Obstetrics

Question 1

Shoulder dystocia management includes:

Answer 1

1. Apply downward suprapubic pressure

2. McRobert’s manoeuvre, woman is supine and the legs are hyperflexed towards the abdomen

Question 2

Following artificial rupture of the membranes, fetal bradycardia is noted on the cardiotocograph (CTG). This prompts the midwife to perform a vaginal examination, during which the umbilical cord is found to be palpable just below the presenting part.

Umbilical cord prolapse noticed management:

Answer 2

1. Call for senior help
2. Push the presenting part into the uterus during contractions to prevent compression of the umbilical cord (if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm)
3. ‘all fours’ (i.e. on the floor on hands and knees) and adopt the knee-to-chest position (bringing the knees towards the chest and raising the bottom in the air so that it is higher than the head).
4. Catheterization of the bladder is performed during umbilical cord prolapse, the purpose of this is to fill the bladder with 500-750mL of saline by attaching the catheter to an intravenous giving set. This helps to elevate the presenting part, preventing compression of the cord.
5. Consider delivery of the baby (caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low).
6. tocolytics may be used to reduce uterine contractions

Question 3

Risk factors for cord prolapse include:

Answer 3

1. prematurity
2. multiparity
3. polyhydramnios
4. twin pregnancy
5. cephalopelvic disproportion
6. abnormal presentations e.g. Breech, transverse lie

Question 4

If after 28/40 weeks, if a woman reports (Physical examination is unremarkable, and observations are stable) reduced fetal movements and kicking has reduced with no complications throughout the pregnancy and no fetal heart is detected with handheld Doppler then what the next step in management:

Answer 4

An immediate ultrasound should be offered

Note if a heartbeat was detected, then a CTG should be used for at least 20 mins to monitor the heart rate

Question 5

Reduced fetal movements can represent:

Answer 5

fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero.

This is concerning, as it reflects risk of stillbirth and fetal growth restriction.

It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Question 6

What is the first onset of recognised fetal movement which occurs between 18-20 weeks gestation is known as

Answer 6

quickening

Question 7

Fetal movements start and increase till what weeks:

Answer 7

18-20 weeks gestation and increase until 32 weeks gestation at which point the frequency of movement tends to plateau

Question 8

Multiparous women will usually experience fetal movements sooner, true or false:

Answer 8

True, they experience it at 16-18 weeks gestation (towards the end of pregnancy, fetal movements should not reduce)

Normally it occurs between 18-20 weeks and increase between until 32 weeks gestation at which point the frequency of movement tends to plateau

Question 9

According to the RCOG what is considered for fetal movements indication for further assessment:

Answer 9

Considers less than 10 movements within 2 hours ((in pregnancies past 28 weeks gestation) an indication for further assessment).

Question 10

If the mother is past 28 weeks gestation, and there’s a heart rate present confirmed via a handheld doppler and then a CTG is used for at least 20 mins which can assist in excluding fetal compromise, but concerns remain, what should be done next:

Answer 10

ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement

Question 11

Gravida number refers to what:

Answer 11

the TOTAL number of pregnancies, including the present one (twin pregnancy counts as one pregnancy) but since two children past 24 wks then para 2

Question 12

Parity refers to:

Answer 12

the number of children delivered whether alive or dead after 24 weeks, twins count as Para 2 but grava 1 (cos one pregnancy)

Question 13

What are the stages of labour:

Answer 13

Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Question 14

primigravida woman have stage 1 labour lasting typically:

Answer 14

10-16 hrs

stage 1 has the latent phase = 0-3 cm dilation, normally takes 6 hours

active phase = 3-10 cm dilation, normally 1cm/hr

Question 15

When you give birth, your baby usually comes out headfirst with 90% of this, this is also called:

Answer 15

vertex position

Question 16

Stage 1 refers to the onset of what….

