Obstetrics Flashcards
(163 cards)
1
Q
Which antihypertensive is used in pregnancy? What if the first line is CI?
A
Labetalol
If BB is contraindicated (e.g. Asthma) -> Nifedipine / Methyldopa
2
Q
Which anti-epileptics are safe for use in pregnancy?
A
Lamotrigine
Carbamazepine
3
Q
Which rheumatoid drugs are safe for use in pregnancy?
A
Hydroxychloroquine
Sulfasalazine
4
Q
What are the antenatal combined test results for Down Syndrome? How does this differ for Edwards and Patau’s?
A
Raised HCG
Low PAPP-A
Thickened nuchal translucency
Edwards and Patau’s = lower PAPP-A
5
Q
When should fetal movements be felt by?
A
24 weeks
6
Q
Which anticoagulants are safe for use in pregnancy?
A
Low molecular weight heparin
Aspirin (Antiplatelet)
(DOAC + Warfarin = CI)
7
Q
What is the normal dose and higher dose of folic acid?
A
Normal dose = 400 micrograms
High dose = 5mg
8
Q
Who needs the higher dose of folic acid?
A
MORE
Metabolic disease (diabetes, coeliac)
Obesity
Relative/personal history of neural tube defects
Epilepsy
Also- sickle cell, thalassaemia
9
Q
When should a woman be induced with intrahepatic cholestasis?
A
37-38 weeks
10
Q
When should a woman with gestational diabetes be induced?
A
37-38 week
11
Q
How is long-standing hypothyroidism treated in a woman who has become pregnant?
A
Increase levothyroxine by 25mcg
12
Q
Are ACEi and ARBs safe in pregnancy?
A
No
13
Q
Are calcium channel blockers safe in pregnancy?
A
Yes
14
Q
How long does methotrexate need to be stopped prior to trying for a baby?
A
6 months in both men and women
15
Q
Which diabetic drugs are safe for use in pregnancy?
A
Only insulin and Metformin
16
Q
How does congenital rubella syndrome present?
A
Congenital sensorineural deafness
Congenital heart disease
Congenital cataracts
Blueberry muffin rash
Congenital hydrocephalus
17
Q
How do you treat a pregnant woman who has been in contact with chickenpox who has not had chickenpox before?
A
If less than 20 weeks - give varicella zoster immunoglobulins (up to 10 days post exposure)
If more than 20 weeks - oral Aciclovir within 24 hours, or give VZIG or Aciclovir between day 7 and day 14
18
Q
How do you treat a pregnant woman who has been diagnosed with chicken pox?
A
Oral Aciclovir
19
Q
What can happen if a woman has chickenpox during pregnancy?
A
Can cause fetal varicella syndrome - skin scarring, eye defects, limb hypoplasia, microcephaly
20
Q
Which infection during pregnancy can cause hydrops fetalis (severe fetal heart failure)?
A
Parvovirus B19
21
Q
What intrapartum prophylaxis is given for Group B strep and which women need it?
A
IV Benzylpenicillin
- Women who have had GBS in a previous pregnancy
- Women with a previous baby with GBS
- Women with pyrexia in labour
- Women in preterm labour
22
Q
When do Anti-D injections need to be given?
A
28 weeks
34 weeks
Birth if baby is confirmed +ve
Any sensitisation events (within 72 hrs)
23
Q
What are sensitisation events?
A
Antepartum haemorrhage
Amniocentesis
Abdominal trauma
Ectopic pregnancy
Miscarriage after 12 weeks
Any bleeding after 12 weeks
Any heavy or painful bleeding before 12 weeks
Termination
Any abdominal trauma (even if no apparent bleeding)
24
Q
How soon after a sensitisation event does Anti-D need to be given?
A
Within 72 hours
25
What additional test needs conducting if a sensitisation event occurs after 20 weeks of pregnancy?
Kleihauer test
To check if any more anti-D is needed
26
What is a small for gestational age baby?
Below 10th centile for gestational age
27
What are causes of a baby being small for gestational age?
Constitutionally small
Placenta-mediated -> pre-eclampsia, maternal smoking/alcohol, anaemia, malnutrition
Non-placenta mediated -> genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism
28
What are maternal risk factors for a baby being small for gestational age?
Previous SGA baby
Obesity
Diabetes
HTN
Pre-Eclampsia
Mother > 35
Multiple pregnancy
Antiphospholipid syndrome
29
What is large for gestational age?
Above the 90th percentile or born more than 4.5 kg
30
What are causes of a baby being born for large for gestational age?
