
20
Q
A 36-year-old woman suffers from a major postpartum haemorrhage after delivering twins.
The obstetric consultant examines her and suspects uterine atony to be the cause.
The protocol for major PPH is initiated.
Bimanual uterine compression fails to control the haemorrhage.
- *Which drug is an appropriate next step in the management of uterine atony?
(6) **
A
The following management should be initiated in sequence:
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine
- intramuscular carboprost
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade
21
Q
You are the obstetric SHO on call. A 32/40 primip has attended the maternity triage reporting a ‘gush of fluid down below’ earlier on in the day. She is otherwise well.
You suspect premature prelabour rupture of membranes (PPROM).
A sterile speculum examination is performed but do not note any fluid in the vaginal vault.
What other investigation could you perform to diagnose PPROM?
(2)
A
When investigating suspected PPROM, if there is no fluid in the posterior vaginal vault then an
ultrasound may be used to look for oligohydramnios
22
Q
A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant.
The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide.
- *What advice should you give her about potential changes to her medication during pregnancy?
(2) **
A
Patient may continue on metformin but gliclazide must be stopped
The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped.
In the management of type 2 diabetes in pregnancy ‘women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin’.
While it is likely that the patient will be required to switch to insulin it is not an absolute requirement.
23
Q
What is Lamotrigine?
(3)
A
Lamotrigine is a medicine used to treat epilepsy.
It can also help prevent low mood (depression) in adults with bipolar disorder.
Lamotrigine is a member of the sodium channel blocking class of antiepileptic drugs
24
Q
A 23-year-old woman at 37-week’s gestation is brought to labour ward.
She reports having been in labour for 4 hours and her uterine contractions are currently 2 minutes apart.
Her 34-week scan identified grade III placenta praevia.
On examination, her cervix is dilated to 8cm and effaced by 90%.
Foetal cartography measurements are within normal limits. There are no signs of vaginal bleeding.
What is the next step in the management of this patient?
(2)
A
If a woman with known placenta praevia goes into labour (with or without bleeding) an emergency caesarean section should be performed
If placenta praevia is detected on routine imaging, particularly grade III and IV placenta praevia, discussions should be made about an elective caesarean section at 37-38 weeks
25
A 24-year-old woman attends her booking scan and finds out that she is pregnant with monochorionic twins.
Her general practitioner asks her specifically to report any sudden increases in the size of her abdomen and/or any breathlessness.
**What complication of monochorionic multiple pregnancy is the GP describing the symptoms of?**
**Twin-to-twin transfusion syndrome** (TTTS) is a relatively common complication of monochorionic pregnancy.
26
A 34-year-old woman who is 32 weeks pregnant presents to her local antenatal unit for a midwife check-up. Her pregnancy has also been complicated by intrahepatic cholestasis of pregnancy, which has been treated with ursodeoxycholic acid. This is her first pregnancy, and she has had no previous miscarriages. She is epileptic, and is being treated with lamotrigine.
She tells her midwife that her step-sister has just had another term stillbirth, after already having 2 prior.
This has made her worried about her own pregnancy.
**Which part of her medical history puts her most at risk for this outcome?**
**(2)**
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth;
therefore induction of labour is generally offered at 37-38 weeks gestation
27
A 32-year-old multiparous female at 9 weeks gestation has presented to her general practitioner to book her pregnancy. Due to her previous history of gestational diabetes, she returns the following day for an oral glucose tolerance test.
## Footnote
**She has bloods which reveal:**
Fasting glucose = 7.2 mmol/L
2-hour glucose = 8.9 mmol/L
**What is the appropriate management plan following these results?**
**Patient to be started on insulin**
If at the time of diagnosis of gestational diabetes, the fasting glucose level is \>= 7 mmol/l immediate **insulin** (plus or minus metformin) **should** **be** **started**
28
On routine antenatal swabs, a mother is found to be colonised with Group B Streptococcus.
However, she did not receive adequate intrapartum antibiotic prophylaxis and she delivers a healthy baby girl by vaginal delivery.
Her baby does not require any resuscitation and remains well in the post natal ward.
The mother is eager for discharge home.
**What is the most appropriate course of action with regards to her child?**
**(7)**
**Regular observations for 24 hours**
Two or more minor risk factor or one red flag warrant empirical antibiotic therapy with Benzylpenicillin and Gentamicin and a full septic screen:
* Suspected or confirmed infection in another baby in the case of a multiple pregnancy
* Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
* Respiratory distress starting more than 4 hours after birth
* Seizures
* Need for mechanical ventilation in a term baby
* Signs of shock
29
At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP).
