Obstetrics Flashcards

Question

Define prolonged deceleration on CTG

Answer 1

* Prolonged deceleration is a deceleration that lasts **more than 3 minutes** * Non-reassuring 2-3 minutes * Abnormal \> 3 mintues

Answer 2

* RARE but concerning - high fetal morbidity and mortality * Smooth, regular wave-like pattern * Frequency of 2-5 cycles a minute * Stable baseline around 120-160 bpm * NO beat to beat variability

Answer 3

* Abrupt decrease in fetal HR of **more than 15 bpm** for **more than 15 sec** * The fetal heart rate is controlled by the autonomic and somatic nervous system. In response to hypoxic stress, the fetus reduces its heart rate to preserve myocardial oxygenation and perfusion. Unlike an adult, a fetus cannot increase its respiration depth and rate. **This reduction in heart rate to reduce myocardial demand** is referred to as a deceleration.

Answer 4

* Early deceleration * Variable deceleration * Late deceleration * Prolonged deeleration * Sinusoidal

Answer 5

Often seen: * During labour and in patients with reduced amniotic fluid volume * Fetus experience stress during labour (reduced fetal perfusion as a result of uterine contractions) * Stress ie expected during labour but it is challenging to pick up **pathological fetal distress** * Caused usually by: **umbilical cord compression**

Answer 6

* Severe fetal hypoxia * Severe fetal anaemia * Fetal/maternal haemorrhage

Answer 7

Late decelerations on CTG are a **_pathological_** finding and urgent **_foetal blood sample_** (investigation) is needed to assess for foetal **_hypoxia_** and **_acidosis_**. A pH of \>**_7.2_** in labour is considered normal. Urgent delivery should be considered if there is foetal **_acidosis_**.

Answer 8

* Aspirin 75mg od from 12 weeks until birth of baby

Answer 9

* Hypertensive disease during previous pregnancies * Chronic Kidney Disease * Autoimmune disorders (SLE or Anti-phospholipid syndrome) * Type 1 or 2 Diabetes Mellitus

Answer 10

* BP usually **falls in first trimester** (particularly diastolic) * Continues to fall until 20-24 weeks * After this the BP usually increases to pre-pregnancy levels by term

Answer 11

* Systolic \> 140 mmHg OR Diastolic \> 90 mmHg -\> Pre-eclampsia * OR increase above booking readings of: * \>30 mmHg systolic or \> 15 mmHg diastolic

Answer 12

Deliver of baby

Answer 13

* Magnesium Sulphate * Crosses placenta freely. Leads to self-limiting hypotonia in the neonate

Answer 14

* Mild * \>140 Systolic * \>90 diastolic * Severe * \>160 systolic * \>110 diastolic

Answer 15

1st Line * IV **H**ydralazine and/or _**L**abetalol\*_ -\> **H**igh to **L**ow BP * HTN * IV magesium sulfate * seizure prophylaxis with * AIM: Get BP to 140-160 systolic and 90-110 diastolic * *Severe systolic HTN leads to loss of cerebral vasculature auto-regulation* 2nd line * Nicardipine and nifedipine PO * Calcium channel blockers Short term/Emergency/Others have failed * IV Nitroglycerin * IV Sodium Nitroprusside. \* LAbetolol first line in NICE 2010

Answer 16

* carefully monitored and reserved for extreme emergencies due to concerns about **cyanide and thiocyanate toxicity in the mother and fetus**, * as well as **increased intracranial pressure in the mother**

Answer 17

Pre-eclampsia with thrombotic microangiopathy involving the liver, characterised by: * Haemolytic anaemia * Low Hb, low Hct, high bilirubin, raised LDH, schistocytes on peripheral smear, dark urine * Elevated Liver Enzymes * Elevated AST/ALT, Epigastric pain, liver failure, abnormal clotting * Low Platelets Warrants _immediate delivery._ Occurs in 10-20% of patients with pre-eclampsia

Answer 18

* Headache * Visual disturbances (scotoma) * Vomiting * Drowsiness * Epigastric/RUQ pain * Oedema * HTN * Proteinuria ++

Answer 19

Maternal * Cerebrovascular accident * Eclampsia * Haemorrhage * Placental abruption * Intra-abdominal * Intra-cerebral * Multi-organ failure * Cardiac failure * Pulmonary oedema * Liver Failure * Renal Failure Foetal * Prematurity * IUGR, growth retardation * Increased mortality/morbiditiy

Answer 20

* Chronic, pre-maternal hypertension * Gestational Hypertension * Chronic hypertension with superimposed pre-eclampsia * HELLP Syndrome * Pre-eclampsia * Eclampsia Differentiate using: * Onset * Severity of HTN * Proteinuria * Oedema * RUQ pain

Answer 21

* characterized by isolated hypertension before 20 weeks' gestation with development of additional signs of preeclampsia after 20 weeks' gestation.

Answer 22

* four-fold increased risk of developing **hypertension** later in life * two-fold increased risk of ischemic **heart disease, stroke**, and **venous thromboembolism**.

Answer 23

* Somnolence (hypersomnia) * Absent deep tendon reflexes * Hypotension * Bradycardia * ECG changes

Answer 24

. Calcium gluconate infusion

Answer 25

Mild preeclampsia * Two serial blood pressure readings of \>140/90 mmHg (either systolic or diastolic) over four hours or more AND * \>0.3 g/24hrs of protein in the urine. Preeclampsia is considered severe with blood pressure of \>160/110 mmHg (either systolic or diastolic), urinary protein of \>5g/day, or if there are signs of end-organ damage such as visual disturbance, hepatocellular injury, thrombocytopenia, oliguria (\<500mL produced per day), fetal growth restriction, or pulmonary edema.

Answer 26

Before 34 weeks (33+6) * Continue **surveillance** unless there are indications for planned early birth. * Offer **intravenous magnesium sulfate** and a course of **antenatal corticosteroids** in planned early birth 34 to 36+6 weeks * Continue **surveillance** unless there are indications for planned early birth * When considering the option of planned early birth, take into account the woman's and baby's condition, risk factors (such as maternal comorbidities, multi-fetal pregnancy) and availability of neonatal unit beds. Consider a course of antenatal corticosteroids in line with the NICE guideline on preterm labour and birth. 37 weeks onwards * Initiate birth within 24–48 hours.

Answer 27

* Inability to control maternal BP despite using 3 or more classes of anti-hypertensives * Maternal O2 sats \<90% * Progressive detrioration in liver funciton, renal function, haemolysis or platelet count * Ongoing neurological features (severe intractable headache, repeated visual scotoma, eclampsia) * Placental abruption * Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph pr stillbirth MDT: Senior obstetrician, anaesthetic team, neonatal team. OFFER: Magnesium sulfate and course of antenatal corticosteroids if planned early birth

Answer 28

* H of HTN before pregnancy * \> 140/90 mmHg before 20 weeks gestation * No proetinuria * No oedema * 3-5% pregnancies and more common in older women

Answer 29

* HTN occuring in second half of pregnancy (\>20 weeks gestation) * No proteinuria * No oedema * 5-7% pregnancies * Resolves following birth (typically after 1 month) * These women are at increased risk of furute pre-eclampsia or HTN in later life

Answer 30

* Pregnancy-induced HTN * Proteinuria (\>0.3g/24hrs) * Oedema but less commonly used as criteria * 5% pregnancies

Answer 31

Moderate RF: * First pregnancy * Multiple pregnancy * ≥ 40 years * Pregnancy interval of \>10 years * BMI ≥ 35 at first visit * FH High RF: * HTN disease in previous pregnancy (PreE, E, HELLP, gHTN) * Chronic Kidney Disease * Autoimmune disease (SLE, Anti-phospholipid syndrome * T1DM, T2DM * Chronic HTN

Answer 32

* HTN \>160/110 mmHg * Proteinuria dipstick ++/+++ * Headache * Visual disturbance * Scotoma * Papilloedema * RUQ/epigastric pain * Hyperreflexia * Low Plt, abnormal LFT, HELLP

Answer 33

* Development of seizures in association with pre-eclampsia: * symptoms \>20 weeks gestation * Pregnancy-induced HTN * Proteinuria

Answer 34

* IV Magnesium Sulfate * Eclampsia: IV bolus 4g over 5-10 minutes, followed by infusion of 1g/hour * Monitor: * Urine output, reflexes, respiratory rate and O2 sats * Respiratory depression as result of Mg toxicity

Answer 35

* Continue for 24 hours after last seizure or delivery * 40% seizures occur post-partum NB: severe pre-eclampsia/eclampsia - fluid restrict to prevent fluid overload

Answer 36

* Foetal cells/amniotic fluid (liqour) enters maternal bloodstream * Stimulates reaction which results in anaphylaxis - obstetric emergency *Rare complication of pregnancy. High mortality rate. Incidence 2 per 100,000 UK.*

Answer 37

* Maternal Age * Induction of labour Many associated RF - multiple and prevention is impossible. Aetiology not been proven but widely accepted concept that maternal circulation must be exposed to liqour

Answer 38

* Majority in labour * Caeserian sections * Immediate post-partum

Answer 39

Signs * Cyanosis * LOW BP * Bronchospasms * HIGH HR * Arrhythmia * Myocardial infarction Symptoms * Chills * Shivering * Sweating * Anxiety * Coughing

Answer 40

* Clinical diagnosis of exclusion * No definitive diagnostic tests

Answer 41

* Critical care unit by MDT * **Supportive** management iwth resuscitation * Blood (FBC, clotting, U&E, cross match) * Treatment of massive obstetric haemorrhage

Answer 42

* At booking (8-12 weeks) * Subsequent hospital admission

Answer 43

* \>35 year * BMI \> 30 * Parity \> 3 * Smoker * Gross varicose veins * Current pre-eclampsia * Immobility * FH of unprovoked VTE * Low risk thrombophilia * Multiple pregnancy * IVF pregnancy * *Hospitalisation* * *Anaesthesia* * *Central venous catheter: Femoral \>\> Subclavian*

Answer 44

* ≥4 RF warrants _immediate treatment_ with LMWH until 6 weeks post-natal period * 3 RF LMWH initiated at 28 weeks and continued until 6 weeks post-natal * If DVT diagnosed shortly before delivery * continue anti-coagulation treatment for at least 3 months (as in other patients qwith provoked DVTs) Pregnant woman with previous VTE history is considered high risk immediately and requires immediate LMWH throughout antenatal period

Answer 45

* Low Molecular Weight Heparin (LMWH) * DO NOT GIVE: * Direct Oral Antigocaulants (DOACs) * Warfarin

Answer 46

* Pregnancy * Malignancy * Thrombophilia * Activated protein C Rsistance, Protein C and S deficiency * Heart failure * Anti-phospholipid syndrome * Behcet's * Polycythaemia * Nephrotic syndrome * Sickle cell disease * Paroxysmal nocturnal haemoglobinuria * Hyperviscosity syndrome * Homocystinuria

