Obstetrics Flashcards

Question

How does methotrexate work and what are the side effects of it?

Answer 1

- It is highly teratogenic and is given as an **intramuscular injection** into a buttock Common side effects include: - Vaginal bleeding - Nausea and vomiting - Abdominal pain - Stomatitis

Answer 2

Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l Is laparoscopic, it should be a **salpingectomy** removal of all the tube. **Salpingotomy** is an alternative with women for risk factors of infertility

Answer 3

A spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks. Late miscarriage is between 12-24

Answer 4

- Missed miscarriage: the foetus is no longer alive but no symptoms have occurred - Threatened miscarriage: vaginal bleeding with a closed cervix and a foetus that is alive - Inevitable miscarriage: vaginal bleeding with an open cervix - Incomplete miscarriage: retained products of conception remain in the uterus after the miscarriage - Complete miscarriage: a full miscarriage has occurred, and there are no products of conception left in the uterus - Anembryonic pregnancy: a gestational sac is present but contains no embryo

Answer 5

- When a foetal heartbeat is visible the pregnancy is considered viable: a foetal heartbeat is expected once **crown-rump length is 7mm** - When there is no foetal heartbeat and CRL is less than 7mm scan repeated in 1 week - A foetal pole is expected once the mean gestational sac is more than 25mm - When there is a mean gestational sac diameter of 25mm without a foetal pole an anembryonic pregnancy is expected

Answer 6

- If there is no pain and no risk factors then use **Expectant management** - A repeat urine pregnancy test is performed 7-10 days and if negative, a miscarriage can be confirmed - When bleeding continues then do further investigation

Answer 7

- Referral to an early pregnancy assessment service - They will arrange an ultrasound scan which will confirm the location and viability of the pregnancy.

Answer 8

- If less than <35mm then can offer expectant, medical or surgical - If greater than 35mm then offer surgical management

Answer 9

**Misoprostol** which is a prostaglandin analogue which softens the cervix and stimulates uterine contractions Can be a vaginal suppository or an oral dose

Answer 10

- Heavier bleeding - Pain - Vomiting - Diarrhoea

Answer 11

Manual vacuum aspiration under local anaesthetic as an outpatient Electric vacuum aspiration under general anaesthetic Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.

Answer 12

Medical management (misoprostol) Surgical management (evacuation of retained products of conception) Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).

Answer 13

Endometritis (infection of the endometrium)

Answer 14

- Diagnosed on transvaginal scan - Requires visualisation of gestation sac, yolk sac and foetal pole, with a CRL of greater than 7mm and no foetal heart activity - Need 2 sonographers to diagnose

Answer 15

- If CRL is less than 22mm then anything can be offered - If CRL is less than 54mm then medical or surgical - If CRL is greater than 54mm then medical treatment should be offered

Answer 16

if continuing the pregnancy involves greater risk to the physical or mental health of: The woman Existing children of the family It is a matter of clinical judgement and must be agreed by 2 separate doctors

Answer 17

- Type of gestational trophoblastic disease - Complete mole caused by a single or two sperm fertilising an egg **which has lost its DNA** - 2-4% risk of developing into a choriocarcinoma - partial is when 2 sperm supply chromosomes but mother are also present - Looks likes **bunch of grapes** - Only treated with surgical management

Answer 18

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

Answer 19

1. Give Mifepristone (anti-progestogen) 2. Give Misoprostol (prostaglandin analogue) 1 – 2 day later Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.

Answer 20

Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures

Answer 21

Identical twins

Answer 22

Non-identical twins

Answer 23

Single amniotic sac

Answer 24

Two separate amniotic sacs

Answer 25

Monochorionic: share a single placenta Dichorionic: two separate placentas

Answer 26

The best outcomes are with diamniotic, dichorionic twin pregnancies, as each foetus has their own nutrient supply.

Answer 27

- Dichorionic diamniotic twins have a membrane between the twins, with a **lambda sign or twin peak sign** - Monochorionic diamniotic twins have a membrane between the twins with a **T sign** - Monochorionic monoamniotic twins have no membrane between them

Answer 28

The triangular appearance where the membrane between the twins meets the chorion

Answer 29

Where the membrane between the twins abruptly meets the chorion giving a t-sign

Answer 30

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Answer 31

Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Answer 32

- It occurs when foetuses share a placenta it is when there is a connection between the blood supplies of the two foetuses - One foetus may receive the majority of the blood from the placenta while the other one is starved of blood - The recipient will become fluid overloaded with heart failure and polyhydramnios - The donor has growth restriction, anaemia and oligohydramnios

