Obstetrics Flashcards
(607 cards)
1
Q
What are the 4 key things to ask ALL pregnant women when taking a history?
A
Foetal movements - change in pattern/frequency/strength
Rupture of membranes - quantity and timing, colour etc.
PV bleeding - quantify, painless/painful, provoked etc.
Abdominal pain - SOCRATES, intermittent/constant
2
Q
Pregnancy is dated from…
A
…the last menstrual period (LMP).
3
Q
How long is the median duration of pregnancy?
A
40 weeks (280 days).
4
Q
How is expected delivery date (EDD) calculated?
A
Taking the date of the last menstrual period, adding 9 months and then adding 7 days.
NOTE: If the patient’s cycle is longer than 28 days, add the difference between their cycle length and 28 to compensate.
5
Q
If the first scan is performed after ___ weeks, the pregnancy cannot be dated.
A
20.
6
Q
NICE Guidance - pregnancy dates should only be set by ultrasound using which 2 measurements?
A
Crown-Rump measurement between 10 weeks to 13+6 weeks.
Head circumference from 14-20 weeks.
7
Q
Define gravidity.
A
Total number of pregnancies regardless of how they ended.
8
Q
Define parity.
A
Number of live births at any gestation or stillbirths after 24 weeks.
9
Q
When taking past gynaecological history, irregular periods may be suggestive of which syndrome?
A
Polycystic ovarian syndrome.
10
Q
Previous pelvic inflammatory disease increases the risk of…
A
…ectopic pregnancy.
11
Q
Recurrent miscarriage may be associated with antiphospholipid syndrome, which increases the risk of…(name 3)
A
…further pregnancy loss, foetal growth restriction and pre-eclampsia.
12
Q
Donor egg or sperm is associated with increased risk of what?
A
Pre-eclampsia.
13
Q
Which are the major pre-existing diseases that impact pregnancy? (8)
A
Diabetes mellitus Hypertension Renal disease Epilepsy Venous thromboembolic disease HIV Connective tissue diseases Myasthenia gravis/myotonic dystrophy
14
Q
In pregnant women, BMI < 20 is associated with…
A
…increased risk of foetal growth restriction and perinatal mortality.
15
Q
In pregnant women, BMI > 30 is associated with…
A
…increased risk of gestational diabetes and hypertension.
16
Q
Urinary examination:
All women should be offered routine screening for _____ by _____ early in pregnancy. This reduces the risk of pyelonephritis.
A
Asymptomatic bacteriuria
MSU culture
17
Q
What is the mean symphysis-fundal height at 20 weeks?
How much does it increase per week?
What should it be at 36 weeks?
A
20 weeks - 20cm
Increases by 1cm per week
36 weeks - 36cm
18
Q
Large symphysis-fundal height may suggest…(name 3)
A
Multiple pregnancy
Macrosomia
Polyhydramnios
19
Q
Small symphysis-fundal height may suggest…(name 2)
A
Foetal growth restriction
Oligohydramnios
20
Q
If a pole is present in the pelvis, what is the lie of the foetus?
A
Longitudinal.
21
Q
When the leading pole is not over the pelvis, but to one side, what is the lie of the foetus?
A
Oblique.
22
Q
What is it called when the foetus lies directly across the abdomen?
A
Transverse.
23
Q
When is the head considered to be ‘engaged’?
A
When it is no longer moveable.
24
Q
If the foetal heartbeat cannot be heard with a Pinard stethoscope, what should you use?
A
Hand-held Doppler.
25
What are the indications for vaginal examination in a pregnant women? (5)
Excessive or offensive discharge
Vaginal bleeding (if the absence of placenta praaevia is known)
To perform a cervical smear
To confirm potential rupture of the membrane
To confirm and assess the extent of female genital mutilation
26
What are the contraindications for digital examination of a pregnant women?
Known placenta praevia or vaginal bleeding when the placental site is unknown and the presenting part unengaged.
Pre-labour rupture of the membranes (increased risk of ascending infection).
27
During examination of a pregnant woman, how many beats of clonus are considered abnormal?
> 3 beats of clonus.
28
Why is oedema of the extremities not a good indicator of pre-eclampsia?
Because it is present in 80% of term pregnancies.
29
What are the 4 main risks of smoking during pregnancy?
Foetal growth restriction
Preterm labour
Placental abruption
Intrauterine foetal death
30
At the booking visit, if BMI is > 35 it is recommended that the woman be reviewed by an obstetric consultant or another healthcare professional that can provide advice on increased pregnancy risks.
What risks are associated with obesity in pregnancy (broken down into antenatal (8), intrapartum (5) and postnatal (4))?
```
Antenatal:
Congenital malformations
Neural tube defects
Gestational diabetes mellitus
Macrosomia
Foetal growth restriction
Hypertension and pre-eclampsia
VTE
Miscarriage/Stillbirth
```
```
Intrapartum:
Difficulty with analgesia
Difficulty with monitoring during labour
Increased rate of instrumental delivery
Increased caesarian section rate
Macrosomia/shoulder dystocia
```
```
Postnatal:
VTE
Wound infection
Depression
Childhood becoming obese/developing diabetes
```
31
What are the WHO recommendations on breastfeeding? (3)
Initiate within 1 hour of birth
Exclusive breast feeding for 6 months
Continued breast feeding up to at least 2 years of age
32
What is urine screened for at each antenatal test and why? (3)
Protein - detect renal disease or pre-eclampsia
Persistent glycosuria - diabetes (pre-existing or gestational)
Nitrites - detect UTIs (if nitrites are present, send for MC&S to detect asymptomatic bacteriuria)
33
What happens to blood pressure in the first and second trimester?