Answer 47

* COCP * 3rd generation \>\> 2nd generation * HRT * O+P \>\> O only * Raloxifene * Tamoxifen * Antipsychotics (Onlazapine)

Answer 48

* Premature birth * Still birth

Answer 49

* _Pruritis_ * Palms, soles, abdomen * Raised bile acids * Bilirubin and LFT may be elevated * 20% are clinically jaundiced

Answer 50

* Induction of labour at 37 weeks * Common practice but not really evidence based * Ursodeoxycholic acid (UDCA) * Used but not clear * Vitamin K supplementation

Answer 51

* Cardiovascular * Repiratory * Blood * Urinary * Biochemical changes * Liver * Uterus

Answer 52

* Increased: * SV (130%) * HR (115%) * CO (140%) * Diastolic BP reduces in 1st and 2nd trimester * Returns to non-pregnant levels by term * Enlarged uterus -\> venous return disruption * Ankle oedema * Supine hypotension * Varicose veins

Answer 53

* Increased * Ventilation (140%) * Tidal volume 500-700mL * Progesterone on respiratory centre * Oxygen requirement (120%) * Overbreathing leads to reduced pCO2 * Give rise to 'dyspnoea' * Basal metabolic rate (115%) * Increased thyroxine and adrenocrotical hormone * Find warm conditions uncomfortable

Answer 54

* Mild Anaemia * Increased Red cell mass (120-30%) * Plasma volume increase (150%) * Net dilution * Macrocytosis * Normal * Folate or B12 deficiency * Neutrophilia * Thrombocytopenia * Increased platelet size * Increase fibrinogen and Factors VII, VIII, X * Low grade increase in coagulant activity * Decreased fibrinolysis * Returns to normal after delivery (?placental disruption) * Increased risk VTE

Answer 55

* Increased * Perfusion (130%) * GFR (130-60%) * Salt and water reabsorption * Elevated sex steroid levels * Urinary protein loss * \>300mg/24hrs in pregnant women * \>150mg/24hrs in non-pregnant * Cautious as sign of pre-eclampsia

Answer 56

* Increased * Calcium requirements * Esp 3rd trimester up until lactation * Ca transported actively acorss placenta * Gut absorption of Ca * Increased 1,25 Vit D * Ionised Ca stable * Decreased * Serum Ca and Pi

Answer 57

* NO CHANGE in hepatic blood flow (unlike renal and uterine) * Raised ALP (150%) * Decreased albumin * Dilutational?

Answer 58

* Increase * Mass 100g -\> 1100g * Hyperplasia THEN hypertrophy * Cervical ectropion and discharge * Braxton-Hicks * Non-painful practice contractions late pregnancy (\>30weeks) * Retroversion mar lead to retention (12-16weeks) usually self corrects

Answer 59

* Rh -ve mother can develop anti-D igG antibodies if they deliver a Rh +ve child * Fetal blood may leak and cause above reaction * In later pregnancies, these IgG can cross placenta and cause haemolysis in the foetus

Answer 60

* Test for D antibodies in Rh -ve mothers at booking * Test Rhesus status * NICE (2008): anti-D to non-sensitised Rh -ve mothers at 28 and 24 weeks * RCOG (2011) - single dose (28wks) or double does (28 and 24 weeks) * If traumatic event is in 2nd/3rd trimester, give large dose of anti-D and perform Kleihauer test

Answer 61

* Determines proportion of fetal RBCs present if traumatic event happens 2nd/3rd trimester * Would also give big dose of anti-D

Answer 62

* Delivery of Rh +ve infant, live or stillborn * Termination of pregnancy * Miscarriage (if gestation \> 12 weeks) * Ectopic pregnancy surgical management * Not required if managed with methotrexate * External cephalic version * Antepartum haemorrhage * Amniocentesis, chorionic villus sampling, fetal blood sampling * Abdominal trauma

Answer 63

* FBC, blood group, Coomb's test * All babies born to Rh -ve mothers - cord blood at delivery * Kleihauer test * Add acid to maternal blood, fetal cellls are resistant

Answer 64

* Oedematus * Hydrops fetalis * As liver devoted to RBC production, albumin falls * Jaundice, anaemia, hepatosplenomegaly * Heart failure * Kernicterus

Answer 65

* Transfusions * UV phototherapy

Answer 66

* When the placenta implants in the lower uterus close to or covering the internal cervical os. * 5% will have low lying placenta when scanned at 16-20 weeks gestation * Incidence at delivery is 0.5% therefore most placentas rise away from cervix IMPORTANT CAUSE OF ANTEPARTUM HAEMORRHAGE DEATH NOW EXTREMELY RARE. Major cause of death in women with placenta praevia is now PPH

Answer 67

* Complete * Completely covers cervical os * Partial * Partially covers cervical os * Marginal * Edge of placenta extends to within 2cm of cervical os

Answer 68

* I - placenta reaches lower segment but not the internal os, extends within 2cm of os * II - placenta reaches internal os but doesn't cover it * III - placenta covers internal os before dilation but not when dilated * IV - placenta completely covers the internal os

Answer 69

Anything that has damaged endometrium and decrease vascularisation * _Previous C-section_ * Abortion * Uterine surgery * _Multiparity_ * _Multiple pregnancies_ Other * Multiple placentas * Placenta with larger than normal SA * Twins or triplets * Maternal age \> 35 * Intrauterine fibroids * Maternal smoking

Answer 70

* _NO pain and uterus NOT tender_ * Lie and presentation may be abnormal * Fetal heart usually normal * _Small bleeds before large_ * _Shock proportional to visible loss_ * Coagulation problems rare

Answer 71

* Often picked up at routine check up **\>20 weeks** on abdominal US * RCOG = transvaginal **ultrasound** to localise placenta * If placenta praevia is possible diagnosis, digital vaginal examination should not be performed until placenta praevia has been excluded -\> cause bleed Could also speculum to check for polyps/ectropion

Answer 72

* If low-lying placenta at 16-20 week scan OR * Placenta praevia with bleeding

Answer 73

* **Rescan at 34 weeks** * No need to limit activity or intercourse UNLESS THEY BLEED * If still present at 34 weeks and grade I or II: * Scan every 2 weeks * If high presenting part or abnormal lie at 37 weeks * C-section deliverr

Answer 74

* Admit * Treat shock * Cross match blood * Find ultrasound at 36-37 weeks to determine method of delivery: * C-section: Grade II or IV at 37-38 weeks * Vaginal delivery: Grade I

Answer 75

* Intrahepatic cholestasis of pregnancy (Obstetric cholestasis) * Acute fatty liver of pregnancy

Answer 76

Obstetric cholestasis

Answer 77

Third trimester Occurs in 1% pregnancies

Answer 78

* **Pruritis** (severe), in palms and soles * No rash (skin changes due to scratching may be present) * Raised bilirubin

Answer 79

* Ursodeoxycholic acid * Symptomatic relief * Weekly LFTs * Induction of labour at 37 weeks

Answer 80

* Increased rate of stillbirth * Not generally associated with increased maternal morbidity

Answer 81

* Third trimester OR * Period immediatelty following delivery

Answer 82

Non-specific presenting symptoms * Abdominal pain * Nausea and vomitting * Headache * Jaundice * Mild pyrexia * Hyupoglycaemia * Severe disease may result in pre-eclampsia OBSTETRIC EMERGENCY

Answer 83

* Elevetaed transaminases (ALT \>500 u/L) * Investigate synthetic function of liver (clotting studies)

Answer 84

* Supportive care * Once established delivery is definitive management

Answer 85

Disorder originating from placental trophoblast * Complete hydatidiform mole * Partial hydatidiform mole * Choriocarcinoma

Answer 86

* Benign tumour of trophoblastic material * When empty egg is fertilised by single sperm * Sperm DNA replicated so all 46 chromsomes are paternal origin

Answer 87

* Bleeding in first or early second trimester * Exaggerated symptoms of pregnancy (Hyperemesis) * Uterus large for dates * Very high levels of hCG * Hypertension and hyperthyroidism may be seen

Answer 88

* Beta hCG similar in structure to LH, FSH and TSH * so B-hCG can stimulate thyroid production of thyroxine (T4) and triiodothyronine (T3) * T4 and T3 have negative feedback on pituitary gland leading to fall in TSH levels

Answer 89

* High B-hCG * High thyroxine * Low TSH

Answer 90

* URGENT referal to specialist centre * Evacuation of uterus is performed * Contraception is recommended to avoid pregnancy in the next 12 months around 2-3% develop choriocarcinoma

Answer 91

* Normal haploid egg may be fertilised by two sperms or by one sperm with duplication of paternal chromosomes * DNA is maternal and paternal in origin * Usually triploid 69 XXX or 69 XXY * Feotal parts may be seen

Answer 92

* Initiation and diagnosis of labour * Braxton Hicks contractyions in third trimester which develop into contraction * Labour diagnosed when there are painful regular contractions which lead to effacement and dilatation of cervix * First Stage * From diagnosis of labour to full dilation of cervix (10cm) * Membranes rupture now normally, if not already * **Latent phase**: Cervix dilates slowly for first 4 cm - takes several hours * **active phase:** 1cm/h dilatation nulliparous women or 2cm/hr in multiparous * Active first stage should NOT last more tha 16 hours

Answer 93

* Initiation and diagnosis of labour * Braxton Hicks contractyions in third trimester which develop into contraction * Labour diagnosed when there are painful regular contractions which lead to effacement and dilatation of cervix

Answer 94

From diagnosis of labour to full dilation of cervix (10cm) * Descent, flexion and internal rotation occur to varying degrees * Membranes rupture now normally, if not already * **Latent phase:** Cervix dilates slowly for first 4 cm - takes several hours * **active phase:** 1 cm/hr dilatation nulliparous women or 2 cm/hr in multiparous * Active first stage should NOT last more than 16 hours

Answer 95

From full dilatation of cervix to delivery of baby * Descent flexion and rotation are _copmleted_ and followed by **extension as head delivers** * **Passive stage**: Full dilatation until head reaches pelvic floor and mother has desire to push. * Rotation and flexion are commonly completed here * May last a few minutes but can last longer * **Active stage**: When mother is pushing * Pressure of head on pelvic floor produces irresistable desire to bear down (epidural may prevent this) * bBaby deliveres after 40 minutes (nulliparous) or 20 minutes (multiparous) * Can be quicker but if it takes \>1 hours, SVD becomees increasingly unlikely

Answer 96

* Head extends out through perineum and out of the pelvis * Perineum stretches and often tears (episiotomy) * Head restitues and rotates 90o to adopt transvere position (same position as it entered the pelvic inlet) * Shoulders deliver in the next contraction * Anterior shoulder comes under symphysis pubis first, then posterior shoulder then rest of body (see pg 285 for more detail)

Answer 97

Time of delivery to delivery of placenta * Uterine muscle fibres contract to compress blood vessels supplying placenta * This hears away from uterine wall and is delivered * Lasts 15 minutes * Normal blood loss up to 500 mL

Answer 98

* Attachment of the placenta to the myometrium due to defective decidua basalis. * Placenta does not properly separate in third stage of labour -\> risk of PPH

Answer 99

* Previous c-section * Placenta praevia * PID

Answer 100

* accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis * increta: chorionic villi invade into the myometrium * percreta: chorionic villi invade through the perimetrium

Answer 101

* Complication of vaginal cephalic delivery * Inability to deliver the body of the foetus using gentle traction, the head already being delivered * Usually due to anterior foetal shoulder impacting on maternal symphysis pubis

Answer 102

Fetal * Macrosomia Maternal * High BMI * Diabetes Mellitus * Prolonged labour (second stage?)

