Obstetrics Flashcards

Question

WHAT IS PLACENTA PREVIA?

Answer 1

Placenta implants low in the uterus, covering part or all of the cervix

Answer 2

**Complete previa** The placenta covers the entire cervical opening **Partial previa** The placenta covers part of the cervical opening **Marginal previa** The placenta borders the cervix

Answer 3

1. Often none 2. Not painful Often after 24 weeks presentation **Can be:** 1. **Small bleeds** before large cramping 2. **Breech position**

Answer 4

1. Normally found at the routine 20 weeks scan 2. Ultrasound with colour flow doppler

Answer 5

1. **Little or no bleeding** * Bed rest, abstian from sex 2. **Heavy bleeding** * Admission * Blood transfusion * C-section at 37 weeks - 38 weeks

Answer 6

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall). Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.

Answer 7

Abnormalities in the lining of the uterus Typically due to scarring after a C-section or other uterine surgery

Answer 8

Placenta accreta often causes no signs or symptoms during pregnancy Vaginal bleeding during the third trimester might occur.

Answer 9

**Heavy vaginal bleeding** Can cause disseminated intravascular coagulopathy Lung failure Kidney failure **Premature birth**

Answer 10

Normally picked up on the 20 week scan

Answer 11

1. C-section and hyserectomy 2. Curettage of the uterus, coupled with methotrexate

Answer 12

Placenta invades even more deeply into the myometrium of the uterus

Answer 13

Placental abruption occurs when the placenta partly or completely separates from the inner wall of the uterus before delivery.

Answer 14

**The cause of placental abruption is often unknown.** 1. **Multiparity** 2. **Maternal trauma** 3. **Increasing maternal age** 4. **Polyhydramnios** 5. Proteinuric hypertension 6. Cocaine use

Answer 15

Placental abruption is most likely to occur in the last trimester of pregnancy, especially in the last few weeks before birth. Vaginal bleeding, **ONLY IN 80% of cases** Abdominal pain (begin suddenly) Back pain (begin suddenly) Uterine tenderness or rigidity - **WOODY** Uterine contractions, often coming one right after another

Answer 16

**_Largely clinical_** 1. Evidence of shock 2. Pain 3. Uterine rigidity 4. Absent fetal heart sounds

Answer 17

1. **Fetus alive and \< 36 weeks** * Fetal distress: immediate caesarean * No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation 2. **Fetus alive and \> 36 weeks** * Fetal distress: immediate caesarean * No fetal distress: deliver vaginally 3. **Fetus dead** * Induce vaginal delivery

Answer 18

When the muscular wall of the uterus tears during pregnancy or childbirth This causes the baby to leek into the abdomen

Answer 19

A uterine scar from a previous cesarean

Answer 20

1. Excessive vaginal bleeding 2. Sudden pain between contractions 3. Contractions that become slower or less intense 4. Abnormal abdominal pain or soreness 5. Recession of the baby’s head into the birth canal 6. Bulging under the pubic bone

Answer 21

Often undiagnosed cause the symptoms are often sudden and non specific

Answer 22

Emergency exploratory laparotomy with ceserean delivery A hysterectomy may be indicated if the woman is bleeding severely

Answer 23

Also called the bloody show or cervical mucus plug It is a sign that labour is impending

Answer 24

It is a plug which seals the cervical canal during pregnancy, it is formed by a small amount of cervical mucus

Answer 25

Acts a barrier to deter bacteria into the uterus Contains a mixture of antimicrobial agents, including immunoglobulins and antimicrobial peptides

Answer 26

When the cervix beings to dilate before labour

Answer 27

Where some fetal umbilical cord vessels run across the cervix They are inside membranes and unprotected by the umbilical cord or placenta

Answer 28

Often no symptoms at all 1. **Rupture of membranes** followed immediately by **vaginal bleeding** 2. Sometimes appear in labour, fetal distress (**bradycardia and late decelerations**) or stillbirth 3. Sometimes there is vaginal bleeding which is darker than normal since fetal blood has less oxygen than the mother

Answer 29

**Velamentous cord** Umbilical cord goes into the membranes, resulting in vessels that are unprotected leading to the placenta **Biobed placenta** Two placentas

Answer 30

Not normally routinely checked for in pregnancy If you have certain risk factors then: Transvaginal ultrasound

Answer 31

1. Placenta previa 2. Previous C-section 3. IVF pregnancy

Answer 32

If picked up on scan then plans can be made to resolve 1. Sometimes resolves on its own 2. Pelvic rest 3. Planned C-section at 35-37 weeks

Answer 33

Defined as excessive blood loss after childbirth \>500mls

Answer 34

**Primary** Occurs in the first 24 hours after delivery **Secondary** Occurs between after 24 hours and 6 weeks after delivery

Answer 35

**4 T's** **Tone:** Uterine atony - failure of uterus to contract down after delivery of the placenta **Trauma** **Tissue:** Retained placenta - placenta remains in the uterus and the vessels continue to bleed **Thromib:** Blood clotting disorders - haemophilia, von Willebrand disease

Answer 36

Placenta previa Multiple pregnancy Pre-eclampsia

Answer 37

1. **IV syntocinon (oxytocin)** 2. **IM carboprost** 3. **Intrauterine balloon tamponade** 4. B-Lynch suture, ligation of the uterine arteries or internal iliac arteries 5. If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Answer 38

1. Oxytocin 2. Misprostol

Answer 39

Infection - endometritis Placental tissue remains in the womb (retained products of conception)

Answer 40

1. Fever 2. Abdo pain 3. Vaginal bleeding

Answer 41

1. FBC 2. Blood cultures 3. Ultrasound - used if RPOC is suspected

Answer 42

Sepsis - urgent referral to the hospital Speculum exam - remove of clots Endometritis - IV piperacillin/tazobactim

Answer 43

During the first week after childbirth, many women get what's often called the "baby blues". Women can experience a low mood and feel midly depressed at a time when they expect they should feel happy after having a baby.