Constitutional
Maternal diabetes
Maternal obesity
Overdue
31
What are complications of a baby being born large for gestational age?
Shoulder dystopia
Failure to progress
Perineal tears
Postpartum haemorrhage
32
What are causes of polyhydramnios?
Impaired swallowing (oesophageal atresia)
Fetal anaemia, maternal diabetes (increased urination)
33
What are causes of oligohydramnios?
Decreased urination (renal agenesis)
Pre-eclampsia
HTN
34
Where should the fundus be palpable?
From 20 weeks - at the umbilicus
From 36 weeks - at the xiphisternum
35
What causes raised alpha-fetoprotein in pregnancy?
Meningocele
Omphacele
Multiple pregnancy
36
What causes low alpha-fetoprotein in pregnancy?
Down syndrome
Edwards syndrome
Maternal diabetes
37
What is the management of choice for UTI in pregnancy?
Nitrofurantoin (not in 3rd trimester)
38
How is VTE risk treated in pregnancy?
Low molecular weight heparin
If 3 risk factors - from 28 weeks to 6 weeks postpartum
If 4 or more risk factors - from 1st trimester to 6 weeks postpartum
39
What are risk factors for VTE in pregnancy?
Smoking
Parity of 3 or more
Age over 35
BMI over 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Varicose veins
Family history
Thrombophilia
IVF
40
How can you differ between gestational hypertension and pre-existing hypertension
Gestational = occurs after 20 weeks of pregnancy
41
What is pre-eclampsia? How does it present?
New hypertension in pregnancy
Proteinuria
Oedema
End organ dysfunction (e.g. raised creatinine)
Headache
Nausea
Abdominal pain
42
What is eclampsia?
Pre-eclampsia with the addition of seizures
43
How is eclampsia managed?
IV Magnesium sulphate
44
How is pre-eclampsia risk managed?
Aspirin daily from 12 weeks
If 1 high risk factor or 2 moderate factors
45
How is diagnose pre-eclampsia treated?
Oral Labetalol
Planned induction
46
What are high risk factors for pre-eclampsia?
Pre-eclampsia in a prior pregnancy
Pre-existing hypertension
Diabetes
Renal disease
47
What are moderate risk factors for pre-eclampsia?
Nulliparity
Obesity
Mother or sister who had pre-eclampsia
Mother aged 40 years or older
Multiple pregnancy
48
What is HELLP syndrome?
Haemolysis (high LDH)
Elevated liver enzymes
Low platelet count
49
How does HELLP syndrome present?
Nausea and vomiting
Right upper quadrant pain
Lethargy
Headache
Bleeding
Changes in vision
Oedema
SOB
Chest pain
50
How is HELLP syndrome managed?
Delivery
51
What is gestational diabetes?
Diabetes triggered by reduced insulin sensitivity in pregnancy
52
What are the main complications of gestational diabetes?
Large for gestational age neonate
Macrosomia
Polyhydramnios
53
How is gestational diabetes diagnosed?
Oral glucose tolerance test
Fasting glucose >5.6
2 hour glucose >7.8
54
How is gestational diabetes treated?
If fasting glucose >7 = insulin (short acting only)
Or if there are any complications such as macrosomia or polyhydramnios = insulin
If fasting glucose <7 and no complications = Metformin
55
How is pre-existing diabetes treated in pregnancy?
Stop all medication other than Metformin and insulin
Start daily folic acid 5mg
Retinopathy screening at booking and at 28 weeks
Delivery between 37 and 39 weeks
56
What are the treatment targets in gestational diabetes?
Fasting = 5.3
2 hour = 6.4
57
What is obstetric cholestasis and how does it present?
Pruritus particularly in hands and feet
Due to reduced outflow of bile from liver
Also may be fatigue, dark urine, pale stools, jaundice
58
What are complications of obstetric cholestasis?
Increased risk of stillbirth and preterm birth
59
Which liver marker is normal to rise in pregnancy?
Alkaline phosphatase
60
How is obstetric cholestasis managed?
Ursodeoxycholic acid
Induction at 37-38 weeks due to increased risk of stillbirth
61
Rash in pregnancy: rash on the abdomen which spares the umbilicus?
Polymorphic eruption of pregnancy
Managed with emollients and topical steroids
62
Rash in pregnancy: red lump often on fingers, can be on gum?
Pyogenic granuloma
Resolves after delivery
63
Rash in pregnancy: fluid filled blisters around the umbilicus?