**Which procedure carries the greatest risk of haemorrhage in the newborn?**
(3)
**Prolonged ventouse delivery**
* The high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate.
* Cephalohaematoma or more severely, subgaleal haemorrhage, can be exacerbated in the context of neonatal thrombocytopenia
*Immune thrombocytopenia (ITP) is an autoimmune condition that can occasionally complicate pregnancies, especially if there is placental passage of maternal antiplatelet antibodies.*
30
A 32-year-old pregnant lady is found to be anaemic 20 weeks gestation.
## Footnote
**A full blood count shows:**
Serum Hb = 104 g/L ***(115-160)***
MCV = 104 fL ***(70-100)***
A blood film shows hypersegmented neutrophils.
She has a past medical history of coeliac disease.
**What does the blood film count show? (2)**
**What is the most likely cause of the anaemia? (2)**
**The full blood count demonstrates a macrocytic anaemia.**
The blood films suggests that the cause of the macrocytosis is a megaloblastic anaemia which can occur due to folate or B12 deficiency.
**The malabsorption associated with coeliac disease makes it particularly likely in this case.**
31
A 23-year-old woman who is 24 weeks pregnant presents to the emergency department with a 48-hour history of epigastric pain and severe headache, that has increased in severity.
On examination, she has a heart rate of **110 beats/min**, a respiratory rate of **21 /min,** a temperature of **36.8ºC**, mild pitting oedema of the ankles and brisk tendon reflexes.
**What is the likely diagnosis?**
**What is the most important sign to elicit?**
**pre-eclampsia**
Brisk reflexes are commonly associated with pre-eclampsia and are more specific than the other answers, which are general clinical signs.
32
A 36-year-old woman comes into your GP clinic, 3 months after giving birth. She reports ongoing palpitations, weight loss of 5kg since the delivery and some tremors in her hands. She reports her baby is doing well and she is bottle feeding.
**You perform thyroid function tests and the results are shown below.**
## Footnote
TSH = 3.5 mU/L
T4 = 20 pmol/L
**What is the likely diagnosis? (2)**
**What treatment is most appropriate? (1)**
This patient has presented with symptoms of postpartum thyroiditis. This is an autoimmune condition which presents as the body transitions back from the immunosuppressed state of pregnancy to normal immunity.
Propranolol is the most appropriate treatment
33
A 32-year-old pregnant woman presents to the maternity department at 41 weeks gestation.
A decision is made for her to undergo an artificial rupture of the membranes.
Shortly after this procedure, during an examination, the umbilical cord is noted to be palpable vaginally.
Given this development, which of the following is the correct position for the woman to adopt?
The correct position for women who have a cord prolapse is on all fours, on knees and elbows
34
A 32-year-old pregnant woman presents to the GP with jaundice and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation. On examination, the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. She denies any tenderness in her abdomen during the examination.
## Footnote
**Blood tests show the following:**
ALT = 206 U/L
AST = 159 U/L
ALP = 796 umol/l
GGT = 397 U/L
Bilirubin (direct) = 56 umol/L
Bile salts = 34 umol/L (0 - 14)
**What is the most likely diagnosis?**
**Obstetric** **cholestasis**, also known as **intrahepatic** **cholestasis** of pregnancy, is a condition caused by the impaired flow of bile.
This, in turn, causes a build-up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta.
It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors.
35
A 23-year-old woman is being reviewed on the labour ward.
She is 39 weeks gestation. She felt her waters breaking 2 hours ago.
She is G1P0, has no had no complications throughout her pregnancy and has no significant past medical history.
On examination, her Bishop's score is calculated as 10. A vaginal exam confirms that her amniotic sac has ruptured. There is no evidence of contractions yet. Foetal heart rate is reassuring at 140/min.
**What is the most appropriate next step in her immediate management?**
Reassure and monitor
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
36
From where is HCG secreted? (2)
What is its function? (2)
At what rate does it increase?
When does its concentration peak?
* **first produced by the embryo** then the **syncytiotrophoblast into the maternal bloodstream**
where it acts to maintain the production of
* **progesterone** by the **corpus luteum in early pregnancy**
hCG levels double approximately every 48 hours in the first few weeks of pregnancy. Levels peak at around 8-10 weeks gestation
37
A 29-year-old woman goes into labour.