Blood pressure falls in the first trimester (a small amount) and will rise to pre-pregnancy levels by the end of the second trimester.
34
What tests are ordered at the booking appointment in pregnancy? (6)
```
FBC
MSU
Blood group and antibody screen
Haemoglobinopathy screen
Infection screen
Dating scan and first trimester screening
```
35
How is anaemia defined in pregnancy (inc. postpartum)?
First trimester < 110 g/L
Second and third trimesters < 105 g/L
Postpartum < 100 g/L
36
When should pregnant women with known haemoglobinopathies be offered ferritin supplementation?
When ferritin is < 30mcg/L
37
What do we give to pregnant women who are rhesus D-negative at the time of potentially sensitising events such as amniocentesis or following trauma?
Anti-D immunoglobulin (ideally within < 72 hours).
38
When is anti-D prophylaxis indicated in pregnancies < 12 weeks? (4)
Ectopic pregnancies
Molar pregnancies
Therapeutic TOP
Uterine bleeding that is repeated, heavy or associated with abdominal pain
39
What is the minimum dose of anti-D immunoglobulin given?
250 IU
40
At what stage in pregnancy are women who are RhD-negative offered prophylactic anti-D immunoglobulin?
28 weeks (given as single large dose at 28 weeks or two doses at 28 and 34 weeks).
NOTE: RhD-negative mothers also receive anti-D postpartum after confirmation that their baby is RhD-positive on cord blood testing.
41
Screening for thalassaemia is offered to all pregnant women at the booking visit using FBC results and/or which questionnaire?
Family Origin Questionnaire (FOQ)
42
Which conditions are screened for in the first trimester infection screen?
Syphilis - can cause miscarriage/stillbirth
Hepatitis B - 90% born to women with HBV get it
HIV
Hepatitis C - only if mother is high-risk (IVDU, HIV etc.)
Rubella - this has largely been stopped due to the MMR vaccine in the UK
43
If a baby is born to a woman with active hepatitis B, what should we do?
The infant should receive the HBV vaccine
One dose of hepatitis B immunoglobulin should be given within 12 hours
Additional doses of vaccine should be given at 1 and 6 months
44
When should women who decline initial screening for HIV be offered screening again?
28 weeks.
45
What is the first trimester ultrasound important for? (4)
Dating
Identification of multiple pregnancies
Screening for trisomies
Examination of the foetus for gross anomalies (e.g. anencephaly, cystic hygroma)
46
When is the first trimester dating/screening ultrasound best performed? What will the crown-rump length be expected to be in this time?
11+3 to 13+6 weeks - CRL is expected to be 45-84mm in this time.
47
Before 14 weeks, the crown-rump length is used to date the pregnancy. What is used from 14-20 weeks?
Head circumference.
48
Nuchal translucency is measured in the first trimester ultrasound to assess for the risk of Down syndrome (amongst other conditions). What is the median NT if crown-rump length is:
45mm
84mm
Median NT if CRL is 45mm = 1.2mm
| Median NT if CRL is 84mm = 1.9mm
49
What findings of beta-hCG and pregnancy-associated plasma protein A (PAPP-A) suggest trisomy 21?
High beta-hCG
| Low PAPP-A
50
NICE recommends that women at high risk of pre-eclampsia should be given 75mg aspirin from 12 weeks to delivery. Who is considered high risk? (6)
Hypertensive disease during previous pregnancy
Chronic kidney disease
Autoimmune disease such as SLE and antiphospholipid syndrome
Diabetes mellitus
Chronic hypertension
51
Women with any high risk factors for pre-eclampsia should be given 75mg aspirin from 12 weeks to delivery, as should women with 2 or more moderate risk factors. What are the moderate risk factors? (6)
```
Primiparity
Advanced maternal age (> 40 years)
Pregnancy interval of more than 10 years
BMI > 35 at booking visit
Family history of pre-eclampsia
Multifoetal pregnancy
```
52
Who is considered at risk of preterm birth? (4)
Previous preterm birth
Previous late miscarriage
Multifoetal pregnancies
Cervical surgery (e.g. cone biopsy) - these women should be offered serial cervical length screening (w/ or w/o monitoring foetal fibronectin)
53
NICE recommend that SFH measurements should be performed at every antenatal appointment from what stage (to assess for foetal growth restriction)?
24 weeks.
54
NICE recommends all pregnant and breastfeeding women take what dose of vitamin D supplements daily?
10 micrograms.
55
When is the anomaly scan carried out? What conditions may be identified? (4)
20-22 weeks.
```
Conditions:
Spina bifida
Major congenital anomalies
Diaphragmatic hernia
Renal agenesis
```
56
What are the criteria for diagnosis of GDM?
Fasting plasma glucose > 5.6 mmol/L
| 2-hour plasma glucose > 7.8 mmol/L
57
What are the risk factors for GDM?
