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Flashcards in ICSM Year 5 Obstetrics Deck (561)
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1

What is an amniotic fluid embolism?

Amniotic fluid and foetal cells enter maternal circulation leading to cardiorespiratory collapse

2

How does the amniotic fluid embolism cause a maternal emergency?

Embolism --> anaphylactic reaction/ complement cascade

Complement --> pulmonary artery spasm

Pulmonary artery pressure and RVP increases

Myocardial and pulmonary capillaries are hypoxically damaged

LVF failure

Death

3

What are the signs and symptoms of Amniotic fluid embolism?

Sudden onset of SOB and cyanosis

Seizures

DIC

Hypotension

4

What would be seen on examination in amniotic fluid embolism?

Tachypnoea

Tachycardia

Pulmonary oedema

Uterine atony

5

What are some appropriate investigations to do in amniotic fluid embolism, and what would they show?

ABG (hypoxaemia, raised pCO2)

FBC (low Hb)

Clotting (DIC: low platelets, raised PT/APTT, decreased fibrinogen)

CROSS MATCH

CXR (cardiomegaly?? Pulmonary oedema)

ECG (right heart strain, rhythm abnormalities)

6

How should amniotic fluid embolism be managed?

ABC and refer to ITU

Circulation: 2 large bore cannulae, fluid resus

Pharmacological: ionotropics, correct the coagulopathy (FFP, platelets etc) PPH management of uterine atony

Consider delivery +/- hysterectomy

7

What is the survival rate of amniotic fluid embolism?

75%

8

What are the Hb values indicative of anaemia in each trimester?

1st TM: <110

2nd TM: <105

3rd TM: <105

Postpartum: <100

9

What is the characteristic blood film appearance of iron deficiency anaemia, folate deficiency and B12 deficiency?

IDA: hypochromia, microcytes, pencil cells

Folate deficiency: megaloblastic picture: hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia

B12 deficiency: also megaloblastic - as above

10

What is the cause of IDA in pregnancy?

Increased use of iron and decreased intake/ absorption - may also be caused by blood loss/ haemolysis

11

What is the cause of folate/B12 deficiency during pregnancy?

Lack in diet can cause both folate and B12 deficiency

Folate deficiency may also be caused by increased demand/ drugs

12

Recall some B12-specific symptoms of anaemia

Glossitis, depression, psychosis/ dementia, paraesthesia, peripheral neuropathy

13

What is the dose of iron given in IDA?

100 -200mg OD

14

Recall some side effects of giving ferrous sulphate

Black stools, constipation, abdo pain

15

When should oral folic acid not be given?

If cause of anaemia is not known - as it could exacerbate symptoms in a B12 anaemia

16

What is the treatment for B12 deficiency?

IM hydroxycobalamin

17

When is asthma most likely to be exacerbated in pregnancy?

24-36 weeks

18

What is the cause of asthma in pregnancy?

Pregnancy itself can't cause it so it must have been present beforehand

19

What are the PEFR values that define severe and life-threatening asthma attacks?

Severe = 50-33%

Life-threatening = <33%

20

What are the appropriate investigations to do in asthma in pregnancy?

Peak flow, pulse oximetry, ABG, FBC (WCC infection?), CRP, UandEs, blood and sputum cultures, daily PEFR monitoring

21

How should chronic asthma be managed in pregnancy?

Continue medications throughout labour

Avoid bronchoconstrictors

Monitor foetal movements daily after 28 weeks

22

How should an acute asthma attack be managed in pregnancy?

High flow O2

Nebulised salbutamol

Ipratropium 0.5mg QDS

Steroids (IV hydrocortisone/ PO prednisolone)

IV magnesium

Summon senior help

23

What is the risk of oral corticosteroid use in first TM?

Cleft lip risk increased

24

What is the difference between the baby blues and post-natal depression?

Baby blues = mild, self-limiting low mood  <2 weeks

PND = pervasive low mood in the PN period > 2 weeks

25

What is the perinatal period defined as?

Pregnancy + 1 year postpartum

26

Which class of drugs can increase risk of post natal depression?

Antipsychotics (ironically)

27

What scoring system is used for post natal depression?

Edinburgh Post Natal Depression Scale

28

Recall 2 breast-feeding safe antidepressants

Sertraline

Paroxetine

29

What is peripartum cardiomyopathy?

New-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum

30

What is the pathophysiology of peripartum cardiomyopathy?

40% rise in blood volume during pregnancy by 28w causing strain

Women with cardiac disease cannot increase CO --> uterine hypoperfusion --> increased pulmonary oedema

31

What classification system is used for cardiac disease in pregnancy?

NYHA classification

32

Recall some cardiovascular system abnormalities that are normal in pregnancy

ESM 3rd heart sound

Peripheral oedema (more volume)

33

In which patients should anticoagulation be used during pregnancy, and what is an appropriate anticoagulant to use?

Patients with:

- CHD

- Pulmonary HTN

- Artificial valves

- Increased risk of AF

Warfarin is teratogenic in 1st TM - so use LMWH instead

34

How can maternal cardiac disease be managed in labour?

Advise epidural to reduce pain-related cardiac strain

2nd stage can be kept short with elective forceps/ ventouse - reduces maternal effort for an increased cardiac output

Do a C-section where any effort is dangerous

Do not use ergometrine in 3rd stage (only syntocinon)

35

How does insulin resistance change throughout pregnancy?

Increases throughout

36

How does pregnancy affect pre-existing diabetes?

Increase in insulin dose requirements in second half of pregnancy

Increased risk of severe hypoglycaemia

Risk of deterioration of any diabetic retinopathy/ nephropathy

37

How does diabetes affect pregnancy?

Increases risk of miscarriage

Risk of spina bifida

Risk of macrosomia

Also increases risk of: pre-eclampsia, still birth, infection

38

Recall the pre-conception checks in diabetes

1. Tight glucose control (HbA1c)

2. Renal testing (UandEs, creatinine)

3. BP checks

4. Retinal checks

5. Stop statins

6. Stop folic acid

39

What is the risk of poor glycaemic control to the baby during pregnancy?

It's teratogenic - can cause midline deformities like spina bifida

It can also cause the baby to be for large for dates 

40

Why does diabetes increase still birth risk?

Placental damage by over-glycosylation of proteins means it may not be able to supply baby

41

What is the biggest risk to the neonate after the cord is cut when there is maternal DM?

Hypoglycaemia 

Foetus has been producing high levels of insulin in utero because of high glucose load from mother, so when the cord is cut they keep producing lots of insulin which prediposes them to hypoglycaemia

42

Why does diabetes increase risk of macrosomia?

Excess maternal glucose --> foetus produces IGF-1 --> growth factor cause macrosomia

43

How often are antenatal diabetes clinics?

Every 2 weeks

44

What precaution should be taken when a diabetic mother requires antenatal steroids?

Insulin therapy is required to maintain normoglycaemia as steroids increase glucose release

45

What are the indications for testing for gestational diabetes in a pregnant woman?

Glycosuria on dipstick, previous GDM, any RF on clerking

46

What is the main investigation to do for GD?

2 hour 75g OGTT

47

What are the values that indicate diagnosis of GD?

5678 Fasting plasma glucose >5.6 2-hour OGTT >7.8

48

What should be the first thing you do if you diagnose GD?

Offer a review at a joint diabetes and antenatal clinic within 1 week

49

Recall the stepwise management of GD

1st line = changes in diet and exercise (CDE) - Only use this if fasting glucose is <7

2nd line - if targets are not met by 1st line in 2 weeks, still <7 fasting glucose = metformin as well as CDE (go straight to insulin if metformin contra-indicated)

3rd line (if >7 fasting glucose or 2nd line ineffective)
= CDE, metformin and insulin 
Offer 3rd line straight away if fasting glucose is 7 or 6-6.9 with complications


4th line - consider glibenclamide

50

What should be done postnatally in mothers with GD?

Immediate discontinuation of blood-glucose lowering treatment GP should perform a fasting plasma glucose at 6-13w pp

51

What is by far the most common site of ectopic pregnancy?

Fallopian tubes - usually ampulla

52

Where is the site of ectopic pregnancy with highest chance of rupture?

Isthmus

53

What is the cause of ectopic pregnancy?

Tube damage due to infection (eg PID), endometriosis, previous tubal surgery, Depo-Provera injection

54

What are the signs and symptoms of ectopic pregnancy?

Abdo pain, diarrhoea, shoulder tip pain, back pain

Amenorrhoea with PV scanty blood

Dizziness if ruptured - with circulatory collapse

55

What will be seen on examination in ectopic pregnancy?

1. Abdomen - rebound tenderness, guarding 2. Vaginal - cervical excitation, adnexal tenderness + mass

56

What are the appropriate investigations for an ectopic?

Pregnancy test

Speculum + bimanual

TVUSS

Bloods: FBC, X match, clotting

57

What signs on TVUSS are indicative of ectopic pregnancy?

Tubal: 'blob' sign, 'bagel' sign

Cervical: 'barrel' cervix, negative sliding sign

58

How does a located ectopic appear?

Empty uterus, adnexal mass with GS and YS, free fluid in uterine cavity

59

What should be done in the case of a pregnancy of unknown location (PUL)?

Depends on increase in serum beta-hCG (taken at 0 and 48 hours)

1. >63% --> developing prenancy: rescan at 7-14 days

2. <63% --> review in EPAU <24 hours

3. <50% --> miscarriage --> expectant management

60

How should all early-pregnancy emergencies first be managed?

Call the on-call gynae

61

When should ectopics be managed expectantly?

Only permissable in stable, asymptomatic patient with falling levels of beta-hCG

62

What are the indications for medical management of an ectopic?

Stable

Normal LFT and UandEs

Beta-hCG <3000

Ectopic <35mm

No blood in pouch of douglas

63

What is the medical management of ectopic?

ONCE IM methotrexate

64

What advice should be given following medical management of an ectopic?