Answer 16

the onset of true labour to when the cervix if fully dilated

Question 17

Stage 2 of labours refers to:

Answer 17

from full dilation to delivery of the fetus

Question 18

Stage 3 of labour refers to:

Answer 18

from delivery of fetus to when the placenta and membranes have been completely delivered

Question 19

When the head of the baby enters the pelvis in the occipito-lateral position, the head normally delivers:

Answer 19

in an occipito-anterior position

Question 20

In stage 1 labour, the first stage of it, latent phase, the dilation is how many cm and takes how long:

Answer 20

0-3 cm dilation, normally takes 6 hrs

Question 21

In stage 1 labour, the second stage of it, active phase, the dilation is how many cm and at what rate:

Answer 21

3-10 cm dilation, normally 1cm/hr

Question 22

The birth of the foetus refers to which stage of labour:

Answer 22

second stage

Question 23

The delivery of the placenta refers to which stage of labour:

Answer 23

3rd stage

Question 24

Stage 1 labour involves which features:

Answer 24

1. Onset of regular contractions
2. Gradual dilation of the cervix
3. It ends once at 10cm cervical dilation when the cervix is considered fully effaced (shortening and thinning of the cervix)

Question 25

How does cervix effacement happens and what stage:

Answer 25

Occurs during stage 1 of labour Fetus's head drops into the pelvis, pushing it against the cervix. This process stretches the cervix, causing it to thin and shorten 10 cm dilation

Question 26

A pregnant woman has pre-eclampsia, but they can't give the first line treatment oral labetalol cos she is asthmatic, what should be given instead:

Answer 26

Nifedipine (e.g. if asthmatic) and hydralazine may also be used

Question 27

A mother at 37 weeks pregnant with preterm-PROM triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia points to:

Answer 27

chorioamnionitis

Question 28

chorioamnionitis, a medical emergency, has what treatment for mother at 37 weeks for example:

Answer 28

- IV antibiotics | - Immediate cesarean section

Question 29

A pregnant has preterm premature rupture of membranes, but now presents with a fever, what is most likely?

Answer 29

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus Considered a medical emergency It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens Prompt delivery of the foetus (via c- section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Question 30

A pregnant woman is at 37 weeks, but prior 3 weeks ago had urinary incontinence with some discharge after, but now presents with a fever, what does it suggest?

Answer 30

chorioamnionitis

Question 31

What is the triad for a woman with | chorioamnionitis with preterm-PROM?

Answer 31

1. Maternal Pyrexia 2. Maternal tachycardia 3. Fetal tachycardia

Question 32

What is the screening test for gestational diabetes:

Answer 32

oral glucose tolerance test (OGTT)

Question 33

Screening for gestational diabetes for a mother with previous GD, should be screened at how many weeks?

Answer 33

- Offered ASAP after booking

Question 34

Screening for gestational diabetes for a mother with previous GD, with a normal first test should be screened at how many weeks?

Answer 34

At 24-28 weeks

Question 35

NICE recommend what test as an alternative to oral glucose tolerance test (OGTT):

Answer 35

Early self-monitoring of blood glucose is an alternative to the oral glucose tolerance test (OGTT)

Question 36

According to NICE, what is the diagnostic thresholds values for gestational diabetes:

Answer 36

NICE, gestational diabetes is diagnosed if either: fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L

Question 37

What is the 6 steps management plan of pre-existing diabetes:

Answer 37

1. weight loss for women with BMI of > 27 kg/m^2 2. stop oral hypoglycaemic agents, apart from metformin, and commence insulin 3. folic acid 5 mg/day from pre-conception to 12 weeks gestation 4. detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts 5. tight glycaemic control reduces complication rates 6. treat retinopathy as can worsen during pregnancy

Question 38

When should glibenclamide be offered in gestational diabetes:

Answer 38

For women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Question 39

When should Metformin used for gestational diabetes:

Answer 39

when the fasting glucose level is below 7mmol/L AND glucose targets are still not being met despite lifestyle changes for 1-2 weeks If patient's blood glucose level is well above 7mmol/L, therefore, offering metformin would not be correct (give insulin instead)

Question 40

If pregnant woman with gestational diabetes declines insulin, what should be given instead:

Answer 40

Glibenclamide Sulfonylureas such as Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Question 41

Can Empagliflozin be given in gestational diabetes?