Previous GDM
Previous macrosomia
Raised BMI
First-degree relative with diabetes mellitus
Asian, black Caribbean or Middle-Eastern origin
58
If risk factors for GDM are present, women should be offered what test at 24-28 weeks?
2-hour 75g oral glucose tolerance test (OGTT)
NOTE: Women with previous GDM should have an OGTT at 16-18 weeks and report at 24-28 weeks.
59
Continuous wave doppler ultrasound is used in the _______ (_ _ _) to provide continuous tracings of the foetal HR (these patterns change when the foetus is _____).
Cardiotocograph (CTG)
| Hypoxic
60
```
At what stage in pregnancy should you be able to:
Visualise the gestational sac
Visualise the yolk sac
Observe and measure the embryo
See the beating of the foetal heart
```
Visualise the gestational sac = 4-5 weeks
Visualise the yolk sac = 5 weeks
Observe and measure the embryo = 5-6 weeks
See the beating of the foetal heart = 6 weeks
61
What is blighted ovum?
The gestational sac is present but it is empty because the foetus has not developed.
62
What 4 measurements can be used in an equation to give an accurate estimate of foetal weight?
Abdominal circumference
Head circumference
Femur length
Biparietal diameter
63
Cessation of growth is suggestive of what condition?
Placental failure
64
What is meant by the term chorionicity?
The number of placentas.
65
When is the best time to perform an ultrasound to assess chorionicity?
9-10 weeks
66
What is placenta praevia?
When a placenta is inserted into the lower segment of the uterus and can cause life-threatening haemorrhage in pregnancy.
67
What percentage of women have a low-lying placenta at 20 weeks?
15-20%.
NOTE: 10% of this group will eventually develop placenta praevia.
68
What generally causes increased amniotic fluid volume?
Congenital abnormalities that impair the ability of the foetus to swallow (e.g. oesophageal atresia).
69
What generally causes decreased amniotic fluid volume?
Congenital abnormalities that cause a failure of urine production (e.g. renal agenesis).
70
Which 2 ultrasound measurement approaches give an indication of amniotic fluid volume?
Maximum vertical pool
| Amniotic fluid index
71
Why is amniotic fluid volume reduced in FGR?
Because of redistribution of the foetal blood away from the kidneys to vital structures such as the brain and heart (this leads to reduced renal perfusion and GFR).
72
How is cervical length best measured?
Transvaginal probe
73
Under which 2 circumstances does NICE recommend serial measurements of cervical length from 16 weeks?
NOTE: Short cervical length suggests high-risk of early delivery.
History of spontaneous preterm birth
| History of mid-trimester loss
74
When do NICE recommend all women are offered US scans? And why?
10-14 weeks - gestational age, multiple pregnancy, nuchal translucency
18-21 weeks - screen for structural abnormalities
75
What features of foetal heart rate are reported on CTG? (4)
Baseline rate
Baseline variability
Accelerations
Decelerations
76
What is considered normal foetal HR?
110-150 bpm
77
What are the causes of foetal tachycardia? (4)
Maternal or foetal infection
Acute foetal hypoxia
Foetal anaemia
Drug (e.g. ritodrine)
78
What is meant by short-term variability?
In normal physiological conditions, the interval between successive foetal heart beats varies.
79
What is meant by baseline variability?
Fluctuations in foetal heart beat occurring 2-6 times per minute.
80
When is baseline variability considered abnormal?
When it is < 10 bpm.
81
What factors affect baseline variability? (4)
Foetal sleep states and activity
Hypoxia
Foetal infection
Drugs (e.g. opioids)
82
Define foetal HR accelerations.
Increases in baseline foetal HR of at least 15 bpm lasting for at least 15 seconds. The presence of 2 or more accelerations on a 20-30 minute antepartum foetal CTG defines a 'reactive trace' and indicates a non-hypoxic foetus.
83
Define foetal HR decelerations. Give 2 causes.
Transient reductions in foetal HR of at least 15 bpm lasting more than 15 seconds.
Causes:
Foetal hypoxia
Umbilical cord compression
84
What is considered a normal CTG (give 3 findings).
Baseline HR of 110-150 bpm
Baseline variability exceeding 10 bpm
More than 1 acceleration in a 20-30 minute tracing
85
What are the 5 acute foetal variables which a biophysical profile (BPP) takes into account?
NOTE: A BPP gives a score of up to 10 (2 for normal on each variable, 0 for suboptimal).
```
Foetal breathing movements (FBMs)
Foetal gross body movement
Foetal tone
CTG
Amniotic fluid volume
```
86
What score is considered normal on a biophysical profile?
8-10.
87
How do waveforms (from Doppler USS) from the umbilical artery indicate placental health?
They provide information on placental resistance to blood flow.
88
What is meant be reversed end-diastolic flow (with regards to umbilical artery doppler USS)?
During diastole, blood is flowing away from the placenta back to the foetus - it is associated with foetal hypoxia and intrauterine death.
89
Which 2 Doppler USS indices are useful as they calculate variability of blood velocity in a vessel?
Pulsatility index
| Resistance index
90
What is cerebral redistribution?
When falling oxygen levels in the foetus lead to redistribution of blood flow to the essential organs.
91
Absent diastolic flow in the foetal aorta is suggestive or what?