Go home and come back for repeat blood tests (hCG) 

No intercourse for 3 months

Don't drink alcohol

Avoid excessive sun exposure

Expect side effects of pain, nausea and diarrhoea

65

What are the indications for surgical management of ectopic pregnancy?

Significant pain

Ectopic with foetal heartbeat

Adnexal mass >35mm

beta-hCG >5000

66

What is the surgical management of ectopic pregnancy?

Laparoscopic salpingectomy

67

When can a salpingostomy be used to treat ectopic pregnancy?

If bleeding is minimal and occlusion is viable to be removed (eg at fimbriae) and the patient only has one viable tube left (as high future risk of ectopics)

68

What type of prophylaxis is required for surgical management of an ectopic?

Anti-D prophylaxis

69

What form of contraception should be avoided following a lap salpingectomy?

Copper IUD

70

How should all seizures in second half of pregnancy be managed?

Immediate treatment for eclampsia until a definitive diagnosis is made

71

How should epilepsy medication be managed in pregnancy?

Minimum possible dose - levetiracetem and lamotrigene are safest agents

Reduce to monotherapy where possible

Explain risk of congenital malformation, as well as risk of recurrent seizures

Pre-conceptional folic acid 5mg, and vit K in last month of pregnancy

72

What congenital abnormalities are associated with anti-epileptic drugs?

Neural tube defects

Facial clefts

Cardiac defects

Valporate is teratogenic

73

What is the main risk of phenytoin use in pregnancy?

Cleft palate

74

Which anti-epileptic drugs are most appropriate in pregnancy?

Lamotrigine

Levetiracetem

Carbamazepine (least teratogenic of the old antiepileptics)

75

What extra source of support and advice could you refer someone to when counselling an epileptic expectant mother in PACES?

Invite to register to the UK Epilepsy and Pregnancy Register

76

What is a hyatidoform mole?

A benign tumour of the trophoblastic tissue

77

What is the aetiology of a hyatidoform mole?

Abnormal fertilisation leads to either a 'complete' mole (empty egg fertilised by 2 sperm) or a partial mole (normal egg fertilised by 2 sperm)

78

What are the signs and symptoms of a hyatidoform mole?

Painless PV bleeding (ie miscarriage)

Uterus larger than expected for GA

Hyperemesis

Often seen on USS before symptoms

79

What are appropriate investigations to do to diagnose hyatidoform mole?

Bloods: Beta-HcG grossly elevated

hCG shares an alpha subunit with TSH, therefore (due to negative feedback) there should be a low TSH and a high T4

Imaging: pelvic USS

- Complete mole: snowstorm/ 'cluster of grapes'

- Incomplete mole = foetal parts, no snowstorm/ cluster of grapes

80

How should hyatidoform mole be managed?

Urgent referral to a specialist centre

1st line = surgical: ERPC (evacuation of retained products of contraception) = suction curettage

Then: monitor serum BhCG, use methotrexate if rising/ stagnant levels, avoid pregnancy until 6 months of normal BhCG

81

What are the main complications of hyatidoform mole to be aware of?

May progress to malignancy (20% of complete moles, 2% of partial)

This would be either an invasive mole or a choriocarcinoma

82

How can the diagnosis of hyatidoform mole be explained in PACES?

When foetus doesn’t form properly, and a baby doesn’t develop, instead there is an irregular mass of pregnancy tissue

83

What is the main risk when gestational trophoblastic disease progresses to malignancy?

Rapid metastasis all over the shop

84

What are the forms of malignant gestational trophoblastic disease?

1. Invasive mole (Hyatidoform mole invades myometrium --> necrosis and haemorrhage)

2. Choriocarcinoma (cytoctrophoblast and synctiotrophoblast without formed chorionic villi invade myometrium)

3. Placental site trophoblastic tumour 

85

Recall 4 things that choriocarcinoma might arise from

50% = molar pregnancy

22% = viable pregnancy

25% = miscarriage

3% = ectopic pregnancy

86

What are the signs and symptoms of malignant gestational trophoblastic disease?

Persistent PV bleeding

Hyperemesis gravidarum

Lower abdo pain

Symptoms of mets to:

- Lung (haemoptysis, dyspnoea, pleuritic pain) 

- Bladder/ bowel (haematuria/ PR bleeding)

On examination: excessive uterine size for GA

87

What are the appropriate investigations to do for malignant gestational trophoblastic disease?

Bloods: serum BhCG, FBC, LFT (mets)

Imaging: pelvic USS, CXR, CTP, MRI brain

88

How is malignant gestational trophoblastic disease managed?

Methotrexate, hysterectomy for placental site trophoblastic tumour

89

What % of women get hyperemesis gravidarum?

1%

90

What % of pregnant women get emesis gravidarum?

80%

91

What lifestyle factor is protective against hyperemesis gravidarum?

Smoking

92

What factors increase risk of hyperemesis gravidarum?

Increased oestrogen (Nulliparity, obesity, multiple pregnancies)

Hyperthyroid

Gestational trophoblastic disease (more BhCG)

93

What are the RCOG diagnostic criteria for hyperemesis gravidarum?

MUST HAVE ALL 3 OF:

>5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

94

When does hyperemesis gravidarum begin?

Between 4th and 7th gestational week

95

When does hyperemesis gravidarum peak?

Week 9

96

When does hyperemesis gravidarum resolve?

By 20th week

97

What investigations should be done in hyperemesis gravidarum?

Body weight (for measuring dehydration)

Urine dipstick (to check ketones)

UandE

Basic obs

98

What scoring system is used to assess the severity of hyperemesis gravidarum, and what score means admission?

PUQE-24

13 or above

99

How should hyperemesis gravidarum be managed?

Always VTE prophylaxis (LMWH) , IV saline with KCl and thiamine supplementation

1st line: antihistamines (eg IV promethazine/ cyclizine)

2nd line: antiemetics (eg IV ondansteron, metoclopramide, domperidone) Metoclopramide is 2nd line due to EPS 3rd line

100

What are the major possible maternal complications of hyperemesis gravidarum?

VTE

Wernicke's

Hypokalaemia

Hyponatraemia

Acute renal tubular necrosis 

Mallory-Weiss tear

101

What are the main risks to the foetus from hyperemesis gravidarum?

IUGR

Pre-term labour

Termination

102

What BP is considered hypertensive, and what is the threshold for 'severe hypertension' during pregnancy?

HTN: 140/90

Severe HTN: >160/110

103

When is HTN considered to be gestational, rather than chronic?

Appearing after 20 weeks

104

What are the features of pre-eclampsia?

New HTN present after 20 weeks

Proteinuria

AND/OR Maternal organ dysfunction

105

What is HELLP syndrome?

Haemolysis, Elevated Liver enzymes, Low Platelets Severe form of pre-eclampsia

106

How is eclampsia defined?

1 or more seizures in someone with pre-eclampsia

107

How is decision to give aspirin for HTN in pregnancy (not pre-eclampsia, just HTN) guided?

Guided by presence of high/ moderate risk factors

Always give aspirin if 1 or more of the following is present:

  • Previous pre-eclampsia
  • CKD
  • AI disease
  • DM
  • Chronic HTN

Give aspirin if they have any two of:

  • Primigravidity
  • Age >40
  • Pregnancy interval >10 years
  • BMI >35
  • Pos FHx
  • Multiple pregnancy

108

What are the signs and symptoms of pre-eclampsia?

Often asymptomatic

Can give: severe headache, visual disturbances, epigastric/ RUQ pain, vomiting, breathlessness, sudden swelling of face/ feet/ hands

109

What investigation is most useful in pre-eclampsia?

Urine dip (proteinuria) - if 1+ on dip or protein creatinine ratio quantification >30mg/mmol 

110

How should pre-eclampsia be managed?

1st line: labetolol (100mg, BD) - contraindicated in asthma

2nd line: nifedipine

3rd line: methyldopa

111

How is eclampsia managed?

IV magnesium sulphate (it's a potent cerebral dialator)

112

What is the threshold for admission for gestational HTN?

Severe HTN (>160/110)

113

What is the target BP for those who have gestational HTN?

135/85

114

How should gestational HTN be managed?

1st line labetolol, 2nd line nifedipine

115

How often should mothers with gestational HTN be monitored, and what checks should be done?

BP measurement: weekly for moderate HTN, every 15-30 mins in severe HTN when mother is admitted

Dipstick: once or twice a week in moderate, daily whilst admitted FBC, LFT and

UandE once at presentation

116

What foetal monitoring should be done in mothers with HTN?

USS for foetal growth

Amniotic fluid assesment

Umbilical artery doppler

117

How does BP usually vary during pregnancy?

Tends to fall in first half of pregnancy before rising back to pre-pregnancy levels before term

118

How often are LFT, FBC and renal fx repeated in pre-eclampsia, eclampsia and gestational HTN?

Done twice a week in moderate pre-eclampsia or 3 times per week in eclampsia - only done once in gestational HTN

119

Describe the planning of birth timing in pre-eclampsia

If birth <34 weeks - offer antenatal steroids and MgSO4

If birth 34-36 weeks, continue surveillance unless delivery indicated in care plan

If birth >37 weeks, initiate birth within 24-48 hours

120

What should be monitored intrapartum in pre-eclampsia?

CTG (continuous) BP monitoring + continue antihypertensives

121

When should anticonvulsants be considered for women with pre-eclampsia?

1. Previous eclamptic fits

2. Birth planned in next 24 hours

3. Features of severe pre-eclampsia present

122

What are the features of severe pre-eclampsia?

Severe headaches

Epigastric pain

Visual scotomata

Oligouria and severe HTN

Nausea and vomitimng

Deteriorating biochemistry

123

What is the first line anticonvulsant to use in eclampsia, and what is its reversing agent?

IV MgSO4

Calcium gluconate (10mls. 10%, over 10 mins)

124

Recall the MgSO4 dosing used to treat severe htn/pre-eclampsia/ eclampsia

Loading dose of 4g IV over 5 mins, followed by an infusion of 1g/hour for 24 hours

125

What are the discharge criteria following eclampsia?