Answer 33

Laser treatment may be used to destroy the connection between the two blood supplies

Answer 34

One twin becomes anaemic and the other develops polycythaemia

Answer 35

A specialist multiple pregnancy obstetric team manages women with a multiple pregnancy. Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at: Booking clinic 20 weeks gestation 28 weeks gestation They also have scans: every 2 weeks for monochorionic twins every 4 weeks for dichorionic twins

Answer 36

- 32 and 33 weeks for uncomplicated monochorionic twins, monoamniotic twins (require a C-section) - 36 weeks for uncomplicated monochorionic diamniotic twins - 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins - Before 35 + 6 weeks for triplets Corticosteroids are given to help mature the lungs

Answer 37

Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks): Vaginal delivery is possible when the first baby has a cephalic presentation (head first) Caesarean section may be required for the second baby after successful birth of the first baby Elective caesarean is advised when the presenting twin is not cephalic presentation

Answer 38

Diabetes caused by pregnancy due to **decreased insulin sensitivity** and resolves after birth

Answer 39

- Can cause **larger for dates** foetus and **macrosomia**. This causes implications for birth causing a risk of shoulder dystocia. - Women are also at higher risk of developing type 2 diabetes after pregnancy. - Anyone with risk factors should be screened with an oral glucose tolerance test at 24-28 weeks

Answer 40

- Previous gestational diabetes - Previous macrosomic baby - BMI above 30 - Ethnic origin - Family history of diabetes

Answer 41

- Risk factors - Larger for date foetus - Polyhydramnios - Glucose on urine dipstick

Answer 42

- Fasting above 5.6 - At 2 hours above 7.8

Answer 43

- They need four weekly ultrasound scans to monitor foetal growth and amniotic fluid from 28-36 weeks - Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin - Fasting glucose above 7 mmol/l: start insulin ± metformin - Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin **Glibenclamide** is another option

Answer 44

- They should take 5mg folic acid preconception - **Retinopathy screening should be performed shortly after booking and at 28 weeks gestation** - Advise a planned delivery between 37 and 38+ 6 weeks for women with pre-existing

Answer 45

A **sliding-scale insulin regime* - A dextrose and insulin infusion is titrated ti blood sugar levels. Also considered

Answer 46

- Women can stop their diabetes medications immediately after birth and will need follow up after 6 weeks - Women should be wary of hypoglycaemia in postnatal period, insulin sensitivity will increase with birth and breastfeeding

Answer 47

- Neonatal hypoglycaemia- babies will need regular blood glucose checking - Polycythaemia - Jaundice - Congenital heart disease - Cardiomyopathy

Answer 48

two complications of gestational diabetes, remember **macrosomia and neonatal hypoglycaemia** Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

Answer 49

1. Sepsis. 2. Sever haemorrhage. 3. Pre-eclampsia. 4. VTE. 5. Prolapse. 6. Incontinence. 7. Depression.

Answer 50

1. Obesity. 2. Anaemia. 3. Diabetes. 4. Amniocentesis/invasive procedures .Impaired immunity/ immunosuppressant medication

Answer 51

1. Endometritis. 2. Skin infections. 3. Pyelonephritis. 4. Chorioamnionitis. 5. Pneumonia.

Answer 52

Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting the functioning of the organs of the body Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.

Answer 53

Chorioamnionitis Urinary tract infections

Answer 54

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. E coli is most common

Answer 55

(3Ts white with sugar) Temperature <36 or >38 degrees Tachycardia -Heart rate > 90bpm (PN) Tachypnoea - Respiratory rate > 20bpm WCC >12 or <4 x 109/l Hyperglycaemia >7.7mmol Low blood pressure Altered consciousness Reduced urine output

Answer 56

Bloods cultures Urine output Fluid Resuscitation Antibiotics Lactate Oxygen piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin. Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.

Answer 57

Pre-eclampsia Sepsis Shoulder Dystocia Gestational diabetes

Answer 58

PCOS. Miscarriage. Infertility.

Answer 59

It has **multifactorial aetiology** Genetic factors – can run in families 40%-60% have a genetic component Foetal factors – low birth weight is associated with hypertension Obesity High alcohol Alcohol intake Insulin intolerance Lack of physical activity Metabolic Syndrome X *cluster of conditions, such as high insulin levels, glucose intolerance, low levels of HDLs, central obesity*

Answer 60

○ Renal e.g. CKD ○ Endocrine e.g. Conn’s syndrome, acromegaly, Cushing’s syndrome ○ Coarctation of the aorta ○ Pre-eclampsia occurring during third trimester of pregnancy

Answer 61

A patient with high BP which is diagnosed prior to pregnancy or before week 20 of pregnancy. Their high BP is not resolved postpartum.