Foetal acidaemia.
92
What is the most sensitive index of foetal academia (and the impending heart failure)?
Increasing pulsatility in the central veins supplying the heart (ductus arteriosus and IVC).
93
Reduced velocity in the ductus venosus A-wave is suggestive of what?
Increasing end-diastolic pressure.
94
A retrograde ductus venosus A-wave is suggestive of what?
Overt cardiac compromise (this may require early delivery).
95
The velocity of blood flow in the middle cerebral artery is an indicator of what?
Foetal anaemia - when the foetus is anaemia, peak systolic velocity increases
96
Doppler USS of which blood vessel can be used to predict pregnancies that are at risk of adverse outcomes such as pre-eclampsia?
Uterine artery
97
High resistance patterns in the uterine artery are associated with what? (3)
Pre-eclampsia
GFR
Placental abruption
98
What is cerebroplacental ratio?
The ratio of the pulsatility indices of the middle cerebral artery and the umbilical artery.
NOTE: Foetuses with abnormal ratio that are appropriately grown for gestational age or have late-onset SGA (> 34 weeks) have a higher incidence of abnormal intrapartum CTG requiring emergency Caesarian section, lower cord pH and an increased rate of admission to NICU.
99
Which hypothesis states that there is an association between reduced foetal growth and increased susceptibility to several adult disease (e.g. coronary heart disease, stroke and diabetes).
Barker hypothesis
100
How do we define 'small for gestational age' (SGA)?
< 10th centile for foetal size.
101
What is the distinction between SGA and FGR?
Many SGA foetuses have reached their full growth potential, but SGA foetuses that have failed to reach their growth potential are termed FGR.
(BUT not all FGR foetuses will be SGA - some will have a birthweight that is within normal limits but still have not reached their growth potential).
102
Foetal hyperinsulinaemia occurs in association with maternal diabetes and results in foetal macrosomia and excessive fat depletion. It can lead to complications such as...(name 3).
Stillbirth
Shoulder dystocia
Neonatal hypoglycaemia
103
Name 3 infections that have been implicated in FGR.
CMV
Toxoplasmosis
Syphilis
104
Give 3 causes of placental insufficiency.
Poor maternal uterine artery blood flow
Thicket placental trophoblast barrier
Abnormal foetus villous development
105
What are the 4 shunts that ensure oxygenated blood from the placenta is delivered to the foetal brain?
Umbilical circulation
Ductus venosus
Foramen oval
Ductus arteriosus
106
Which circulation carries blood to and from the placenta for gas and nutrient exchange?
Umbilical circulation
107
The umbilical arteries arise from...
...the caudal end of the dorsal foetal aorta.
108
In a normal foetus, how many foetal arteries and veins are there in the umbilical circulation?
2 foetal arteries
| 1 foetal vein
109
The ductus venosus allows most oxygenated foetal blood to bypass the liver, and then joins the IVC before entering the right atrium. What stops the well-oxygenated blood in the ductus venosus and the desaturated blood in the IVC mixing?
The streaming of the ductus venosus blood, and a membranous valve in the right atrium called the crista dividens.
110
How does the ductus venosus stream pass into the left atrium?
Through the foramen ovale (from the right atrium).
111
Deoxygenated blood from the foetal head and lower body flows through the right side of the heart into the pulmonary artery - it then bypasses the lungs via what?
The ductus arteriosus. This means that deoxygenated blood from the right ventricle will pass down the aorta and enter the umbilical arterial circulation to be returned to the placenta for oxygenation.
112
Which 2 local vasodilators keep the ductus arteriosus patent before birth?
Prostaglandin E2
| Prostacyclin
113
What can cause premature closure of the ductus arteriosus?
COX inhibitors.
114
At birth, what causes closure of the foramen ovale?
Cessation of umbilical blood flow causes cessation of flow into the ductus venosus. This causes a fall in pressure in the right atrium which closes the foramen ovale.
115
What causes the significant increase in pulmonary circulation at birth?
Ventilation of the lungs opens the pulmonary circulation, causing a rapid fall in pulmonary vascular resistance which dramatically increases pulmonary circulation.
116
What causes persistent foetal circulation?
The pulmonary vascular resistance fails to fall despite adequate breathing, resulting in left-to-right shunting of blood from the aorta through the ductus arteriosus into the lungs. The baby will be cyanosed and may suffer form life-threatening hypoxia.
117
There is a rapid increase in which type of brain matter in the last trimester?
Grey matter.
118
The lungs first appear as an outgrowth from which structure at about 3-4 weeks post-conception?
The primitive foregut.
119
Describe the development of the respiratory system.
1. The lungs first appear as an outgrowth from the primitive foregut at about 3-4 weeks post-conception.
2. By 4-7 weeks ,epithelial tube branches and vascular connections are forming.
3. By 20 weeks, the conductive airway tree and parallel vascular tree is well developed.
4. By 26 weeks, type I and II epithelial cells are beginning to differentiate.
5. By 30 weeks, surfactant production has started.
6. Up to delivery, dilatation of the airspaces, alveolar formation and maturation of surfactant continues.
120
What is the main phospholipid in pulmonary surfactant?
Phosphatidylcholine (lecithin).