Answer 44

"Baby blues" are probably due to the sudden hormonal and chemical changes that take place in your body after childbirth

Answer 45

Feeling emotional and bursting into tears for no apparent reason Feeling irritable or touchy Low mood Anxiety and restlessness All these symptoms are normal and usually only last for a few days.

Answer 46

Get as much rest as you can. Accept help from family and friends. Connect with other new moms. Create time to take care of yourself. Avoid alcohol and recreational drugs, which can make mood swings worse.

Answer 47

Depression after the birth of your baby

Answer 48

1. Usual features of depression 2. Fears about baby's health 3. Maternal deficiencies 4. Marital tensions including loss of sexual interest

Answer 49

1 month and 3 months

Answer 50

**Edinburgh scale** Order blood tests to determine whether an underactive thyroid is contributing to your signs and symptoms Order other tests, if warranted, to rule out other causes for your symptoms

Answer 51

Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine\* may be used if symptoms are severe\*\* - whilst they are secreted in breast milk it is not thought to be harmful to the infant

Answer 52

Postpartum psychosis (or puerperal psychosis) is a severe mental illness. It starts suddenly in the days, or weeks, after having a baby. Symptoms vary, and can change rapidly.

Answer 53

Several things seem to play a part in postpartum psychosis. Your family history and genetic factors are important - you are more likely to have postpartum psychosis if a close relative has had it. Hormone levels and disturbed sleep patterns may also be involved

Answer 54

1. Confusion and disorientation 2. Obsessive thoughts about your baby 3. Hallucinations and delusions 4. Sleep disturbances 5. Excessive energy and agitation 6. Paranoia 7. Attempts to harm yourself or your baby

Answer 55

1. Urgent admission to hospital 2. **Preferably with the baby** 3. Antipsychotic 4. ECT

Answer 56

A puerperal infection occurs when bacteria infect the uterus and surrounding areas after a woman gives birth. It’s also known as a postpartum infection.

Answer 57

**Endometritis** An infection of the uterine lining **Myometritis** An infection of the uterine muscle **Parametritis** An infection of the areas around the uterus

Answer 58

fever pain in the lower abdomen or pelvis caused by a swollen uterus foul-smelling vaginal discharge pale skin, which can be a sign of large volume blood loss chills feelings of discomfort or illness headache loss of appetite increased heart rate

Answer 59

1. Physical exam 2. High vaginal swab 3. Throat swab 4. Blood culture 5. Urine analysis

Answer 60

1. IV Antibitoics in hospital 2. **Clindamycin + Gentamycin**

Answer 61

Temp above 38 degrees

Answer 62

Endometritis: most common cause Urinary tract infection Wound infections (perineal tears + caesarean section) Mastitis Venous thromboembolism

Answer 63

1. If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics 2. Clindamycin and gentamicin until afebrile for greater than 24 hours

Answer 64

Venous thromboembolism (VTE) refers to the formation of a thrombus within veins

Answer 65

1. Age \> 35 2. Body mass index \> 30 3. Parity \> 3 4. Smoker 5. Gross varicose veins 6. Current pre-eclampsia 7. Immobility 8. Family history of unprovoked VTE 9. Low risk thrombophilia 10. Multiple pregnancy 11. IVF pregnancy

Answer 66

**DVT** Leg pain and discomfort (the left is more commonly affected), swelling, tenderness, oedema, increased temperature and a raised white cell count **PE** Dyspnoea, pleuritic chest pain, haemoptysis, faintness, collapse. The patient may have focal signs in the chest, tachypnoea, a raised jugular venous pressure (JVP) and there may be ECG changes (S1Q3T3)

Answer 67

**DVT** Duplex ultrasound scan **PE** Chest X-ray ECG Compression duplex ultrasound

Answer 68

**Four or more risk factors** Low molecular weight heparin antenatally + 6 weeks postpartum **Three risk factors** Low molecular weight heparin from 28 weeks + 6 weeks postpartum **If DVT diagnosis is made shortly before delivery** Continue LMW Heparin for 3 weeks postpartum Anti-Xa acitvity to monitor is it's working

Answer 69

DOAC Warfarin

Answer 70

Iron-deficiency anemia Folate-deficiency anemia Vitamin B12 deficiency

Answer 71

Folate/B12 - macrocytic Iron deficiency anaemia - microcytic

Answer 72

1. Pale skin, lips, and nails 2. Feeling tired or weak 3. Dizziness 4. Shortness of breath 5. Rapid heartbeat 6. Trouble concentrating