Pemphigoid gestatationitis
64
What is placenta praevia?
When the placenta is lying too low in the uterus and covering the internal cervical os
Can cause antepartum haemorrhage
65
What are the two main causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
66
How does placenta praevia present?
Usually asymptomatic until bleeding occurs
No pain, uterus is soft and non-tender
67
How is placenta praevia diagnosed?
TVUSS
Do not perform a bimanual examination (can trigger bleeding)
68
How is a bleeding placenta praevia managed?
Less than 34 weeks -> admit for antenatal corticosteroids
More than 34 weeks -> C section
69
How is an asymptomatic placenta praevia diagnosed on scan managed?
Planned CS at 37-38 weeks
70
What is a vasa praevia?
Exposure of the fetal vessels outside of the umbilical cord placenta, these then pass through the internal cervical os
These vessels are prone to bleeding during labour
71
How is vasa praevia managed?
Elective CS at 34-36 weeks
72
What is placental abruption?
The placenta separates from the wall of the uterus during pregnancy
Causes antepartum haemorrhage
73
How does placental abruption present?
Sudden onset severe abdominal pain
Vaginal bleeding
Woody, hard, tender abdomen
Patient may be in shock - hypotension, tachycardia
May be concealed - cervical os remains closed and blood remains in the uterine cavity
74
How is a placental abruption managed?
ABCDE
Gain access
Fluid and blood resus
CTG - If fetal distress, immediate CS
If no feral distress - induce vaginal labour if >36w, admit for antenatal corticosteroids if <36 weeks
75
What are risk factors for placental abruption?
Cocaine use
Multi parity
Maternal trauma
Increasing maternal age
Previous abruption
Polyhydramnios
Infection (chorioamnionitis)
HTN, pre-eclampsia
76
What is placenta accreta?
When the placenta attached to the myometrium instead of the endometrium
Placenta cannot fully separate after delivery
Leads to postpartum haemorrhage
77
How is placenta accreta managed?
Elective CS at 35-37 weeks, hysterectomy
78
What are the four different types of breech presentation?
Complete = knees and hips fully flexed
Incomplete = one leg extended at knee
Frank = both legs extended at knee
Footling = foot through cervix
79
When should external cephalic version be tried?
If woman is nulliparous - by 36 weeks
If not nulliparous - at 37 weeks
80
What are contraindications to external cephalic version?
Antepartum haemorrhage in last 7 days
Abnormal CTG
Major uterine abnormality
Ruptured membranes
Multiple pregnancy
81
What are causes of reduced fetal movement?
Posture of mother
Placental position
Fetal position
Medication
Maternal obesity
Oligohydramnios/polyhydramnios
SGA fetus
82
How should reduced fetal movements be investigated?
Handheld Doppler
If no heartbeat -> immediate ultrasound
If heartbeat -> CTG for 20 mins
83
Which antibiotics should be avoided in pregnancy and breastfeeding?
Tetracyclines - doxycycline
Trimethoprim (safe in breastfeeding)
Clarithromycin
Ciprofloxacin
84
What is the definition of stillbirth?
Birth of a dead fetus from 24 weeks
85
What are causes of stillbirth?
Unexplained
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse
Infection
86
How is stillbirth managed?
Vaginal delivery is preferred
Can give oral mifepristone and vaginal misoprostol to induce
If mother is Rh -ve give Anti-D
87
How is preterm premature rupture of membranes managed?
Admit for oral erythromycin 10 days
Antenatal corticosteroids
88
What are indications for induction of labour?
Prolonged pregnancy
Premature rupture of membranes
Diabetic mother >38 weeks
Pre-eclampsia
Fetal growth restriction
Bishop score <5
89
What is the stepwise approach for induction of labour?
1. Membrane sweep
2. Vaginal prostaglandins (E2) - gel/pessary
3. Cervical ripening balloon
90
What is uterine hyper stimulation and how is it managed?
Prolonged and frequent contractions caused by induction
Can cause uterine rupture
Remove prostaglandins and administer tocolysis
91
How is the Bishop score calculated?
Position - posterior, middle, anterior
Consistency - firm, medium, soft
Effacement
Dilation
Foetal station
92
What two things does a CTG measure?
Fetal heart rate
Contractions
93
What are indications for continuous CTG during labour?
Sepsis/fever
Maternal tachycardia
Pre-eclampsia / severe HTN
Antepartum haemorrhage that starts in labour
Significant meconium
94
What is the normal baseline rate on a CTG?
110-160
95
What is normal variability on a CTG?