Answer 62

New high BP after 20w gestation and resolves after giving birth. There is no proteinuria or end organ damage

Answer 63

- Chronic hypertension: High blood pressure that exists before 20 weeks gestation - Pregnancy induced hypertension: is hypertension that occurs after 20 weeks gestation **without proteinuria** - Pre-eclampsia is pregnancy induced hypertension associated with organ damage notably **proteinuria** - Eclampsia is when seizures occur as a result of pre-eclampsia

Answer 64

- Hypertension - Proteinuria - Oedema

Answer 65

- When a placenta grows into the endometrium it forms finger-like projections called **chorionic villi** these contain foetal blood vessels - When invasion occurs the endometrium sends signals to spiral arteries in the area to reduce their vascular resistance, this causes them to breakdown and causes pools of blood called **lacunae** - Maternal blood flows in and out of these lacunae through uterine veins and arteries (this occurs at 20 weeks)

Answer 66

- When the process of forming lacunae is inadequate, women can develop pre-eclampsia - It is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. - This causes oxidative stress in the placenta and the release of inflammatory chemical leading to systemic inflammation and impaired endothelial function in the blood vessels

Answer 67

- Pre-existing hypertension - Previous hypertension in pregnancy - Existing autoimmune conditions (SLE) - Diabetes - Chronic kidney disease

Answer 68

- Older than 40 - BMI above 35 - More than 10 years since previous pregnancy - Multiple pregnancy - First pregnancy - Family history of pre-eclampsia

Answer 69

**Aspirin** women are offered from 12 weeks until birth if they have 1 high risk factor or more than 1 moderate risk factor

Answer 70

- Headache - Visual disturbance or blurriness - Nausea and vomiting - Upper abdominal or epigastric pain (due to liver swelling) - Oedema - Reduced urine output - Brisk reflexes (clonus)

Answer 71

Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Answer 72

Measure placental growth factor levels will be **Low** in pre-eclampsia Measure between 20-35 weeks to rule out

Answer 73

Treating to aim for a blood pressure below 135/85 mmHg **Admission for women with a blood pressure above 160/110 mmHg** Urine dipstick testing at least weekly Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) Monitoring foetal growth by serial growth scans PlGF testing on one occasion

Answer 74

Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S) Blood pressure is monitored closely (at least every 48 hours) Urine dipstick testing is not routinely necessary (the diagnosis is already made) Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

Answer 75

- **Labetalol** is first-line as an antihypertensive - **Nifedipine** (modified-release) is commonly used second-line - **Methyldopa** is used third-line (needs to be stopped within two days of birth) - **Intravenous hydralazine** may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

Answer 76

- Iv magnesium sulphate to prevent seizures - Fluid restriction to avoid fluid overload

Answer 77

- Enalapril (first-line) - Nifedipine or amlodipine (first-line in black African or Caribbean patients) - Labetalol or atenolol (third-line)

Answer 78

A low concentration of **haemoglobin in the blood**

Answer 79

- Booking clinic - 28 weeks gestation

Answer 80

- Plasma volume increases during pregnancy, this results in a reduction in the haemoglobin concentration

Answer 81

Booking bloods: > 110 g/l 28 weeks gestation: > 105 g/l Post partum: > 100 g/l

Answer 82

Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

Answer 83

- 28 weeks if there are 3 risk factors - First trimester if there are 4 or more risk factors

Answer 84

- LMWH such as enoxaparin, dalteparin, tinzaparin

Answer 85

Almost always **unilateral** - Calf or leg swelling - Dilated superficial veins - Tenderness to the calf - Oedema - Colour changes to the leg

Answer 86

- Doppler ultrasound The wells score is not validated for pregnant women. D-dimers also not helpful as pregnancy raises it anyway

Answer 87

- 50% asymptomatic - Malodorous, purulent discharge from the urethra, cervix, vagina 3-5 days after exposure - Simultaneous urethral infection (70% to 90%) - Infection of the pharynx (10% to 20%) - Gonococcal conjunctivitis - Polyarthritis

Answer 88

Microscopy of gram stained smears of genital secretions looking for gram negative diplococci Male - urethra Female - endocervix Rectum

Answer 89

- A single dose of IM ceftriaxone 1g if sensitives not known - A single doe of oral ciprofloxacin 500mg if sensitives known

Answer 90

Women without chorioamnionitis Use Benzylpenicillin. Women with chorioamnionitis Use Benzylpenicillin plus gentamicin plus metronidazole.