The midwife examines her and states that the
"head is now at the level of ischial spine"
**What terminology is used to describe the head in relation to the ischial spine?**
**Station** is the term used to describe the head in relation to the ischial spine.
The station is '0' when the head is directly at the level of the ischial spines, if the station was describes as -2, it would be 2cm above the ischial spines, and it was +2 it would be 2cm below the ischial spine.
38
A 34-year-old **male** with rheumatoid arthritis attends his GP practice as he wants counselling regarding starting a family.
He has no other medical history and his regular medications are methotrexate, paracetamol, ibuprofen, and lansoprazole. He is aware that his sister had to stop some of her medications for rheumatoid arthritis prior to conceiving and wants to know if he needs to do the same.
**What is the appropriate management advice for this patient?**
(3)
There is a risk that **methotrexate** can **damage the sperm** in males and can cause s**pontaneous early abortion** in females.
In order to allow full 'wash-out' of the drug and to improve sperm quality, it is advised that methotrexate is **stopped** at least **six months prior to conception**.
39
Rheumatoid arthritis management in pregnancy
(4)
RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery.
**sulfasalazine** and **hydroxychloroquine** are considered safe in pregnancy
low-dose corticosteroids may be used in pregnancy to control symptoms
NSAIDs may be used **until 32 weeks** but after this time should be withdrawn due to the risk of **early close of the ductus arteriosus**
40
A 37-year-old pregnant woman has a vaginal swab taken at 35 weeks gestation despite being asymptomatic. She tells you that during her previous pregnancy a bacteria which can cause sepsis in babies was detected on one of her swabs, which is why she needs to be tested again.
**The microbiology report contains the following:**
**Sample**: +ve (awaiting sensitivities)
**Gram** **stain**: +ve
**Morphology**: Cocci in chains
**Growth** **requirements**: Facultative anaerobe
**Which organism is most likely to be present?**
**(3)**
**Streptococcus** **agalacticae** is the bacterium which causes
**Group B Streptococcal disease (GBS)**,
the most common cause of severe infection in neonates
41
A pregnant woman at 40 weeks gestation with a history of type 2 diabetes starts going into labour.
A vaginal delivery is attempted.
However during the delivery, the baby's right shoulder becomes stuck despite gentle downward traction.
Senior help is called and arrive shortly afterwards and perform an episiotomy.
**How should this situation then be managed?**
**(2)**
Vaginal PGE2 is the preferred method of induction of labour,
After administering vaginal PGE2 the cervix should be reassessed at 6 hours before considering oxytocin infusion.
42
When is an amniotomy performed?
| (2)
Amniotomy is offered when the cervix is **considered**'**ripe**' **(bishop score ≥7)**
and may be **used in combination with an oxytocin infusion**.
43
A 28-year-old woman who is 34 weeks pregnant is diagnosed with a urinary tract infection after routine dipstick testing.
Laboratory analysis shows group B streptococcus to be the cause and this is treated with a short course of oral antibiotics.
How should this woman be managed with respect to delivering her baby in a few weeks time?
Intrapartum antibiotics
For non-penicillin-allergic patients intrapartum antibiotics will consist of intravenous benzylpenicillin given as soon as possible after the start of labour, then at 4-hourly intervals until delivery.
44
A 24-week pregnant woman attends the early pregnancy unit as she has been told that her uterus is small for this date.
On ultrasound she is found to have oligohydraminos.
**Which of the options are a cause of oligohydramnios?**
**_Causes_**
* premature rupture of membranes
* fetal renal problems e.g. **renal** **agenesis**
* intrauterine growth restriction
* post-term gestation
* pre-eclampsia
45
How long should women take folic acid for?
Pregnant women should also take folic acid daily for the first 12 weeks.
46
A 28-year-old woman who is P1 G2 is 30 minutes post-partum of an uncomplicated delivery.
She suddenly begins gasping for breath with a blood pressure of 83/65mmHg, heart rate of 120bpm and a respiratory rate of 33/min.
She appears cyanosed.
She becomes unresponsive.
What is the most likely diagnosis and why?
(4)
* respiratory distress
* hypoxia
* hypotension
* within 30 minutes of labour.
are clear signs of an **amniotic** **fluid** **embolism**.
47
A 45-year-old G3P2 is brought to the emergency department by the paramedics after she suffered a generalized tonic-clonic seizure.