Answer 41

No as SGLT-2-inhibitors have no role in the management of gestational diabetes

Question 42

If a pt has a fasting blood glucose above 7, will advising to maintain a healthy diet and exercise be enough to avoid the complications?

Answer 42

Nope, a fasting glucose above 7 requires medication (insulin) Whilst the patient can be advised to maintain a healthy diet and exercise regularly, this must be done in conjunction with medication. Simply eating healthy and exercising will not be enough to prevent the complications of gestational diabetes. Metformin is given if the fasting blood glucose is below 7mmol/L

Question 43

Gestational diabetes, what should be started if the fasting plasma glucose level is < 7 mmol/l and a trial of diet and exercise is offered but the glucose targets are not met within 1-2 weeks of altering diet/exercise?

Answer 43

metformin

Question 44

If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, what should be started?

Answer 44

insulin

Question 45

What's the first line in gestational diabetes, if the fasting plasma glucose level is < 7 mmol/l? Should a medication first be started?

Answer 45

No, a trial of diet and exercise should be offered for 1-2 weeks first If not glucose targets not met, then start on metformin

Question 46

The diet for gestational diabetes should include one with a:

Answer 46

low glycaemic index Remember exercise should be included

Question 47

Gestational diabetes is treated with what sort of sub-cut insulin: long or short?

Answer 47

SHORT acting Not long acting SC insulin Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman

Question 48

If glucose targets not met after, diet, exercise and metformin, what should be started:

Answer 48

Insulin

Question 49

Fetal bradycardia is classically seen in what of the causes of antepartum haemorrhage:

Answer 49

Vasa praevia

Question 50

Tender, tense uterus but with normal lie and presentation, and constant abdo pain is what of the causes of APH?

Answer 50

Placental abruption

Question 51

Which examination should NOT be performed in primary care for APH before doing a ultrasound?

Answer 51

vaginal examination, women with placenta praevia may haemorrhage

Question 52

Hydatidiform mole has what features:

Answer 52

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis The uterus may be large for dates and serum hCG is very high

Question 53

A pregnant woman has ruptured her membrane, but following this, there is vaginal bleeding immediately, fetal bradycardiac, what is the cause of the APH?

Answer 53

Vasa praevia

Question 54

What is the cause of APH, there is painless vaginal bleeding?