5-25
96
What do short episodes of decreased variability on a CTG suggest?
Fetus is asleep
97
When are variable decelerations ok?
If they last less than 2 minutes
If there are brief accelerations before and after
98
What kind of decelerations are normal?
Early decelerations (correspond to contractions)
Decelerations that last less than 2 minutes
99
What should you do if there is a prolonged deceleration?
If deceleration is more than 2 minutes this is prolonged
3 mins - call for help
6 mins - move to theatre
9 mins - prepare for delivery
12 mins - deliver baby
100
How can you diagnose the cause late decelerations?
Do fetal blood sampling
If pH is low then baby is hypoxic
101
What are causes of baseline tachycardia on CTG?
Maternal pyrexia
Chorioamnionitis
Hypoxia (cord compression)
Prematurity
102
What are obstetric analgesia options? (During labour)
Gas and air (Entonox)
Paracetamol
Oral codeine or IV Diamorohine
Epidural (only once in established labour)
Pudendal nerve block
103
How is failure to progress managed?
If due to contraction power - oxytocin
If due to abnormality of baby/passage - instrumental delivery or C section
104
What is an umbilical cord prolapse?
Umbilical cord descends below the present in part - into the vagina
105
How is umbilical cord prolapse seen on CTG?
Variable or prolonged decelerations
106
How is umbilical cord prolapse managed?
Get woman on all fours
Elevate presenting part
Immediate c-section
107
What is shoulder dystocia?
Anterior shoulder becomes stuck behind pubic symphysis after head has been delivered
108
What is the main cause of shoulder dystocia?
Macrosomia - usually due to gestational diabetes
109
How does shoulder dystocia present?
Failure of resuscitation - baby does not turn sideways
Turtle neck sign - baby’s head retracts back up to vagina
110
How is shoulder dystocia managed?
McRoberts manoeuvre - bring knees to abdomen and apply suprapubic pressure
If this fails - episiotomy
111
What is a complication of shoulder dystocia?
Brachial plexus palsy (Erb's palsy)
112
What are the 4 types of perineal tears and how are they managed?
1st degree - frenulum of labia minors and superficial skin (no sutures needed)
2nd degree - includes perineal muscles (sutures needed)
3rd degree - includes anal sphincter (repair in theatre)
4th degree - includes rectal mucosa (repair in theatre)
113
What are complications of perineal tears?
Urinary incontinence
Faecal incontinence (3rd and 4th degree)
Dyspareunia
114
How much blood loss is needed to count as a postpartum haemorrhage?
More than 500ml after vaginal delivery
More than 1000ml after c-section
115
What is the difference between a primary and secondary PPH?
Primary - from birth to 24 hours
Secondary - from 24 hours to 12 weeks
116
What are causes of secondary PPH?
Retained products of conception (treated with D+C)
Infection (endometritis) - treated with Abx
117
What are the four main causes of primary PPH?
Tone (uterine atony - uterus fails to contract after delivery)
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder)
118
How do you treat uterine atony?
Uterine massage (Bimanual stimulation)
IV syntocinon
IM Carboprost
119
What are the two main causes of maternal sepsis?
Chorioamnionitis
Urinary tract infections
120
What is Chorioamnionitis?
Bacterial infection of the amniotic fluid/membranes/placenta
121
How is chorioamnionitis managed?
IV Abx
Prompt delivery
122
How do you investigate signs of sepsis in a pregnant woman?
Bloods
Urine dipstick
High vaginal swab
123
What is an amniotic fluid embolism and how does it present?
When amniotic fluid passes into the mothers blood
Presents around labour/delivery - often with sudden collapse
124
What is the difference between baby blues and postnatal depression?
Baby blues - first week of life, usually resolves within 2 weeks of delivery
Postnatal depression - low mood, Anhedonia, low energy, presents around 3 months after birth
125
How is postnatal depression managed?
Mild - self-help
Moderate - SSRIs (Sertraline/Paroxetine) / CBT
Severe - psych services
126
What is puerperal psychosis and how is it managed?
Psychotic symptoms - delusions, hallucinations, depression, mania, confusion
Presents 2-3 weeks after delivery
Urgent psychiatric assessment - usually admission to Mother & Baby Unit
127
Which medications are safe during breastfeeding (but unsafe during pregnancy)?
Trimethoprim
Sodium valproate
Warfarin
128
What is lactational amenorrhoea?
Complete amenorrhoea when a woman is fully or nearly breastfeeding
This is an effective contraception for up to 6 months
129
What causes a raised alpha feto-protein in pregnancy?
