OB-GYN Revision 9

Question 2

Describe the risk of infection of chickenpox during pregnancy [+]

Answer 2

Risk of Fetal varicella syndrome (FVS):
- skin scarring
- eye defects (microphthalmia) and cataracts
- scars and significant skin changes located in dermatomes
- limb hypoplasia
- microcephaly
- learning disabilities

Lecture notes:
- soft-tissue calcification
* polyhydramnios,
* limb defects and dermatomal skin scarring (due to fetal herpes zoster),
* soft-tissue calcification
* damage to the eyes and CNS.

Neurological defects include cortical atrophy, microcephaly, limb paresis, spinal cord atrophy, encephalitis, seizures and Horner’s syndrome.

Question 3

severe neonatal varicella:
* if the mother develops rash between [] days before and [] days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 3

severe neonatal varicella:
- if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Question 4

Describe how you manage chickenpox exposure during pregnancy [1]

Describe how you manage chickenpox infection during pregnancy [1]

Answer 4

oral aciclovir (or valaciclovir) is now the first choice of PEP for pregnant women at any stage of pregnancy who are exposed to chickenpox
- antivirals should be given at day 7 to day 14 after exposure, NOT immediately

Infection:
- consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’

NB why wait: n a study evaluating the comparative effectiveness of 7 days course of aciclovir given either immediately after exposure or starting at day 7 after exposure to healthy children, the incidence and severity of varicella infection was significantly higher in those given aciclovir immediately (10/13 (77%) who received aciclovir immediately developed clinical varicella compared with 3/14 (21%) who started aciclovir at day 7

Question 5

Describe the features of congenital rubella syndrome [5]

What is the clinical triad? [3]

Answer 5

• Congenital deafness
• Congenital cataracts
• ‘Salt and Pepper’ chorioretinitis
• Congenital heart disease (PDA and pulmonary stenosis)
• Learning disability
• Cerebral palsy

Triad:
- Microcephaly
- PDA
- Cataracts

Lecture:
- Hearing loss, learning disability, heart malformations and eye defects, neurodevelopmental delay, and endocrinopathies.

Question 6

Rubella infection causing congenital rubella sydnrome is caused by maternal infection within the first [] weeks of pregancy.

When is there the highest risk? [1]

What is the clinical significance of this? [1]

Answer 6

First 20 weeks - but first 10 weeks poses highest risk

When primary infection occurs before 12weeks’ gestation, given the risk of fetal infection and the risk of an infected fetus developing severe abnormalities, it is reasonable to consider termination of pregnancy when appropriate

Question 7

Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene to prevent which infection? [1]

What is the clinical manifestation of having this infection in pregnancy? [1]

Answer 7

Listeria:
- Listeriosis in pregnant women has a high rate of miscarriage or fetal death.
- It can also cause severe neonatal infection.

Question 8

The features of congenital CMV are [5]

Answer 8

The features of congenital CMV are:
* ‘Blueberry muffin rash’
* Petachial rash
* Fetal growth restriction
* Microcephaly
* Hearing loss - this is the key one to remember
* Vision loss
* Learning disability
* Seizures

NB: With approximately 40,000 infected children per year, congenital CMV infection is the most common cause of congenital non-genetic hearing loss

Question 9

Bilateral cataracts in a newborn would most likely indicate..[1]

Answer 9

Congential rubella infection

Question 10

There is a classic triad of features in congenital toxoplasmosis.

What is it? [3]

Answer 10

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

Question 11

How do you treat listeriosis infection in pregnancy? [2]

Answer 11

Ampicillin and gentamicin

Question 12

Fetal hydrops would indicate infection from..?[1]

Answer 12

Parvovirus B19

Question 13

Blueberry muffin rash has which 2 key ddx? [2]

Answer 13

CMV
Rubella

Question 14

Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters. Complications are: [4]

Answer 14

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

Question 15

What causes fetal anaemia from parvovirus B19 infection? [1]
What effect does this have? [1]

Answer 15

Fetal anaemia is caused by parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver.
- This anaemia leads to heart failure, referred to as hydrops fetalis.

Question 16

What is the triad of seen in pregnant parvovirus b19 infection? [3]

Answer 16

It involves a triad of hydrops fetalis, placental oedema and oedema in the mother
- + hypertension and proteinuria.

Question 17

Women suspected of parvovirus infection need which tests? [3]

Answer 17

• IgM to parvovirus, which tests for acute infection within the past four weeks
• IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
• Rubella antibodies (as a differential diagnosis)
  *

Question 18

A baby born with congenital Zika syndrome which would [2]

Answer 18

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

Question 19

Causes of polyhydramnios can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid
.
Excess production can be due? [4]

Insufficient removal can be due to reduced foetal swallowing. Due to: [4]

Answer 19

Excess production can be due to increased foetal urination:
* Maternal diabetes mellitus
* Foetal renal disorders
* Foetal anaemia
* Twin-to-twin transfusion syndrome

Insufficient removal can be due to reduced foetal swallowing. Due to: [4]
* Oesophageal or duodenal atresia
* Diaphragmatic hernia
* Anencephaly
* Chromosomal disorders

Question 20

What are the maternal [4] complications of polyhydramnios?