Answer 103

* ASK FOR HELP as soon as shoulder dystocia identified * McRobert's maneouvre performed, if unsuccessful: * Can use the woodscrew maneouvre * Rubin maneouvre * Mother on all fours on all fours * If nothing works Push head back and do emergency c-section

Answer 104

* Hyperflexion and abduction of mother's hips, with her thighs towards her abdomen * Apply suprapubic pressure * This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery

Answer 105

* Putting hand in the vagina to attempt to rotate baby 180 degrees

Answer 106

Cephalic replacement via reversal of the cardinal movements of labour Not first-line option

Answer 107

Formation of neural tube defects

Answer 108

* Folic acid converted to tetrahydrofolate (THF). * Role in transfer of 1-carbon unite (methyl etc) to essential substrates involved in DNA and RNA synthesis

Answer 109

Supplementation Green leafy vegetables

Answer 110

* Phenytoin * Methotrexate * Pregnancy * EtOH excess

Answer 111

* Macrocytic , megaloblastic anaemia * Neural tube defects

Answer 112

* ALL women should take 0.4mg (400mcg) folic acid/day pre-conception and continue until 13 weeks * Started pre-conception as neural tube forms within first 28d of embryo development * Women at high risk of conceiving a child with NTD should take 5 mg/day pre conception until 12th week pregnancy

Answer 113

* Previous child with NTD (or FH) * Diabetes mellitus * Anti-epileptic * Obese (BMI \>30) * HIV +ve taking co-trimoxazole * Sickle cell (thalassamie trait) * Coeliac disease (malabsorption)

Answer 114

* Vaginal discharge containing blood, mucous and uterine tissue during _puerperium_ * Period of 6 weeks after birth in which mother;s reproductive organs return to normal * L:ochia is normal part of this process

Answer 115

Ultrasound if lochia persists beyond 6 weeks

Answer 116

Counsel * Lochia is normal bleeding post partum * Consists of blood, mucous and uterine tissue * Can pressit up to 6 weeks * Bright red first and then changes colour before finally stopping Safety net to seek medical help if: * Offensive smell * Increase in volume * Or persists past 6 weeks

Answer 117

* Membranes rupture \< 37 weeks * Aetiology often unknown but all causes of pre-term labour may be implicated * Occurs in 2% pregnancies but make up around 40% of preterm deliveries

Answer 118

Too much inside * Multiple pregnancy * Antepartum haemorrhage * Polyhydramnios Defenders escape (foetal survival repsponse) * Antepartum haemorrhage * IUGR * Pre-eclampsia * Foetal distress (?) Weak wall * Cervical incompetence * Uterine abnormalities Other (Enemy) * Infection * Diabetes * Idiopathic * Iatrogenic

Answer 119

Foteal * Preterm delivery (within 48hrs in 50% cases) * Infection * Funisitis (cord infeciton) * Pulmonary hypoplasia * Umbilical cord prolapse (rare) Maternal * Chorioamnionitis

Answer 120

History * Gush of clear fluid is normal * Followed by further leaking * \<37 weeks gestation

Answer 121

* Sterile Speculum examination * Pool of fluid in posterior fornix is diagnostic - variable * AVOID DRE * Could cause infection * Features of chorioamnionitis * Contractions or abdominal pain * Fever or hypothermia * Tachycardia * Uterine tenderness * Coloured offensive liqour * Clinical signs often appear late

Answer 122

* Actim Partus * helps decide whether to send mother home or admit * USS * Reduced liqour (oligohydramnios) but can be normal as foetus produces urine * Look for infectyion * High vaginal swab * FBC * CRP * Lactate * CTG * Foetal well-being * Persistent tachycardia suggestive of infection

Answer 123

* Admission * Regular observations to ensure chorioamnionitis is not developing * Oral erythromycin for 10 days * Antenatal corticosteroids * Reduce risk of RDS * Delivery considered at 34 weeks gestation * Trade off between risk of maternal chorioamnionitis with decrease risk of RDS in baby as pregnancy progresses * Co-amoxiclav CONTRAINDICATED as neonate prone to NEC

Answer 124

* Baby blues * Postnatal depression * Peuperal psychosis

Answer 125

* Baby Blues = 3-7d following birth, common in primimaprous mothers * Postnatl depression = month post-partum and peaks at 3 months * Peurperal psychosis = first 2-3 weeks following birth

Answer 126

* Baby blues * Anxious, tearful and irritable * Postnatal depression * Similar to depression in other contexts (low mood, energy and anhedonia) * Peurperal psychosis * Severe mood swings (similar to bipolar disorder) * Disordered perception (auditory hallucinations)

Answer 127

* Reassurance and provide support * Health visitor plays key role

Answer 128

* Reassurance and support as with baby blues * CBT first line! * Severe symptoms: SSRI (sertraline or paroxetine) * Secreted in breast milk but not harmful to babay

Answer 129

* Admission to hospital * 20% risk of recurrence following future pregnancies

Answer 130

11 - 13 +6 weeks

Answer 131

8-12 weeks (booking visit)

Answer 132

* 1st degree = Superficial damage with no muscle invovlement (not past fourchette) * 2nd degree = injury to perineal muscle but not involving anal sphincter * 3rd degree = injury to perineum involving anal sphincter complex * 3a = \<50% of external anal sphincter thickenss torn * 3b = \>50% EAS thickness torn * 3c = IAS torn * 4th degree = involves EAS and IAS AND rectal mucosa

Answer 133

* Primigravida * Large baby (macrosomia) * Precipitant labour (very rapid childbirth 1st and 2nd stage labour \< 2hours) * Shoulder dystocia * Forceps delivery

Answer 134

* Placenta praevia = painless and bright red bleeding (usually small bleeds then large, with shock proportional to loss) * Placental abruption = associated with pain and dark red bleed * Vasa praevia = painless PV bleed + fetal bradycardia and membrane rupture

Answer 135

* Blood loss of \>500mL * Primary = within 24hrs of delivery * Secondary = more than 24 hours -12 weeks post birth * Apparently changed from 6 weeks

Answer 136

* Uterine atony (90% of cases) * Other causes: * Genital trauma * Clotting disorders (DIC or deficiencies)

Answer 137

Basically anything that causes distension of uterus or anything that stops it contracting * Previous PPH * Prolonged labour * Pre-eclampsia * Increased maternal age * Polyhydramnios * Emergency C-section * Placenta praevia * Placenta accreta * MAcrosomia * Ritodrine * B2 adrenergic receptor aghonist used for tocolysis Previously thought multiparity was RF but recent modern studies show nulliparity is RF

Answer 138

* Seek senior help! 222 call * ABC (+14G cannulae) * Medical * IV syntocinon 10 IU or IV ergomwetrine 500mcg * RCOG says 5 IU double check * IM carboprost * Surgical * Intrauterine balloon tamponade first line * Where uterine atony is only or main cause of haemorrhage * Others * B-Lynch suture * Ligation of uterine arteries orinternal iliac arteries * Severe haemorrhage * Hysterectomy = life-saving procedure

Answer 139

* Retained placental tissue * Endometritis

Answer 140

* Maternal pyrexia * Maternal tachycardia * Fetal tachycardia Reasonable differentials: PID, UTI (maybe STI)

Answer 141

* Ascending bacterial infection of amniotic fluid/membranes/placenta * Preterm premature rupture of membrane (however can still occur when membranes are intact) exposes sterile uterus to patohgens

Answer 142

* Obstetric emergency * Prompt delivery of foetus (via c-section if necessary) * IV antibiotics initial treatment

Answer 143

* Separation of normally sited placenta form uterine wall * results in maternal haemorrhage into intervening space Occurs in ~1/200 pregnancies

Answer 144

* Proteinuric hypertension * Multiparity * Maternal trauma * Increasing maternal age

Answer 145

* Constant abdominal pain * Shock disproportionate to blood loss * 20% of placental abruptions are concealed - trapped behind placenta and doses not drain * Uterus may be in spasm and feel firm or woody * Fetal heart: absent or distressed * coagulation problems * Beware pre-eclampsia, DIC, anuria

Answer 146

* Prematurity * Prolonged rupture of membranes * Previous sibling with GBS infection * Maternal pyrexia (secondary to chorioamnionitis)

Answer 147

* Universal screening for GBS should NOT be offered to all women * Maternal request is also NOT an indication for screening * Mothers who have had GBS detected in previous pregnancy should be informed of their risk of maternal GBS carriage (50%) * Offer maternal IV antibiotic prophylaxis (IAP) * OR testing in late pregnancy and then antibiotics if still positive * IAP

Answer 148

* Mother has GBS in previous pregnancy * Positive test in late pregnancy * Mothers with previous baby with earl- or late-onset GBS disease * Women in preterm labour - regardless of GBS status * Women with pyrexia during labour (\>38)

Answer 149

Benzylpenicillin

Answer 150

Streptococcus agalactiae Gram positive, coccus in chains, facilitative anaerobe

Answer 151

* 35-37 weeks OR * 3-5 weeks prior to anticipated delivery date

Answer 152

* Neisseria gonorrhoea * Gram negative diplococcus * Obligate anaerobe * Conjunctivites

Answer 153

Varied definitions * \<500mL at 32-36 weeks AND * Amniotic Fluid Index (AFI) \< 5th percentile

Answer 154

* Premature rupture of membranes * Foetal renal problems (e.g. renal agenesis) * IUGR * Post-term gestation * Pre-eclampsia

Answer 155

* Spontaneous abortion * Ectopic pregnancy * Hydatidiform mole Exclude STIs and cervical polyps

Answer 156

* Spontaneous abortion * Hydatidiform mole * Placental abruption Exclude STIs and cervical polyps

Answer 157

* Bloody show * Placental abruption * Placenta praevia * Vasa praevia Exclude STIs and cervical polyps

Answer 158

Bleeding after 24 weeks

Answer 159

Ectopic pregnancy

Answer 160

Hydatidiform mole

Answer 161

Placental abruption

Answer 162

Placenta praevia

Answer 163

Vasa praevia

Answer 164

No Can cause haemorrahge esp placenta praevia

Answer 165

* Sodium valproate - Neural tube defects and teratogenic * Carbamazepine - teratogenic (least of older AED) * Phenytoin - cleft palate * Lamotrigine -low rate of ocngenital malformations