Answer 73

A preterm or low-birth-weight baby A blood transfusion (if you lose a significant amount of blood during delivery) Postpartum depression A baby with anemia A child with developmental delays

Answer 74

Preterm or low-birth-weight baby Baby with a serious birth defect of the spine or brain (neural tube defects)

Answer 75

Hemoglobin test Hematocrit test

Answer 76

1. Give oral iron therapy 2. Different for different times

Answer 77

1. women should take 400mcg of folic acid until the 12th week of pregnancy 2. women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

Answer 78

1. Phenytoin 2. Methotrexate 3. Pregnancy 4. Alcohol excess

Answer 79

1. Either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD 2. The woman is taking **antiepileptic drugs** or has **coeliac disease**, **diabetes**, or **thalassaemia trait**. 3. The woman is **obese** (defined as a body mass index [BMI] of 30 kg/m2 or more)

Answer 80

Hemolytic disease of the newborn (HDN) is a blood problem in newborn babies. It occurs when your baby's red blood cells break down at a fast rate. It’s also called erythroblastosis fetalis.

Answer 81

HDN happens most often when an Rh negative mother has a baby with an Rh positive father. If the baby's Rh factor is positive, like his or her father's, this can be an issue if the baby's red blood cells cross to the Rh negative mother.

Answer 82

**Mother** 1. A yellow coloring of amniotic fluid **Baby** 1. Oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) 2. Jaundice, anaemia, hepatosplenomegaly 3. Heart failure 4. Kernicterus (brain damage)

Answer 83

1. **Blood test** * Rh positive antibodies in your blood (anti-D IgG) 2. **Percutaneous umbilical cord blood sampling** * _Coombs test_: direct antiglobulin, will demonstrate antibodies on RBCs of baby * _Kleihauer test_: add acid to maternal blood, fetal cells are resistant 3. **Ultrasound** * Enlarged organs or fluid buildup in your baby 4. **Amniocentesis** * Amount of bilirubin in the amniotic fluid

Answer 84

1. Transfusions 2. Phototherapy

Answer 85

If you’re Rh negative and have not been sensitized, you’ll get a medicine called **Rh immunoglobulin (RhoGAM)** 28 + 34 weeks

Answer 86

A UTI occurs when bacteria from somewhere outside of a woman’s body gets inside her urethra (basically the urinary tract) and causes an infection.

Answer 87

Growing fetus can put pressure on the bladder and urinary tract. This traps bacteria or causes urine to leak. Ureteral dilation, when the urethra expands and continues to expand until delivery. Urine to become more still in the urethra. This allows bacteria to grow. Urine gets more concentrated. It also has certain types of hormones and sugar. These can encourage bacterial growth and lower your body’s ability to fight off “bad” bacteria trying to get in.

Answer 88

burning or painful urination cloudy or blood-tinged urine pelvic or lower back pain frequent urination feeling that you have to urinate frequently fever nausea or vomiting

Answer 89

Early labour Small baby

Answer 90

1. First line - Nitrofurantoin 2. Second line - Amoxicillin or cefalexin

Answer 91

Regular contractions and the opening of your cervix after 20 weeks and before 37 weeks

Answer 92

Regular or frequent sensations of abdominal tightening (contractions) Constant low, dull backache A sensation of pelvic or lower abdominal pressure Vaginal spotting or light bleeding Preterm rupture of membranes — in a gush or a continuous trickle of fluid after the membrane around the baby breaks or tears A change in type of vaginal discharge — watery, mucus-like or bloody

Answer 93

Previous preterm labor or premature birth, particularly in the most recent pregnancy or in more than one previous pregnancy Pregnancy with twins, triplets or other multiples Shortened cervix Smoking cigarettes or using illicit drugs Certain infections, particularly of the amniotic fluid and lower genital tract Some chronic conditions, such as high blood pressure, diabetes, autoimmune disease and depression

Answer 94

Cervix has begun to soften, thin and open (dilate) before 37 weeks of pregnancy **Pelvic exam** - firmness and tenderness of the uterus **Ultrasound** - measure the length of the cervix **Uterine monitoring** **- Tocodynamometers** uterine montior to measure the duration and spacing of contractions **Lab tests** - swab for infection and fibronectin

Answer 95

1. **Corticosteroids** * ****Help develop baby's lungs maturity, mainly between 23 and 34 weeks 2. **Tocolytics** * E.g. magnesium sulfate, terbutaline, nifedipine * Slow down contractions 3. **Magnesium sulfate** * Between 24 and 34 weeks to help prevent cerebral palsy 4. **Cervical cerclage - Stitches or tape to reinforce the cervix** * If short cervix 5. **Progesterone analogue** * Hydroxyprogesterone caproate if history of premature birth

Answer 96

Rupture of membranes prior to the onset of labour, in a patient who is at less than 37 weeks of gestation

Answer 97

The mother may give history of a 'popping sensation' or a 'gush' with continuous watery liquid draining thereafter. Their underwear or pad may be damp.

