Obstetrics

Question 1

Management for hyperemesis gravidarum in the community

Answer 1

Oral promethazine / cyclizine
Ondansetron (inc risk of cleft palate tho)

Question 2

Management for hyperemesdis gravidarum on admission

Answer 2

IM anti sickness - e.g. promethazine
Fluids - NaCL 0.9%, add KCl, thiamine and folic acid to prevent Wernicke’s

Question 3

Risk factors for hyperemesis gravidarum

Answer 3

Multiple pregnancies
Trophoblastic disease
Hyperthyroid
Nulliparity
Obesity

Question 4

Preeclampsia

Answer 4

Caused by placental dysfunction (so babies often small)

Presentation:

• New onset HTN (after 20 weeks) - more than 140/90
• Proteinuria
• Organ involvement - e.g. renal insufficiency, liver dysfunction
• Oedema
• Visual changes, headache

Investigations:

• BP
• FBCs, U+Es, LFTs
• Urine
• ?CTG
• ?Growth scan

Management:

• Oral labetalol
• If 160/110 - admit for obs inc catheter. May consider IV antihypertensives, magnesium sulphate, delivery of baby.

Question 5

High risk factors for preeclampsia

Answer 5

• Personal history
• CKD
• SLE
• Diabetes
• HTN

Question 6

Moderate risk factors for preeclampsia

Answer 6

• First pregnancy
• Age 40+
• 10 years since last preg
• BMI - 35+
• FH
• Multiple pregnancy

Question 7

Who gets aspirin during pregnancy for preeclampsia prophylaxis

Answer 7

• If any high risk factors
• If 2 moderate risk factors

Take from 12 weeks - near delivery

Question 8

HELLP Syndrome

Answer 8

Haemolysis
Elevated liver enzymes
Low platelets

Presentation:

• Nausea and vomiting
• RUQ pain
• Lethargy

Investigations:

• FBC, LFTs
• Clotting
• G&S

Management:

• Delivery

Question 9

Causes of PPH

Answer 9

Tone - uterine atony (most common)
Trauma - tears
Tissue - retained placenta
Thrombin - clotting/bleeding disorder

Question 10

Definition of PPH

Answer 10

more than 500ml of blood loss after vaginal delivery (or 1000ml after C section) within 24hrs

Question 11

Risk factors of PPH

Answer 11

Previous PPH
Prolonged labour
Preeclampsia
Older age
Polyhydramnios
Emergency C-section
Placenta praevia, acreta
Macrosomia

Question 12

General causes of female infertility and how to assess

Answer 12

• Ovulation problem - e.g. hypothalamic, PCOS - measure serum progesterone, LH, FSH, US ovaries to count follicles
• Tubal cause - e.g. PID, endometriosis, adhesions - contrast US
• Uterine - e.g. adhesions, fibroids - hysteroscopy
• Unexplained

Question 13

Placenta praevia

Answer 13

Low lying placenta

Presentation:
- Painless bleeding
- May be shocked

Investigation:
- TVUS - if picked up at 20wks, scan again at 32wks and grade it - keep scanning every 2 weeks. On the final scan at 36/37 weeks - decide how to deliver.

Management:
- grades 3/4 - elective C-section at 37/38 wks - and if labour before then, it’ll be emergency

Question 14

Risk factors for placenta praevia

Answer 14

Multiparity
Multiple pregnancy
Previous c-section

Question 15

Risk factors for gestational diabetes

Answer 15

BMI of more than 30
Previous macrosmia
Previous gestational diabetes
1st degree relative with diabetes

Question 16

Screening tests for gestational diabetes

Answer 16

Booking test and 24-28weeks if at risk

Question 17

Consequences of gestational diabetes

Answer 17

Macrosomia
Polyhydramnios
Premature birth
Preeclampsia
Neonatal jaundice
Rarely, stillbirth

Question 18

Preterm prelabour rupture of the membranes (PPROMS)

Answer 18

Investigations:
- Speculum - check for pooling of amniotic fluid
- Test fluid for PAMG-1 or IGF binding protein
- US for oligohydramnios

Management:
- Admit for observation
- Give oral erythromycin as risk of chorioamnionitis
- Corticosteroids to prevent RDS
- If more than 34wks, consider delivery

Question 19

When do foetal movements start?

Answer 19

18-20wks

Question 20

Risk factors for VTE

Answer 20

Age 35+
BMI over 30
Parity over 3
Smokes
Varicose veins
Pre eclampsia
Immobility
FH of unprovoked VTE
Thrombophilia
Multiple pregnancy
IVF pregnancy

Question 21

Risk factors for breech baby

Answer 21

Uterine malformations eg. fibroids
Placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormality
Prematurity

Question 22

Major complication of breech baby

Answer 22

Cord prolapse

Question 23

Placental abruption

Answer 23

Separation of the placenta from the uterine wall

Presentation:

• Tense, tender abdo
• Vaginal bleeding
• Shock - out of keeping with visible loss - still traps in uterus

Investigation:

• CTG - monitor foetus

Management:

• If foetal distress - immediate C-section
• If no distress - before 36 wks observe and give steroids; if after 36 wks - vaginal delivery

Question 24

Umbilical cord prolapse

Answer 24

When the cord descends before the foetus - can cause foetal hypoxia and death

Management:
- Emergency C -section
- In the meantime - get the women to go on all fours, push the presenting part of foetus back in to avoid compression, don’t touch the cord (vasospasm!) and give tocolytics to reduce contractions. Refil bladder to lift presenting part

Question 25

Obstetric cholestasis

Answer 25

Build up of bile acids - increased risk of premature and still birth Presentation: - After 24wks - Puritis - no rash - Fatigue - Nausea - RUQ pain - (v rarely jaundice) Investigations: - FBCs, LFTs, bile acids Management: - Chorphenamine to reduce itch - Ursodeoxycholic acid - to reduce serum bile acids - Early delivery at 37/38 wks

Question 26

Acute fatty liver of pregnancy

Answer 26

Presentation: - 3rd trimester - Abdo pain, nausea, vomiting - Headache - Jaundice - Hypoglycaemia Investigations: - FBC, LFTs Management: - Stabilise - Deliver

Question 27

Options for induction of labour

Answer 27

1. Membrane sweep 2. If Bishop's score is less than 6 - vaginal prostaglandins 2. If Bishop's score is more than 6 - amniotomy plus oxytocin infusion 3. Balloon catheter

Question 28

Thresholds for iron treatment

Answer 28

First trimester - 110 2nd trimester - 105 3rd trimester and post partum - 100