Answer 166

barbiturates

Answer 167

* Pre-eclampsia/Eclampsia * Hypertension * Diabetes and GDM * Cardiac Disease * Respiratory disease * Epilepsy * Thyroid disease * Liver disease * Renal Disease * Thrombophilia * VTE * Obesity * Psychiatric * Reacreational Drug use * Anaemia * Haemoglobinopathies * Foetal Genital mutilation

Answer 168

* Pre-existing * Type I * Type II * Gestational diabetes

Answer 169

* Carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy (NICE 2015) * Becoming more prevalent due toobesity and varying diagnostic thresholds * Pregnancy is a pro-diabetic state, therefore women with impaired glucose tolerance can deteriorate and be classified as diabetic in pregnancy

Answer 170

* Fasting glucose ≥ 5.6 mmol/L OR * \>7.8 mmol 2 hours after a 75g glucose load (Glucose tolerance test GTT)

Answer 171

Complications due to elevated glucose levels * Cognenital abnormalities (NTD and cardiac) 3-4x * Preterm labour * Immature lungs compared to non-DM pregnancies * Macrosomia * Polyhydramnios * Polyuria, increased liqour * Dystocia and birth trauma * Foetal compromise, distress and sudden foetal death * Poor third trimester glucose control

Answer 172

Complications are related to glucose levels, so women with GDM (and better control) are less affected * Increased insulin requirements (300%) * Hypoglycaemias * Ketoacidosis (rare) * Infection * UTI * delivery wound or endometrial infection * Hypertension * Pre-eclampsia * Caeserean or instrumental delivery * Foetal compromise and macrosomia * Diabetic nephropathy * Proteinuria and renal deterioration * Diabetic retinopathy * Due to rapid control of blood glucose

Answer 173

* Glucose control * Monthly HbA1c \<6.5% * Preganancy not adviced it \>10% * Fasting glucose 4-7 mmol/L * Metformin and insulin are appropriate, stop other hypoglycaemic drugs * Other * 5mg Folic acid * Stop statins * Switch to pregnancy safe anti-HTN (labeteolol, methyldopa) * Renal function; creatinine \< 120 umol/L * Blood pressure * Retina assessment

Answer 174

* HbA1c checked at booking * Glucose checked at home: * Fasted in the morning * Before meals * 1 hour after meals * Bedtime * Result aims: without hypoglycaemia * Fasting \< 5.3 mmol/L AND * 1hour glucose \< 7.8 mmol/L * Contact with healthcare professional should be no less than 2 weekly ## Footnote * NICE GDM =* * Fasting glucose ≥ 5.6 mmol/L OR* * \>7.8 mmol 2 hours after a 75g glucose load (Glucose tolerance test GTT)*

Answer 175

* Metformin OR Insulin * MEtformin dose will usually need to be increased as pregnancy advances and may need to be supplemented with insulin in type II * Insulin: combo of : * once or twice daily long-intermmediate acting AND 3 preprandial short-acting insulin injuections * Insulin pumps for poor control * Advise exercise and diet!

Answer 176

In addition to the usual pregnancy scans, fetal echocardiography is indicated. Ultrasound is used to monitor **_fetal growth_** and **_liquor volume_** at **_32_** and **_36_** weeks. Even where glucose control has been good, macrosomia and polyhydramnios can occur (Fig. 21.5). Umbilical artery Doppler is not useful unless pre-eclampsia or intrauterine growth restriction (IUGR) develops.

Answer 177

* Delivery 37-39 weeks * Elective C-section * Likely birth trauma if US (though unprecise) estimates fetal weight \> 4kg

Answer 178

Sliding scale of insulin and dextrose infusion

Answer 179

* Preconceptual glucose control * Assess maternal diabetic complications * PAtient education and MDT] * Glucose monitoring and insulin adjustment * Anomaly and cardiac USS and foetal surveillance * Delivery 37-39 weeks

Answer 180

Risk-based screening; if +1 risk factors * Oral Glucose Tolerance Test (OGTT) at 24-28 weeks OR * If previous GDM, OGTT at 16-18 weeks. If normal repeat OGTT at 24-28 weeks

Answer 181

* Previous large baby (\>4.5 kg) or Unexplained still birth * Previous history of GDM * First-degree relative (parents or siblings) with diabetes * BMI \> 30 * Minority ethnicity (S. asian, black Caribbean, Middle Eastyern) * *Polyhydramnios*

Answer 182

* Fasting \> 5.6 mmol/L OR * 2h glucose \> 7.8 mmol/L

Answer 183

* Explain Implications of GDM to mother and foetus * Blood glucose monitoring * Diet and exercise * Pharmacological management of glucose

Answer 184

* Carbamezapine * Lamotrigine

Answer 185

* 5mg Folic acid throughout pregnancy * 10mg Vit K po from 36 weeks * 20 week scan and feotal echocardiography to exclude foetal abnormalities

Answer 186

* Thromboembolism * Pre eclampsia * Diabetes * C-section * Wound infections * Difficult surgery * Postpartum haemorrhage * Maternal death

Answer 187

* Congenital abnormalities (NTD) * Diabetes * Perinatal mortality (pre-eclampsia)

Answer 188

* Preconceptual weight loss * Preconceptual 5mg Folic acid + Vitmain D * Weight is best maintained during pregnancy * Loss may lead to malnutrition * BMI \> 35 = high risk pregnancy * BMI \> 40 = formal anaesthetic risk assessment and antenatal thromboprophylaxis

Answer 189

* Premature rupture of membranes (PROM) * Pre-term premature rupture of membranes (PPROM)

Answer 190

* Rupture of foetal membranes at least 1 hour prior to onset of labour at ≥37 weeks gestation * 10-15% term pregnancies, minimal risk to mother and foetus due to advanced gestation

Answer 191

* Rupture of foetal membranes occuring at \<37 weeks gestation * Complicates 2% pregnancies and has high rate of maternal and foetal complications * Associated with 40% preterm deliveries

Answer 192

* The fetal membranes consist of the **_chorion_** and the **_amnion_**. They are strengthened by **_collagen_**, and under normal circumstances, become weaker at term in preparation for labour. * The physiological processes underlying this weakening include apoptosis and collagen breakdown by **_enzymes_**. * In cases of premature rupture of membranes and P-PROM, a combination of factors can lead to the early weakening and rupture of fetal membranes: * **_Early activation of normal physiological processes_** – higher than normal levels of apoptotic markers and MMPs in the amniotic fluid. * **_Infection_** – inflammatory markers e.g. cytokines contribute to the weakening of fetal membranes. Approximately 1/3 of women with P-PROM have positive amniotic fluid cultures. * **_Genetic predisposition_**

Answer 193

* Smoking (esp \<28 wk gest) * Previous PROM/pre-term delivery * Vaginal bleeding during pregnancy * Lower genital tract infecition * Iatrogenic (amniocentesis) * Polyhydramnios * Multiplpe pregnancy * Cervical insufficiency ## Footnote *In many cases of PROM/PPROM, there are no identifiable risk factors*

Answer 194

* Typical history of broken water * Painless popping senstion followed by gush of watery fluid from the vagina * Can be non-specific - gradual leak * Speculum - may see pooling in posterior vaginal fornix * Speculum not needed if amniotic fluid is seen draining from vagina * Lack of normal vaginal discharge (washed clean)

Answer 195

* Urinary incontinence * Normal vaginal secretions in pregnancy * Cervical infection * Loss of mucus plug

Answer 196

Diagnosis usually made by i) maternal history of membrane rupture and ii) positive examination findigns * **High vaginal swab** in ALL cases * May grow GBS, which would indicate intrapartum Abx * ferning test * Leting cervical secretions dry from a glass slide - forms fern-pattern * Ultra sound * Not routinely used but can be used if diagnosis unclear *

Answer 197

* Rupture of membrane will stimulate uterus - therefore majority of women go into labour withing 24-48 hours * If women do not go into labour, induction of labour may be considered: * Balancing gestational age (dont induce so foetus can develop more) * Risk of infection Summary: IOL and delivery if \>34 weeks Expectant management if \< 34 weeks

Answer 198

Expectant management * wait 24hr as 60% go into labour naturally * IOL recommended if \>24hr * Monitor signs of clinical chorioamnionitis * High vaginal swab * Clindamycin/penicillin intrapartum if +ve

Answer 199

* IOL and delivery recommended * Monitor signs of chorioamnionitis * Avoid sexual intercourse * Prophylactic erythromycin 250mg QDS for 10 days * high vaginal swab * Clindamycin/penicillin intrapartum * Corticosteroids

Answer 200

* Aim expectant management until 34 weeks * Monitor signs of chorioaminonitis * Avoid sexual intercourse * Prophylactic erythromycin 250mg QDS 10days * Corticosteroids ## Footnote *Historically the aim was to get the pregnancy to 36 weeks if there was no evidence of infection. However, with improvements in neonatal care (and evidence for poorer outcomes in babies if there is maternal infection), management has shifted towards 34 weeks and induction of labour once there has been a course of steroids.*

Answer 201

Outcome or PROM correlates with gestational age of foetus. Majority women go into labour after PROM but there is a **greater latency period** the younger the gestational age. Pre-disposes greater risk of maternal and foetal complications * Chorioamnionitis * Infection of foetal membrane * Risk increases longer membranes remained ruptured and baby undelivered * Oligohydramnios * Sig in \<24 weeks gestation, increases risk of lung hypoplasia * Neonatal death * Prematurity, sepsis, pulmonary hypoplasia * Placental abruption * Umbilical cord prolapse

Answer 202

* Process of starting labour artificially * Most women go into labour sponataneously by 42 weeks of gestation, roughly 1 in 5 will require an induction * *IOL performed when its though that the baby will be safer delivered than remaining in utero. Also could be due to concerns for maternal health*

Answer 203

IOL indicated when delivering baby is safer for the baby and or mother thanfor baby to remain in utero * Prolonged gestation * PROM/PPROM * Maternal health problems * Foetal growth restriction * Intrauterine foetal death

Answer 204

* If uncomplicated, offer between **41⁺⁰ to 42⁺⁰ weeks' gestation.**

Answer 205

* Avoid risk of foetal compromise and still birht (thought to be secondary to placental ageing)

Answer 206

* Increased frequency of monitoring from 42 weeksa onwards * at least twice‑weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth

Answer 207

\>37 week gestation * Offer IOL * OR expectant management for a **maximum 24 hours** * Any longer increases risk of ascending infection -chorioamnionitis * 84% women will spontaneously go into labour withitn first 24 hours * *High vaginal swab* * *Clindamycin/penicillin intrapartum if +ve*

Answer 208

Dependent on stage of gestation: _\<34 weeks gestation_ * Delay IOL unless obstetric factors indicate otherwise (foetal distress) - Aim for 34 weeks gestation * *Monitor signs of chorioaminonitis* * *Avoid sexual intercourse* * *Prophylactic erythromycin 250mg QDS 10days* * *Corticosteroids* _\>34 weeks gestation_ * IOL and delivery recommended * Timing depends on risk v benefits of delaying pregnancy further (increased risk of infection) * *Monitor signs of chorioamnionitis* * *Avoid sexual intercourse* * *Prophylactic erythromycin 250mg QDS for 10 days* * *high vaginal swab* * *Clindamycin/penicillin intrapartum* * *Corticosteroids*