Answer 91

Mother- Asymptomatic Preterm labour Chorioamnionitis PID Neonate- Conjunctivitis Pneumonia

Answer 92

1-week oral doxycycline (a tetracycline) **Pregnant – oral erythromycin (14 days) or oral azithromycin - (macrolides)**

Answer 93

T.Pallidum

Answer 94

Primary syphilis **involves a painless ulcer called a chancre at the original site of infection** Secondary syphilis Latent syphilis *symptoms disappear and the patient becomes asymptomatic despite still being infected.* Tertiary syphilis Neurosyphilis occurs if the infection involves the central nervous system

Answer 95

A painless genital ulcer will resolve after 3-8 weeks

Answer 96

Typically starts after the chancre has healed, with symptoms of: Maculopapular rash **Condylomata lata** (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 97

- A single deep **intramuscular dose of benzathine benzylpenicillin**

Answer 98

- Still birth - Maculopapular rash - Hepatosplenomegaly - Cardiovascular anomalies - Sensorineural deafness

Answer 99

- It refers to an overgrowth of bacteria in the vagina specifically **anaerobic bacteria** - It is not **Sexually transmitted**

Answer 100

Loss of lactobacilli which produce lactic acid and keep the vaginal pH low

Answer 101

Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species

Answer 102

- Multiple sexual partners - Excessive vaginal cleaning - Recent antibiotics - Smoking - Copper coil

Answer 103

Fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.

Answer 104

- Test vaginal pH anything above 4.5 is bad - charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.

Answer 105

Clue cells

Answer 106

Metronidazole Or clindamycin but is less effective

Answer 107

It increases risk of **STI** - Also can cause problems in pregnancy Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis

Answer 108

A type of parasite spread through sexual intercourse

Answer 109

-Vaginal discharge (frothy green which may have a fishy smell - Itching - Dysuria - Balanitis - Painful sex 50% of cases are asymptomatic

Answer 110

Strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection Also vaginal pH would be high like bacterial vaginosis

Answer 111

Metronidazole

Answer 112

Trichomonas vaginalis - its type of parasite classed as a protozoan, and is a single-celled organism with flagella Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.

Answer 113

during or relating to the period of about six weeks after childbirth (known as the puerperium) during which the mother's reproductive organs return to their original non-pregnant condition.

Answer 114

Endometritis C - Section infection Mastitis Breast engorgement Necrotising fasicitis Psychiatric issues

Answer 115

infection of the endometrium that often invades the underlying myometrium. Risk factors Miscarriage (when fetal tissue is left behind) C - Section Prolonged rupture of membranes, multiple vaginal examinations,

Answer 116

Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding. It occurs most commonly 5–10 days after delivery.

Answer 117

The first line is IV Clindamycin and Gentamicin.

Answer 118

This is a condition that refers to inflammation of the breast – It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus

Answer 119

Erythematous, tender, swollen area of breast – Systemic upset with fevers, chills and fatigue – 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied – If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days

Answer 120

Caused by vascular and lymphatic stasis May occur on days 2–4 postpartum in women who are not nursing or at any time if breastfeeding is interrupted. Management conservatively with ice packs and painkillers

Answer 121

Trichomonas vaginalis - its type of parasite classed as a protozoan, and is a single-celled organism with flagella Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.

Answer 122

- Can cause a preterm delivery - Low birth weight - Pre-eclampsia

Answer 123

- When there is bacteria present in urine without symptoms of infection - This puts women at higher risk of developing UTIs such as LUTI or pyelonephritis

Answer 124

- They should be routinely tested for it and then have urine samples sent to lab - They should be treated, this would not be the case for non-pregnant people

Answer 125

- Dysuria (pain, stinging or burning when passing urine) - Suprapubic pain or discomfort - Increased frequency of urination - Urgency - Incontinence - Haematuria

Answer 126

- **Fever** - Loin, suprapubic or back pain - Vomiting - Loss of appetite - Haematuria - Renal angle tenderness

Answer 127

- **E. Coli is the most common** - **Klebsiella pneumoniae (gram-negative anaerobic rod)** - Enterococcus - Pseudomonas aeruginosa - Staphylococcus saprophyticus - Candida albicans (fungal)

Answer 128

- Nitrofurantoin (avoid in third trimester) - Amoxicillin (only after sensitives are known) - Cefalexin

Answer 129

Nitrofurantoin: needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells). Trimethoprim: needs to be avoided in the first trimester as it is works as a folate antagonist. It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.