Answer 54

``` Placental praevia (no pain) Placental abruption has constant abdo pain ```

Question 55

A tender tense uterus with normal lie and presentation in APH is:

Answer 55

Placental abruption

Question 56

A woman presents in the first and another woman in the second, both present with bleeding and exaggerated symptoms of pregancy such as hyperemesis. The scan the uterus is large for date and serum hCG is very high, what is the APH diagnosis?

Answer 56

Hydatidiform mole

Question 57

What should be ruled out if bleeding during pregnancy?

Answer 57

STIs and cervical polys should be excluded

Question 58

Potential Gestational diabetes: if the fasting plasma glucose is < 7 mmol/l a trial of diet and exercise should be offered for 1-2 weeks....what diet should be offered?

Answer 58

advised to eat a high fibre diet with minimal foods containing refined sugars balanced diet, high in fruit, vegetables, and unrefined foods

Question 59

Gestational diabetes is caused by:

Answer 59

insulin insensitivity which affects women across the BMI spectrum

Question 60

What are the four signs of labour?

Answer 60

- regular and painful uterine contractions - a show (shedding of mucous plug) - rupture of the membranes (not always) - shortening and dilation of the cervix

Question 61

What drug should NOT be given in the presence of hypertension?

Answer 61

Ergometrine (should not be given in the presence of hypertension)

Question 62

Between Ergometrine and Oxytocin, which one casues less nausea and vomitting?

Answer 62

Oxytocin

Question 63

3rd stage of labour, active management of this stage is recommended in order to reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery. What does the guidelines suggest to use?

Answer 63

10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder

Question 64

10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of what?

Answer 64

anterior shoulder

Question 65

Pregnant obese women (BMI >30 kg/m2) in the 1st trimester, should be given

Answer 65

high dose 5mg folic acid

Question 66

Most pregnant patients, how much of folic acid and over how long?

Answer 66

0.4mg (400mcg) daily in the first 12 weeks of pregnancy is sufficient

Question 67

folic acid should also be prescribed at a 5mg daily dose, for what?

Answer 67

- diabetes - sickle cell disease (SCD) - thalassaemia trait - coeliac disease - on anti-epileptic medication - personal or family history of NTD - who have previously given birth to a baby with an NTD

Question 68

all pregnant patients take what vitamin?

Answer 68

vitamin D 10mcg (400 units) daily. This should be continued throughout the duration of their entire pregnancy

Question 69

Causes of folic acid deficiency:

Answer 69

- phenytoin - methotrexate - pregnancy - alcohol excess

Question 70

There's a number of anaesthetic techniques during labour which can be broadly classified as:

Answer 70

regional and non-regional (with non-regional being the most widely used)

Question 71

Non-regional anaesthetics for labour include:

Answer 71

inhaled nitrous oxide, and systemic analgesics such as pethidine

Question 72

Regional anaesthetics for labour include:

Answer 72

epidural anaesthesia, which has been shown to be extremely effective in pain management

Question 73

Regional techniques include epidural anaesthesia, shows there's an association:

Answer 73

prolongation of labour and increased operative vaginal delivery No association between epidural analgesia and an increased risk of Caesarean delivery or post-partum backache has been found

Question 74

Performing an episiotomy can form the management for what?

Answer 74

shoulder dystocia as it can make more space for manoeuvres

Question 75

terbutaline, nifedipine are examples of what in terms of uterus and contractions?

Answer 75

tocolytics (e.g. terbutaline, nifedipine) can be used to relax the uterus and stop contractions to delay delivery while transferring a patient to theatre for a caesarian section

Question 76

For cord prolapse, pushing the cord back inside the vagina does what?

Answer 76

touching the cord can precipitate vasospasm and result in foetal hypoxia

Question 77

Apply suprapubic pressure forms the management for what?

Answer 77

shoulder dystocia Whereby pressure is placed behind the anterior shoulder of the foetus to disimpact it from underneath the maternal pubic symphysis

Question 78

Suprapubic pressure for shoulder dystocia, helps with:

Answer 78

Pressure is placed behind the anterior shoulder of the foetus to disimpact it from underneath the maternal pubic symphysis

Question 79

Is IV oxytocin appropriate to give for cord prolapse?

Answer 79

NO! This would induce contractions, Instead tocolytics e.g. terbutaline, nifedipine can be used to relax the uterus and stop contractions to delay delivery while transferring a patient to theatre for a caesarian section

Question 80

Can a instrumental vaginal delivery be used for a cord prolapse?

Answer 80

an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low although caesarian section is the usual first-line method of delivery

Question 81

what does a first-degree tears involve the perineal muscle, and do require repair?

Answer 81