No symptoms of pre-eclampsia

BP <150/110

Blood test results stable/ improving

126

Recall some anti-hypertensives that are not recommended whilst breastfeeding

ARBs

ACE inhibitors

Amlodipine

127

What drugs for HTN are safe when breastfeeding?

Labetolol, nifedipine, enalapril, captopril, atenolol

128

What is the aetiology of eclampsia?

Impaired trophoblastic invasion of spiral arteries --> high resistance flow --> poor placental perfusion --> release of factors from placenta into circulation --> factors cause symptoms

129

What is TORCH syndrome?

Toxoplasmosis, Other agents, Rubella, CMV, HSV

Cluster of symptoms caused by congenital infection with the above

130

Recall the 4 signs and symptoms of congenital toxoplasmosis

Chorioretinitis

Hydrocephalus

Convulsions

Intracranial calcifications

131

How should congenital toxoplasmosis be managed?

Pyrimethamine

132

What pathogens come under the 'other' section of TORCH?

Syphillis, Parvovirus B19, hepatitis, VZV, HIV

133

What are the signs and symptoms of congenital syphilis?

Rash (soles and palms)

Bloody rhinitis

Nose deformity

Saber shins

Hutchinson's teeth

Clutton's joints

 

134

What condition does congenital parvovirus B19 cause?

Hydrops fetalis - causes heart failure

135

When does congenital HIV present?

6 months

136

What are the signs and symptoms of congenital rubella?

Cataracts (from chorioretinitis)

PDA heart defect

Microcephaly

137

What are the signs and symptoms of congenital CMV?

Chorioretinitis --> cataracts

Intracranial calcifications

Microcephaly

Hepatosplenomegally

Jaundice

Purpura/ petichiae

138

How should congenital CMV be managed?

Ganciclovir

139

What disease is caused by congenital HSV?

SEM (skin eyes mouth) disease/ disseminated disease

140

What other organisms can cause neonatal sepsis?

GBS. Listeria monocytogenes

141

How should congenital GBS be treated?

Benzylpenicillin

142

How should congenital listeria be managed?

Amoxicillin/ ampicillin

143

What is the organism responsible for toxoplasmosis and how is it spread?

Protozoon toxoplasma gondii

Parasite excreted in cat faeces - transmission is faeco-oral route (from infected meat and cat faeces)

144

What are the maternal signs and symptoms of toxoplasmosis?

Often asymptomatic but may have fever, malaise, arthralgia

145

What are the signs and symptoms of congenital toxoplasmosis?

60% are asymptomatic but may develop deafness, low IQ and microcephaly

40% have classic '4 Cs of toxoplasmosis':

  • Chorioretinitis
  • hydroCephalus
  • intracranial Calcifications
  • Convulsions

146

What is the test for toxoplasmosis?

Sabin Feldman Dye test

147

How should toxoplasmosis be managed in pregnancy?

Prophylaxis: mother should avoid eating raw/ rare meat and handling cats/ cat litter

If +ve mother and -ve baby: spiramycin (prevents vertical transmission)

If +ve mother and +ve baby: pyrimethamine and sulfadiazine with prednisolone adjunct

148

What is the name, shape and gram status of the organism causing syphillis?

Treponema pallidum: gram neg spirochete

149

What are the symptoms of primary syphillis?

Painless chancres and local lymphadenopathy

150

What is the difference bwtween early and late latent syphillis?

Early = signs/symptoms <2 years, late = >2 years

151

What are the different types of tertiary syphillis?

Gummatous, cardiovascular and neurosyphilis

152

What is the most useful treponomal test?

EIA

153

How is syphillis treated?

Benzathine-penicillin OR doxycycline

Early: Benzathine-penicillin STAT or doxy BD 14/7

Late: Benzathine-penicillin IM once weekly 3/52 OR doxy BD 28/7

Neurosyphilis: Benzathine-penicillin IV 4-hourly, 14/7

Prednisolone used as an adjunct to avoid Jarish-Herxheimer reaction

154

For how long is parvovirus B19 infectious?

From 10 days prior to the rash to 1 day after the rash appears

155

How is parvovirus transmitted?

Aerosol/ blood-borne

156

How does the parvovirus rash usually appear?

Slapped cheek' appearance

157

What symptoms are to be expected in an infant with parvovirus?

Coryzal symptoms + headache + rash

158

What is the risk of parvovirus in pregnancy?

Crosses placenta at 4-20w GA, destroying RBCs and --> hydrops foetalis (10% infant mortality)

159

How is hydrops fetalis managed?

Blood transfusion

160

If a baby is born to a HepB + mother, how should they be managed?

1. Vaccination - at birth, 1 month and 6 months

2. HBV IV Ig within 12 hours of birth

161

Is Hep B transmitted by breastfeeding?

No

162

How can Hep C infection be confirmed?

PCR

163

How should hep C be treated in pregnancy?

It shouldn't as it is contraindicated (ribavarin and interferon)

164

What is the danger of having Hep E in pregnancy?

If contracted in third TM can cause a severe reaction and a fulminant hepatitis

165

What should pregnant mothers avoid eating to avoid hep E?

Pork and shellfish

166

For how long is VZV infectious?

From 48 hours before rash until the vesicles crust over

167

How does congenital varicella syndrome appear?

Chorioretinitis

Cutaneous scarring

Microcephaly

IUGR

168

In which period is VZV infection considered 'neonatal'?

Maternal infection 7 days before or after birth

169

How does neonatal VZV present?

Mild disease: pneumonua, disseminated skin lesions and visceral infections (ie hepatitis)

170

How should antenatal chickenpox be managed?

VZIg within 10 days of exposure (before 20/40 gestation)

Once symptoms have developed, VZIg cannot be given

If after 20/40 weeks gestation --> Aciclovir 800mgs QDS

171

What should be done if there is doubt about whether a mother has previously had VZV?

Maternal blood checked urgently for VZ Ig

172

What are the possible complications of delivery during viraemic period in varicella zoster infection?

Haematological: bleeding, DIC, thrombocytopaenia

Hepatitis

VZV infection of new born

173

When should an HIV test be done antenatally?

Routinely in antenatal booking

174

How is HIV diagnosed in children?

Direct viral amplification by PCR carried out at birth, on discharge, at 6 , 12 and 18 weeks if mother is HIV+

175

How should maternal ARVs be managed during pregnancy?

Don't change them they're continual

176

How should the babies of HIV + mothers be treated?

First 2-4w of life: ARVs - zidovudine monotherapy

If viral load is undetectable or less than 50: vaginal delivery

If viral load >50 at 36 weeks: ELCS at 38 weeks

If viral load is detectable: intrapartum zidovudine

One of the only infections where avoidance of breastfeeding should be advised - offer cabergoline to suppress lactation

177

What are the S/S of rubella?

Coryzal symptoms + arthralgia + maculopapular rash

Soft palate lesions (NO koplik spots though) 

178

Describe the spread of the rash in Rubella

Starts behind ears, spreads to head and neck and then to rest of body

179

At what point during gestation is there highest risk of congenital rubella syndrome?

<12 weeks GA

180

What are the features of congenital rubella syndrome?

Chorioretinitis, sensorineural hearing loss

181

At what point in gestation does maternal rubella become very low risk?

20 weeks

182

What investigations are appropriate for rubella?

Blood serology

USS for foetal abnormalities

183

How should maternal rubella be managed?

Rest, fluids and paracetamol (no treatment)

Offer TOP if <16w GA

184

What are the possible sites of latent CMV infection?

Dorsal root ganglion 

B cells

Monocytes

185

At what stage of pregnancy is CMV most likely to transmit vertically?

Unlike other infections during pregnancy, CMV just as likely (30- 40%) to vertically transmit at any point

186

How does congenital CMV present?

90% are asymptomatic, although some will go on to develop sensorineural hearing loss 

10% are symptomatic: Sensorineural hearing loss, pre-ventricular calcification, chorioretinitis, 'blueberry muffin rash'

187

What investigations are appropriate when a pregnant woman has CMV?

Maternal serology

USS of foetus

Amniocentesis

PCR

188

How should maternal CMV be managed?

Do not treat, but if evidence of CNS damage to foetus --> offer TOP

Foetal USS every 2w following diagnosis 

Can offer foetal MRI at 28wGA

189

How should congenital CMV be managed?

IV ganciclovir

Audiology follow-up

Ophthalmology follow-up

190

Which type of HSV is which?

HSV1 = oral, HSV2 = genital

191

What are the features of SEM disease?

Blistering vesicular rash, chorioretinitis

192

What are the possible presentations of congenital HSV infection?

1. CNS disease + SEM (seizures, lethargy, poor feeding + skin/eye/mouth disease)

2. Disseminated infection - encephalitis, CNS abnormalities

193

How is congenital HSV diagnosed?

Clinically + STI screen + PCR

194

How should congenital HSV infection be managed?

Acute infection --> Aciclovir Oral for mother, IV for child

195

When should a C section be done in maternal HSV?

If first episode <6 weeks prior to EDD

196

What antigen characterises the Group B Strep pathogen?

Group B Lancefield antigen

197

Is group B strep gram pos or neg?

Pos (cocci in chains)

198

What causes group B strep infection?

Commensal in vagina and rectum carried by 25% of women

199

What are the signs/symptoms of GBS?

Often asymptomatic until incidental finding

200

How should maternal group B strep be managed?

Intrapartum IV benzylpenicillin (or vancomycin if penicillin allergy) if pyrexial

201

In what situations would group B strep prophylaxis be given?

When there are RFs for an early-onset neonatal sepsis:

- intrapartum fever/ chorioamnionitis

- prolonged rupture of membranes (PROM)

- Pre-term birth

202

How should sepsis monitoring occur in neonates?