Answer 209

* Hypertension * Pre-eclampsia * Diabetes * Obstetric Cholestasis Decision will depend on health of mother and foetus

Answer 210

* Foetal growth restriction * Aim: Deliver baby **prior** to foetal compromise

Answer 211

* MOther physically well with intat membranes

Answer 212

* Ceophalopelvic disproportion * Major placenta praevia * Vasa praevia * Cord prolapse * Transverse lie * Active primary genital herpes * Previous classical C-Section

Answer 213

* Breech presentation * Triplet or higher order pregnancy * Two or more previous low transverse C-section

Answer 214

Increased risk of: * Emergency caeseran * Uterine rupture

Answer 215

* Frank breech * Complete breech * Incomplete breech * Footling breech * Kneeling breech

Answer 216

* Vaginal prostaglandins * Amniotomy * Membrane Sweep

Answer 217

* Vaginal prostaglandins * Prostaglandins * act to prepare the cervix by ripening it * have a role in contraction of smooth muscle of uterus

Answer 218

* Tablet/gel regimen * 1 cycle = 1st dose, plus 2nd dose if labour has not started within 6 hours * Pessary regimen * 1 cycle = 1 dose over 24 hours Recommended maximum of one cycle in 24 hours (IOL can sometimes take multiple days)

Answer 219

* Membranes are ruptured artificially using an amniohook * Like in membrane sweep, this process releases prostaglandins in an attempt to expedite labour * Often given with Syntocinon infusion

Answer 220

* Increases strength and frequemncey of contractions The aim is to start **_low_** and titrate **_upwards_** until there are **_4_** **_contractions_** every **_10_** minutes

Answer 221

The aim of amniotomy + syntocinon infusion is to start **_low_** and titrate **_upwards_** until there are **_4_** **_contractions_** every **_10_** minutes

Answer 222

* NOT FIRST LINE for IOL * Only when cervis is ripe (Bishop Score ≥ 7) * OR Prostaglandin use is contraindicated (high risk of uterine hyperstimulation)

Answer 223

* Inserting gloved finger through cervix and rotating against foetal membranes * Aims to separate chorionic membrane from the decidua * Separation helps release natural prostaglandins to attemtp to kick-start labour

Answer 224

Used as an adjunct of IOL. Perfomring it increases likelihood of spontaneous delivery reducing need for formal induction * 40-41 weeks nulliparous women * At 41 weeks multiparous women

Answer 225

* Bishop Score * CTG

Answer 226

* Assessment of cervical ripeness based on factors taken during vaginal examination * Checked prior to induction and during induction to assess progress (6 hours post-tablet/gel, 24 hours post-pessary)

Answer 227

* Dilation (cm) of cervix * Length of cervix (cm) * Station (relative to ischeal spines) * Consistency of cervix * Position of cervix

Answer 228

* ≥ 7 = cervix is ripe or favourable * High cance of responsiveness to interventions made to induce labour (ie IOL possible) * \<4 * Labour unlikely to progress naturally * therefore prostaglandin therpay required

Answer 229

Caeserian section

Answer 230

* CTG prior to IOL to confirm reassuring foetal HR * After IOL initiation, when contraction begins, assess foetal HR until normal rate is confirmed (use continuous CTG) * Subsequently assess using intermittent auscultation * If oxytocin infusion is stated, mointor using continuous CTG throughout labour

Answer 231

* Failure of induction (15%) * Offer further cycle of prostaglandins or C-section * Uterine hyperstimulation (1-5) * Contractions too long or too frequent leading to foetal distress * Manage with tocolytics (terbutaline) * Cord prolapse * Can occur at amniotomy, esp when presentation of foetal head is high * Infection * Fewer veginal examinations * Pain * IOL more painful than spontaneous labour * Epidural analgesia * Uterine rupture (rare) * Increased rate of further intervention vs spontaneous labour

Answer 232

Delivery of baby through surgical incision in the abdomen and uterus

Answer 233

* Category 1 * Immediate threat to life of woman or foetus * Deliver in 30 minutes (some 20 min) * Category 2 * Maternal or foetal compromise that is not immediately life-threatening * Deliver in 60-75 minutes * category 3 * No maternal or foetal compromise but needs early delivery * Category 4 * Elective

Answer 234

* Failure to progress in labour * Suspected/confirmed foetal compromise

Answer 235

* Breech presentation at term * Other malpresentations * Unstable, Transverse, Oblique lie * Twin pregnancy * When first twin is NOT cephalic presentation * Maternal medical conditions * Cardiomyopathy * Foetal compromise * Transmissable disease * Poorly controlled HIV * Primary genital herpes * in third trimester * Placenta praevia * Maternal diabetes * Foetal weight \> 4.5 kg * Previous major shoulder dystocia * Previous 3rd/4th perineal tear * Maternal request

Answer 236

* After 39 weeks * Reduce respiratory distress in neonate (TTN) * If before 39 weeks consider corticosteroid administration * Developmoent of foetal lungs

Answer 237

* FBC and G&S * blood loss 500-1000mL * H2-receptor antagonist * Ranitidine +/- ?metoclopramide * VTE risk score * TED stockings +/- LMWH * Type of anaesthesia * Regional anaesthetis (epidural or spinal) * General anaesthetic

Answer 238

* Aspiration of gastric contents into the lung leading to chemical pneumonitis * Caused by pressure from gravid uterus on gastric ocntents

Answer 239

* Skin * Fat * Muscle * Suprspinous ligaments * Interspinous ligaments * Ligamentum flavum * Dura * Subdural space * Arachnoid mater * Subarachnoid space

Answer 240

* Pre-incision * Left lateral tilt of 15⁰ - reduce risk of supine hypotension due to aortocaval compression * Foley's catheter - drain bladder and reduce risk of injury * Skin cleaned and antibiotics administered * Skin incision * Sharp or blunt dissection into abdomen * Incision of visceral peritoneum * Uterine incision * Oxytocin 5IU * Closure

Answer 241

* Pfannenstiel * Joel-Cohen

Answer 242

* Skin * Camper's fascia - superficial layer of SC tissue * Scarpa's fascia - deep membranous layer of SC tissue * Rectus sheath - anterior and posterior * rectus muscle * Parietal peritoneum (abdominal) * Uterus/bladder

Answer 243

Doyen retractor

Answer 244

* Transverse curvilinear incision * Digitally extended * De Lee's incision * Lower vertical - required if lower uterine incision is poorl;y formed(rare

Answer 245

* given IV by anaesthetist to aid delivery of placenta by controlled cord traction by surgeon

Answer 246

* Early warning chart * Lochia * PV bleed loss

Answer 247

Early mobilisation Eating and drinking removal of catheter

Answer 248

* Perineal trauma and pain * Urinary incontinence * Anal incontinence * Uterovaginal prolapse * Late stillbirth * Early neonatal infection

Answer 249

* PPH \>1000mL * Wound haematoma (high BMI, diabetes, immunosup.) * Intra-abdo haemorrhage * Bladder/bowel trauma (esp in those with previous abdo surgery) * Neonatal * TTN * Foetal lacerations

Answer 250

* Infection * UTI * Endometritis * Respiratory (in GA) * VTE

Answer 251

* Urinary tract trauma (fistula) * Subfertility * Psyhcological sequelae * VBAC - Vaginal birth after c-section * Placenta Praevia/accrete * Caeserean scar ectopic pregnancy

Answer 252

* Vaginal birth after C-section (VBAC) * Planned elective repeat C-section

Answer 253

* Multiple pregnancy * Macrosomia * Maternal age \> 40 y

Answer 254

* Shorter hospital stay and recovery - **VBAC** * Greater risk of uterine rupture - **VBAC** * No risk of anal sphincter injury - **ERCS** * Higher risk of maternal death - **ERCS** * Likely to require future C-Section - **ERCS** * Higher risk of neonatal respiratory morbidity - **ERCS** * Higher risk of hypoxic ischaemic encephalopathy (HIE) - **VBAC** * Increased risk of placental problems and adhesion formation - **ERCS**

Answer 255

* Deliver in hospital setting (emergency c-section and advanced neonatal resuscitation) * Continuous CTG monitoring * Additional analgesic requirements * Avoid induction where possible * risk of rupture is less with mechanical tehcniques (amniotomy) vs with prostaglandins * Augmentation can increase risk of uterine scar rupture * Senior obstetrician input * \>39 weeks = recommended elective repeat C-section *

Answer 256

* Classical caeserean scar * Previous uterine rupture * Other contraindications for vaginal birth that apply to the clinical scenario (eg placenta praevia)

Answer 257

* Complex uterine scars * \>2 prior lower segment C-sections

Answer 258

* Full thickness disruption of uterine muscle and overlying serosa * Foetus can be extruded from uterus resulting in foetal hypoxia and large internal haemorrhage RARE but significant maternal and foeatl morbidity nad mortality

Answer 259

* Incomplete * Peritoneum overlying uterus is intact * Uterine contents remain in the uterus * Complete * Peritoneum is also torn * Uterine contants can escape into the petioneal cavity

Answer 260

* **Previous C-section** * Previous uterine surgery (myomectomy) * Induction (prostaglandins or augmentation of labour) * Obstruction of labour * Developing countries * Multiple pregnancy * Multiparity

Answer 261

Non-specific * **Abdominal pain** * Persists between contractions * Shoulder tip pain * Vaginal bleeding

Answer 262

* Regression of presenting part * Scar tenderness on palpation * Palpable foetal parts * Hypovolaemic shock * Significant haemorrhage * Foetal distress or absent heart sounds

Answer 263

* Placental abruption * Abdo pain +/- vaginal bleeding * Uterus often described as tense on palpation and woody * Placenta praevia * Painless vaginal bleeding * Vasa praevia * Triad: * Ruptured membranes * Painless vaginal bleeding * Foetal bradycardia

Answer 264

* Painless vaginal bleeding * Rupture of membranes * Foetal bradycardia

Answer 265

* Intrapartum CTG (in women at risk of rupture) * Recurrent or late decelerations * Proloinged foetal bradycardia * Maternal haematuria * Catheter * Ultrasound * Suspicion of uterine rupture in pre-labour setting * Abnormal foetal lie or presentation * Haemoperitoneum * Abesnt uterine wall

Answer 266

OBSTETRIC EMERGENCY * Call for senior help and appropriate staff * A-E approach * 222 call * Resuscitation * Surgical management

Answer 267

* Deliver by C-section * Uterus repair or hysterectomy * Decision-incision interval in operative intervention should be \<30 minutes

Answer 268

Use of an instrument to aid delivery of foetus

Answer 269

* Ventouse * Forceps

Answer 270

* Forcep delivery

Answer 271

* Abandon if after **three contractions** and **pulls** with any instrument, there is no reasonable progress