Answer 20

Maternal:
- respiratory compromise due to increased pressure on the diaphragm
- Increased risk of urinary tract infections due to increased pressure on the urinary system
- Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks
* Increased incidence of caesarean section delivery

Question 21

What are the foetal [4] complications of polyhydramnios?

Answer 21

• Pre-term labour and delivery
• Premature rupture of membranes
• Placental abruption
• Malpresentation of the foetus (the foetus has more space to “move” within the uterus)
• Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Question 22

Lecture notes

It causes up to 21% of all congenital hearing loss at birth and 10% of all cases of cerebral palsy

Refers to

CMV
VZV
Rubella
Parvovirus
Toxoplasmosis

Answer 22

Lecture notes

It causes up to 21% of all congenital hearing loss at birth and 10% of all cases of cerebral palsy

Refers to

CMV
VZV
Rubella
Parvovirus
Toxoplasmosis

Question 23

Lecture

When is the greatest risk of transmission of CMV in pregnancy? [1]

When is the greatest risk of severe fetal infection? [1]

Answer 23

The risk of congenital infection appears to vary according to the point in gestation at which primary infection occurs, increasing from around 30% in the first trimester to 47% in the third trimester.

While the risk of viral transmission is lower in early pregnancy, the proportion of cases with a prenatal diagnosis of severe fetal infection is higher when infection occurs in the first compared with the third trimester of pregnancy.

Question 24

Which of the following best describes CMV in pregnancy

• Infection is most likely in first trimester; biggest risk to baby in first trimester
• Infection is most likely in first trimester; biggest risk to baby in third trimester
• Infection is most likely in third trimester; biggest risk to baby in third trimester
• Infection is most likely in third trimester; biggest risk to baby in first trimester

Answer 24

• Infection is most likely in third trimester; biggest risk to baby in first trimester

Question 25

Describe how you dx CMV in pregnancy [2]

Answer 25

The diagnosis of primary CMV infection in pregnancy can be made following either: the appearance of **CMV-specific IgG** in a woman who **was previously seronegative**; or detection of **CMV IgM antibody and low IgG avidity**

Question 26

Lecture: **The main sequelae of congenital toxoplasma infection** involve the **CNS** and **eyes**, and typically include [**4**]

Answer 26

The main sequelae of congenital toxoplasma infection involve the CNS and eyes, and typically include **microcephaly, hydrocephalus, ventriculomegaly and chorioretinitis**. These may lead to developmental delay, epilepsy and blindness.

Question 27

How do you treat TG infection: - to prevent vertical transmission after maternal infection [1] - If vertical transmission is confirmed [4]

Answer 27

**Spiramycin** (until the end of the pregnancy, in the absence of confirmed vertical transmission) **should be used to prevent vertical transmission after maternal toxoplasma infection during pregnancy** If **vertical transmission** is **confirmed**: - fetal infection should be treated by **spiramycin** **only for 1 week,** followed by **pyrimethamine** **plus** **sulfadiazine** **plus** **folinic** **acid** **throughout** the **pregnancy** and the **infant treated for 1further year.**

Question 28

# Parvovirus Fetal anaemia and fetal hydrops both visible on ultrasound. Anaemia can be assessed measuring at the how exactly? [1]

Answer 28

Fetal anaemia and fetal hydrops both visible on ultrasound. Anaemia can be assessed measuring at the **Peak Systolic on Middle Cerebral artery (raised MCA-PSV).**

Question 29

Describe how herpes simplex can impact new born? [3]

Answer 29

Can cause **localised to skin, eye and/or mouth lesions or local central nervous system (CNS) disease (encephalitis)**

Question 30

How do you treat HSV infection in pregnancy? [2]

Answer 30

Treatment should not be delayed. Management of the woman should be in line with her clinical condition and will usually involve the **use of oral** (or intravenous for disseminated HSV) **aciclovir** in **standard doses** (400 mg three times daily, usually for 5 days). **In the third trimester, treatment will usually continue with daily suppressive aciclovir 400 mg three times daily until delivery**. **Caesarean** **section** should be the **recommended mode of delivery** for all women developing **first episode genital herpes in the third trimester**, particularly those **developing symptoms within 6 weeks of expected delivery**, as the risk of neonatal transmission of HSV is very high at 41%

Question 31

Describe how you would deliver a patient with polyhydramnios: - moderate [1] - severe [1] - what would do for baby afterwards birth [1]

Answer 31

Delivery: * Risk of malpresentation / cord prolapse/ pre term labour * Aim **delivery** around **37 weeks** for **severe polyhydramnios** * **38-40 weeks** for **moderate** **polyhydramnios** * **Nasogastric tube postnatally** to ensure there is **no blockage in oesophgus/ tracheoesophageal fistula**

Question 32

Describe the legal framework of abortions [1]