Answer 130

- It can lead to pneumonitis, hepatitis or encephalitis in the mother - Fetal varicella syndrome - Severe neonatal varicella infection (if infection around birth)

Answer 131

- If mother has had previous exposure she is safe - If unsure then test varicella IgG levels - If not got IgG then vaccinate

Answer 132

- If not immune then you can treat with IV varicella immunoglobulins as prophylaxis within **10 days of exposure** - If rash starts in pregnancy then can treat with oral Aciclovir within 24 hours if more than **20 weeks gestation**

Answer 133

Occurs in 1% of cases of chickenpox in pregnancy features include: - Fetal growth restriction - Microcephaly, hydrocephalus and learning disability - Scars and significant skin changes following the dermatomes - Limb hypoplasia (underdeveloped limbs) - Cataracts and inflammation in the eye (chorioretinitis)

Answer 134

Toxoplasma Gondii Other -Parvovirus B19, VZV, Zika, Syphilis Rubella Cytomegalovirus, Chlamydia, Coxsackie Virus Herpes Simplex 2, HIV, Hepatitis B

Answer 135

- A term used to describe an abnormally high level of amniotic fluid during pregnancy - It is when it is above the 95 percentile - It causes over-distension of the uterus and can lead to preterm birth and other complications

Answer 136

- Can be idiopathic in majority of cases - Maternal diabetes - Twin transfusion syndrome

Answer 137

- Large uterus - Dyspnoea - Premature labour - Difficulty hearing/palpating Fetal heart **Should be expected if fundal height is significantly more that expected for gestational age**

Answer 138

- Antacids to relieve heartburn and nausea for the mother - Nonsteroidal anti-inflammatory drugs (indomethacin) can decrease fetal urine production, but may cause premature closure of the fetal ductus arteriosus. - Removal of fluid by amniocentesis is only transiently effective.

Answer 139

A term used to describe abnormally low level of amniotic fluid during pregnancy - Less than 500ml at 32-36 weeks

Answer 140

- Low production of fetal urine - Poor placental diffusion - Leakage of amniotic fluid (main cause 50%)

Answer 141

- Abnormal lie and development - Poor respiratory development

Answer 142

Lie- the relationship between the long axis of the fetus and the mother Presentation- the fetal part that the first enters the maternal pelvis Position- the position of the fetal head as it exits the birth canal

Answer 143

Cephalic vertex presentation is the most common and is considered the safest Other presentations include breech, shoulder, face and brow

Answer 144

Longitudinal, transverse or oblique

Answer 145

An **External cephalic version** is the manipulation of the fetus to a cephalic presentation through the maternal abdomen If this fails then perform a C-section

Answer 146

- Complete- this is where the the caudal end of the fetus is in the lower segment - Frank: the most common where the buttocks occupy the lower segment - Footling: this is where the foot is in the pelvis **most dangerous**

Answer 147

If less than 36 weeks no action is required If greater than 36 weeks : - 1st line is ECV offered at 36 weeks for first time and 37 weeks for other - Do not perform where there is an abnormal ccg or multiple pregnancies - Offer elective C-section or vaginal breech delivery if unsuccessful

Answer 148

When the size of the pelvis can't allow the fetus to pass through the birth canal This mat be due to a small pelvis, a large fetus or unfavourable orientation

Answer 149

If fetus is too large than induction pre-term can be arranged, if not then will result in a C-section

Answer 150

- Where the muscle layer of the uterus (myometrium) ruptures. - This causes significant bleeding and the baby may be released from the uterus into the peritoneal cavity

Answer 151

Incomplete the uterine serosa surrounding the uterus remains intact In complete this ruptures along with the myometrium releasing the uterus into the peritoneal cavity

Answer 152

A previous C-section as the scar on the uterus becomes a point of weakness and may rupture with excessive pressure It is extremely rare in first time mothers. The risk factors to consider are: Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 153

- An acutely unwell mother with an abnormal CTG signs and symptoms include: - Abdo pain - Vaginal bleeding - Ceasing of uterine contractions - hypotension - Tachycardia

Answer 154

Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 155

A baby before 37 weeks gestation earlier=worse outcomes Babies are considered non-viable below 23 weeks and have 10% chance of survival

Answer 156

Under 28 weeks: extreme preterm 28 – 32 weeks: very preterm 32 – 37 weeks: moderate to late preterm