If 1 risk factor: remain in hospital for 24 hours for obs

If 2 or more risk factors, or one red flag, --> Abx + septic screen Sepsis

Abx in neonate: cefotaxime, amikacin, ampicillin

Red flags: seizure, resp distress, shock 

203

What are the S/S of listeriosis?

Often asymptomatic or non-specific

204

How can listeriosis be diagnosed?

Isolation of organism from blood, vaginal swabs or placenta

205

How is listeriosis managed?

IV amoxicillin/ ampicillin

206

What is the prognosis for listeriosis?

Bad unless treated (then good)

207

What is a Braxton-Hicks contraction?

Painless contractions with no cervical change

208

Define the 3 stages of labour

1. Painful uterine contractions --> full (10cm) cervical dilatation 2. Starts with urge to push and ends with delivery of foetus 3. Delivery of placenta and foetal membranes

209

Up to how long should the 3rd stage of labour last ideally?

Up to 30 mins

210

What factors determine the progress of labour?

1. Power (contractions) 2. Passage (dimensions of pelvis) 3. Passenger (diameter of foetal head)

211

What is a possible complication of shoulder dystocia?

Erb's palsy

212

What is 'restitution'?

Bringing head in line with shoulders

213

Recall the management of shoulder dystocia

In LESS THAN 5 MINS:

1. Call for senior help and discourage pushing

2. McRobert's manoevre and suprapubic pressure

3. Evaluate for episiomtomy

4. Either Rubin's manoevre or Wood's Screw or deliver posterior arm

 

214

What is McRobert's manoevre?

Legs up to abdomen

215

What is Rubin's manoevre?

Push anterior shoulder towards baby's chest

216

What is Wood's Screw?

Rubin's + push posterior shoulder towards baby's back --> rotation

217

What score is used to decide how likely it is that a woman will go into labour imminently?

Bishop's score

218

What is 'effacement'?

Reported as a %, measure of how thin the cervix is

219

What is the 'foetal station'?

Position of the baby's head relative to the ischial spines of the maternal pelvis

220

How should the 1st stage of labour be managed?

One-to-one midwifery care

Vaginal exams performed 4-hourly or as clinically-indicated

Ensurance of adequate: analgesia, antacids, hydration, light diet to provide ketosis

221

What is the normal progress of the first stage of labour?

1cm per hour

222

How should a delayed first stage of labour be managed?

1st - if membranes intact - ARM (artificial rupture of membranes) 2nd (if membranes ruptured) - oxytocin

223

What is the most common cause of primary dysfunctional labour?

Ineffective uterine action

224

When is the second stage of labour considered 'delayed'?

In nulliparous women: 3 hours with an epidural or 2 hours without

In multiparous women: 2 hours with epidural or 1 hour without

225

How should a delayed 2nd stage of labour be treated?

Same as delayed 1st stage with regards to ARM and oxytocin

226

What is 'crowning'?

When head no longer recedes between contractions

227

What does the midwife do as the baby crowns?

Flex the foetal head and guard the perineum

228

How should the woman be instructed once the head has crowned?

Discouraged from bearing down and should take rapid, shallow breaths

229

Recall the immediate care of the neonate

After clamping/ cutting of the umbilical cord, baby should have an apgar scre calculated at 1 min and at 5 mins

230

What apgar score is considered normal?

>7

231

What does APGAR stand for?

Appearance, pulse, grimace, activity, respiration

232

How quickly should initiation of breastfeeding be encouraged?

Within 1 hour

233

What medication should be given to the baby whilst still in the delivery room?

Vit K

234

What are the causes of PPH?

4 Ts: Tone (uterine atony) Tissue (retained products) Trauma (laceration) Thrombin (coagulopathy)

235

What is PPH?

Post Partum Haemorrhage

236

What is the normal duration of the 3rd stage of labour?

5-10 mins

237

Describe the physiological management of the 3rd stage of labour

Associated with more bleeding (and therefore greater need for transfusions) than active management

Active Mx recommended if placenta undelivered within 60 mins or haemorrhage may occur

238

Describe the active management of the 3rd stage of labour

10 IU syntocinon (IM)/ ergometrine

Drug can be delivered after delivery of anterior shoulder or immediately after delivery (and before cord is clamped and cut)

Remove placenta using controlled cord traction

239

What are the signs of placental separation?

Gush of blood, cord lengthening, uterus rising, uterus becoming round

240

What should be done immediately following delivery of the placenta?

1. Inspection of placenta for missing cotyledone/ succenturiate lobe

2. Inspect vulva for tears

241

After how long of active management is it considered 'prolonged'?

30 mins

242

Recall the options for induction of labour, from 1st to 5th line

1. Prior to formal induction: membrane sweeping - for nulliparous women = at 40-41 weeks - for multiparous women = at 41 weeks

2. Prepare the cervix --> prostaglandins (Prostin/ Propress; vaginal PGE2)
- this is the preferred formal method of induction, can be administered as a tablet, gel or pessary - max of 2 doses
- Risk of uterine hyperstimulation 

3. Artificial Rupture of Membranes
- ARM = amniohook
- Should not be used first line

4. Syntocinon

5. C section

243

At how many weeks is induction offered?

41 weeks

244

If induction is declined when it is indicated, what should be done?

Twice weekly USS and CTG

245

In what circumstances can labour be induced at maternal request?

Special circumstancs eg. If partner has to go away to serve in armed forces - only consider after 40 weeks

246

What should be done in the scenario of intrauterine foetal death?

If membranes are intact, offer an induction

If ruptured membranes/ infection/ bleeding - immediate induction with oral mifepristone, followed by prostin/ misoprostol

247

Recall 3 scenarios in which induction is not recommended

Breech/ transverse lie

IUGR

Suspected foetal macrosomia

248

Recall 3 non-pharmacological methods of analgesia

TENS

Breathing techniques

Massage

249

Recall 4 pharmacological analgesics used in pregnancy, with their side effects

Entonox (nausea, light-headed, dry mouth)

Meperidine ('sleepy baby', low baby RR, constipation)

Morphine/ diamorphine ('sleepy baby', low baby RR, constipation)

Fentanyl ('sleepy baby', low baby RR, constipation)

250

Recall 2 surgical methods of analgesia

Lumbar epidural (bupivocaine, ropivacaine etc)

Combined lumbar-spinal epidural (fentanyl + bupivacaine)

251

What is a partogram, and what score is based on its results?

Records condition of mother, foetus and progress of labour

Used to calculate a Bishop's score

252

Define puerperal pyrexia

>38C in first 14 days following delivery

253

What is the most common cause of puerperal pyrexia?

Maternal endometritis

254

How should puerperal pyrexia be managed?

Until fever has abated for >24 hours: - IV clindamycin AND IV gentamycin

255

What weight at term are macrosomic babies?

>4/4.5kg (definition varies)

256

What tools are used to diagnose LGA prenatally?

1st: symphisis-fundal height

2nd: abdominal circumference

3rd: estimated foetal weight

If in 90th/95th centile for GA = LGA

257

What investigations should be done if a baby seems LGA prenatally?

OGTT (gestational diabetes? This can cause LGA)

Bloods (serum beta-hCG, as molar pregnancy can cause polyhydramnios)

USS (liquor volume, biometry)

Genetic testing

258

How should LGA be managed, if detected at 18-21 weeks?

Repeat scan

259

How should LGA be managed, if detected at 24-36 weeks?

If acceleration of growth, arrange

USS for foetal biometry

Offer OGTT

260

How should LGA be managed, if detected at 36-40 weeks?

If SFH is in 90th centile, USS for foetal biometry

Perform OGTT

Care in labour + postnatally as per gestational diabetes at earlier gestation

261

Recall some complications of delivery in LGA

Shoulder dystocia

Hypoglycaemia in GDM

Respiratory distress syndrome (baby) 

Intrauterine deformations eg matatarsus adductus, (hip subluxation)

Increased mortality

Perineal tear

262

Define SGA

<10th centile for GA

263

What are the biggest risk factors for SGA?

Previous stillbirth, APLS, renal disease

Others include: chromosomal abnormalities, infection, multiple pregnancy, placental insufficiency

264

How should SGA be investigated?

At booking assesment, note any minor or major RFs

If 1 major or 3 minor RFs, reassess at 20 weeks

At 20 weeks, if still at risk, consider:

- Minor risk: uterine artery doppler (if abnormal, serial USS from 26-28 weeks)

- Major risk: foetal size and umbilical artery doppler

265

What does USS biometry measure?

Biparietal diameter, head circumference, abdo circumference, femur length

266

How should SGA be managed?

Stop any smoking/ EtOH/ drugs

Low dose aspirin may have some role in preventing (not reversing) IUGR in high-risk pregnancies

Monitoring: SFH at booking and at antenatal appointment, confirm SGA with foetal biometry at 20 weeks, uterine artery doppler at 20-24 weeks

If abnormal, serial scans every week from 26w onwards

Indications for immediate delivery: abnormal CTG, reversal of end-diastolic flow


Delivery by 37 weeks is usually necessary

267

What are ths symptoms of obstetric cholestasis during pregnancy?

Pruritis, no rash

268

Recall some possible complications of obstetric cholestasis

PPH, foetal distress, meconium delivery, PTL, IVH

269

What does IVH stand for?

Intraventricular haemorrhage

270

Where does the pruritis usually affect the worst in obstetric cholestasis, and at what point in the day?

Palms and soles

Night time

271

Recall some appropriate investigations in suspected obstetric cholestasis

Bile acids and LFTs

CTG (to check baby)

Coagulation screen (may be high if vit K deficient)

Fasting serum cholesterol (high)

Hep C serology (increased risk of OC in hep C)

272

How should obstetric cholestasis be managed?

Ursodeoxycholic acid (reduces itching and improves LFTs)

Vit K if deficient

Sedating antihistamines

273

How should mothers with obstetric cholestasis be monitored?

Weekly LFTs until delivery, two-weekly doppler and CTG until delivery

274

How should delivery be managed in mothers with obstetric cholestasis?