Answer 272

* Silastic cup attached to electric pump * Only if foetus in occipital-anterior position * Kiwi - handheld disposable device * Omni-cup, used for all foetal positions and rotational deliveries * Bird cup * Occipital-posterior positions

Answer 273

* Cup with centre over the flexion point of the foetal skull * Midline, 3cm anterior to the posterior fontanelle During contractions, traction is applied perpendicular to the cup

Answer 274

* **Lower** success rate * **Less** maternal perineal injuries * **Less** pain * **More** cephalhaematoma * **More** Subgaleal haematoma * **More** foetal retinal haemorrhage

Answer 275

* Rhodes, Neville-Barnes or Simpsons * OA positions * Wrigley's * C-section * Kielland's * Rotational deliveries

Answer 276

* Blades introduced to pelvis (taking care not to cause trauma to maternal tissue) * Applied around sides of foetal head * Blades lock together * Gentle traction during uterine contractions, following the J shape of the maternal pelvis

Answer 277

* **Higher** rate of 3rd/4th degree tears * Used **less** often to rotate * **Does not** require maternal effort

Answer 278

Considered in 2nd stage of labour. Is there a valid clinical indication to intervene? Is the patient a suitable case for an intrumental delivery? Maternal: * Inadequate progress * Nulliparous women - general rule to expect delivery after two hours of active pushing * Multiparous women - expect delivery within one hour of active pushing * Maternal exhaustion * Maternal medical conditions that means active pushing or prolonged exertions should be avoidied * Intracranial patholgies * Maternal congenital heart disease * Severe hypertension Foetal * Suspected foetal compromise in 2nd stage of labour * CTG monitoring * Abnormal foetal blood sample * Clinical concerns * Significant antepartum haemorrhage

Answer 279

* Fully dilated * Ruptured membranes * Cephalic presentation * Defined foetal position * Foetal head at least at the level of ischial spines and no more than 1/5 palpable per abdomen * Empty bladder * Adequate pain relief * adequate maternal pelvis

Answer 280

* Unengaged foetal head in singletone pregnancies * Incompletely dilated cervix in singleton pregnancies * True cephalo-pelvic disproportion (foetal head too large to pass through maternal pelvis) * Breech and face presentation * Preterm gestation (\<34 weeks) for ventouse * High likelihood of fetal coagulation disorder for ventouse

Answer 281

* Severe non-reassuring foetal status, with station of the head above the level of pelvic floor (foetal scalp not visible) * Delivery of second twin when the head is not quite engaged or the cervix has reformed * Prolapse of the umbilical cord with foetal compromise when the cervix is completely dilated and the station is mid cavity

Answer 282

Classified by degree of foetal descent. The lower the classification, the less the risk of complications

Answer 283

Outlet * Foetal scalp visible with labie parted * Foetal skull reached pelvic floor * Foetal head on perineum Low * Lowest presenting part (not caput) is +2, or further below the ischial spines. subdivided to: * \>45 degrees - rotation needed * \<45 degrees - no rotation needed Midline * 1/5 palpable abdominally. Lowest part is above +2 but is lower than ischial spines. Subdivided to: * \>45 degrees - rotation needed * \<45 degrees - no rotation needed

Answer 284

Foetal * Neonatatl jaundice * Scalp lacerations * Cephalhaematoma * Subgaleal haematoma * Facial bruising * Facial nerve damage * Skull fractures * Retinal haemorrhage Maternal * Vaginal tears (3rd/4th degree) * Forceps \>\> ventouse \> vaginal delivery * VTE * Incontinence * PPH * Shoulder dystocia * Infection

Answer 285

* Infant birth weight **\<10th centile** for gestational age * Severe SGA = birth weight **\<3rd centile**

Answer 286

* Estimated foetal weight (EFW) or adbominal circumference (AC) \<10th centile * Severe = EFW or AC \< 3rd centile

Answer 287

* When genetic growth is restricted by a pathological process * This can present with features of foetal compromise: * Reduced liqour volume * Abnormal doppler studies * Likelihood of FGR is higher in severe SGA foetus

Answer 288

* Birth weight \<2.5kg (2500g)

Answer 289

* Normal (constitutionally) small * Placenta mediated growth restriction * Non-placenta mediated growth restriction

Answer 290

* Small size at all stages but **follows growth centiles** * No pathology is present * Conrtibuting factors include ethnicity, sex, parental height 50-70% SGA foetus/infants are consitutionally small

Answer 291

* Growth normal initially but **slows *in utero*** * Leads to placental insufficiency * Common cause of FGR and can be due to maternal factors

Answer 292

* Low-pregnancy weight * Substance abuse * Autoimmune disease * Renal disease * Diabetes * Chronic HTN

Answer 293

* Growth affected by foetal factors * Chromosomal or structural anomaly * Error in metabolism * Foetal infection

Answer 294

* Booking visit AND * 20 weeks gestation

Answer 295

* Maternal age ≥35 * Smoker 1-10/day * Nulliparity * BMI \< 20 or 25-34.9 * IVF singleton * Previous pre-eclampsia * Pregnancy interval \<6 or ≥60 months (5 years) * Low fruit-intake pre-pregnancy

Answer 296

* Maternal age \>40 * Smoker ≥ 11/day * Previous SGA baby * Maternal/paternal SGA * Previous stillbirth * Cocaine use * Daily vigorous exercise * MAternal disease (Chronic HTN, renal impariment, diabetes w/ vascular disease, APS) * Heavy bleeding * Low PAPP-A

Answer 297

* 3 minor risk factors present -\> UAD * Major risk factor present -\> serial ultrasound and UAD

Answer 298

* **Ultrasound** * Diagnosis and surveillance of SGA * Foetal anatomical survey * Uterine artery doppler (UAD) * Karyotyping * Infection screen * Congenitcal CMV * Congenital toxoplasmosis * Congenital syphilis * Congenital malaria

Answer 299

* Biometrics - plotted on centil charts (take into account maternal height, weight, ethnicity, parity) * EFW (estimated foetal weight) * Abdominal circumference (AC) * Head circumferenc (HC):AC ratio * Symmetrically small foetus likely to be constitutionally small * Asymmetrically small foetus more likely due to placental insufficiency * Brain sparing effect * Reduced amniotic fluid * Impaired foetal kidney function as a result of placental insufficiency

Answer 300

* Prevention * Surveillance * Delivery

Answer 301

* MAnage modifieable risk factors for SGA * Smoking cessation * Optimise maternal disease * 75mgaspirin 16 weeks gestation until delivery * For women at high risk of pre-eclampsia

Answer 302

* **Uterine artery doppler** (AUD) primary surveillance tool in SGA foetus * If normal, repeat every 14d * If abnormal, repeat more frequently and consider delivery * Other surveillance tests: * Symphysis fundal height (SFH) * Middle Cerebral artery (MCA) doppler * Ductus venous (DV) doppler * CTG * Amniotic fluid volume

Answer 303

* If considering delivery 24 to 35+6 weeks gestation = single course **antenatal steroids**

Answer 304

Increased risk of still-birth

Answer 305

* Birth asphyxia * Meconium aspiration * Hypothermia * Hypo/Hyperglycaemia * Polycythaemia * Retinopathy of prematurity * Persistent pulmonary hypertension * Pulmonary haemorrhage * Necrotising enterocolitis

Answer 306

* Cerebral palsy * T2DM * Obesity * Hypertension * Precocious puberty * Behavioural problems * Depression * Alzheimer's disease * Cancer (breast, ovarian, colon, lung, blood)

Answer 307

* Pregnancies which persist up to and beyond 42 weeks gestation * AKA Post-term or post-dates pregnancy * 5-10% pregnancies

Answer 308

Unlcear but: * Nulliparity * Maternal age \>40 * Previous prolonged pregnancy * High BMI * FH of prolonged pregnancies

Answer 309

* Static growth * Maybe macrosomia * Oligohydramnios * Reduced foetal movements * Presence of meconium * Meconium staining (on nails) * Dry/flaky skin with reduced vernix * Vernix is white, waxy substance on skin of newborn babies

Answer 310

* Diagnosis based on gestational age * Dating between 11+0 and 13+6 weeks in first trimester is most reliable as foetus rarely shows signs of being consitutionally large or small until later gestational stage * Ultrasound scanning to check growth, liqour volume, dopplers performed in women with prolonged pregnancy

Answer 311

NICE/RCOG: Deliver by 42 weeks gestation to reduce risk of stillbirth * Membrane sweep (offer from 40+0 in nulliparous and 41+0 in parous women) * IOL (offer 41+0 and 42+0) Women who decline IOL should be offereed twice weekly CTG monitoring and USS with amniotic fluid measurement to identify foetal distress, in which case emergency c-section might be indicated

Answer 312

* Increased risk of still birth * Rate exponentially rises after 37 weeks gestation * Foetal acidaemia and meconium aspiration in labour * Due to placental insufficiency * Neonatal hypoglycaemia * Placental degradataion/insufficiency, so reduced O2 and nutrient transfer * Can deplete foetal glycogen stores

Answer 313

* when part of or all of placenta separates from the wall of the uterus prematurely * Important cause of antepartum haemorrhage (pv bleed from week 24 until delivery)

Answer 314

* Occus following a rupture of materna lvessels within basal layer of endometrium * Blood accumulates and splits the placental attachment form the basal layer * Detached portion of placenta is unable to function leading to foetal compromise

Answer 315

* Revealed * Bleeding tracks down from the site of placental separation and drains through the cervix * Results in vaginal bleeding * Concealed * Bleeding remains in the uterus and typically forms a clot retroplacentally * Bleeding is not visible but can be severe enought to cause systemic shock

Answer 316

* Previous placental abruption (most predictive factor) * Pre-eclampsia and HTN disorders * Abnormal lie of baby (transverse) * Polyhydramnios * Abdominal trauma * Smoking or drug use (cocaine) * Bleeding in first trimester * Haematoma is seen inside uterus on first trimester scan * Underlying thrombophilias * Multiple pregnancy

Answer 317

* Painful vaginal bleeding * Bleedig may be concealed * Inquire about pain during contraction if in labour * O/E, uterus may be woody (tense all the time) and painful on palpation

Answer 318

* Placental abruption (not most common) * Placenta praevia * Marginal placental bleed * Small placental abruption large enough to cause revealed bleeding but small enough not to cause maternal or foetal compromise * Vasa praevia * Uterine rupture * Local genital cause * Benign or malignant * Polyps, carcinoma, cervical ectropion (common) * Infection * Candida, bacterial vaginosis, chlamydia

Answer 319

* Haematology * FBC * Clotting profile * Kleihauer test * if woman is Rh negative, to determine amount of foeto-maternal haemorrhage and this the dose of Anti-D required * Group and save * Cross match * Biochemistry * U&E * LFT * *exclude hypertensive disroders (pre-eclampsia, HELLP)* * Foetal wellbeing - CTG * Imaging * Ultrasound scan * Whwen patient is stable * retroplacental haematoma might be seen * Good positive predictive value but poor negative predictive value * Therefore should not be used to exclude abruption

Answer 320

* ABCDE approach Ongoing management of placental abruption is dependent of foetal health * Emergency delivery * C-section if there is maternal or foetal compromise * IOL * Haemorrhage at term without maternal/foetal compromise * Recommende to avoid further bleeding * Conservative * Some partial or marginal abruptions without maternal or foetal compromise All cases give anti-D within 72 hours on the onset of bleeding if woman is Rh -ve

Answer 321

* Dizygotic twins (DZ) * Results from fertilisation of different oocytes by different sperm * Foetuses can be different sexes and are no more genetically similar than siblings from different pregnancies * Monozygotic twins (MZ) * Results from mitotic division of a single zygote into identical twins. * Whether they share the same amnion or placenta depends on the time at which division into separate zygotes occured

Answer 322

The time at which the zygote divides to form separate zygotes

Answer 323

* Dichorionic diamniotic (DCDA) * Division before day 3 * Monochorionic diamniotic (MCDA) * Division 4-8 day * Monochorionic monoamniotic (MCMA) * Division 9-13 days * Conjoined twins * Incomplete division Placenta basically established earlier than amnion.