Her blood pressure was found to be 190/125 mmHg.
The paramedics obtained IV access and also administered intramuscular magnesium sulfate to treat her seizures.
She was then put on an IV infusion of magnesium sulfate.
On her arrival to the accident and emergency department, her respiratory rate is found to be 10 breaths per minute.
You suspect this might be a case of respiratory depression secondary to magnesium sulfate.
What is the drug of choice for reversing respiratory depression caused by magnesium sulphate?
**Calcium** **gluconate** is first-line treatment for magnesium sulphate induced respiratory depression
48
Anti-epileptics used in pregnancy:
| (2)
## Footnote
**Lamotrigine**: studies to date suggest the rate of congenital malformations may be low.
**carbamazepine**: often considered the least teratogenic of the older antiepileptics
49
A 23-year-old pregnant woman presents at 16 weeks gestation.
She is complaining of painless vaginal bleeding, excessive morning sickness and shortness of breath.
Routine examination of the patient's abdomen reveals a uterus which extends up to the umbilicus.
Ultrasound revealed a solid collection of echoes with numerous small anechoic spaces.
**What is the most likely diagnosis?**
**(2)**
**Hydatidiform mole**
On ultrasound, the mole appears as a **solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes** (also known as 'snow-storm' appearance).
50
A 37-year-old female, who is breastfeeding, presented with an episode of mastitis. On examination there is erythema around the nipple.
Which antibiotic should be prescribed?
Which analgesic is absolutely contraindicated in this patient?
1. Fluclox oral
## Footnote
**2. Aspirin in breastfeeding must be avoided**
51
You are reviewing a female patient who is currently 28 weeks pregnant with her second child.
Her first child, who is now 2 years old had neonatal sepsis caused by Group B Streptococcus (GBS).
Given this history, the patient is asking what will happen to her and/or the baby to prevent this from happening again in this pregnancy.
**What treatment will the patient and/or baby require?**
**Maternal intravenous (IV) antibiotics during labour**
Maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
52
A 30-year-old female presents in the emergency department. She is anxious that her waters broke this morning and describes a sudden 'gush' which soaked her trousers.
She is 30 weeks gestation and has had an uncomplicated pregnancy so far.
What is the most appropriate investigation to perform initially?
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
53
A 33-year-old woman who is 32 weeks pregnant is referred to the obstetrics team as she has had a two-week history of itchy hands and feet with no rash present. This is often worse at night for her and she also has elevated liver function tests, with a bile acid level of 106mmol/l.
In view of the history and results above, a discussion is offered by the obstetrician with this patient regarding induction of labour (IOL) after which week of gestation?
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
54
A 28-year-old woman is 30 weeks into her first pregnancy.
She is found to have a blood pressure of 162/110 mmHg and a urine dipstick shows protein +++.
She also has marked oedema of her ankles but feels well in herself.
**What is the first line therapy to manage her high blood pressure?**
hypertension in pregnancy (160/110mmHg or higher) should be treated with **labetalol** as first line treatment.
**Delivery should not be offered to women before 34 weeks unless:**
* severe hypertension remains refractory to treatment
* maternal or fetal indications develop as specified in the consultant plan
55
A 23-year-old patient with a history of well-controlled epilepsy presents to general practice with her partner.
They have been trying to conceive with regular sexual intercourse for the past 11 months.
Her current medications include omeprazole, **levetiracetam**, folic acid 400 micrograms and paracetamol as required.
**What medication changes are most appropriate?**
Women on antiepileptics, who try to conceive, should receive folic acid 5mg instead of 400mcg OD
Although it is true that no medications should be started for infertility before 12 months of regular intercourse, this patient is at risk of having a child with a neural tube defect due to her antiepileptic medication. Therefore, she should be started on a high dose of folic acid.
56
A 17-year-old female who is 23 weeks pregnant (G1PO) presents to the emergency department after severe lower abdominal pain.
She has multiple sexual partners and has recently been treated for gonorrhoea with ceftriaxone.
She takes no regular medications, but admits to illicit drug use which includes marijuana and cocaine use.
You palpate her abdomen to find her uterus is hard and tender.