Answer 98

Do not perform a vaginal exam as this will increase the risk of infection! 1. Seeing **amniotic fluid** pooling in the vagina as the woman has been lying down for 30 minutes 2. Sterile **speculum** examination 3. **Ultrasound** for gestation and liquor volume 4. Temperature for infection 5. Fetal monitoring

Answer 99

Smoking Previous preterm delivery. Vaginal bleeding Lower genital tract infection Positive amniotic fluid cultures

Answer 100

**Urgent referral to hospital** **Antibotic prophylaxis** Erythromycin for 10 days, if contraindicated then penicillin **Antenatal steroids** Prednisolone **Delivery considered at 34 weeks**

Answer 101

Placenta does not develop properly, or is damaged which fails to deliver proper nutrients to the fetus

Answer 102

1. Preeclampsia 2. Gestational diabetes 3. Smoking and/or taking illegal drugs 4. Taking blood thinner medications 5. Maternal blood clotting

Answer 103

1. Often no maternal symptoms **_They may have:_** 1. Smaller uterus than in previous pregnancies 2. The fetus may also be moving less than expected

Answer 104

1. Greater risk of oxygen deprivation at birth (can cause cerebral palsy and other complications) 2. Learning disabilities 3. Low body temperature (hypothermia) 4. Low blood sugar (hypoglycemia) 5. Too little blood calcium (hypocalcemia) 6. Excess red blood cells (polycythemia) 7. Premature labor

Answer 105

1. Pregnancy ultrasound to measure the size of the placenta 2. Ultrasound to monitor the size of the fetus 3. Alpha-fetoprotein levels in the mother’s blood (a protein made in the baby’s liver) 4. Fetal nonstress test

Answer 106

1. **Treat underlying risk factors** Preeclampsia Gestational diabetes 2. **Corticosteroids**

Answer 107

The loss of the fetus before 20 weeks of pregnancy

Answer 108

1. **Antiphospholipid syndrome** 2. **Endocrine disorders** * Poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome 3. **Uterine abnormality:** * e.g. uterine septum 4. **Parental chromosomal abnormalities** 5. **Smoking**

Answer 109

1. Increased maternal age 2. Smoking in pregnancy 3. Consuming alcohol 4. Recreational drug use 5. High caffeine intake 6. Obesity 7. Infections and food poisoning 8. Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes 9. Medicines, such as ibuprofen, methotrexate and retinoids 10. Unusual shape or structure of womb 11. Cervical incompetence

Answer 110

1. Heavy spotting 2. Vaginal bleeding 3. Discharge of tissue or fluid from your vagina 4. Severe abdominal pain or cramping 5. Mild to severe back pain

Answer 111

**Genetic or chromosomal abnormalities** Intrauterine fetal demise Blighted ovum Molar pregnancy **Underlying conditions and lifestyle habits** Poor diet Alcohol and drug use Maternal age

Answer 112

**Complete miscarriage:** All pregnancy tissues have been expelled from your body **Incomplete miscarriage:** You’ve passed some tissue or placental material, but some still remains in your body **Missed miscarriage:** The embryo dies without your knowledge, and you don’t deliver it **Threatened miscarriage:** Bleeding and cramps point to a possible upcoming miscarriage, cervix is **closed** **Inevitable miscarriage:** The presence of bleeding, cramping, and cervical dilation indicates that a miscarriage is inevitable **Septic miscarriage:** An infection has occurred within your uterus

Answer 113

1. **Ultrasound** * Empty uterus 2. Blood test - HCG 3. Tissue tests

Answer 114

1. **Threatened miscarriage** * Rest until the fetus passes 2. **Expectant miscarriage** * Let it pass naturally 3. **Medical treatment** * Vaginal Misoprostol 4. **Surgical treatment** * Dilation and curettage (D&C) * Vaccum aspiration

Answer 115

No cardiac activity and: The crown-rump length is greater than 7mm OR The gestational sack is greater than 25mm

Answer 116

Gestational diabetes is diabetes that develops during pregnancy

Answer 117

1. BMI of \> 30 kg/m² 2. Previous macrosomic baby weighing 4.5 kg or above 3. Previous gestational diabetes 4. First-degree relative with diabetes 5. Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 118

For most women, gestational diabetes doesn't cause noticeable signs or symptoms. Increased thirst and more-frequent urination are possible symptoms.

Answer 119

1. Excessive birth weight 2. Early (preterm) birth 3. Serious breathing difficulties 4. Low blood sugar (hypoglycemia). Severe episodes of hypoglycemia may cause seizures in the baby. 5. Obesity and type 2 diabetes later in life. 6. Stillbirth.

Answer 120

**FIRST LINE - Oral glucose tolerance test (OGTT)** Done around 24 to 28 weeks Fasting glucose is \>= 5.6 mmol/l 2-hour glucose is \>= 7.8 mmol/l

Answer 121

**\< 7 mmol/l** Trial of diet and exercise should be offered **If glucose targets are not met within 1-2 weeks** Altering diet/exercise metformin should be started **If glucose targets are still not met** Short-acting Insulin should be added to diet/exercise/ **\>= 7 mmol/l** SHORT ACTING Insulin ONLY should be started **6-6.9 mmol/l** Evidence of complications such as macrosomia or hydramnios, insulin should be offered

Answer 122

OGTT immediately after bookimng, and at 24-28 weeks

Answer 123

Group B strep (streptococcus) is a common bacterium often carried in the intestines or lower genital tract. The bacterium is usually harmless in healthy adults. In newborns, however, it can cause a serious illness known as group B strep disease.