121
What 3 factors can enhance the production of phosphatidylcholine?
Cortisol
Growth restriction
Prolonged rupture of the membranes
122
In which condition is surfactant production delayed?
Maternal diabetes mellitus.
123
What are the acute complications of respiratory distress syndrome? (3)
Hypoxia/asphyxia
Intraventricular haemorrhage
Necrotising enterocolitis
124
How can we reduce the incidence and severity of respiratory distress syndrome?
Antenatal steroids - these cross the placenta and stimulate premature release of stored foetal pulmonary surfactant in foetal alveoli.
125
Prolonged absence or impairment of foetal breathing movements (FBMs) results in reduced mean lung expansion and can lead to what condition?
Pulmonary hypoplasia.
126
What are the causes of pulmonary hypoplasia? (4)
Prolonged absence or impairment of foetal breathing movements
Oligohydramnios
Decreased intrathroacic space (e.g. diaphragmatic hernia)
Chest wall deformities
127
What does the foregut endoderm give rise to? (5)
```
Oesophagus
Stomach
Proximal half of the duodenum
Liver
Pancreas
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128
What does the midgut endoderm give rise to? (7)
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Distal half of duodenum
Jejunum
Ileum
Caecum
Appendix
Ascending colon
Transverse colon
```
129
What does the handgun endoderm give rise to? (3)
Descending colon
Sigmoid colon
Rectum
130
Failure of the midgut to re-enter the abdominal cavity results in what condition?
Omphalocele (exomphalos).
131
What is the most common fistula seen in foetal development?
Tracheo-oesophageal fistula. It may be seen alongside other congenital abnormalities (VACTERL association).
132
What is meant by an 'atresia' in the development of the alimentary canal?
When a segment of the alimentary canal has a lumen that is not patent.
133
Why will bowel atresias cause polyhydramnios in foetuses?
Because the foetus swallows amniotic fluid, so an obstruction that prevents passage of the fluid through the GI tract will cause polyhydramnios.
134
When does peristalsis begin in the intestines?
2nd trimester.
135
In the 3rd trimester, what happens to water content, glycogen stores and fat stores?
Water content decreases
| Glycogen and fat stores increase (5x)
136
The liver and biliary tree of a foetus appear late in the 3rd week as what?
The hepatic diverticulum (an outgrowth from the ventral wall of the distal foregut).
NOTE: The larger portion of the diverticulum becomes to hepatocytes and hepatic ducts, and the smaller portion becomes the gallbladder.
137
At what stage does the foetal liver perform haematopoiesis?
From 6 weeks onward. This peaks at 12-16 weeks and stops at 36 weeks.
138
Why do neonates get transient unconjugated hyperbilirubinaemia (physiological jaundice)?
Because during foetal life, the placenta does the job of the liver, so the foetal liver has deficiencies of the enzymes required to conjugate bilirubin. After birth, loss of the placenta leads to transient unconjugated hyperbilirubinaemia.
139
What are the 2 primitive forms of the kidneys?
NOTE: The final form is known as the metanephric kidney.
Pronephros
| Mesonephros
140
Explain the formation of the kidneys and urinary tract in foetuses.
1. Pronephros originates at about 3 weeks in a ridge that forms on either side of the midline in the embryo (nephrogenic ridge)
2. In this region, epithelial cells will arrange themselves in a series of tubules and join laterally with the pronephric duct
3. Each pronephric duct will grow towards the tail of the embryo during which it will induce intermediate mesoderm in the thoracolumbar area to become mesonephric tubules
4. The prenephros will then degrade whilst the mesonephric (Wolffian) duct extends towards the most caudal end of the embryo, ultimately attaching to the cloaca
5. During the 5th week, the ureteric bud develops as an outpouching from the Wolffian duct
6. This bud grows into the intermediate mesoderm and branches to form the collecting duct system (ureter, pelvis, calyces and collecting ducts) of the kidney. It also induces the formation of the renal secretory system (glomeruli, convoluted tubules, loops of Henle)
7. Then, the lower portions of the nephric duct will migrate caudally and connect with the bladder, thereby forming the ureters
8. As the foetus develops, the torso elongates and the kidneys rotate and migrate upwards within the abdomen causing the length of the ureters to increase
141
Failure of normal migration of the kidneys can lead to which condition?
Pelvic kidneys
142
Bilateral renal agenesis causes Potter's syndrome, which is associated with what? (6)
```
Widely-spaced eyes
Small jaw
Low-set ears
Secondary oligohydramnios
Renal failure (and death)
Pulmonary hypoplasia (secondary to oligohydramnios)
```
143
What does the epidermis develop from?
The surface ectoderm.
144
What do the dermis and hypodermic develop from?
Mesenchymal cells in the mesoderm.
145
Explain the development of the skin in utero.
1. By 4 weeks gestation, a single-cell layer of ectoderm surrounds the embryo
2. At 6 weeks, the ectodermal layer differentiates into an outer periderm and an inner basal layer
- The periderm will slough off as vernix
- The basal layer produces the epidermis and the glands/nails/hair follicles
3. Eventually the epidermis becomes stratified and by 16-20 weeks, all layers of the epidermis are developed
146
When do hair follicles develop in utero?
12-16 weeks. By 24 weeks they are producing lanugo hair.