**What is the likely diagnosis? (1)**
**Which is the most significant risk factor in her history? (1)**
**Cocaine** **abuse** increases risk of **placental** **abruption**
* Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
* occurs in approximately 1/200 pregnancies
57
A woman at 32 weeks gestation comes into maternity assessment unit for reduced fetal movements (RFM). She reports that she has not felt her baby move for the last 12 hours. She has not noticed any vaginal bleeding or experienced any pain. The midwife cannot detect a heart beat with the handheld Doppler.
What would be done next to investigate the reduced fetal movements?
**If after 28/40 weeks**, if a woman reports reduced fetal movements and no heart is detected with **handheld** **Doppler** then an immediate **ultrasound** should be offered
58
What is your next investigation of choice to assess for preterm prelabour rupture of membranes (PPROM)?
(2)
When investigating suspected **PPROM**, if there is no fluid in the posterior vaginal vault then an ultrasound may be used to look for **oligohydramnios**
59
A 32-year-old pregnant woman is being screened for gestational diabetes. She has no past medical history of note and this is her first pregnancy.
She is found to have a fasting blood glucose of 7.2 mmol/L.
What is the most appropriate management?
Start insulin only
Gestational diabetes - insulin should be commenced if fasting glucose level is \>= 7 mmol/l insulin at the time of diagnosis
60
A primigravida 25-year-old woman at 31 weeks gestation presents with vaginal bleeding and severe abdominal pain.
The abdominal pain started suddenly in the night (awoke her from sleep), about 4 hours previously.
It is a severe dull pain in the suprapubic region and doesn't radiate anywhere.
The pain has not settled at all since onset (she has not taken any medications) and is not positional.
She says it is a 10/10 severity.
She passed about 2 cupfuls of blood 1 hour previously.
She says the bleeding has since soaked through 2 sanitary pads.
She also complains of back pain and is exquisitely tender on suprapubic palpation.
She has not noticed any decreased foetal movements, although says that her baby is not particularly active usually.
**Which is the most likely diagnosis?**
**Placenta** **abruption** presents with painful vaginal bleeding, whereas placenta praevia is usually painless.
A woody, hard uterus may be palpable in placenta abruptio - this is because retroplacental blood tracks into the myometrium.
The fetal heart is often absent and the woman may be shocked.
Resuscitation is vital in these cases and the baby will need urgent delivery when stable.
There is an increased risk of postpartum haemorrhage.
61
A 29-year-old lady is in labour with her first child. However, during the second stage, fetal distress is identified and instrumental delivery considered.
**Which conditions must be met before an instrumental delivery?**
**(7)**
**The requirements for instrumental delivery can be easily remembered by the mnemonic FORCEPS:**
* **F**ully dilated cervix generally the second stage of labour must have been reached
* **O**cciput anterior position
* **R**uptured Membranes
* **C**ephalic presentation
* **E**ngaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally
* **P**ain relief
* **S**phincter (bladder) empty this will usually require catheterization
62
A 28 -year-old is found to have an ectopic pregnancy at 10 weeks gestation.
She undergoes surgical management of the ectopic with a salpingectomy.
She is known to be rhesus negative.
**What is the recommendation with regard to anti-D?**
**(2)**
In surgical management of an ectopic pregnancy then Anti-D immunoglobulin should be administered.
Anti-D is not required in circumstances where a medical management of the ectopic has been used, nor for treatment of pregnancy of unknown location.
63
Rhesus negative pregnancy
(5)
* around 15% of mothers are rhesus negative (Rh -ve)
* if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
* this causes anti-D IgG antibodies to form in mother
* in later pregnancies these can cross placenta and cause haemolysis in fetus
* this can also occur in the first pregnancy due to leaks
**Prevention**
* test for D antibodies in all Rh -ve mothers at booking
64
Blood cord tests at delivery
| (3)
## Footnote
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
65
A 36-year-old woman presents to her GP with symptoms of itching. She is currently 31 weeks pregnant and has no complications so far. She describes that, for the past few days, the palms of her hands and soles of the feet have been incredibly itchy. This sensation has since spread to the abdomen. Aside from this, she feels completely well in herself and denies nausea, vomiting or abdominal pain.
On examination, she appears well and there is no evidence of jaundice, nor any rash. Observations are within normal limits. Blood tests are generally unremarkable except for a mildly elevated bilirubin.
Given the likely diagnosis, which of the following is most appropriate to discuss with her regarding definitive management?
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
66
A hepatitis B serology positive woman gives birth to a healthy baby girl.
The mother is surface antigen positive.
What treatment should be given to the baby?