Offer induction at 37 weeks

275

What are the main possible complications of obstetric cholestasis?

1. Intrauterine death (due to intracranial haemorrhage)

2. PPH (due to low vit K)

276

Describe the epidemiology of Acute Fatty Liver of pregnancy

Rare

277

What is the aetiology of Acute Fatty Liver of pregnancy?

Probably a mitochondrial disorder affecting fatty acid oxidation

278

What is the main differential diagnosis in Acute Fatty Liver of pregnancy?

HELLP (haemolysis, elevated liver enzymes, low platelets)

279

Recall the S/S of AFL of pregnancy

Normally 3rd TM Nauea/ vomiting/ abdo pain Jaundice, bleeding, ascites, manifestations of coagulopathy 50% have proteinuric HTN

280

How can AFL of pregnancy be differentiated from OC?

Pruritis absent in AFL

281

What investigations are appropriate in AFL of pregnancy?

ALT typically very elevated

Low blood glucose

Elevated uric acid

USS to show fatty liver

282

How should AFL of pregnancy be managed?

Supportive care to stabilise

Once stabilised, delivery is the definitive management to prevent deterioration

283

What is the prognosis of AFL of pregnancy?

Maternal mortality of 10-20%, perinatal of 20-30%

284

What % of pregnancies are breech at term?

3-5%

285

Recall some signs of breech delivery

Palpable head at fundus, soft breech in pelvis

Vaginal: soft presenting part, ischial tuberosities, anus or genitalia may be felt

Footling breech: foot felt or seen through cervix

286

What are the different types of breech presentation?

Frank breech

Footling breech

Complete breech

287

Recall some antenatal features of vaginal breech birth being high risk

Hyperextended neck

High EFW

Also Low EFW?!?!

288

How information should be given at term in breech presentation?

1. Offer ECV (exteral cephalic version) at 36w if nulliparous, 37w if multiparous: 

- 50-60% success rate

- Foetal distress --> emergency CS

 

2. If ECV unsuccessful/ declined --> council risks for CS

289

What is the most dangerous form of breech delivery?

Footling

290

How should a breech delivery be managed?

'Hands off' approach (baby hopefully will deliver self - if handling - put thumbs on sacrum and fingers on ASIS - Pinard manoevre may be needed)

291

What is a Pinard manoevre?

Poke the baby in the popliteal fossa - this makes the bend their knees

292

How will you tell if the baby's head is stuck after the body is delivered in breech delilvery?

Winging of scapulae

293

How should a stuck head be managed in breech delivery?

Loveset's manoevre: rotate baby into transverse position and pull anterior arm down

If it stays stuck: perform Mauriceau-Smellie-Veit manoevre - you basically just haul them out resting baby on forearm and pulling head downwards

294

Recall 3 types of unstable lie

Transverse, face, brow

295

How should unstable lie be investigated?

USS to confirm the lie

296

How should unstable lie be managed?

If already in labour, CS

Transverse lie can be altered by ECV with 50% success rate 

Brow lie should --> CS if persistent/ 2nd stage labour

Face:mentoposteroir --> CS, mentoanterior = SVD is oky

297

Define miscarriage

Loss of pregnancy at <20 weeks gestation

298

What is a 'threatened' miscarriage?

PV bleed with foetal heartbeat present: the cervical os must be closed

299

What is an incomplete miscarriage?

Passage of products of conception but uterus not empty on USS

300

What is a missed miscarriage?

USS diagnosis of miscarriage in absence of symptoms

301

What is recurrent miscarriage?

>3 consecutive miscarriages

No cause found in 50%

302

What is the most common cause of miscarriage?

Chromosomal abnormalities in the embryo (eg trisomy 16)

303

What causes must be considered in recurrent miscarriage?

Structural abnormalities (fibroids, bicornate/ septate uteri)

Cervical incompetence

Medical conditions (diabetes, SLE)

Clotting abnormalities (eg FVL, ATIII deficiency, APLS)

304

What measure is used to date pregnancies <14 weeks?

CRL (crown rump length) using USS

305

What measure is used to date pregnancies >14 weeks?

Head circumference is the main one

306

What is needed to identify a IUP (rather than a PUL)?

Yolk sac and gestational sac

307

Recall the process of TVUSS dating of pregnancies

1st. Look for foetal heartbeat

2nd. Find foetal poles for CRL (crown rump length)

3rd. If not foetal pole, look for gestational sac

308

How would a miscarriage be identified on TVUSS?

Absence of foetal HR and CRL >7mm

OR

Growth Sac > 25mm + no foetus

Also need 2 opinions - one USS alone is not enough

309

What happens if a TVUSS shows no FH and CRL <7mm?

PUV (pregnancy of unknown viability)

Repeat TVUSS in 7 days

310

What investigations should be done in recurrent miscarriage?

Cytogenic analysis of products of conception, pelvic USS, anti- phospholipid antibodies, screen for BV

Explain that cause is often never found

311

Recall the management of PV bleeding during pregnancy

If signs of an ectopic or severe bleeding: admit to surgeons

If more than 6w pregnant: GDR/EPU referral

If a viable pregnancy: go home and follow expectant management

If a complete miscarriage: council and go home

If <6w pregnant, expectant mx: no USS

312

How should miscarriage with retained products be managed?

1st line is expectant management for 7-14 days: if the bleeding/ pain settle, have a pregnancy test after 3 weeks.

Return if +ve.

If pain/ bleeding persist, go to follow up clinic in 4 weeks.

2nd line is medical or surgical management - depends on patient

Medical: misoprostol

Surgical: Suctioned RPC

313

How should thrombophilia/ anti-phospholipid syndrome be managed in pregnancy?

Low-dose aspirin and LMWH (clexane (enoxaparin))

314

What is the 'chorion' and 'amnion'?

Chorion = outermost foetal membrane

Amnion = membrane closely covering embryo

315

What % of monozygotic twins are dichorionic diamniotic - and what sign on USS shows this?

2 placenta and 2 amniotic sacs = 25%

Lambda sign

316

What % of monozygotic twins are monochorionic diamniotic - and what sign on US is useful for identifying this?

75% - 1 shared placenta

T sign

317

What is lambda sign?

In dichorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be a triangular placental tissue projection into the base of the membrane

318

What is the T sign?

In monochorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be no placental tissue projection into the base of the membrane

319

How should multiple pregnancy be managed antenatally?

FBC at 20-24 weeks

BP (as increased risk of eclampsia)

GTT (Increased likelihood of diabetes)

TTTS monitoring/ growth scans - every 2w starting at 16w for shared placentas, every 4w starting at 20w for no shared placenta

Serial USS for foetal growths

320

How can a breech baby be turned in a multiple pregnancy when the other baby is cephalic?

Internal pedalic version

321

Recall some possible foetal complications of multiple pregnancy

IUGR

Downs

Structural abnormalities

Twin to twin transfusion syndrome (TTTS)

322

Recall 3 possble maternal complications to multiple pregnancy

Pre-eclampsia, hyperemesis gravidarum, GDM

323

In what type of pregnancy does TTTS occur?

Monochorionic twins

324

What are the symptoms of TTTS?

Sudden increase in abdominal size, SOB

325

How should TTTS be managed?

If <26w, foetoscopic laser ablation of vascular anastomoses

If >26w, delivery

326

What is the pathogenesis of TTTS?

Direct arterial to venous flow in placenta

- Donor baby = SGA + oligohydramnios

- Recipient baby = LGA + polyhydramnios

327

What is the diagnostic criterion for TTTS?

>25% difference between EFW

328

What are the risks to the recipient baby in TTTS

More blood --> more cardiac strain --> hydrops fetalis

329

What BMI is classified as obesity?

>30

330

What should be considered pre-delivery in obese mums?

Assess risk of giving birth vaginally and whether there needs to be induction/CS

331

How is oligohydramnios defined?

<5th centile

Deepest pool <2cm

332

Recall the risk factors for oligohydramnios

Reduced input fluid: placental insufficiency, pre-eclampsia

Reduced output fluid: structural pathology, medications

Lost fluid: ROM, IUGR, post-term pregnancy carry, TTTS

Chromosomal abnormalities

333

What are the signs and symptoms of oligohydramnios?

Hx of fluid leak PV

Abdo exam - decreased fundal height, foetal parts easily palpable

Speculum - assess for membrane rupture

334

What are the risk factors for polyhydramnios?

Congenital infections

Foetal polyuria

Any failure of foetal swallowing

335

What investigations are useful in polyhydramnios?

Liquor volume, foetal growth, UA doppler, exclude foetal abnormalities

Also exclude maternal DM

336

How should polyhydramnios be managed?

Antenatal foetal monitoring and DM monitoring

Amnioreduction - if gross reduction COX inhibition

Internal pedalic version - to decrease foetal urine output

337

What is placenta praevia?

Low-lying placenta = placental edge <2cm from internal os on TVUSS - placenta lies over internal os

338

After what GA can placenta praevia be diagnosed?

32w

339

Recall 2 signs/symptoms of placenta praevia

Painless PV bleeding

Potential signs of shock

340

What is the first line investigation for diagnosis of placenta praevia?

TVUSS

341

What other investigations should be done in placenta praevia?

Kleihauer test/ Rhesus test

If mother RhD -ve --> Kleihauer test (check level of blood in maternal circulation).

Administer RhD

Do not perform a bimanual

342

How should placenta praevia be managed when there is minimal bleeding?

Symptomatic management - if bleeding settles, they should be admitted for 48 hours for observation

343

How should a low-lying placenta at 20w scan be managed?

Rescan at 32w as only 10% go on to have a low-lying placenta later in pregnancy

If still present and grade I/II at 32 weeks, rescan at 36w --> if still low, recommend CS

If still present and grade III/IV, admit at 34w and CS 37 weeks USS at 36w to decid

344

How should PP be managed (with and without bleeding/ labour or no labour)?