147
What is the source of blood cells before 8 weeks in utero?
The blood islands of the yolk sac.
148
What is the source of blood cells between 8 and 20 weeks in utero?
The liver.
149
What is the source of blood cells after 20 weeks in utero?
The bone marrow.
150
At what stage are circulating mature T cells present?
From 16 weeks.
151
At what stage are B cells present in the circulation?
By 12 weeks.
152
Detection of IgM or IgA in the newborn without IgG is suggestive of what?
Foetal infection.
153
At what stage in utero is there a switch from HbF to HbA?
From 28-34 weeks.
154
When do foetal movements begin?
7-8 weeks.
155
What are the 4 foetal behavioural states?
1F - quiescence (like non-REM sleep in a neonate)
2F - frequent and periodic gross body movements with eye movements (like REM sleep)
3F - no gross body movements but eye movements (like quiet wakefulness)
4F - vigorous continual activity with eye movements (like active wakefulness)
156
At what stage does the amnion surface adhere to the chorion surface?
NOTE: They never fuse.
12 weeks.
157
Choriodecidual function is thought to be important in the initiation of labour by the production of what> (2)
Prostaglandin E2
| Prostaglandin F2a
158
Amniotic fluid is initially secreted by the amnion, but by the 10th week it is mainly what?
Transudate of foetal serum via the skin and umbilical cord.
159
At what stage does the foetal skin become impermeable to water?
NOTE: This means that transudate of foetal serum via the skin can no longer contribute to amniotic fluid. The net increase in amniotic fluid thereafter is due to contributions through the kidneys and lung fluids.
16 weeks.
160
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Give the expected amniotic fluid volume at:
10 weeks
20 weeks
30 weeks
38 weeks
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and after term, at:
40 weeks
42 weeks
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10 weeks = 30ml
20 weeks = 300ml
30 weeks = 600ml
38 weeks = 1000ml
40 weeks = 800ml
42 weeks = 350ml
```
161
What are the functions of the amniotic fluid? (4)
Protection from mechanical injury
Permit movement of the foetus while preventing limb contracture
Prevent adhesions between foetus and amnion
Permit foetal lung development in which there is two-way movement of fluid into the foetal bronchioles
162
What are the causes of oligohydramnios? (3)
Renal agenesis
PKD (cystic kidneys)
FGR
163
What are the causes of polyhydramnios? (3)
Congenital neuromuscular disorders
Anencephaly
Oesophageal/duodenal atresia (prevents swallowing of amniotic fluid)
164
What is cell-free foetal DNA (cffDNA) used for? (3)
Determination of foetal blood group in cases of RhD alloimmunisation.
Determination of foetal sex in X-linked disorders.
Diagnose skeletal dysplasia (e.g. achondroplasia).
165
Which cells are collected in chorionic villus sampling?
Foetal trophoblast cells in the mesenchyme of the villi. These divide rapidly in the first trimester.
166
Before what stage in pregnancy should chorionic villus not be performed?
Before 10 weeks.
167
Amniocentesis is an investigation whereby 15-20mL of amniotic fluid is sampled and tested. Which important cells are contained in amniotic fluid?
Amniocytes and fibroblasts - these are shed from foetal membranes, skin and foetal genitourinary tract.
168
What is the advantage of chorionic villus sampling over amniocentesis?
CVS can be performed earlier in pregnancy (amniocentesis should not be performed until 15 weeks).
NOTE: CVS also provides a larger sample of DNA.
169
Which investigation is used when a sample of foetal blood is needed?
Cordocentesis.
170
What are the 2 most common conditions that cordocentesis is used to test for?
Suspected severe foetal anaemia
| Thrombocytopenia
171
At what stage in pregnancy is it okay to perform cordocentesis?
From 20 weeks.
172
What is the screening test of choice for Down syndrome in the 2nd trimester?
Quadruple test - hCG, AFP, unconjugated oestriol and inhibit A.
173
Which mutation is associated with autosomal dominant severe skeletal dysplasia (achondroplasia, thanatophoric dysplasia)?
Mutation in FGFR3.
174
Backache during pregnancy causes exaggerated lumbar lordosis. What is it caused by?
Shifting centre of gravity as the uterus grows, additional weight gain and hormone-induced laxity of the spinal ligaments.
175
What is symphysis pubis dysfunction?
A very painful condition occurring in the 3rd trimester, where the symphysis pubis becomes loose causing the 2 halves of the pelvis to rub against each other when walking or moving (improves after delivery).
176
What is carpal tunnel syndrome?
Where the median nerve is compressed as it passes through the carpel tunnel - this often occurs in pregnancy due to increased soft tissue swelling.
177
What causes constipation in pregnancy?
A combination of hormonal and mechanical factors that slow gut motility.
178
Hyperemesis gravidarum:
Definition
Complications (5)
Definition: Severe, intractable form of nausea and vomiting seen in pregnancy (symptoms are usually most pronounced in the first trimester).
```
Complications:
Electrolyte imbalances
Malnutrition
Vitamin deficiencies
Adverse pregnancy outcome (increased risk of preterm birth and LBW)
Mallory-Weiss tears
```
179
Hyperemesis gravidarum management.
Antiemetics:
Antihistamines (e.g. cyclising) and phenothiazines (e.g. promethazine) are first line.