Hep B vaccine and 0.5 millilitres of HBIG within 12 hours of birth with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months
67
A 31-year-old woman attends clinic, concerned about her pregnancy. She is at 32 weeks gestation, and she reports the pregnancy being uneventful so far. However, for the past few days, she feels that the baby has been moving less than earlier in the pregnancy. She is otherwise well - she has had no recent infection, nor feeling unwell. She has no significant past medical history. This is her first pregnancy.
Obstetric abdominal examination is unremarkable and the patient looks completely well.
**What should the initial management be?**
The RCOG guidelines stratify management of reduced fetal movements by gestation.
**If the patient is past 28 weeks, as in this scenario, the most appropriate initial step is to use handheld Doppler to confirm fetal heartbeat.**
**If this is not detectable, ultrasound should be offered immediately.**
If a heartbeat was detected, cardiotocography should be used for 20 minutes to monitor the heart rate.
68
A 33-year-old lady has developed a massive obstetric haemorrhage. A diagnosis of uterine atony is made. After initial stabilisation and general measures, what is the first-line medical management?
Syntocinon
69
What is the correct definition of **primary** postpartum haemorrhage (PPH)?
The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby
70
A 30-year-old primigravida lady is 41 weeks pregnant. At her 41 week antenatal visit, she was offered a vaginal examination and a membrane sweeping hoping that she would go into labour. However, to no avail, she does not go into labour even after 6 hours. On examination her cervix is firm, 1cm dilated, 1.5cm in length and in the middle position. Fetal head station is -3. She is otherwise healthy and there were no problems with the pregnancy.
What would be the appropriate next course of action?
Vaginal PGE2 is the preferred method of induction of labour,
From this scenario, the Bishop score was \<5. This means that labour is unlikely unless induction ensues.
71
You are seeing a G3P1 12-weeks pregnant woman in the GP surgery. She is worried because she developed postpartum psychosis in her previous pregnancy which resulted in a hospital admission.
How likely is she to develop this condition again?
The recurrence rate of postnatal psychosis is 25-50%
72
You see a 38-year-old woman at the antenatal clinic. She has just had her anomaly scan and is being routinely reviewed. She mentions to the consultant how she is yet to feel the baby move, although in her previous pregnancies she felt movement by 18 weeks gestation.
At what gestation would a referral to the maternal fetal medicine unit for her presentation be warranted?
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
73
A 33-year-old woman who is 35 weeks pregnant presents to the Emergency Department with severe continuous abdominal pain. She had some vaginal bleeding an hour ago but this has mostly stopped now, with only a small amount of bloody discharge remaining. She is pale and clammy and obstetric examination reveals a firm, woody uterus which is very tender. Her pulse is 102bpm and her blood pressure is 98/65 mmHg.
What is the most likely diagnosis?
**Placental Abruption**
* continuous abdominal pain
* shock disproportionate to the amount of blood loss (20% of placental abruptions are 'concealed' - the blood is trapped behind the placenta and does not drain)
* the uterus may be in spasm and feel firm or 'woody'
* the fetus may be hard to feel
* the fetal heart may be hard to auscultate
74
A 28-year-old lady who is 9 weeks pregnant comes to see you for review of booking bloods.
Her haemoglobin is 105 g/L and the mean cell volume (MCV) is 70 fL (normal range 77-95 fL).
What is the most appropriate management?
In this question the Hb is checked at booking and is less than 110 g/L therefore this is a first trimester anaemia.
**Oral iron tablets**
75
A 34-year-old woman complains of severe itching during pregnancy which is worse at night and particularly affects her hands and feet.
There is no obvious rash.
She has previously had a stillbirth at 37 weeks.
What is the most effective treatment for her condition?
**Ursodeoxycholic acid**
This patient is most likely suffering with obstetric cholestasis. There is an increased risk of premature birth and stillbirth.
The hallmark is intense pruritus and serum bile acids are usually elevated.
76
A 36-year-old female who is 30 weeks pregnant presents to the emergency department with severe lower abdominal pain.
She is tachycardic but is otherwise stable. On examination, her uterus is tender and hard, but fetal lie is normal. Cardiotocography shows no signs of fetal distress.
**Here are her vital signs:**
* Heart rate = 110bpm
* Respiratory rate = 20/minute
* Blood pressure = 118/84mmHg
* Oxygen saturation = 95% on air
* Temperature = 37.5ºC
**What is the best next step in management?**
Management of **placental** **abruption** when the fetus is alive, \<36 weeks and not showing signs of distress is to admit and **administer** **steroids**
77
A 28-year-old woman 27 weeks into her first pregnancy presents with vaginal bleeding.