No bleeding, no labour, preterm: Monitoring, possibly in hospital, steroids if pre term, anti-D if Rhesus negative

No bleeding, labour, preterm: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative

No bleeding, at term: Normally C-section after 35 weeks

Bleeding: Stabilise the mother haemodynamically. The secondary goal is to ensure foetal survival

  • Not stabilized by resus: Emergency C-section
  • Stabilised, not in labour: MDT discussion with seniors, corticosteroids if less than 34 weeks
  • Stabilised, pre-term labour: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative

Stabilised at term or labour: Emergency C-section

345

What are the complications for the mother in PP?

Haemorrhage, antepartum haemorrhage and postpartum haemorrhage, DIC, hysterectomy

346

Recall the pathophysiology of vasa praevia

Foetal vessels course through membrane over the internal cervical os and below foetal presenting part, unprotected by placental tissue or umbilical cord. When baby descends they can rupture the vessels.

347

What is the difference between type 1 and 2 VP?

Type 1 = velamentous cord insertion in a single/ bilobed placenta

Type 2 = foetal vessels running between lobes of placenta with at least 1 accessory lobe

348

What is the haemorrhage of blood called when the vessels rupture in vasa praevia?

Benckaiser's haemorrhage

349

What are the signs and symptoms of VP?

ROM --> fresh PV bleeding + foetal bradychardia

350

What symptoms of vasa praevia are seen in the foetus?

HR abnormalities - decelerations, bradycardia, sinusoidal trace

351

What investigations should be done in suspected vasa praevia?

Kleihauer test: measures amount of foetal Hb in a mother's bloodstream

Hb electrophoresis: identify if foetal or maternal blood (takes a wee while)

Doppler USS

352

How should vasa praevia be managed?

C section

353

What are the complications of vasa praevia?

No major maternal risk but dangerous for foetus

Foetus loses relatively small amounts of blood, which can have major implications

Need to rapidly deliver and aggressively resuscitate including transfusion if necessary

354

What is placental abruption?

Separation of the placenta from the uterine wall before delivery (>24w, if <24w = miscarriage)

355

What is the pathophysiology of placental abruption?

As placenta separates, retroperitoneal bleeding results in further detachment

356

What are the signs and symptoms of placental abruption?

Constant abdo pain +/- PV bleeding, SUSTAINED contractions

OE: shock, speculum can show bleeding, abdomen reveals woody, tender uterus, vaginal exam (NOT IN PRAEVIA) shows cervical dilatation

357

How can placental abruption and placenta praevia be distingiushed clinically?

Need to distinguish so that you don't inappropriately do a vaginal exam on someone with placenta praevia

PP - bleed, no pain

Abruption = bleed and pain

358

How should mild placental abruption be managed?

If preterm and stable: conservative management with close monitoring

Admit for at least 48 hours or until bleeding stops

Anti-D Ig followed by Kleihauer test

359

How should severe placental abruption be managed?

ABC

Emergency CS

2 x wide bore cannulae, fluids, blood transfusions, correct coagulopathies

FBC/X match/ Kleihauer test/ anti-D if needed, steroids

CTG if >27w, consider IOL if foetal compromise, TVUSS if query PP

360

What are the possible maternal complications of placental abruption?

  • Haemorrhage (APH/PPH)
  • DIC
  • Renal failure
  • Couvelaire uterus (it goes rock solid because of blood that has extravasated into the myometrium and beneath the peritoneum)

361

What are the possible foetal complications of placental abruption?

Birth asphyxia, death

362

Define PPH

Blood loss >500 mls SVD or >1000mls at CS

363

What is a secondary PPH?

24 hours to 12w PP

364

What are the causes of PPH?

Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)

Tone = Uterine atony

Tissue = related to placental products (membranes, cotyledon, succenturiate lobe)

Trauma

Thrombin = coagulopathy (existing or acquired)

365

How can uterine atony be avoided?

Giving oxytocin with delivery of anterior shoulder or placenta

366

Recall 4 causes of secondary PPH

Endometritis

Retained products

Abnormal involution of placental site

Trophoblastic disease

367

What are the signs and symptoms of primary PPH?

General (shock)

Abdomen will have atonic uterus above umbiloicus

Speculum: exclude trauma

Vaginal - evacuate clots from cervix

368

What classifies as a 'major PPH'?

>1000mls blood loss or signs of shock

369

How should PPH be managed?

If major - ring emergency buzzer

1. Bimanual compression (rub up a contraction if in theatre)

2. IM/IV Syntocinon (oxytocin)

3. IM Ergometrine (not in HTN/ asthmatics)

4. IM Carboprost

5. Balloon tamponade

6. B-lynch suture, ligate

370

What is placenta accreta?

Strong attachment of placenta - but not into the muscle wall

371

What is placenta increta?

Strong attahment of placenta into uterine wall

372

What is placenta percreta?

Strong attachent of placenta, through the uterine wall

373

What is the biggest risk factor for placenta accreta/increta/percreta?

Previous CS or uterine surgery

374

What investigations should be done in placenta accreta/increta/percreta?

TVUSS

MRI to assess depth of invasion

375

How should placenta accreta/increta/percreta be managed?

Managed delivery +/- caesarean hysterectomy

376

What is the difference between PROM and PPROM?

PROM = pre-labour rupture at TERM, PPROM = premature rupture

377

What is the cause of PROM?

Just physiological - but only affects <10% of women

378

What is the cause of PPROM?

Can be caused by weakening of membranes due to infective cause (often subclinical)

379

What are the signs and symptoms of (P)PROM?

Sudden gush of fluid leading to a constant trickle

380

What investigations should be done in (P)PROM?

DO NOT DO A BIMANUAL (like in PP)

1st: speculum: amniotic fluid pooling is diagnostic

  • If >30w, contractions and os closed, TVUSS for cervical length
  • If is >15mm it is unlikely to be a PTL

2nd: IGFBP-1/PAMG-1: these are suuuper sensitive so if a negative result, there is a v low chance of PROM

3rd: Foetal Fibronectin (FFN) may be present - positive in PROM

381

How should PPROM be managed?

Admission and expectant management until 37w

Do not offer tocolysis

Erythromycin and CS (24hours) and MgSO4 (if <30w)

Carefully monitor for chorioamnionitis

382

How should PROM be managed?

If clear liquor: expectant management for 24 hours, if >24 hours --> IOL

If meconium, induce labour asap

383

Define PTL, very PTL and extremely PTL

PTL = 32-37w GA

Very PTL = 28-32w GA

Extremely PTL = <28w GA

384

What is the biggest risk factor for PTL?

Infection

385

What is the biggest maternal lifestyle risk factor for PTL?

Smoking

386

How should PTL be investigated?

CTG monitor

Urine dip +/- MCandS if indicated

387

How should PTL be managed?

If membranes rupture --> PPROM management

If membranes not ruptured:

Medication:

  • Tocolysis (if less than 34w: 1st line is nifedipine, 2nd line is atosiban)
  • 24 hours of corticosteroids 
  • MgSO4 if less than 30w

Surgery:

  • Emergency 'rescue' cerclage

388

What is the indication for surgical management for PTL?

16-28w

Dilated cervix

Exposed unruptured membranes

389

Give 3 contraindications of surgical management of PTL

Infection, bleeding, uterine contractions

390

What PTL prophylaxis be given?

Vaginal progesterone

Cervical cerclage

391

Which women are offered prophylaxis for PTL?

If they have a hx of PTL and any of:

  • cervical length <25mm 
  •  >16w GA miscarriage
  • Cervical length <25mm and hx of PPROM
  • cervical trauma

392

What are the 'big four' complications of pre-term birth?

Respiratory distress syndrome

NEC

Intrvascular haemorrhage

Periventricular leukomalacia

393

What % of the population are Rh negative?

15%

394

Describe the process of Rhesus disease development

Rh neg mother has a Rh pos child

Sensitising event mixes blood (Simple SVD is not a sensitising event)

Mother develops IgM anti-Rh Abs

Mother delivers or miscarries child

*Time passes*

Mother has a second Rh+ child --> Mother's IgG anti-Rh crosses the placenta

--> hydrops fetalis

395

Why does Rhesus disease never occur in first primoparous mothers?

IgM cannot cross the placenta - IgG (produced later) can

396

What test should be done in a known Rh neg mother?

cffDNA testing - tests for the child's Rh status

397

Recall the pathophysiology of hydrops fetalis in Rh disease

IgG anti-Rh Abs against foetal RBCs --> HDN = anaemia + high BR --> hydrops fetalis, foetal anaemia + kernicterus

398

What is the Kleiheur test?

It measures the amount of foetal Hb that passes into the mother's bloodstream

399

Recall the indication and management for routine anti-D prophylaxis

Indication: Rh neg mother

Management: Indirect antigobulin test at booking

Either 2 doses of 500IU at 28 + 34w, or 1 dose of 1500IU at 28w

Foetal cord bloods post-delivery and prophylaxis in 72 hours if baby pos with Kleiheur

400

Recall the prophylaxis protocol following a sensitising event

Needs to be done within 72 hours of the event

If <20w --> 250IU

If >20w --> 500IU

401

How can a baby be monitored when a mother has anti-D antibodies?

Middle cerebral artery dopplers

402

What are the 5 skin diseases of pregnancy?

Pemphygoid gestationis

PUPPP

Prurigo of pregnancy

Pruritis folliculitis A

atopic eczema

403

Recall some physiological changes in the skin during pregnancy

Pre-existing conditions worsen

Increased pigmentation

Spider naevi affecting face, arms and upper torso

Broad pink linear striae - striae gravidarum common over lower abdo + thighs

Hand and nipple eczema post-partum

Psoriasis

404

What is pemphigoid gestationis?

Rare pruritic autoimmune bullous disorder

405

When does pemphioid gestationis present?

2nd or 3rd trimester

406

What are the signs and symptoms of pemphigoid gestationis?

Widespread clustered blisters, sparing face: usually begin on abdomen

407

How should pemphigoid gestationis be managed?