Answer 124

Streptococcus agalacticae

Answer 125

During pregnancy, many women experience symptomatic vaginal discharge, which may prompt health professionals to take a swab for culture **Usually no signs or symptoms** 1. A strong, persistent urge to urinate 2. A burning sensation or pain when urinating 3. Passing frequent, small amounts of urine 4. Urine that appears red, bright pink or cola colored — a sign of blood in the urine 5. Pelvic pain

Answer 126

1. Prematurity 2. Prolonged rupture of the membranes 3. Previous sibling GBS infection 4. Maternal pyrexia e.g. secondary to chorioamnionitis 5. The mother previously delivered an infant with group B strep disease

Answer 127

1. IV antibiotics (Benpen or erthyromycin) during labour 2. No point giving it before as has a chance of coming back

Answer 128

Swab between 35 and 37 weeks of pregnancy

Answer 129

1. IV antibiotics 2. Benzylpenicillin

Answer 130

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

Answer 131

1. Damage to tubes (pelvic inflammatory disease, surgery) 2. Previous ectopic 3. Black race 4. Age \>35 years 5. Endometriosis 6. IUCD 7. Progesterone only pill 8. IVF (3% of pregnancies are ectopic)

Answer 132

1. Light to heavy vaginal spotting or bleeding 2. Sharp waves of pain in the abdomen, pelvis, shoulder, or neck 3. Severe pain that occurs on one side of the abdomen

Answer 133

1. A pregnancy test will be positive. 2. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

Answer 134

1. **Expectant (watchful waiting)** 2. **Medical** Methotrexate 3. **Surgical** * ****Laparoscopic Salpingectomy * Open salpingectomy if ruptured and haemodynamically unstable * **Also have to give anti-D if mother negative**

Answer 135

1. An unruptured embryo 2. \<35mm in size 3. Have no heartbeat 4. Be asymptomatic 5. Have a B-hCG level of \<1,000IU/L and declining

Answer 136

1. Size \<35mm 2. Unruptured 3. No significant pain 4. No fetal heartbeat 5. Serum B-hCG \<1,500IU/L

Answer 137

1. Size \>35mm 2. Can be ruptured 3. Pain 4. Visible fetal heartbeat 5. Serum B-hCG \>1,500IU/L

Answer 138

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body

Answer 139

1. **Maternal** * Postpartum haemorrhage * Perineal tears 2. **Fetal** * Brachial plexus injury * Neonatal death

Answer 140

1. Fetal macrosomia 2. High maternal body mass index 3. Diabetes mellitus 4. Prolonged labour

Answer 141

Difficulty in delivery of the fetal head or chin. **Failure of restitution** – the fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’. **‘Turtle Neck‘ sign** – the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell.

Answer 142

**McRoberts' manoeuvre** should be performed. This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery **Episiotomy**

Answer 143

Malpresentation is the situation where a foetus within the uterus is in any position that is not cephalic - i.e. head down.

Answer 144

1. Face 2. Brow 3. Breech 4. Shoulder

Answer 145

1. **Complete breech** - feet presenting but flexed hips and knees 2. **Frank breech -** hips flexed and legs extended over anterior surface of body 3. **Footling breech** * At least 1 extended fetal hip * Contraindication to labor

Answer 146

1. Uterine malformations, fibroids 2. Placenta praevia 3. Polyhydramnios or oligohydramnios 4. Fetal abnormality (e.g. CNS malformation, chromosomal disorders) 5. Prematurity (due to increased incidence earlier in gestation)

Answer 147

Cord prolapse

Answer 148

**If \< 36 weeks** Many fetuses will turn spontaneously ``` **36 weeks** Externalcephalic version (ECV) ``` **if the baby is still breech** Planned caesarean section or vaginal delivery

Answer 149

Where caesarean delivery is required Antepartum haemorrhage within the last 7 days Abnormal cardiotocography Major uterine anomaly Ruptured membranes Multiple pregnancy

Answer 150

**Dichorionic diamniotic (DCDA)** If two eggs are fertilised or if one egg splits soon after fertilisation, each baby has its own placenta with its own outer membrane called a ‘chorion’ and its own amniotic sac **Monochorionic diamniotic (MCDA)** If the fertilised egg splits a little later, the babies share a placenta and chorion but they each have their own amniotic sac; these babies are always identical **Monochorionic monoamniotic (MCMA)** Much less commonly, the fertilised egg splits later still and the babies share the placenta and chorion and are inside the same amniotic sac; these babies are always identical; this is rare and carries additional risks.