Answer 157

Vaginal progesterone- it decreases the activity of the myometrium and prevents the cervix from remodelling and preparing for delivery Offered to women around 16-24 weeks

Answer 158

Involves putting a stich in the cervix to add support and keep it closed

Answer 159

When amniotic sac ruptures releasing fluid before 37 weeks

Answer 160

Can be diagnosed by speculum examination Tests can be performed when there is doubt: **Insulin-like growth factor-binding protein-1 (IGFBP-1)** is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid **Placental alpha-microglobin-1 (PAMG-1)** is a similar alternative to IGFBP-1

Answer 161

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend **erythromycin 250mg four times daily for ten days**, or until labour is established if within ten days. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 162

Where there is regular painful contractions and cervical dilation without rupture of the amniotic sac

Answer 163

Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour. More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.

Answer 164

Using medications to stop uterine contractions **nifedipine is used a CCB** **Atosiban** is an oxytocin receptor antagonist as an alternative

Answer 165

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation. An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Answer 166

It helps protect the fetal brain and reduces the risk and severity of cerebral palsy. it is given 24 hours before delivery for mothers who are before 34 weeks gestation

Answer 167

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are: Reduced respiratory rate Reduced blood pressure Absent reflexes

Answer 168

When the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina after rupture of the foetal membranes

Answer 169

There is a significant danger of the presenting part compressing the cord resulting in foetal hypoxia

Answer 170

When the fetus is in an abnormal lie after 37 weeks gestation as it provides space for the cord to prolapse below the presenting part

Answer 171

- When there are signs of foetal distress on a CTG - Should be diagnosed by vaginal examination or speculum

Answer 172

Emergency C-section as a normal delivery has a high risk of cord compression and hypoxia to the baby Pushing the cord back in is not recommended

Answer 173

Ventouse suction cup or forceps. Tools are used to help deliver the baby's head. About 10% of births in the UK are assisted by instrumental delivery

Answer 174

A single dose of co-amoxiclav to reduce the risk of maternal infection

Answer 175

Some key features are: - Failure to progress - Foetal distress - Maternal exhaustion - Control of the head Increased need for instrumental when given an epidural

Answer 176

- Post partum haemorrhage - Episiotomy - Perineal tears - Injury to the anal sphincter - Incontinence of bladder or bowel - Nerve injury

Answer 177

- Injury to the femoral nerve causes weakness of the knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg - Obturator nerve causes weakness of hip adduction and rotation as well as numbness of the medial thig

Answer 178

cut in the area between the vagina and anus (perineum) during childbirth, to make the opening of the vagina a bit wider, allowing the baby to come through it more easily. Sometimes a woman’s perineum may tear as their baby comes out. In some births, an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly. Episiotomy is equivalent to a second-degree perineal laceration

Answer 179

- Cephalohematoma with Ventouse - Facial nerve palsy with forceps

Answer 180

First degree - tear within vaginal mucosa only.

Answer 181

Second degree - tear into sub-cutaneous tissue.

Answer 182

Third degree - laceration extends into external anal sphincter.

Answer 183

Fourth degree - laceration extends through external anal sphincter into rectal mucosa.

Answer 184

1. Primigravida. 2. Macrosomia and shoulder dystocia. 3. Forceps delivery.

Answer 185

a large or abnormally positioned baby - eg shoulder dystocia, or macrosomia small pelvis - if a girl is a teenager/young, malnutrition or lack of vit D exposure problems with the birth canal - FGM, tumors

Answer 186

When the anterior shoulder of the baby becomes stuck behind the pubic synthesis of the the pelvis after the head has been delivered Often caused by macrosomia

Answer 187

where the head is delivered but then retracts back into the vagina.

Answer 188

Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary. McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis. Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis. Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards. Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Answer 189

- Foetal hypoxia - Brachial plexus injury and Erb's palsy - Perianal tears - Postpartum haemorrhage

Answer 190

Where the placenta implants deeper and past the endometrium making it difficult to separate the placenta after delivery of the baby

Answer 191

Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels Myometrium, the middle layer that contains smooth muscle Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)

Answer 192

- Placenta implants beyond the endometrium into the myometrium and beyond making it difficult to separate during labour and increasing the risk of post partum haemorrhage

Answer 193

Superficial placenta accreta: is where the placenta implants in the surface of the myometrium, but not beyond Placenta increta: is where the placenta attaches deeply into the myometrium Placenta percreta: is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 194

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 195

- Ideally diagnosed antenatally by ultrasound and then MRI used to assess the depth - The options during caesarean are: Planned for C-section Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time