Potent topical steroids to relieve pruritis, oral prednisolone to stop new blisters forming

408

What does PUPPP stand for?

Pruritic Urticarial Papules and Plaques of Pregnancy

409

Where does Polymorphic Eruption of Pregnancy (PEP) tend to present?

Abdomen - umbilicus sparing - then extending to thigh/ buttock etc

410

When does Polymorphic Eruption of Pregnancy present?

3rd trimester/ immediately post-partum

411

How should Polymorphic Eruption of Pregnancy be managed?

Symptomatic management only

412

What % of normal pregnancies are affected by prurigo?

20%

413

When does prurigo present?

Beginning in 3rd trimester and resolves upon delivery

414

What does prurigo look like?

Excoriated papules on extensor limbs, abdomen and shoulder

415

How should prurigo be managed?

Symptomatic treatment + topical steroids and emollients

416

Where does pruritis folliculitis affect?

Trunk, can involve limbs

417

When does pruritis folliculitis present?

2nd/3rd TM, may resolve on delivery

418

Describe the appearance of pruritis folliculitis 

Apears like acne (consider a type of hormone-induced acne)

419

How should pruritis folliculitis be treated?

Topical steroids

420

What are the main complications of maternal EtOH use at delivery?

Miscarriage, still birth, congenital abnormalities, LBW, SGA

421

What is the main area of development affected by maternal EtOH use?

Neurodevelopmental

422

How does smoking affect pregnancy?

Damages umbilical cord structure

Increased risk of ectopic/ placental abruption/ miscarriage

423

How does smoking affect the neonate?

LBW/ PTL

424

How does smoking affect the baby in the longterm

Less likely to have a long term effect

425

How does cannabis affect pregnancy?

Increases NICU admission, as well as chance of LBW, SGA and PTL

426

How does maternal cannabis use affect child development?

Adverse consequences of growth of foetal and adolescent brains

Reduced attention and executive funtioning skills

Poor academic achievement

Behavioural problems

427

How does maternal cocaine use affect pregnancy?

Increases chance of PROM, PTL, LBW, SGA and placental abruption - due to vasospasm of uterine vessels

428

How does maternal opioid use affect pregnancy?

Can cause 3rd TM bleeding and SGA

429

How does maternal opioid use affect the neonate?

SIDS, toxaemia, microcephaly

430

What is the name of the withdrawl syndrome from opioids in babies?

Neonatal abstinence syndrome

431

Recall the presentation of neonatal opioid withdrawl

Irritability, hypertonia, seizures, emesis, respiratory distress

432

What investigation should be done in a suspected DVT?

Duplex USS

433

What investigation should be done in a suspected PE?

CXR, duplex USS - if both neg then do CTPA (better than V/Q scan as delivers smalled dose to baby)

434

How should DVT be managed?

LMWH + elevate leg, apply graduated elastic stockings

435

How should PE be managed in the longterm?

LMWH until 6w post-partum or 3m total treatment - whichever is greater

436

How should minor PE be managed?

LMWH ie enoxaparin treatment dose

ECG + CXR --> If CXR is abnormal and clinical suspicion of PE --> CTPA

437

How should massive PE be managed?

1st line = unfractionated heparin 2nd line = thrombolytic therapy, thoracotomy or surgical embolectomty

438

How should unfractionated heparin be monitored?

APTT

439

When is central venous sinus thrombosis most common?

Post-partum

440

What are the signs and symptoms of central venous sinus thrombosis?

Headache and varying neurology

441

How should suspected central venous sinus thrombosis first be investgated?

MRI

442

How should central venous sinus thrombosis be managed?

IV unfractionated heparin --> thrombolysis --> 3-6m anticogulation

443

Recall 2 possible side effects of heparin

Heparin-induced thrombocytopaenia

Heparin allergy

444

How should VTE at term be managed?

IV unfractionated heparin --> thrombolysis --> 3-6m anticogulation

445

How long before a planned delivery should LMWH be stopped?

24 hours prior to planned delivery

446

How long after the last LMWH dose can an epidural be given?

24 hours

447

How long after the epidural catheter removal can LMWH be given again?

4 hours after

448

What drug is used to reverse IV unfractionated heparin?

Protamine sulphate

449

By what route is clexane given?

Subcut

450

How is VTE prevented in high-risk patients?

Prolonged use of LMWH and graduated elastic compression stockings

451

In women of extremes of weight, how should VTE prophylactic treatment be measured?

Anti Xa levels

452

What change in the thyroid fx is expected in pregnancy?

Fall in TSH and rise in T4 in 1st TM

453

How should pre-existing thyroid medication be managed during pregnancy?

Thyroxine should be increased by 25 nanograms, even if currently euthyroid - helps to mimic physiological rise in T4 in 1st TM

454

What thyroid disorder is associated with pregnancy?

Post-partum thyroiditis

455

What are the diagnostic criteria for post-partum thyroiditis?

THREE criteria:

- Less than 12 months since pt gave birth

- Clinical manifestations are suggestive of hypothyroidism

- TFTs alone (no need to measure TPO Ig)

456

Describe the progression of postpartum thyroiditis

Stage 1 = thyrotoxicosis

Stage 2 = hypothyroidism

Stage 3 = Euthyroid

457

What is the cause of postpartum thyroiditis?

It's autoimmune - anti-TPO is present in 90%

458

How should postpartum thyroiditis be managed?

Thyrotoxic phase = propranolol

Hypothyroid phase: thyroxine

459

How should hyperthyroidism during pregnancy be managed?

Treat medically - no surgery, at lowest possible dose

Propylthiouracil in 1st TM

Carbimazole in 2nd/3rd TM

460

What are the potential side effects of hyperthyroidism treatment on the foetus?

Foetal hypothyroidism - from high doses crossing the placenta

Agranulocytosis (do regular checks of maternal WCC)

461

How should mild hyperparathyroidism be managed in pregnancy?

Adequate hydration and low calcium diet

462

How should major hyperparathyroidism be managed in pregnancy?

Parathyroidectomy may be indicated for severe cases

463

What are the signs and symptoms of UTI/ bacteruria in pregnancy?

FUNDHIPS

464

How frequently is urinalysis and urine MCandS during pregnancy?

Urinalysis at every antenatal visit

MSU sent at booking visit

465

What is the most likely causative organism in asymptomatic bacteriuria?

GBS (group B strep) - which is streptococcus agalactiae

466

How should asymptomatic bacteriuria be managed?

Nitrofurantoin - but AVOID AT TERM

OR

Amoxicillin

OR

Cephalexin

467

How should symptomatic UTI in pregnancy be managed?

MCandS showing GBS --> Abx

Do MSU before Abx starts

7 days nitrofurantoin

Amox/ cephalexin is 2nd line

468

How should pyelonephritis be managed in pregnancy?

Cephalexin/ cefuroxime

469

What common abx used in UTI is contraindicated in pregnancy?

Trimethoprim is contraindicated in 1st TM

470

Recall 4 generic complications of ERPC

Bleeding, infection, procedural failure, necessity to repeat

471

Recall 2 specific complications of ERPC

Intrauterine adhesions, perforation of uterus

472

What is ECV?

External Cephalic Version

External manipulation of foetus through maternal abdomen to achieve a cephalic presentation

473

What is the success rate of ECV?

50-60%

474

When should ECV be offered?

If nulliparous - at 36 weeks

If multiparous - at 37 weeks

475

How can the success rate of ECV be improved?

Add tocolysis and beta agonists

476

Recall 3 drugs that can be used for tocolysis

Nifedipine

Atosiban (oxytocin receptor antagonist)

Terbutaline (beta agonist so not in asthma)

477

What is the main contraindication for ECV?

Ruptured membranes

478

What are the possible complications for ECV?

V low complication rate, but there may be procedural failure, placental abruption, uterine ruption

479

What is CTG?

Cardiotocography

Continuous monitoring of the foetal heart and uterine activity, used in labour

480

When is the booking appointment?

12 weeks

481

When is the anomaly scan?

20+6w

482

How is a foetal doppler done?

Used to monitor foetal HR and should be placed over the anterior shoulder of foetus

483

How is foetal blood sampling done?

Blood withdrawn from umbilical vein

484

What is foetal blood sampling used for?

Determine if severe anaemia caused by Rh sensitisation

485

Recall a systemic method for interpreting CTGs

DR C BRAVADO:

DR = define risk - why are they on a CTG monitor? Previous CTGs?

C - contractions - normal is 5 contractions in 10 mins

BRA - baseline rate: 110-160bpm

V - variability: 5-25 bpm

A - accelerations: at least 2 every 15 mins

D - deceleratons: present? variable? Early? Late?

O - overall impression

486

What is an acceleration?

Rise in foetal HR of >15bpm lasting >15s

Occurs in response to foetal movements

487

What is a deceleration?

Drop of foetal HR of >15 bpm lasting >15 s

Late decelerations are much worse than early decelerations

488

Define the baseline values for foetal bradycardia and tachycardia

<110bpm, >160bpm

489

What counts as a loss of baseline variability, and what might cause it?

<5bpm (5-25 is normal)

May be caused by prematurity or hypoxia

490

What is an early deceleration?

Deceleration that commences with onset of contraction and returns to normal with completion of contraction

491

Recall one cause of early deceleration

Head compression (innocuous)

Generally not of concern

492

What is a late deceleration?

Lags the onset of a contraction and does not return to normal until after 30s following end of contraction

493

What is the cause of late decelerations?

Reduced uroplacental flow

494

What is the cause of variable decelerations?

Cord compression

495

Recall 2 indications for emergency CS that could be seen on CTG

Terminal braycardia: FHR <100bpm for more than 10 mins

Terminal deceleration: FHR drops and does not recover for more than 3 mins

496

Recall the FHR, BV, decelerations and accelerations that typify a normal CTG

FHR: 110-160bpm

BV: 5-25

Dec: absent/early

Acc: 2 in 20 mins

497

Recall the FHR, BV, decelerations and accelerations that typify a 'non- reassuring' CTG

FHR: 100-110, 161-180

BV: <5/

Late decelerations in >50% of contractions for >90 mins

Variable decelerations:

  • Alone for >90 mins
  • With <50% of contractions for >30 mins
  • With >50% of contractions for <30 mins

498

What characterises as a pathological CTG?