Neural tube defects - meningocele, anencephaly
Abdominal wall defects - omphacele, gastroschisis
Multiple pregnancy
130
How is UTI in pregnancy treated?
Nitrofurantoin/Amoxicillin
Avoid Nitrofurantoin in the last trimester
131
How is chlamydia in pregnancy treated?
Azithromycin/erythromycin
132
When should folic acid be started and stopped for pregnancy?
Started = upon trying to conceive
Stopped = end of first trimester
133
Which conditions are all pregnant woman offered screening for?
Anaemia
Bacteriuria
Blood group
Down syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Syphilis
134
How is premature rupture of the membranes diagnosed?
Speculum examination to look for pooling of amniotic fluid in the posterior vagina vault
Avoid digital examination due to the risk of infection
Consider ultrasound If no fluid seen in vault
135
Which liver enzyme can be raised in pregnancy?
ALP due to placental ALP
136
How is lactation mastitis treated?
Symptoms less than 12-24 hours - conservative
More than 12-24 hours - Oral flucloxacillin
Continue breastfeeding
137
How is nipple candidiasis treated?
Miconazole cream for the mother
Nystatin suspension for the baby
138
What is the cut off of how much weight breastfed babies should lose in the first week of life?
No more than 10%
If more than 10% -> refer to midwife led breastfeeding clinic
139
Which foods should be avoided in pregnancy?
Unpasteurised milk
Ripen soft cheeses e.g. camembert, brie and blue veined cheeses
Pâté
Liver
140
From what gestation should a travel be avoided in pregnancy?
From 37 weeks or from 32 weeks if multiple pregnancy
141
What is the stepwise management for uterine atony?
Bimanual uterine compression/uterine massage
IV oxytocin and/or ergometrine
IM carboprost
Intramyometrial carboprost
Rectal misoprostol
Surgical intervention e.g. balloon tamponade
142
Which cardiovascular signs can be normal in pregnancy?
Third heart sound
Ejection systolic murmur
Forceful Apex beat
Peripheral oedema
143
What are the requirements for an instrumental delivery?
Fully dilated cervix
OA position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Empty bladder
144
Which medications are contraindicated in breastfeeding?
Aspirin
Amiodarone
Codeine
Lithium
Naproxen
Ciprofloxacin
Methotrexate
Any diabetic drugs except Metformin
ACEi/ARB
145
 is sodium valproate safe in breastfeeding?
Yes nearly all antiepileptic drugs are safe in breastfeeding
146
Is warfarin safe in breastfeeding?
Yes
147
Which VTE prophylaxis is used in pregnancy?
Low molecular weight heparin
148
What are the SSRIs of choice in breastfeeding women?
Sertraline or paroxetine
149
How do you manage a woman with known placenta previa who goes into labour?
Emergency Caesarean
150
How is anaemia in pregnancy treated?
Oral iron tablets
151
How long should magnesium sulphate treatment for eclampsia continue for?
24 hours after the last seizure or delivery
152
What is a complication of magnesium sulphate and how can this be treated?
Magnesium sulphate can cause respiratory depression
Calcium gluconate can be used to treat this
153
Can a VBAC occur at home?
No - must be on labour ward
154
How long after delivering can an IUD/IUS be inserted?
Either in first 48 hours after birth
Or then must wait at least 4 weeks
155
What's the difference between placenta accreta, increta and percreta?
Accreta = placenta attached to superficial myometrium
Increta = placenta invades into the myometrium
Percreta = placenta goes through the myometrium
156
What is the earliest gestation that a pregnant woman can be diagnosed with pre-eclampsia/gestational HTN?
20 weeks- any earlier is chronic hypertension
157
How long do you need to take folic acid?
Til end of first trimester
158
What medication is routinely given prior to a c section? Why?
PPI
Reduces the risk of acid aspiration
159
When can an artificial rupture of membranes be performed as part of induction of labour?
If cervix is ripe and head is well engaged
160
Why does maternal diabetes casue polyhydramnios?
Hyperglycaemia --> Increased urination
161
What are contraindications to tocolysis?
```
>34w
Non-reassuring CTG
IUGR
Cervical dilation >4cm
Chorioamnionitis
Pre-eclampsia
APH
Haemodynamic instability
```
162
After how long does lochia need to persist before ultrasound is warranted?
6 weeks
163
How much weight is normal for a breastfed baby to lose in the first week of life?
No more than 10% of birthweight
If more than 10% - referral needed