Answer 151

1. Anaemia 2. Pre-eclampsia 3. A higher chance of bleeding more heavily than normal after the birth 4. A higher chance of needing a caesarean section or assisted vaginal delivery to deliver your babies

Answer 152

1. Increased spontaneous miscarriage, perinatal mortality rate 2. Increased malformations, IUGR, prematurity 3. **Twin-to-twin transfusions:** recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels) * Regular checks at 16 and 24 weeks

Answer 153

Previous twins Family history Increasing maternal age Multigravida Induced ovulation and in-vitro fertilisation Race e.g. Afro-Caribbean

Answer 154

1. Ultrasound for diagnosis + monthly checks 2. **Additional iron + folate** 3. **More antenatal care** (e.g. weekly \> 30 weeks) 4. **Precautions at labour** (e.g. 2 obstetricians present) 5. 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks

Answer 155

1. Longitudinal lie (99.7% of foetuses at term) 2. Transverse lie (\<0.3% of foetuses at term) 3. Oblique (\<0.1% of foetuses at term)

Answer 156

Abnormal foetal lie will be detected during routine antenatal appointments with a midwife during abdominal examination. **Abdominal examination** The head and buttocks are not palpable at each end of the uterus. The foetus can be felt to be lying directly across the uterus. **Ultrasound scan** Allows direct visualisation of the foetal lie. Foetal heart rate is also auscultated to assess for distress.

Answer 157

1. Pre-term rupture membranes (PROM) 2. Cord-prolapse (20%) If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK.

Answer 158

**Before 36 weeks gestation** no management required. **After 36 weeks gestation** _Perform external cephalic version (ECV)_ of the foetus. This can be performed late in pregnancy and even early labour if the membranes have not yet ruptured Contraindications include maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality. Success rate is around 50% _Elective caesarian section_

Answer 159

Lower segment caesarean section: now comprises 99% of cases Classic caesarean section: longitudinal incision in the upper segment of the uterus

Answer 160

Previous uterine rupture or classical caesarean scar

Answer 161

Oligohydramnios refers to a low level of amniotic fluid during pregnancy.

Answer 162

1. Premature rupture of membranes 2. Fetal renal problems e.g. renal agenesis 3. Intrauterine growth restriction 4. Post-term gestation 5. Pre-eclampsia

Answer 163

No maternal symptoms other than a sense of decreased fetal movement Uterine size may be less than expected based on dates.

Answer 164

1. Investigation of placental function 2. Ultrasound examination of the foetal kidneys and urogenital system

Answer 165

**Before term:** Expectant management Ongoing antepartum surveillance Continuous fetal heart rate monitoring during labour **At term:** Delivery is often the most appropriate management. **After term:** Isolated oligohydramnios in the post-term patient has no greater risk for caesarean delivery and there is insufficient evidence to support induction for women with oligohydramnios

Answer 166

AFI \<5 Or fluid \<500ml

Answer 167

AFI \>24cm Or fluid \> 2000ml

Answer 168

1. Reduced urea 2. Reduced creatinine 3. Increased urinary protein loss

Answer 169

**Booking visit** 1. General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes 2. BP, urine dipstick, check BMI **Booking bloods/urine** 1. FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies 2. hepatitis B, syphilis 3. HIV test is offered to all women 4. urine culture to detect asymptomatic bacteriuria

Answer 170

1. Early scan to confirm **dates** 2. Exclude **multiple pregnancy**

Answer 171

Down's syndrome screening including nuchal scan

Answer 172

1. Information on the anomaly scan in week 18-20+6weeks 2. Blood results from booking 8-12 weeks visit 3. If Hb \< 11 g/dl consider iron 4. Routine care: BP and urine dipstick

Answer 173

**Anomly scan** 1. Anencephaly 2. Open spina bifida 3. Cleft lip 4. Diaphragmatic hernia 5. Gastroschisis 6. Exomphalos 7. Serious cardiac abnormalities 8. Bilateral renal agenesis 9. Lethal skeletal dysplasia 10. Edwards' syndrome, or T18 11. Patau's syndrome, or T13

Answer 174

**Routine care:** 1. BP 2. Urine dipstick 3. Symphysis-fundal height (SFH)

Answer 175

1. Routine care: BP, urine dipstick, SFH **Blood stuff** 1. Second screen for anaemia and atypical red cell alloantibodies. 2. If Hb \< 10.5 g/dl consider iron 3. First dose of anti-D prophylaxis to rhesus negative women

Answer 176

1. Routine care: BP, urine dipstick, SFH 2. Second screen for anaemia and atypical red cell alloantibodies. 3. If Hb \< 10.5 g/dl consider iron

Answer 177

1. Routine care: BP, urine dipstick, SFH 2. Second dose of anti-D prophylaxis to rhesus negative women\* 3. Information on labour and birth plan

Answer 178

Routine care as above Check presentation - offer external cephalic version if indicated Information on breast feeding, vitamin K, 'baby-blues'

Answer 179

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres

Answer 180

It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Answer 181

Ultrasound

Answer 182

Caput succedaneum is a subcutaneous, extraperiosteal, collection of fluid that collects as the result of pressure on the baby's head during delivery

Answer 183

A cephalhaematoma is a haemorrhage between the skull and periosteum. Because the swelling is subperiosteal, it's limited by the boundaries of the baby's cranial bones.

Answer 184

A chignon is a temporary swelling left on an infant's head after a ventouse suction cap has been used to deliver him or her

Answer 185

A carbuncle is a red, swollen, and painful cluster of boils that are connected to each other under the skin.

Answer 186

1. Hepatitis B 2. HIV 3. Syphillis

Answer 187

Cessation of menstruation for 3–6 months in women with previously normal and regular menses, or for 6–12 months in women with previous oligomenorrhoea.