They involve the skin and the subcutaneous tissue between the vagina and the anus It does not involve the perineal muscle (like the second degree one) They do not require repair

Question 82

second degree tear involve involves the

Answer 82

perineal muscle but does not involve the anal sphincter It can be sutured on the ward by an experienced midwife or doctor.

Question 83

Third-degree tears involve:

Answer 83

anal sphincter and require repair in theatre They are commonly caused by instrumental delivery

Question 84

A fourth-degree tear involves:

Answer 84

the rectal mucosa This requires repair in theatre.

Question 85

Risk factors for perineal tears:

Answer 85

- primigravida - large babies - precipitant labour - shoulder dystocia - forceps delivery

Question 86

What is the most common cause of early-onset severe infection in the neonatal period?

Answer 86

Group B Streptococcus (GBS)

Question 87

Risk factors for Group B Streptococcus (GBS) infection:

Answer 87

- prematurity - prolonged rupture of the membranes - previous sibling GBS infection - maternal pyrexia e.g. secondary to chorioamnionitis

Question 88

GBS prophylaxis antibiotic choice:

Answer 88

benzylpenicillin

Question 89

Women with a pyrexia during labour (>38ºC) should be given:

Answer 89

benzylpenicillin as a intrapartum antibiotic GBS prophylaxis

Question 90

Group B Streptococcus (GBS) screening done for all:

Answer 90

universal screening for GBS should not be offered to all women

Question 91

If women are to have swabs for GBS this should be offered at what weeks?

Answer 91

35-37 weeks or 3-5 weeks prior to the anticipated delivery date

Question 92

Instrumentation is necessary for delivery, which equipment associated with successful outcomes?

Answer 92

Kielland's forceps are associated with the most successful outcomes compared to ventouse, however require particular expertise

Question 93

Which position of the baby is gives the mother an earlier urge to push? OP or OA?

Answer 93

OP where the baby's head is facing the back of the mother (delivery in the OP position, also causes labour to be longer and more painful

Question 94

On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?

Answer 94

The fetal head may rotate spontaneously to on OA position

Question 95

Stage 2 of labour is:

Answer 95

associated with transient fetal bradycardia

Question 96

In stage 2, what may be necessary following crowning?

Answer 96

episiotomy

Question 97

Active second stage refers to what:

Answer 97

active process of maternal pushing

Question 98

Normally, stage 2 (from full dilation to delivery of the fetus) takes 1hr, but they were given epidural so it took longer than 1 hr, what should be considered?

Answer 98

Consider Ventouse extraction, forceps delivery or caesarean section

Question 99

If a baby's head on vaginal examination, the occiput can be palpated posteriorly (near the sacrum)! What should be considered?

Answer 99

The fetal head may rotate spontaneously to an OA position

Question 100

Management for grade III or IV placenta praevia is a scheduled:

Answer 100

elective caesarean section at 37-38 weeks Spontaneous vaginal delivery carries a significant risk of haemorrhage in grade III and grade IV placenta praevia and the patient should be counselled about the risk of this

Question 101

Why is the management for grade III or IV placenta praevia is a scheduled elective caesarean section at 37-38 weeks?

Answer 101

This is to prevent a massive obstetric haemorrhage which may occur if cervical ripening and dilatation occurs with the placenta overlying the cervical os.

Question 102

If low-lying placenta at the 20-week scan, rescan at?

Answer 102

34 weeks, if still present at 34 weeks and grade I/II then scan every 2 weeks

Question 103

For low-lying placenta, should activity or intercourse be limited?

Answer 103

No need for it to be limited unless they bleed

Question 104

All grades of low lying placenta, should be advised for c-section?

Answer 104

False, Grade I can have a trial of vaginal delivery may offered

Question 105

A history of sudden unwell and collapse with hypotension and tachycardia occurring soon after a rupture of membranes is suggestive of

Answer 105

amniotic fluid embolism (Amniotic fluid emboli can indirectly lead to myocardial infarcts) hypovolaemic shock would also typically evolve at a slower pace

Question 106

Amniotic fluid embolism is:

Answer 106

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below. Clinical presentation: - The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum - Symptoms include: chills, shivering, sweating, anxiety and coughing - Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Question 107

What is the management of amniotic fluid embolism?

Answer 107

Critical care unit by a multidisciplinary team, management is predominantly supportive

Question 108

Both placenta praevia and vasa praevia both present with painless vaginal bleeding, what would help you differentiate both of them?

Answer 108

vasa praevia other expected features would include fetal bradycardia and membrane rupture

Question 109

What is the difference between placenta praevia and placenta abruption?

Answer 109

Placenta praevia is painless bleeding, bright red Placenta abruption is painful bleeding, usually dark red