Which one of the following features would point towards a diagnosis of placenta praevia rather than placenta abruption?
No pain
78
A 27-year-old is found to have a blood pressure of 165/111 mmHg and ++proteinuria on urinalysis on a routine visit to the antenatal clinic. Her consulting doctor is worried about pre-eclampsia and admits her to the obstetrics assessment unit. She has recently moved here and therefore her medical notes are not accessible. She is quite fit and well and does not take any medications apart from her blue and brown inhalers. She has recently completed a 5-day course of steroids after being hospitalised for a severe exacerbation of **asthma**.
**Which is the choice of drug for managing her hypertension?**
## Footnote
**(5)**
**Labetalol** is first line
**Nifedipine** is the first line anti-hypertensive for pre-eclampsia in women with severe asthma
**Methyldopa** and **hydralazine** are used to treat hypertension in pre-eclampsia but neither one is used as first line management
***\*Ramipril** use during pregnancy has been linked to an increased risk of birth defects in babies.*
79
Managing hypertension in pregnancy
| (5)
**Labetalol** is first line
**Nifedipine** is the first line anti-hypertensive for pre-eclampsia in women with severe asthma
**Methyldopa** and **hydralazine** are used to treat hypertension in pre-eclampsia but neither one is used as first line management
*\***Ramipril** use during pregnancy has been linked to an increased risk of birth defects in babies.*
80
A 38+2 weeks gestation primigravida attends the maternity ward for induction of labour. The only complication of her pregnancy has been gestational diabetes which she controls well with insulin. Her most recent ultrasound report indicates a cephalic, singleton pregnancy with mild-moderate oligohydramnios and an anterior lying placenta. She has a continuous cardiotocography (CTG) assessment, however, after 5 minutes the midwife notices pathological features on the CTG indicative of foetal distress. **A vaginal examination is performed and the cord is noted to be prolapsed.**
**What is the greatest risk factor in this patient's history for this emergency?**
ARound 50% of cord prolapse occurs after artificial rupture of membranes
81
**_Management of cord compression_**
| (8)
* cord prolapse is an obstetric emergency
* the presenting part of the fetus may be pushed back into the uterus to avoid compression
* if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
* the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out
* the left lateral position is an alternative
* tocolytics may be used to reduce uterine contractions
* retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
* although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
82
A 23-year-old primigravida attends her 36-week gestation check-up with her midwife in the community. She has had an uncomplicated pregnancy so far and is feeling well in herself. Her birth plan is for a water birth at her local midwife-led birth centre. Her observations show a temperature of 36.7ºC, heart rate of 90 beats/min, blood pressure of 161/112 mmHg, oxygen saturation of 98% in room air with a respiratory rate of 21/min.
**Urinalysis shows:**
## Footnote
Leucocytes = negative
Nitrites = positive
pH = 6.0
Protein = negative
Blood = negative
**What is the most appropriate management plan for this patient?**
**Admit to local maternity unit for observation and consideration of medication**
Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
*This patient is hypertensive at 35 weeks gestation. **Historically, pre-eclampsia has been defined as hypertension and proteinuria during pregnancy** - however, the currently accepted diagnosis is with hypertension and any end-organ damage.*
***As the patient feels well in herself, it is not strongly suspected that this patient has any end-organ damage**, but she should be admitted to the local maternity unit for further investigation of this as her blood pressure exceeds 160/110 mmHg.*
83
A 37-year-old woman presents for review. She is 26 weeks pregnant and has had no problems with her pregnancy to date. Blood pressure is 144/92 mmHg, a rise from her booking reading of 110/80 mmHg. Urine dipstick reveals the following:
## Footnote
Protein = negative
Leucocytes = negative
Blood = negative
**What is the most appropriate description of her condition?**
**Gestational hypertension**
Hypertension in pregnancy in usually defined as:
* systolic \> 140 mmHg or diastolic \> 90 mmHg
* or an increase above booking readings of \> 30 mmHg systolic or \> 15 mmHg diastolic
84
**_Intrahepatic cholestasis of pregnancy_**
vs
**_Acute fatty liver of pregnancy_**
**_Intrahepatic cholestasis of pregnancy_**
It will give a cholestatic picture of liver function tests (LFTs) with a **high ALP and GGT, with a lesser rise in ALT.** *Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment.*
**_Acute fatty liver of pregnancy_** also occurs in the third term of pregnancy but a hepatic picture would be expected on LFTs, **with a rise in ALT/AST greater than that of ALP,** a raised white cell count and potential clotting abnormalities. *This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy.*
85
A 32-year-old primiparous woman, who is 33 weeks pregnant, attends the emergency department after the onset of abdominal pain and vaginal bleeding. She quantified the bleeding as about a teaspoon of blood, and both the bleeding and the pain have now stopped. Her pregnancy has been uncomplicated so far, and she has been engaging well with antenatal care. She is certain her waters have not broken.