Answer 32

The **legal framework** for a **termination of pregnancy is the 1967 Abortion Act.** The **1990 Human Fertilisation and Embryology Act** altered and expanded the criteria for an abortion, and **reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks.**

Question 33

An abortion can be performed at any time during a pregnancy in which circumstances? [3]

Answer 33

**Continuing** the pregnancy is likely to **risk the life of the woman** **Terminating** the **pregnancy** will **prevent** “**grave permanent injury**” to the **physical or mental health** of the woman There is “**substantial** **risk**” that the **child** would **suffer physical or mental abnormalities** making it seriously **handicapped**

Question 34

What are the legal requirements for an abortion to proceed? [2]

Answer 34

**Two** **registered** **medical** **practitioners** must sign to agree abortion is **indicated** - have to be **doctors**. **Sign an HSA1 form** - **Form** **retained** for **7 years in the notes** It must be **carried** **out** by a **registered medical practitioner in an NHS hospital or approved premise**

Question 35

Under which clause are 98% of abortions under? [1]

Answer 35

**Clause C**: - carrying a pregnancy to term is physically more dangerous than having an abortion - if dont want a pregnancy - then this clause protects their mental health

Question 36

Descrine the difference in types of medical / surgical abortion offered depending on gestation time [4]

Answer 36

**Medical** * **< 12 weeks**: early medical abortions: at home or clinical facility * **>12 weeks:** have to be at a clinic **Surgical** * **< 14 weeks**: manual or electic aspiration * **> 14 weeks**: dilatation or evacuation

Question 37

In England & Wales - up to when can you have pills by post (early medical management)? [1] In Scotland? [1] Describe the medical management [2]

Answer 37

England & Wales: < 10 weeks Scotland: < 12 weeks Medication: - **MiFepristone** - **F**irst drug @ home or in clinic. Ends the pregnancy but doesn't cause the pregnancy to pass. Therefore 24-48 hrs later.. - **MiSoprostol** - **S**econd drug. Acts to cause contractions that pass the pregnancy, at home or clinic.

Question 38

Describe what the symptoms are like for someone who has undergone medical abortion < 10 / 12 weeks [5]

Answer 38

**Symptoms** typically start **2-3 hours** after starting **misoprostol** (second medication) * **Vaginal bleeding** - gestational age correlates to bleeding amount * **Heavy with clots** * Some **bleeding** up to **2-3 weeks** - normal * **Lower abdominal pain** - stronger than period pain **Bad period-like cramping pain** * Most **complete** within **6-8 hours**, almost all by **24 hours** Since telemedicine, EMA can be provided in many circumstances without the need for a scan

Question 39

Describe the medical management for an abortion > 10/12 weeks? [2]

Answer 39

**Mifepristone** **200 mg orally** * **Repeated** **doses** of **misoprostol** at **3 hour intervals** starting **24 hours post mifepristone** - because pregnancy is more developed and larger * In patient

Question 40

How do you medically manage a pregnancy > 22 weeks? [2]

Answer 40

**Feticide** recommended from **22 weeks to avoid** **possibility** of **birth with signs of life** * **Digoxin**: intraamniotic, intrafetal, intracardiac * **Potassium** **chloride**: intracardiac

Question 41

How do you perform vacuum aspiration - up to 14 weeks? [2]

Answer 41

* **Dilation of cervix** and **aspiration** of **pregnancy** **tissue** with **electric or manual suction** * **Local** (manual suction) or **general** anaesthesia (electric) or **conscious** sedation

Question 42

Describe the surgical process from 14+ plus [3]

Answer 42

**Dilatation and evacuation (D&E)** Typically from **14-24 weeks** * **Cervical** **preparation** with **mifepristone** / **misoprostol (or both) / osmotic dilators** inserted into cervical os; absorb fluid and then dilate cervix * **Cervical dilation and removal of fetus and placenta using forceps and vacuum aspiration**

Question 43

Post-surgery, what medication do you need to consider / give? [2]

Answer 43

**Antibiotic prophylaxis** * Not required for early medical abortion * Surgical: **doxycycline 100mg bd for 3 days** (or Azithromycin 1g oral) **Anti-D** * Not required for early medical abortion * **Prophylactic anti-D for all Rh negative, non-sensitised women** undergoing surgical abortion * Administer within 72 hours of abortion

Question 44

What is the most common complication from EMA? [1]

Answer 44

Question 45

How do you follow up an abortion? [1]

Answer 45

**Important** to do **low sensitivity PT 3 weeks after medical abortion** - Low sensitivity because the high street ones are too sensitive and would detect a +ve result even though levels are appriopriate post abortion

Question 46

When should a patient seek medical attention post-abortion? [5]

Answer 46

**Very heavy bleeding** * If soaking more than two pads per hour for two consecutive hours * Symptoms of anaemia e.g. dizziness, SOB, palpitations, fatigue **Persistent bleeding or pain** (more than a week) **Offensive vaginal discharge** **High fever or feeling systemically unwell** Also should contact abortion service if **persistent bleeding >3 weeks** or **positive low sensitivity pregnancy test at 3 weeks post EMA**