Answer 188

1. Pregnancy 2. Hypothalamic amenorrhoea (e.g. Stress, excessive exercise) 3. Polycystic ovarian syndrome (PCOS) 4. Hyperprolactinaemia 5. Premature ovarian failure 6. Thyrotoxicosis\* 7. Sheehan's syndrome 8. Asherman's syndrome (intrauterine adhesions)

Answer 189

Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus

Answer 190

Fetal hypoxia Irreversible damage or death

Answer 191

1. Transverse and oblique lie 2. A breech presentation 3. Disproportion 4. Multiple pregnancy 5. Polyhydramnios 6. Pelvic tumours 7. **A pre-term rupture of membranes** 8. Placenta praevia

Answer 192

The majority of cord prolapses occur at artificial rupture of the membranes.

Answer 193

Fetal heart rate becomes abnormal Cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Answer 194

1. The presenting part of the **fetus** may be **pushed back** into the uterus to avoid compression. 2. **Tocolytics (e.g Terbutaline, Indomethacin, Nifedipine, Magnesium Suldate)** may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside. 3. The patient is asked to go on **'all fours'** until preparations for an **immediate caesarian section** have been carried out 4. Retrofilling the bladder with 500-700ml of saline may be helpful

Answer 195

Nausea and vomiting of pregnancy' (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.

Answer 196

Elevated levels of Beta hCG

Answer 197

Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks

Answer 198

1. Multiple pregnancies 2. Trophoblastic disease 3. Hyperthyroidism 4. Nulliparity 5. Obesity

Answer 199

1. **5% pre-pregnancy weight loss** 2. **Dehydration** 3. **Electrolyte imbalance** * Low chloride * Low sodium * Elevated urea * Raised ketones

Answer 200

1. **Thiamine** **First line - Antihistamines** 1. Promethazine 2. Cyclizine **Second line - Antiemetics** 1. Ondansetron 2. Metoclopramide Ginger and P6 (wrist) acupressure **Admission may be needed for IV hydration**

Answer 201

1. Wernicke's encephalopathy 2. Mallory-Weiss tear 3. Central pontine myelinolysis 4. Acute tubular necrosis 5. Fetal: small for gestational age, pre-term birth

Answer 202

Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP

Answer 203

Jaundice in the first 24 hrs is always pathological Causes of jaundice in the first 24 hrs 1. Rhesus haemolytic disease 2. ABO haemolytic disease 3. Hereditary spherocytosis 4. Glucose-6-phosphodehydrogenase

Answer 204

1. Biliary atresia 2. Hypothyroidism 3. Galactosaemia 4. Urinary tract infection 5. Breast milk jaundice 6. Congenital infections e.g. CMV, toxoplasmosis

Answer 205

Two registered medical practitioners must sign a legal document (in an emergency only one is needed) Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Answer 206

1. **Less than 9 weeks** ORal Mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions 2. **Less than 13 weeks** Surgical dilation and suction of uterine contents 3. **more than 15 weeks** Surgical dilation and evacuation of uterine contents **OR** late medical abortion (induces 'mini-labour') - INFECTION RISK

Answer 207

1. Induction of labour at 37-38 weeks is common practice but may not be evidence based 2. Ursodeoxycholic acid - again widely used but evidence base not clear 3. Vitamin K supplementation

Answer 208

Significant rise in rubella IgG antibodies IgM also deteced within 4-6 weeks after contact

Answer 209

In first 8-10 weeks risk of damage to fetus is as high as 90% Damage is rare after 16 weeks

Answer 210

1. sensorineural deafness 2. congenital cataracts 3. congenital heart disease (e.g. patent ductus arteriosus) 4. growth retardation 5. hepatosplenomegaly 6. purpuric skin lesions 7. 'salt and pepper' chorioretinitis 8. microphthalmia 9. cerebral palsy

Answer 211

1. **Non-immune mothers should be offered the MMR vaccination in the post-natal period** 2. **MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant** 3. Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit 4. Since 2016, rubella immunity is no longer routinely checked at the booking visit 5. If a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella

Answer 212

1. Down's syndrome 2. **Congenital heart defects** 3. Abdominal wall defects

Answer 213

Between 11 and 13 weeks

Answer 214

1. Cystic fibrosis 2. Down's syndrome 3. Cytomegalovirus infection

Answer 215

Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for **6 weeks after childbirth.**

Answer 216

If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.

Answer 217

If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.

Answer 218

1. Handheld doppler 2. Ultrasound scan 3. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Answer 219

1. A Kleihauer test is a test for **Fetomaternal Hemorrhage (FMH)** 2. Detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. 3. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.