Answer 196

When the placenta is attached in the lower portion of the uterus lower than the presenting part of the foetus

Answer 197

- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os - Placenta praevia is used only when the placenta is over the internal cervical os

Answer 198

- Placenta praevia - Placental abruption - Vasa praevia

Answer 199

- Premature separation of the placenta from the uterine wall - Concealed or revealed haemorrhage - **Woody-hard, tense uterus** - Fetal distress - Maternal shock out of proportion to bleeding

Answer 200

- Antepartum haemorrhage - Emergency C-section - Hysterectomy - Anaemia - Preterm birth and low birth weight - Still birth

Answer 201

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os Partial praevia, or grade III – the placenta is partially covering the internal cervical os Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

Answer 202

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 203

At the 20 week scan

Answer 204

Planned delivery around 36-37 weeks gestation - Advise to present if pain/bleeding - Advise against sexual intercourse

Answer 205

32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)

Answer 206

Where foetal vessels are within the foetal membranes and travel across the internal cervical os

Answer 207

- Two umbilical arteries - Umbilical vein

Answer 208

- **Velamentous umbilical cord**: is where the umbilical cord inserts into the chorioamniotic membranes and the foetal vessels travel unprotected through the membrane - An accessory lobe of the placental is connected by foetal vessels that travel through the chorioamniotic membranes between the placental lobes

Answer 209

- When the vessels pass across the internal cervical os. These exposed vessels are prone to bleeding particularly when the membrane are ruptured during labour

Answer 210

- Type I vasa praevia: the foetal vessels are exposed as a Velamentous umbilical cord - Type II vasa praevia: the foetal vessels are exposed as they travel to an accessory placental lobe

Answer 211

- Low lying placenta - IVF pregnancy - Multiple pregnancy

Answer 212

- No presentations but may be detected on an ultrasound. If it is detected then an C-section may be performed - Can also present with antepartum haemorrhage with bleeding during second or third trimester of pregnancy - It is very dangerous during labour when foetal distress and dark red bleeding occurs following rupture of the membranes

Answer 213

Refers to bleeding after delivery of the baby and placenta.

Answer 214

- 500ml after a vaginal delivery - 1000ml after a caesarean section

Answer 215

- Minor PPH is under 1000ml blood loss - Major PPH over 1000ml blood loss (moderate major= 1000-2000: Severe PPH 2000ml)

Answer 216

Primary PPH: bleeding within 24 hours of birth Secondary PPH: from 24 hours to 12 weeks after birth

Answer 217

Four Ts T- Tone (uterine atony) T- Trauma ( perineal tear) T- Tissue (retained placenta) T- Thrombin (bleeding disorder)

Answer 218

- Previous PPH - Multiple pregnancy - Obesity - Large baby - Failure to progress in the second stage of labour - Prolonged third stage - Pre-eclampsia - Placenta accreta - Retained placenta - Instrumental delivery - General anaesthesia - Episiotomy or perineal tear

Answer 219

- Treating anaemia - Giving birth with an empty bladder ( a full bladder reduces uterine contraction) - Active management of the third stage ( IM oxytocin) - Intravenous tranexamic acid

Answer 220

- Resuscitation with an ABCDE approach - Lie the woman flat, keep her warm and communicate with her and the partner - Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen - Group and cross match 4 units - Warmed IV fluid and blood resuscitation as required - Oxygen (regardless of saturations) - Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 221

- Rubbing the uterus: through the abdomen to stimulates a uterine contraction - Catheterisation (bladder distension prevents uterus contractions)

Answer 222

- Oxytocin (slow injection followed by continuous infusion) - Ergometrine ( intravenous or intramuscular0 stimulates smooth muscle contraction - Carboprost (intramuscular): is a prostaglandin analogue and stimulates uterine contraction - Misoprostol (sublingual): is also a prostaglandin analogue and stimulates uterine contraction - Tranexamic acid (intravenous): is an antifibrinolytic that reduces bleeding

Answer 223

- When a women that is rhesus-D negative becomes pregnant we have to consider the possibility that her child will be rhesus positive - It is likely at some point in the pregnancy that the blood from the baby will find a way into the mothers blood. - This means that the mother will produce antibodies against the Rhesus D antibodies. The mother has then become sensitised to Rhesus-D antigens

Answer 224

- When during a second pregnancy these antibodies can cross the placenta into the foetus and attack the red blood cells. - This will cause the destruction of the red blood cells causing haemolytic disease of the newborn