Answer 324

**_Monochorionic_** twins have a higher foetal loss rate, particularlty before **_24_** weeks

Answer 325

* Increasing maternal age - DZ twinning * Increasing parity - DZ twinning * Assisted conception * 20% IVF conceptions * 5-10% clomiphene-assisted conceptions * Genetic factors

Answer 326

* More marked vomiting in early pregnancy * Uterus larger than expected from dates * Palpable before 12 weeks * Three or more poles felt later in pregnancy

Answer 327

Ultrasound

Answer 328

All obstetric risks are exaggerated in multiple pregnancies * **Gestational diabetes** * **Pre-eclampsia** * Miscarriage and preterm delivery * IUGR * Anaemia * Greater increase in blood volume and more demeand for iron and folic aicd * Congenital abnormalities * Antepartum and postpartum haemorrhage * Malpresentation * TTTS in MC twins only

Answer 329

Complications are due to preterm delivery, IUGR, and monochorionicity * Mortatlity (6x) * Long-term handicap (5x) * Triplets 18x * Miscarriage * 1st trimester death and late miscarriages * Preterm delivery * IUGR * Congenital abnormalities

Answer 330

Result from shared blood supply in the single placenta * Twin-Twin Transfusion Syndrome (TTTS) * Twin anaemia polycythaemia sequence (TAPS) * Twin Reversed arterial perfusion (TRAP) * IUGR * Co-twin death

Answer 331

Occurs only in MCDA twins * Unequal blood distribution through **vascular anastomoses** of the shared placenta * The donor twin is volume depleted and develops anaemia, IUGR and oligohydramnios. * The recipient twin becomes volume overloaded and may develop polycythaemia, cardiac failure, massive polyhydramnios (*in extremis,* causes massive distension of uterus)

Answer 332

* Anaemia * IUGR * Oligohydramnios

Answer 333

* Volume overloaded * Polycythaemia * Cardiac failure * Polyhydramnios

Answer 334

Quintero staging (1-5) III - absent or reversed end-diastolic flow in the umbilical artery, pulsatile uymbilical venous flow, reverse ductus venosus flow

Answer 335

* *In utero* death * Severely pre-term delivery

Answer 336

* Occurs when there is marked Hb differences between MC twins but in the **absence of liqour volume changes** characterisitic of TTTS * These occur due to small placental anastomoses, following incomplete laser ablation for TTTS

Answer 337

Rare abnormality in MC twins * Abnormal, acardiac foetus, perfused by a normal 'pump' twin * Oxygenated blood comes in from UV into fRV. Deoxygenated blood come out of the pump twins UA into the acardiac foetus UA through anastomoses in placental bed. * This blood then leaves acardiac foetus through its UV back into the placenta

Answer 338

cardiac failure

Answer 339

* Intrauterine growth restriction is more common in MC twins, in the absence of clear blood volume discordancy. * A particular problem is where the umbilical artery waveform of the smaller twin is very erratic (selective IUGR with intermittent absent or reversed end-diastolic flow, abbreviated to sIUGR with iAREDF). * This may be the result of the superficial artery–artery anastomoses, shown in Fig. 27.4; an ultrasound of these is shown inFig. 27.5. * Sudden in utero death occurs in up to 20%, handicap in 8%.

Answer 340

Co-twin death: If one of an MC twin pair dies, due to TTTS or any other cause, the drop in its **_Bloood_** **_pressure_** allows acute transfusion of blood from the other twin. This rapidly leads to **_hypovolaemia_** and, in about 30% of cases, death or **_neurological_** damage. The survivor of a dichorionic twin pregnancy is not at risk, except of **_preterm_** **_delivery_**, because the circulation is not shared.

Answer 341

In monochorionic monoamniotic twins, the **_cords_** are always **_tangled_**. *In utero* **_demise_** is common, probably because of this and/or sudden acute **_shuinting_** of blood between the two babies in anastomoses between the close cord insertions

Answer 342

* Lambda sign * Dividing membrane is thicker as it meeths the placentas. * Remembe dichorionic twins form when fertilised egg divides early

Answer 343

* T sign * The dividing membrane is thinner as it meets the placentas * Remember monochorionic twins form when fertilised egg divides later

Answer 344

High risk pregnancies, consultant-led * Iron and folic acid supplementation * Low dose aspirin if other RF for pre-eclampsia

Answer 345

Twins of **opposite** gender are always **Dizygotic**

Answer 346

Identification of risk of preterm delivery: Transvaginal ultrasound of **_cervical_** length is not advised in the UK but may identify those at most risk. In contrast to singletons, neither progesterone nor cervical **_cerclage_** prevents **_preterm**_ _**birth_** in multiple pregnancies.

Answer 347

* More difficult to identify vs singleton pregnancies * Serial ultrasound examinations performed at **28, 32, 36 weeks** and more often with monochorionic twins

Answer 348

* 37 weeks * Dichorionic twins * 36 weeks * Uncomplicated monochorionic twins

Answer 349

* Start 12 weeks and scan every 2 weeks until 24 weeks, at which it should be 2-3 weekly * Features: * TTTS (16-24 weeks) * growth * liqour volume discordances * Polyhydramnios * Tricuspid reguritation (overload)

Answer 350

* Laser ablation of the entire placental interfacce in a foetal medicine centre using ultrasound and foetoscopy Survival both twins 50%, one twin 80%

Answer 351

* Selective reduction to twin pregnancy at 12 weeks * Needs discussion * Balance between increased early miscarriage rates and reduced preterm birth (therefore cerebral palsy) * Safest before 14 weeks * Surveillance according to chorionicitiy * Deliver by 36 weeks

Answer 352

* Vaginal delivery - if first foetus is cephalic, regardless of second's lie or presentation * C-section - if first foetus is breech or transverse lie. With high order multiple pregnancies. If there have been antepartum complications. (some places - all monochorionic twins)

Answer 353

* When to deliver 37 weeks (DC) or 36 weeks (MC) * continious CTG * Contractions diminish after first baby delivered - can give oxyitocin if contractions dont start again * ECV of second twin can pe performed if not longiutuidinal * If foetal distress or cord prolapse, delivery can be expedited with ventouse or breech extraction * Prophylactic oxytocin to prevent PPH

Answer 354

* Scaring the mother (too mamny people present) * Failure to monitor second twin properly * Overstimulation of uterus with oxytocin * Early rupture of membranes * PPH

Answer 355

* Foetus presents buttocks or feet first (rather than cephalic presentation - head) * Breech delivery has higher perinatal mortality and morbidity (due to birth asphyxia/trauma, prematurity, congenital malformations)

Answer 356

* Complete (flexed) breech * Both legs are flexed at hips and knees * Foetus sitting cross-legged * Frank (extended) breech * Both legs are flexed at the hip and extended at the knee * Most common type of breech presentation * Footling breech * Onr or both legs are extended at the hip * foot is presenting part

Answer 357

* Multiparity * Uterine malformation (septate uterus) * Fibroids * Placenta praevia

Answer 358

* Prematuritty * Macrosomia * Polyhydramnios * Twin pregnancy (or higher order) * Abnormality (anencephaly)

Answer 359

* Limited = 32- 35 weeks * Likely to revert to cephalic presentation before delivery * Important = \>37 weeks

Answer 360

* Clinical examination * Palpation of abdoman - round foetal head in upper part of uterus and irregular mass (foetal buttock and legs) in pelvis * Foetal heart auscultated higher on maternal abdomen * 20% not diagnosed until labour * Vaginal examination - sacrum or foot may be felt through the cervical opening

Answer 361

Meconium stained liqour

Answer 362

* Oblique lie * Transverse lie * Unstable lie

Answer 363

* Ultrasound scan * Reveal type of breech * Identify foetal or uterine abnormalities that predisposes the breech presentaiton

Answer 364

* External cephalic version * Caeserian section * Vaginal breech birth

Answer 365

* Manipulation of ofetus to cephalic presentation through maternal abdomen * If successful -\> vaginal delivery * 40% success in primiparous, 60% in multiparous

Answer 366

* Transient foetal hear abnormalities (revert ot onrmal) * Persistent hear rate abnormalities (fetal bradycardia) -rarer * Placental abruption -rARE

Answer 367

* Recent antepartum haemorrhage * Ruptured membranes * Uterine abnormalities * Previous C-Section

Answer 368

* If ECV is unsuccessful, contraindicated or declined by woman * Based on evidence that higher perinatal mortality and morbidity in planned vaginal breech biorths vs c-section in term babies

Answer 369

* Footling breech * Shoulders or head can become trapped in non-fully dilated cervix

Answer 370

* Hand off the breech * Traction on baby during delivery can cause feotal head to extend, getting trapped in delivery * Foetal sacrum needs to be maintained anteriorly, which is done by holding foetal pelvis * If baby does not deliver spontaneously, maneouvres may be required

Answer 371

* Flexing foetal knees * enables delivery of legs * Loovsett's maneouvre * Rotate the body and deliver shoulders * Mauriceau-Smellie-Veit (MSV) maneouvre * Delivery of head by flexion * if MSV fails, forceps can be used

Answer 372

* **Cord prolapse** * Cord drops down below presenting part of baby and becomes compressed * Foetal head entrapment * PROMs * Birth asphyxia * Secondary to delay in delivery * Intracranial haemorrhage * Rapid compression of head during delivery

Answer 373

* Relationship between the long axis of of foetus and the mother * Longitudinal * Transverse * Oblique

Answer 374

* The foetal part that first enters the maternal pelvis * Cephalix vertex = most common and safest * Breech * Shoulder * Face * Brow

Answer 375

* Position of foetal head as it exits the birth canal * Usually head angages in the occipito-anterior position (foetal occiput facting anteriorly) * Ideal for birth * Occipito-posterior * Occipito-transverse ## Footnote *Right is vertex presentation*