Metoclompramide/Ondansetron are second line.
Rehydration and correction of electrolyte imbalances:
Normal saline with additional potassium chloride in each bag.
Check U&Es daily.
Thaimine supplementation.
180
How should severity of hyperemesis gravidarum be assessed?
Pregnancy-Unique Quantification of Emesis (PUQE) score.
181
What are the potential side-effects of phenothiazines and metoclompramide?
Extra-pyramidal side-effects and oculogyric crises.
182
What causes gastro-oesophageal reflux in pregnant women?
Weight effect of the pregnant uterus and hormonally induced relaxation of the oesophageal sphincter.
183
Why are haemorrhoids more common during pregnancy?
Effects of circulating progesterone on the vasculature, pressure on the superior rectal veins by the gravid uterus and increasing circulating volume.
184
Obstetric cholestasis (aka intrahepatic cholestasis of pregnancy):
Presentation
Associations (3)
Treatment
Presentation: Pruritus and deranged LFTs without an alternative cause, usually in the 2nd half of pregnancy.
Associations:
Increased risk of spontaneous preterm birth, iatrogenic preterm birth and foetal death.
Treatment:
Ursodeoxycholic acid - treats pruritus and hepatic function.
185
What causes varicose veins in pregnancy? What complication can occur in a large varicose vein?
The relaxant effect of progesterone on vascular smooth muscle. Thrombophlebitis may occur in a large varicose vein.
186
What causes oedema in pregnancy?
Generalised soft-tissue swelling and increase capillary permeability, allowing intravascular fluid yo leak into the extravascular compartment.
187
What is it important to rule out in a patient with generalised oedema in pregnancy?
Pre-eclampsia.
188
What is meant by the term chloasma?
A common skin condition among pregnant women. It usually presents as dark, brownish patches of skin, mostly on the forehead, nose, upper lip, and cheeks.
189
What is chloasma?
A common skin condition among pregnant women. It usually presents as dark, brownish patches of skin, mostly on the forehead, nose, upper lip, and cheeks.
190
Fibroids (Leiomyomata):
What are they?
Where are they found?
What are they?
Compact masses of smooth muscle which may enlarge during pregnancy, causing problems during later pregnancy or delivery.
Where are they found?
In the cavity of the uterus (submucous)
Within the uterine muscle (intramural)
On the outside surface of the uterus (subserous)
NOTE: A subserous pedunculate fibroid case tort, causing acute abdominal pain and tenderness.
191
Red degeneration:
Definition
Differential diagnoses (5)
One of the most common fibroid complications in pregnancy. As fibroids grow they can become ischaemic, manifesting as acute pain, tenderness over the fibroid and vomiting. If severe, it can precipitate uterine contractions causing preterm labour or miscarriage.
```
Differential diagnoses:
Acute appendicitis
Pyelonephritis/UTI
Ovarian cyst accident
Placental abruption
Torted subserous pedunculate fibroid
```
192
What proportion of women have a retroverted uterus?
15%
193
What complication of a retroverted uterus tends to present at 12-14 weeks?
Urinary retention.
194
The shape of the uterus is embryologically determined by fusion of the _____ _____.
Mullerian ducts.
195
Abnormalities in fusion of the Mullerian ducts can lead to which uterine anomalies?
```
Arcuate uterus
Supseptate uterus
Septate uterus
Bicornate uterus
Uterus didelphys
```
196
What are the 2 subtypes of uterus didelphys?
Bicollis (2 vaginas)
| Unicollis (1 vagina)
197
What are the most common pathological ovarian cysts? (2)
Serous cyst
| Benign teratoma
198
What are the 3 major problems that can occur with ovarian cysts?
Torsion
Haemorrhage
Rupture
NOTE: These cause acute abdominal pain and may result in miscarriage or preterm labour.
199
```
UTI (in pregnancy):
Definition
Associations (2)
Predisposing factors (4)
First-line antibiotics
Most common organism
```
Definition: > 10^5 colony forming units/mL in urine culture.
Associations:
LBW
Preterm delivery
```
Predisposing factors:
History of recurrent cystitis
Renal tract abnormalities
Diabetes mellitus
Bladder emptying problems (e.g. with multiple sclerosis)
```
First-line antibiotics:
Amoxicillin or oral cephalosporins.
Most common organism:
E. coli.
200
What is the most common cause of direct maternal death in the UK?
Venous thromboembolism.
201
What changes to the thrombotic and fibrinolytic systems are seen in pregnancy?
Increase in factors 8, 9, 10 and fibrinogen
| Decrease in protein C and antithrombin-III
202
How much is VTE risk increased in pregnancy?
6-10 fold.
203
What are the risk factors of thromboembolic disease in pregnancy (excluding pre-existing risk factors such as obesity etc.)? (7)
```
Multiple gestation
Pre-eclampsia
Grand multiparty
Caesarian section
Damage to pelvic veins
Sepsis
Prolonged bed rest
```
204
What is acquired thrombophilia in pregnancy most commonly associated with?
Anti-phospholipid syndrome (APS).
205
Define anti-phospholipid syndrome (APS).
The combination of lupus anticoagulant with or without anti-cardiolipin antibodies, with a history of recurrent miscarriage and/or thrombosis.