Question 110

Investigation for placenta praevia is picked up on the routine what?

Answer 110

20 week abdominal ultrasound the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Question 111

What are the classical grading of the placenta praevia?

Answer 111

I - placenta reaches lower segment but not the internal os II - placenta reaches internal os but doesn't cover it III - placenta covers the internal os before dilation but not when dilated IV ('major') - placenta completely covers the internal os

Question 112

For placenta praevia, the uterus is:

Answer 112

uterus not tender

Question 113

Remember to see how the back of the head of the baby is positioned, if the back of the head is positioned on the spine it's occiput posterior whereas if the back of the head is facing the abdo, then it's occiput anterior, but the occipital bone which is the semi circle is facing where...towards the left or right, then it's left occiput posterior or right occiput anterior

Question 114

Intrahepatic cholestasis of pregnancy is also known as:

Answer 114

obstetric cholestasis

Question 115

What are the features of Intrahepatic cholestasis of pregnancy?

Answer 115

Features - pruritus - may be intense - typical worse palms, soles and abdomen - clinically detectable jaundice occurs in around 20% of patients - raised bilirubin is seen in > 90% of cases

Question 116

What is the management of Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis)?

Answer 116

Management - induction of labour at 37-38 weeks is common practice but may not be evidence based - ursodeoxycholic acid - again widely used but evidence base not clear vitamin K supplementation

Question 117

Is there a recurrence of intrahepatic cholestasis of pregnancy in subsequent pregnancies?

Answer 117

Yes, it's 45-90% in subsequent pregnancies

Question 118

Obstetric cholestasis, also known as intrahepatic cholestasis of pregnancy, is a condition caused by:

Answer 118

- Impaired flow of bile - This, in turn, causes a build-up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta - It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors. - Although the pruritic symptoms can be distressing for the mother, the build of bile salts can also be detrimental to foetal well-being The combination of the immature foetal liver's ability to cope with breaking down the excessive bile salt levels as well as the vasoconstricting effect of bile salts on human placental chorionic veins, has been theorised to be the cause of sudden asphyxial events in the foetus leading to anoxia and death.

Question 119

What is the investigation of choice for gestational diabetes?

Answer 119

oral glucose tolerance test

Question 120

What are the risks of gestational diabetes?

Answer 120

severe pregnancy complications such as pre-eclampsia, stillbirth, or macrosomia

Question 121

For a cord prolapse, what medication can be used to relax the uterus?

Answer 121

Tocolytic, such as terbinafine, to relax the uterus

Question 122

If a pregnant woman is above 28 weeks and she reports reduced fetal movements then what's the initial management:

Answer 122

- Handheld doppler should be used to confirm fetal heartbeat as a first step - If this is not detectable, ultrasound should be offered immediately - If a heartbeat was detected, cardiotocography should be used for 20 minutes to monitor the heart rate

Question 123

At how many weeks should there be a referral to fetal medicine unit if no movements had been felt at all by:

Answer 123

24 weeks

Question 124

Give a list of reasons for reduced fetal movements including posture, distraction, placental position and fetal position, body habitus, amniotic fluid volume:

Answer 124

Risk factors for reduced fetal movements Posture: There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing Distraction: Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent Placental position: Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements Medication: Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements Fetal position: Anterior fetal position means movements are less noticeable Body habitus: Obese patients are less likely to feel prominent fetal movements Amniotic fluid volume: Both oligohydramnios and polyhydramnios can cause reduction in fetal movements Fetal size: Up to 29% of women presenting with RFM have a SGA fetus

Question 125

What are the three features of Intrahepatic cholestasis of pregnancy:

Answer 125

Features - pruritus, often in the palms and soles - no rash (although skin changes may be seen due to scratching) - raised bilirubin

Question 126

What are the three management features of Intrahepatic cholestasis of pregnancy:

Answer 126

Management - ursodeoxycholic acid is used for symptomatic relief - weekly liver function tests - women are typically induced at 37 weeks

Question 127

Is there a rash present in obstetric cholestasis?

Answer 127

No skin rash present, diagnosed if there are abnormal liver function tests, with pruritis in the absence of a skin rash

Question 128

What is raised in obstetric cholestasis?

Answer 128

It is bile acids that are raised in obstetric cholestasis

Question 129

When does Acute fatty liver of pregnancy occur?

Answer 129

Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.

Question 130

Acute fatty liver of pregnancy, what is the Investigation and what level is it elevated?

Answer 130

ALT is typically elevated e.g. 500 u/l

Question 131

What is the management of Acute fatty liver of pregnancy?

Answer 131

Management - support care - once stabilised delivery is the definitive management

Question 132

HIV in pregnancy: what is recommended if viral load is less than 50 copies/ml at 36 weeks?

Answer 132

vaginal delivery Caesarean section at 38-39 weeks is recommended by BHIVA if viral load is >50 copies/mL Intravenous zidovudine infusion is recommended if viral load is >1000

Question 133

When is Zidovudine considered in pregnant woman with HIV?

Answer 133

Delivery Zidovudine is only recommended for vaginal deliveries if a woman presents in labour or with spontaneous rupture of membranes (SROM) and has a viral load of >1000 or an unknown viral load. Zidovudine can also be considered if viral load 50-1000 and presenting with labour or SROM.

Question 134

Most often hypersegmented neutrophils are associated with which type of anemia and what are the causes?

Answer 134

Megaloblastic anemia Megaloblastic anemia can be caused by folic acid deficiency or vitamin B12 deficiency including pernicious anemia

Question 135

Folic acid is converted to what and what is its role? What are good sources of folic acid?

Answer 135

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid Functions THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Question 136

Chickenpox exposure in pregnancy, what is the first step?

Answer 136

check varicella antibiotics

Question 137

If a pregnant patient >20 weeks gestation is found to not be immune to varicella-zoster after antibody testing, they should be prescribed what?

Answer 137

Prescribed varicella-zoster immunoglobulin or they should be given oral acyclovir 7-14 days post-exposure. Delaying the administration of oral acyclovir has been shown to reduce the rate of development of chickenpox. Oral acyclovir is indicated if a pregnant patient >20 weeks gestation develops chickenpox. It can also be used in caution in a patient <20 weeks gestation. As this patient doesn't have signs and symptoms of chickenpox as of yet, this is not indicated.

Question 138

What is the triad for pre-eclampsia?

Answer 138

- new-onset hypertension (≥ 140/90 mmHg after 20 weeks of pregnancy) - proteinuria - oedema

Question 139

If a pregnant woman over 20 weeks, has a bp ≥ 160/110 mmHg are likely should she be admitted and observed?

Answer 139

Yes

Question 140

Which of the following presentations has the greatest mortality and morbidity?

Answer 140

Footling presentation at delivery There is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency

Question 141

Transverse lie is what part of the baby is presenting? And when does it occur?

Answer 141

Shoulder Multiparous women due to their uterine muscles being less tight than a nulliparous woman Extracephalic version may be attempted from 32 weeks and thus is manageable at 30 weeks.

Question 142

For a In occipitoposterior presentation where the the posterior fontanelle is found in the posterior quadrant of the pelvis; greater rotation is required so labour is usually longer, what is the best intervention?

Answer 142

22% require forceps and 5% require caesarean section

Question 143

40% of babies are breech at 20 weeks but what is the % at term?

Answer 143

only 3% at term- there is still plenty of room for the foetus to turn around and resolve to head down.

Question 144

Pre-eclampsia: Pregnancy-induced hypertension in association with proteinuria what is the level?

Answer 144

> 0.3g / 24 hours

Question 145

What is the scale for screening tool for postnatal depression?

Answer 145

The Edinburgh Scale

Question 146

Is there a difference between baby blues and postnatal depression?

Answer 146

yes, even the management is different. baby blues seen in 60-70% of pts vs postnatal depression affects 10% of pts baby blues short term 3-7 days so just needs reassurance and support, the health vistor has a key role vs postanatal depression has reassurance and support PLUS cbt and ssris such as sertraline and paroxetine (cos of low milk/plasma ratio) may be used if symptoms are severe Fluoxetine is best avoided due to a long half-life

Question 147

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative. What is the most appropriate management for prophylaxis of Rhesus sensitisation?

Answer 147

One dose of anti-D immunoglobulin followed by a Kleihauer test APH is associated with fetomaternal haemorrhage (FMH) and therefore an increased risk of Rhesus sensitisation and Rhesus disease of the newborn in subsequent pregnancies. This is a question about the prophylaxis of Rhesus sensitisation in a Rhesus negative Mother with antepartum haemorrhage.

Question 148

What does the Kleihauer test determine?

Answer 148

The proportion of fetal RBCs present in the maternal blood circulation A Kleihauer test is a test for fetomaternal haemorrhage (FMH) which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation

Question 149

At how many weeks, is anti-D immunoglobulin given according to BCSH guidelines?

Answer 149

After 20 weeks gestation