Answer 225

- This involves giving intramuscular anti-D injections to rhesus-D negative women - It attaches itself to the rhesus- D antigens on the foetal red blood cells in the mothers circulation and destroys them preventing them from becoming sensitised to them

Answer 226

28 weeks gestation Birth (if the baby’s blood group is found to be rhesus-positive)

Answer 227

The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required. The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth

Answer 228

- Latent phase: contractions that are irregular, mucoid plug, cervix is beginning to dilate and can last 2-3 days - First phase: Stronger uterine contractions, cervix is continuing to dilate up to 10cm - Second phase: From full dilation to the birth of the fetus - Third phase: from the birth of the fetus to the expulsion of the placenta

Answer 229

- Oxytocin: a surge in the oxytocin levels at the onset of labour will contract the uterus - Prostaglandins: to aid with cervical ripening - Oestrogen: surges at the onset of labour to inhibit progesterone to prepare the smooth muscles for labour

Answer 230

Before 10 weeks: Booking clinic Offer a baseline assessment and plan the pregnancy Between 10 and 13 + 6: Dating scan An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified 16 weeks: Antenatal appointment Discuss results and plan future appointments Between 18 and 20 + 6: Anomaly scan An ultrasound to identify any anomalies, such as heart conditions

Answer 231

A set of booking bloods are taken for: Blood group, antibodies and rhesus D status Full blood count for anaemia Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) Patients are also offered screening for infectious diseases, by testing antibodies for: HIV Hepatitis B Syphilis Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onward

Answer 232

Nuchal translucency, beta hCG, PAPPA

Answer 233

The triple test is performed between 14 and 20 weeks gestation. It only involves maternal blood tests: Beta-HCG – a higher result indicates greater risk Alpha-fetoprotein (AFP) – a lower result indicates a greater risk Serum oestriol (female sex hormone) – a lower result indicates a greater risk When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling.

Answer 234

Abstain from ejaculation for at least 3 days and at most 7 days Avoid hot baths, sauna and tight underwear during the lead up to providing a sample Attempt to catch the full sample Deliver the sample to the lab within 1 hour of ejaculation Keep the sample warm (e.g. in underwear) before delivery

Answer 235

Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 236

Semen volume (more than 1.5ml) Semen pH (greater than 7.2) Concentration of sperm (more than 15 million per ml) Total number of sperm (more than 39 million per sample) Motility of sperm (more than 40% of sperm are mobile) Vitality of sperm (more than 58% of sperm are active) Percentage of normal sperm (more than 4%)

Answer 237

Pathology of the pituitary gland or hypothalamus Suppression due to stress, chronic conditions or hyperprolactinaemia Kallman syndrome

Answer 238

Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer

Answer 239

Klinefelter syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia (absent testes)

Answer 240

Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens (may be associated with cystic fibrosis) Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Answer 241

The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation. The second stage is from 10cm cervical dilatation to delivery of the baby. The third stage is from delivery of the baby to delivery of the placenta.

Answer 242

Power, passenger and passage

Answer 243

Size: of the head Attitude: the posture of the fetus Lie: The position of the fetus in relation to the mother Presentation: the part of the fetus closest to the cervix

Answer 244

Engagement Descent Flexion Internal rotation Extension Restitution Expulsion

Answer 245

Obstetricians describe the position of the baby’s head in relation to the mother’s ischial spines during the descent phase. Descent is measured in centimetres, from: -5: when the baby is high up at around the pelvic inlet 0: when the head is at the ischial spines (this is when the head is “engaged”) +5: when the fetal head has descended further out

Answer 246

Fetal station (scored 0 – 3) Cervical position (scored 0 – 2) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2) A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.

Answer 247

Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks). Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.

Answer 248

Booking scan

Answer 249

Dating scan An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified

Answer 250

Antenatal appointment Discuss results and plan future appointments

Answer 251

Anomaly scan

Answer 252

28 and 34 weeks

Answer 253

Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter Live vaccines, such as the MMR vaccine, are avoided in pregnancy.

Answer 254

**between 11 and 14 weeks** - Ultrasound for nuchal translucency (thicker than 6mm means higher risk) - beta-HCG (higher means higher risk) - PAPPA (low means higher risk)

Answer 255

The triple test is performed between 14 and 20 weeks gestation. It only involves maternal blood tests: Beta-HCG – a higher result indicates greater risk Alpha-fetoprotein (AFP) – a lower result indicates a greater risk Serum oestriol (female sex hormone) – a lower result indicates a greater risk

Obstetrics Flashcards

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