Answer 376

* Prematurity * Multiple Pregnancy * Uterine abnormalities (fibroids, partial septate uterus) * Foetal abnormalities * Placenta praevia * Primiparity

Answer 377

abdominal examination

Answer 378

abdominal examination

Answer 379

Vaginal examination

Answer 380

* High maternal BMI * Full bladder * Small foetus * Polyhydramnios

Answer 381

* Longitudinal * Cephalic vertex * Occipito-anterior position

Answer 382

Confirmed by ultrasound scan Could demonstrate predisposing uterine or foetal abnormalities

Answer 383

* External cephalic version between 36-38 weeks

Answer 384

Dependent on the presentation * Breech - attempt ECV, vaginal breech delivery or C-Section * Brow - C-section * Face * Chin anterior (mento-anterior) normal labour possible * Likley prolonged and risk of C-section being required * Chin posterior (mento-posterior) C-section * Shoulder - C-section Bascially C-section except for breech (ECV then C-section/Breech vaginal delivery) or Mento-anterior face presentation

Answer 385

* 90% spontaneously rotate to occipito-anterior as labour progresses * If foteal head does not rotate -\> rotation and operative vaginal delivery can be attempted * C-section is alternative

Answer 386

* **Foetal urine output** * Small contributions from placenta * Small contributions from foetal secretions (respiratory)

Answer 387

* Amniotic fluid volume increases steadily until 33 weeks gestation * Plateaus 33-38 weeks and then declines * Volume at term ~ 500mL

Answer 388

* Foetus breathes and swallows amniotic fluid * Gets processed, fills bladder and voided * Cycle repeats * Problems with any structures on this pathway can lead to too much or too little fluid

Answer 389

* Low level of amniotic fluid during pregnancy * Amniotic fluid index \< 5th centile for gestational age * 4.5% term pregnancies

Answer 390

Anything that reduces foetal urine production, output blockade or rupture of membranes * P-PROM * Placental insufficiency * Blood flow redistribution to foetal brain rather than abdomen and kidneys. Poor urine output * Renal agenesis (Potter's Syndrome) * Non-functioning foetal kidneys * Bilateral multicystic dysplastic kidneys * Obstructive uropathy * Genetic/chromosomal anomalies * Viral infections * Can also cause polyhydramnios

Answer 391

Ultrasound examination * Amniotic fluid index * Measuring cord-free vertical pocket of fluid in four quadratns of uterus and adding them together * Maximum pool depth * Vertical measurement in any area Both have similar diagnostic accuracy but AFI is more commonly used

Answer 392

* History * Symptoms of leaking fluid * Feeling damp all the time * New urinary inctontinence * Examination * Symphysis fundal height * Speculum examination - pooling of liqour * Ultrasound * Liqour volume, structural abnormalities, renal agenesis, obstructive uropathy * Foetal size * Small babies result from placental insufficiency which causes oligohydramnios * Rise in pulsatility index of umbilical artery doppler in placental insuffieicney * Karytopying * Early and unexplained oligohydramnios * IGFBP-1 in vagina * If suspecting ruyptrued membrane * Found in amniotic fluid, if positive = strongly suggestive of membrane rupture

Answer 393

Dependent on the underlying cause. Most common two causes are: * Rupture of membranes * Placental insufficiency

Answer 394

* Labour likely to comence in 24-48 hours * in P-PROM (\<37 weeks) IOL considered 34-36 weeks in absence of infection * Course of steroids fro foetal lung development * Antibiotics to reduce ascending infection

Answer 395

* Deliver, which is dependent on: * Rate of foetal growth * Umbilical artery and middle cerebral artery doppler scans * CTG * Likely delivered \<36-37 weeks

Answer 396

* Oligohydramnios in the **_second_** trimester carries poor prognosis. In these cases, there is PROM+/- infection, with subsequent **_premature_** delivery and pulmonary **_hypoplasia_** (lead to respiratory distress at birth * Oligohydramnios associated with **_placental**_ _**insufficiency**_ carries higher rate of preterm deliveries (usually through planned IOL). These have _**poorer_** prognosis than that of normal growing foetus * Amniotic fluid allows foetus to move its limbs *in utero* (exercise). Without this, the foetus can develop severe **_muscle**_ _**contractures**_ - which may lead to _**disability_** despite physiotherapy after birth

Answer 397

Premature rupture of membranes (PROMs) ## Footnote *Treatment is by optimising gestation of delivery*

Answer 398

* Abnormally large level of amniotic fluid during pregnancy * Amniotic fluid index \> 95th centile for gestational age

Answer 399

* Idiopathic 50-60% * Any condition that prevents foetus from swallowing * Oesophageal atresia, CNS abnormalities, muscular dystrophy, congenital diaphragmatic hernia obstructing oesophagus * Duodenal atresia * Double bubble sign on USS * Anaemia * Alloimmune disorders, viral infection * Foetal hydrops * TTTS * Increased lung secretions * Cystic adenomatoid malformation of lung * Genetic or chromosomal abnormalities * Maternal diabetes * MAterna lithium * Foetal diabetes insipidus * Macrosomia * Large babies produce more urine

Answer 400

Ultrasound scan (with amniotic fluid index and/or maximum depth pool)

Answer 401

* Examination * Tense uterus on palpation * Ultrasound scan * Measurement of liqour volume * Assess foetal size * Assess foetal anatomy (structural causes) * Doppler - foetal anaemia * Maternal GTT * GDM or maternal DM * Karyotypiung * Viral infections (TORCH) * Maternal red cell antibodies * at 28 weeks

Answer 402

No medicla intervention in majortiy of women * Maternal symptoms (breathlessness) * Amnioreduction * Associated with infection and placental abruption * Not performed routinely * Indomethacin * Enhance water retnetion and reduces foetal urine output * Premature closure of ductus arteriosus. DO NOT use beyond 32 weeks * Idiopathic polyhydramnios * Baby must be examined before first feed to ensure no fistulas or oesophageal atresias

Answer 403

* Severe and persistently unexplained polyhydramnios = increased perinatal mortality, due to: * Presence of underlying abnomralitiy or congenital malformation * Increased incidence of preterm labour (due to over-distension of uterus)

Answer 404

* Perinatal mortality * Malpresentation * Transverse lie or breech presentation * foetus has more room to move * High risk of cord prolapse at rupture of membranes * PPH * Uteurs has to contract further to achieve haemostasis

Answer 405

* Preterm labour * Anaemia * Perinatal mortality and morbidity

Answer 406

Pyelonephritis (20%)

Answer 407

* Urine culture at booking visit * Treat asymptomatic bacteruria at booking * Culture if nitrites found on urinalysios

Answer 408

* Fever * Loin tenderness and abdominal pain * Dysuria * Rigors * Tachycardia * Vomitting

Answer 409

IV antibiotics * ?Erythromycin/?cephalosporin

Answer 410

* E coli * Resistant to amoxiciillin

Answer 411

Thyroid status does not alter in pregnancy, although **_iodine_** clearance is increased. Goitre is more common. Fetal thyroxine production starts at **_12_** weeks; before, it is dependent on maternal thyroxine. Maternal thyroid-stimulating hormone (TSH) is **_increased_** in early pregnancy.

Answer 412

* Hashimoto's thyroiditis * Thyroid surgery (iatrogenic) * Iodine defieicny (developing countries)

Answer 413

* Perinatal mortality * Miscarriage * Preterm delivery * Intellectual impariemtn in childhoof * Pre-eclampsia (esp if anti-thyroid Ab present)

Answer 414

* Replacement of thyroxine * Monitor TSH 6-weekly

Answer 415

Graves disease

Answer 416

perinatal mortality

Answer 417

Antithyroid antibodies also cross the **_placenta_**; rarely, this causes neonatal **_thyrotoxicosis_** and goitre. For the mother, thyrotoxicosis may improve in late pregnancy but poorly controlled disease risks a ‘**_thyroid_** storm’ whereby the mother gets acute symptoms and **_heart_** failure. Symptoms may be confused with those of pregnancy.

Answer 418

* Propylthiouracil (PTU) in 1st trimester * Instead of carbimazole * PTU crosses placenta * Can sometimes cause neonatal hypothyroidism * Lowest possible dose used * TFT tested monthly * Grtaves worsens post-partum

Answer 419

Postpartum thyroiditis common 5-10%

Answer 420

* Antithyroid antibodies * Type 1 diabetes

Answer 421

* Transient and usually subclinical **_hyper_**thyroidism, usually about **_3_** months post-partum * this is followed by **_4_** months of **_hypo_**thyroidism * Permanent in 20%

Answer 422

Heterosexual intercourse

Answer 423

* Pre-eclampsoa * GDM

Answer 424

* Stillbirth * pre eclampsia * Growth restriction * Prematurity

Answer 425

* Beyond 36 weeks * Intrapartum * Breastfeeding

Answer 426

* Low CD4 counts * High viral load * Coexistent infection * Premature delivery * Intrapartum * Prolonged rupture of membranes \>4 hours

Answer 427

Screening and prophylaxis * Screened at booking * STI and PCP surveillance * LFTs and renal function (drug toxicity) * Hb and glucose monitoring Preventing transmisison * Control viral load with HAART * Continued throughout pregnancy and delivery * Neonate treated with PeP for first 6 weeks * If woman was not on treatment pre-pregnancy, then start therapy at 28 weeks * C-section ig viral load \>50 copies/mL and co-existing Hep C infection * Avoid breastfeedging

Answer 428

* Female circumcision * Partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons * *Practised in Africa and Middle East, Malaysia and Indonesia for different reasons, including ideas of preservation of virginity, promoting hygeine, adherence to cultural norms and religion - FGM is not condoned in the Bible or the Koran* * *Violation of human rights, child abuse and has no health benefits*

Answer 429

Type 1 * Clitoridectomy * Partial or total removal of the clitoris, or of the prepuce Type 2 * Excision * Partial or total removal of the clitoris and the labia minora ± the labia majora Type 3 * Infibulation * Narrowing of the vaginal opening by cutting and repositioning the labia, with or without removal of the clitoris Type 4 * Other * All other non-medical procedures to female genitalia for non-medical purposes (?peircings)

Answer 430

* Short term * Pain, bleeding, infection, urinary retention, damage to pelvic organs, death * Longer term * Failure to heal, UTI, difficulty urinating/menstruating, chronic pelvic infection, vulval pain (cysts and neuromas), dyspareunia, infertility, fistula, severe perineal trauma during childbirth * Psychological

Answer 431

* In the UK it is illegal to perform FGM, including reinstatement after vaginal birth, or to arrange for FGM to happen. - **TRUE** * It is illegal to take or arrange for a girl to be taken to another country for FGM, even if it is legal in that country. -**TRUE** * Female children may be at risk of FGM and healthcare workers have a statutory duty to safeguard them. - **TRUE**

Obstetrics Flashcards

(463 cards)