Answer 220

1. Fetal distress in the second stage of labour 2. Maternal distress in the second stage of labour 3. Failure to progress in the second stage of labour 4. Control of head in breech deliver

Answer 221

Use during the first trimester gives a small increased risk of congenital heart defects Use during the third trimester can result in persistent pulmonary hypertension of the newborn Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Answer 222

1. Nuchal translucency measurement 2. Serum B-HCG 3. Pregnancy-associated plasma protein A (PAPP-A) These tests should be done between **11 - 13+6 weeks**

Answer 223

Down's syndrome is suggested by: 1. **↑ HCG** 2. **↓ PAPP-A** 3. **Thickened nuchal translucency** Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the **PAPP-A** tends to be lower

Answer 224

**Triple test** Alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin **Quadruple test** Alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A

Answer 225

1. 1st degree = tear within vaginal mucosa only 2. 2nd degree = tear into subcutaneous tissue 3. 3rd degree = laceration extends into external anal sphincter 4. 4th degree = laceration extends through external anal sphincter into rectal mucosa

Answer 226

1. **Neural tube defects** * Meningocele * Myelomeningocele * Anencephaly) 2. **Abdominal wall defects** * Omphalocele * Gastroschisis 3. **Multiple pregnancy**

Answer 227

1. Down's syndrome 2. Trisomy 18 (Edward's) 3. Maternal diabetes mellitus

Answer 228

1. Superficial **fascia** 2. Deep **fascia** 3. Anterior rectus sheath 4. Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) 5. Transversalis fascia 6. Extraperitoneal connective tissue 7. Peritoneum 8. Uterus

Answer 229

Cabergoline

Answer 230

Endocervical swabs

Answer 231

1. Ceftriaxone IM Tetracyclines and fluoroquinolones should be avoided in pregnancy

Answer 232

Nomally little effect, sometimes: 1. Prematurity 2. Intrauterine growth retardation

Answer 233

Deformity of the pelvis as a result of osteomalacia

Answer 234

No progress despite strong uterine contractions.

Answer 235

**_Powers_** 1. Hypotonic contraction **_Passage_** 1. Small pelvis **_Passenger_** 1. Size of baby 2. Malposition

Answer 236

**Maternal factors:** 1. Pelvic inflammation 2. Pelvic tumour / fibroid 3. Arcuate or septate uterus 4. Oligohydramnios 5. Placenta praevia **Foetal factors:** 1. Prematurity 2. Multiple pregnancy 3. Fetal malformation e.g. hydrocephalus 4. Intrauterine death

Answer 237

1. Prematurity 2. Intrauterine growth retardation 3. Pregnancy induced hypertension 4. Anaemia 5. Polyhydramnios 6. Congenital malformations

Answer 238

1. Malpresentation 2. Postpartum haemorrhage 3. Cord prolapse

Answer 239

1. Supplementation of iron and folic acid 2. Regular monitoring of haemoglobin levels 3. Increased level of review in antenatal clinic 4. Booking of the birth into a specialist unit

Answer 240

Volume of amniotic fluid \>1500ml

Answer 241

**_Foetal causes:_** 1. Twin pregnancy, especially uniovular twins 2. Anencephaly interferes with foetal swallowing 3. Oesophageal or duodenal atresia prevents foetal swallowing 4. Spina bifida **_Maternal causes:_** 1. Poorly controlled maternal diabetes results in foetal polyuria 2. Multiple pregnancy

Answer 242

1. Malpresentation and malposition 2. Umbilical cord prolapse on membrane rupture 3. Postpartum haemorrhage 4. Placental abruption 5. Premature labour

Answer 243

Largely clinical 1. Tense uterus 2. Difficulty in palpation of fetal parts 3. Difficulty in hearing fetal heart sounds

Answer 244

Slow release of amnitotic fluid via a transabdominal needle

Answer 245

1. **First degree** * Superficial damage with no muscle involvement 2. **Second degree** * Injury to the perineal muscle, but not involving the anal spincter 3. **Third degree** * Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter 4. **Fourth degree** * Injury to perineum involving the anal sphincter complex and rectal mucosa

Answer 246

1. **First degree** * Do not require any repair 2. **Second degree** * Require suturing on the ward by a suitably experienced midwife or clinican 3. **Thirs degree** * Require repair in theatre by a suitably trained clinician 4. **Fourth degree** * Require repair in theatre by a suitably trained clinician

Answer 247

Antihistamine e.g. promethazine

Answer 248

1. **Liver - High levels of vit A** 2. **Listeriosis** * Avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat 3. **Salmonella** * Avoid raw or partially cooked eggs and meat, especially poultry

Answer 249

If there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies

Answer 250

1. if the pregnant woman \<= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible 2. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure

Answer 251

1. if the pregnant woman \> 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Answer 252

1. Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. 2. It is associated with an i**ncreased risk of premature birth + stillbirth**

Answer 253

1. pruritus - may be intense - typical worse palms, soles and abdomen 2. clinically detectable jaundice occurs in around 20% of patients 3. raised bilirubin is seen in \> 90% of cases

Answer 254

1. **Induction of labour at 37-38 weeks** is common practice but may not be evidence based 2. Ursodeoxycholic acid - again widely used but evidence base not clear 3. Vitamin K supplementation

Answer 255

1. fetal distress in the second stage of labour 2. maternal distress in the second stage of labour 3. failure to progress in the second stage of labour 4. control of head in breech deliver

Answer 256

Hep B vaccine and 0.5 ml of HBIG within 12 hours with a further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

Answer 257

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction

Answer 258

1. The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum. 2. Symptoms include: chills, shivering, sweating, anxiety and coughing. 3. Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Answer 259

1. Maternal pyrexia 2. Maternal tachycardia 3. Fetal tachycardia

Obstetrics Flashcards

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