<100bm/ >180bpm

Late decelerations >30 mins

Loss of BV/ too much BV

Acute bradycardia/ a single prolonged deceleration lasting >3 mins

SINUSOIDAL RHYTHM

499

How should a sinusoidal rhythm seen on CTG be managed?

Immediate cat 1 emergency c section

500

If a CTG is borderline, what is the next test you should do and why?

Foetal blood sampling - check for acisosis, which is a LATE marker of reduced oxygen delivery

501

How many 'non-reassuring' features of CTG should there be for it to be considered pathological? 

2

502

How does foetal head compression affect the CTG?

Causes a baroreceptor reflex that leads to a uniform deceleration

503

What should be the first course of action when a late deceleration is detected?

Immediate foetal blood sampling

504

How should a non-reassuring CTG be managed?

1. Left lateral position

2. Stop oxytocin and consider tocolysis - exclude an acute event (like cord prolapse or uterine rupture), correct any underlying causes and give fluids (IV/ oral)

3. Digital foetal scalp stimulation (this accelerates the HR)

505

Recall 4 indications for IUD

Long-term contraception

Endometriosis

Menorrhagia

HRT

506

Recall 7 requirements for forceps delivery

FORCEPS

Fully dilated cervix

OA position

Ruptured membranes

Cephalic presentation

Engaged presenting part

Pain relief

Sphincter (bladder) empty

507

What are the 4 categories of CS

Cat 1 = immediate threat to life of woman/ foetus

Cat 2 = immediate threat to life of woman/ foetus

Cat 3 = requires early delivery

Cat 4 - elective CS 

508

What is the main complication risk with forceps delivery?

3rd degree perianal tears

509

Which type of instrumental delivery is more dangerous for the foetus?

Ventouse

510

What is the main risk of a prolonged ventouse delivery?

Haemorrhage in the newborn

511

What are the possible complications of ventouse delivery?

Cephalohaematoma

Intracerebral haemorrhage

Retinal haemorrhage

Jaundice

512

What is the main risk to the foetus from forceps deliveries?

Facial nerve palsies eg. Erb's palsy from shoulder dystocia 

513

Recall 3 absolute contradicitions for vaginal birth after C section (VBAC) 

Previous uterine rupture

Classical (vertical) C section scar

Other non-C section contraindications (eg maor placenta praevia) 

514

Which has fewer complications: elective repeat CS or vaginal birth after CS?

VBAC

515

What are the main benefits of elective repeat C section?

No risk of rupture

Able to plan recovery

516

What are the main risks of elective repeat CS?

Pelvic adhesions

Longer recovery

Risk of bladder/ bowel injury (rare)

Placenta praevia/ accreta

Neonatal respiratory morbidity

517

After how many weeks should an elective repeat C section be performed?

After 39 weeks

518

What two forms of prophylactic treatment should all women getting a CS receive?

Thromboprophylaxis

Prophylactic Abx

519

Recall the 3 points of aftercare for a C section scar

1. Keep it dry and get sutures taken out after 5 days

2. No heavy lifting for 6 weeks

3. No getting pregnant for 12-18 months

520

Describe the two options for surgical sterilisation

1. Hysteroscopic sterilisation - expanding springs inserted into tubal ostia via hysteroscope --> induce fibrosis

2. Tubal occlusion - occlude fallopian tubes with Filshie chips

521

What is a safer, quicker procedure for surgical contraception than sterilisation?

Vasectomy

522

For how long after a sterilisation operation shoud women abstain from UPSI?

3 weeks

523

What should always be done before the sterilisation procedure?

Pregnancy test

524

For how long after sterilisation is effective contraception required?

If laparoscopic procedure: the next menstrual period

If hysteroscopic procedure: 3 months

525

What obstetric condition are women who have been sterilised at higher risk of?

Ectopic pregnancy

526

Recall the indications for TOP under the Abortion Act

  • [A] Continuation of pregnancy involves risk to pregnant woman greater than if pregnancy were terminated

 

  • [B] Termination necessary to prevent grave permanent injury to physical/mental health of pregnant woman

 

  • [C; majority] Pregnancy has not exceeded 24th week and continuance of the pregnancy would involve risk, greater than if pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

 

  • [D] Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing children of the family of the pregnant woman

 

  • [E] There is substantial risk that if the child were born it would suffer from physical or mental abnormalities

 

  • [EMERGENCY; F] To save the life of the pregnant woman; or

 

  • [EMERGENCY; G] To prevent grave permanent injury to the physical or mental health of the pregnant woman

527

What is the % risk of infection from TOP?

10%

528

What is required for a sign off of a TOP?

2 doctors unless an emergency

529

What must be done before a TOP?

Abx prophylaxis

Screen for chlamydia/ other STI if indicated

Assess VTE risk

Discuss future contraceptive needs (OCP/ IUD)

Check Rh status Bloods (eg haemaglobinopathy)

530

What is the max time between seeing a GP and having a TOP?

Less than 2 weeks

531

Recall the medical option for abortion at each stage of pregnancy

2 pills = 200mg mifepristone, then misoprostol (prostaglandin, 24-48 hours later)

0-9w: administer at home (bleeding for 2w after abortion)

9-24w: administer in clinic and repeat misopristol 3-hourly until expulsion

>22w: use feticide (intracardiac KCl injection)

532

Recall the surgical option for TOP

<14w: misoprostol (dilates) then ERPC (vacuum aspiration) + hCG level

>14w: misoprostol (dilates) then dilatation and curettage - under LA or GA

533

What are the booking tests done in pregnancy?

  • FBC
  • MSU
  • Blood group and antibody screen
  • Rhesus status and atypical antibodies
  • Haemaglobinopathy screen if indicated
  • Infection screen (Hep B, syphilis, HIV, rubella)

534

Recall a mnemonic to remember the causes of microcytic anaemia

TAILS

Thalassaemia

Anaemia of chronic disease

IDA

Lead poisoning

Sideroblastic anaemia

535

What type of hepatitis is included within the 1st trimester infection screen?

Hep B and now (recently) C

536

What test can be used to predict risk of trisomy 13/18/21 follwing a result of increased nuchal translucency (but isn't yet funded by the NHS in most trusts)?

cffDNA

537

What is the expected B-hCG and PAPP-A in trisomy 21?

High B-hCG and low PAPP-A

538

When is the 'triple test' done and what does it involve?

14-20w

AFP, PAPP-A, b-hCG

539

What does the anomaly scan look for?

Spina bifida

Diaphragmatic hernia

Major congenital abnormalities

Renal agenesis

540

What supplementation is given to all women during pregnancy?

Folic acid 400micrograms (5mg in epilepsy/ BMI >30)

Vit D

541

What breast changes should be expected at 12w, and why?

Nipples darken and breasts enlarge as this is highest oestrogen and human placental lactogen

542

What is hPL and what is its role?

Homologue to GH:

  • Decreases insulin sensitivity
  • Increases lipolysis to increase glucose availability for baby
  • Decreases glucose utilisation

543

What is B-hCG a homologue to?

TSH

544

What steroid and dose is used antenatally?

2x12mg IM Betamethasone - given 24 hours apart

Alternative: 4 doses of 6mg IM dexamethosone 12 hours apart

545

What is a partogram?

Pictorial assessment of the progress of labour, allowing rapid identification of slow/ obstructed labour

546

Who needs a partogram?

All women in active labour (>4cm dilated, contracting >3 in 10)

All women on synctocinon

Threatened premature labour with the use of atosiban

547

What is the mechanism of action of atosiban?

Inhibits ocytocin and vasopressin

548

What are the components of a partogram?

Maternal HR every 30 mins

Contractions every 30 mins

Colour of liquor every 30 mins

Cervicograph

Cervical dilation every 4 hours

BP and temp every 4 hours

Abdominal descent

549

What is the expected speed of cervical dilatation in a nulliparous vs a multiparous woman?

Nulliparous: 0.5cm/ hour

Parous: 0.5-1cm/ hour

550

What speed of labour on the partogram may suggest a prolonged labour?

0.5cm/ hour

551

What is the 'action line' on the partogram?

4 hours right of the alert line - if the cervical dilation crosses this then urgent obstetric review is needed

552

What is the first point of management in cord prolapse?

Summon senior help (and consider baby monitoring with CTG)

553

How can further cord prolapses be prevented?

Digital vaginal exam

Elevate the presenting part/ fill the bladder to reduce pressure

Tocolytics

Avoid handling the cord as this causes cord spasm

IF CORD PAST INTROITUS, DON'T PUSH BACK IN

Deliver ASAP

554

How should the mother be positioned in cord prolapse?

Either on all 4s or in left lateral position

555

Recall the definition of the 4 degrees of tear

1st degree = superficial damage with no muscle involvement

2nd degree = injury to perineal muscle, but no anal sphincter involvement

3rd degree = injury involves anal sphincter complex (3a = <50% of external anal sphincter involved, 3b = >50% of eas, 3c = involves interna sphincter)

4th degree = injury to perineum involving anal sphincter and rectal mu

556

What types of tear can be managed by the GP alone?

1st and 2nd degree

557

By how much does cardiac output input increase during pregnancy?

50%

558

How much does stroke volume increase by in pregnancy?

35%

559

By how much does tidal volume increase during preganancy?

30-50%

560

How do kidneys change during pregnancy?

More aldosterone (fluid retention)

GFR increases in 1st TM

561

What are the expected haematological changes in pregnancy?

Macrocytosis

Neutrophilia

Thrombocytopaenia

Dilutional Anaemia

Increased VWF, F7 F8, fibrinogen

Decreased protein S