On examination, her vital signs are stable, and a handheld doppler is reassuring in terms of foetal heart rate. She has a tense and tender abdomen.
Transvaginal ultrasound shows a small retroplacental haemorrhage and an apically located placenta.
What is the next most appropriate step in her management?
Placental abruption is characterised by constant pain, shock out of keeping with the visible loss, tender and tense uterus
Admit for IV corticosteroids and monitoring
86
A 28-year-old woman, 2 weeks postpartum, is bought in by her husband after saying her baby is the devil. She has not been sleeping and she has been talking to people who are not there. Her husband states she has had big mood swings in the past 2 weeks and is concerned for the safety of his baby.
She has no relevant medical or mental health history and no family history of mental health illnesses.
What is the next step in management for this condition?
Women with postpartum psychosis usually requires hospitalisation, ideally in a **Mother & Baby Uni**t
87
A 34-year-old female with a history of primary generalised epilepsy presents to her GP as she plans to start a family. She currently takes lamotrigine as monotherapy. What advice should be given regarding the prevention of neural tube defects?
Epilepsy + pregnancy = 5mg folic acid
88
A woman who is 32 weeks pregnant presents to the emergency department with a painless leakage of fluid from the vagina. There was an initial gush 2 hours ago, and a steady drip since. She is examined with a sterile speculum and the fluid is confirmed as amniotic fluid. The woman also states she has a severe allergy to penicillin. What is the best management to reduce the risk of infection?
10 days erythromycin should be given to all women with PPROM
89
A 31-year-old woman attends the antenatal clinic at 41-weeks gestation into her first pregnancy. She has not yet started to feel contractions.
On examination, her abdomen is soft with a palpable uterus in keeping with a term pregnancy. Her cervix is firm and dilated to 1cm. The foetal head is stationed to 1cm below the ischial spines.
A membrane sweep is performed and the obstetrician decides to commence treatment with vaginal prostaglandins.
What is the most likely complication of this procedure?
**Uterine hyperstimulation**
* the main complication of induction of labour
* refers to prolonged and frequent uterine contractions - sometimes called tachysystole
**_Potential consequences_**
* intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
* uterine rupture (rare)
**_Management_**
* removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
* tocolysis with terbutaline
90
Uterine hyperstimulation (2)
Potential consequences (2)
Management (2)
**Uterine hyperstimulation**
* the main complication of induction of labour
* refers to prolonged and frequent uterine contractions - sometimes called tachysystole
**Potential consequences**
* intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
* uterine rupture (rare)
**Management**
* removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
* tocolysis with terbutaline
91
A 30-year-old para 1+0 has presented at term in labour. On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?
The fetal head may rotate spontaneously to an OA position
92
A mother brings her 6-day old son to see you as she is concerned that her son has lost weight. He was born at term and there were no complications around the time of birth. He is exclusively breastfed. The infant has had a normal amount of wet nappies so far today and is not in any distress. Observations are all within normal limits and he is well hydrated. His birth weight was 3000g and today he weighs 2680g.
What would be the most appropriate next step in managing this infant's weight loss?
If a breastfed baby loses \> 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
93
A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus.
Which of the following test results would be expected in this patient?
**High beta hCG, low TSH, high thyroxine**
The clinical presentation in this question is consistent with that of a molar pregnancy.
Molar pregnancies are characterised by significantly high levels of beta hCG for gestational age, and are therefore used as a tumour marker of gestational trophoblastic disease.
The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.
94
A 28-year-old pregnant woman is seen at her booking appointment. Her obstetric history revealed she had pre-eclampsia in her last pregnancy. Which of the following medications should this patient be started on at 12-14 weeks gestation to reduce the risk of intrauterine growth retardation?
Low dose aspirin