206
What its the first investigation used in suspected DVT in a pregnant woman?
Compression duplex ultrasound.
207
Why is warfarin contraindicated in pregnancy (except in women with mechanical heart valves)?
Because it closes the placenta and can cause limb and facial defects and foetal intracerebral haemorrhage.
208
What is the anticoagulant of choice in pregnancy?
Low molecular weight heparin (LMWH).
209
Under what circumstances should IVC filters be considered in the permpartum period?
For patients with iliac vein VTE or with proven DVT and those who have recurrent PE despite anticoagulation.
210
What are the treatment options for massive PE in pregnant women? (4)
IV unfractionated heparin
Thrombolytic therapy
Thoracotomy
Surgical embolectomy
211
What is the maintenance treatment of VTE in pregnancy?
Treatment with subcutaneous LMWH for the remainder of the pregnancy and for at least 6 weeks postnatally, and until at least 3 months of treatment in total.
212
What anticoagulant can be given during labour if necessary?
IV unfractionated heparin.
213
How long before planned delivery should LMWH be stopped?
24 hours.
214
Which markers of acute alcohol abuse are not reliable during pregnancy? (2)
MCV
| GGT
215
Smoking in pregnancy reduces placental perfusion, and is associated with what? (3)
NOTE: Cessation by 15 weeks gestation reduces the risk as much as quitting before pregnancy.
Increased perinatal mortality
Smaller babies
Higher risk of placental abruption
216
OIligohydramnios:
Definition
Causes (7)
Consequences of severe early-onset oligohydramnios (2)
Definition: Amniotic fluid index (AFI) < 5th centile for gestation (AFI is an ultrasound estimation of amniotic fluid volume).
```
Causes:
Renal agenesis (incompatible with life)
Multicystic kidneys
urinary tract abnormalities/obstruction
FGR and placental insufficiency
Maternal drugs (e.g. NSAIDs)
Post-dates pregnancy
PPROM
```
Consequences of severe early-onset oligohydramnios:
Pulmonary hypoplasia
Limb deformities
217
Polyhydramnios:
Definition
Maternal causes (4)
Foetal causes (6)
Definition: AFI > 95th centile for gestation.
```
Maternal causes:
Diabetes
Placental
Chorioangioma
AV fistula
```
Foetal causes:
Multiple gestation
Idiopathic
Oesophageal atresia/tracheo-oesophageal fistula
Duodenal atresia
Neuromuscular fetal condition which prevents swallowing
Anencephaly
218
What are the 3 types of breech? Which is most common?
Extended (Frank) - most common
Flexed (Complete)
Footling
219
What are the 3 treatment options for breech?
External cephalic version
Vaginal breech delivery
Elective caesarian section
220
What is the best method of delivery a term breech singleton?
Planned caesarian section
Reasoning: Vaginal delivery is associated with 3% increased risk of death or serious morbidity to the baby. Also, although risk of maternal complications is lower in successful vaginal delivery than planned C-section, 40% of attempted vaginal deliveries result in emergency C-section, which has a higher incidence of maternal complications.
221
What are the features of high risk in a planned vaginal delivery in a breech presentation? (5)
```
Hyperextended neck on USS
High estimated foetal weight
Low estimated foetal weight
Footling presentation
Evidence of antenatal foetal compromise
```
222
External cephalic version can be performed at or after what stage in pregnancy?
37 weeks.
NOTE: A tocolytic (e.g. nifedipine) should given to prevent contractions.
223
What are the contraindications for external cephalic version? (8)
```
Foetal abnormality (e.g. hydrocephalus)
Placenta praevia
Oligo/polyhydramnios
History of antepartum haemorrhage
Previous C-section or myomectomy scar on the uterus
Multiple gestation
Pre-eclampsia or hypertension
Plan to deliver by C-section anyway
```
224
In vaginal delivery of a breech presentation, which manoeuvre can be used to deliver the legs if they are extended?
NOTE: If the legs are flexed, they will deliver spontaneously.
Pinard's manoeuvre - use a finger to flex the leg at the knee and extend the hip, first anteriorly and then posteriorly.
225
Although unnecessary to perform routinely, which manoeuvre can be used to deliver the shoulders of a breech baby in a vaginal delivery?
Loveset's manoeuvre.
226
How is the head of a breech baby delivered in a vaginal delivery?
Using the Mauriceau-Smellie-Veit manoeuvre - the baby lies on the obstetrician's arm with downward traction on the head via a finger in the mouth and one on each axilla. Delivery occurs with first downward and then upward movement.
227
Other than breech presentations, what foetal malpresentation exist? (2)
Transverse lie
Oblique lie
NOTE: Normal lie is known as longitudinal.
228
What risks are associated with transverse and oblique lie?
Cord prolapse following spontaneous rupture of the membranes
| Prolapse of the hand, shoulder or foot once in labour
229
Post-term pregnancy:
Definition
What proportion of pregnancies are affected?
Definition: Pregnancy that has extended to or beyond 42 weeks gestation.
What proportion of pregnancies are affected?
10%.
230
In cases of post-term pregnancy, under which circumstances should immediate induction of labour take place? (5)
```
Reduced amniotic fluid on ultrasound
Foetal growth is reduced
Reduced foetal movements
CTG abnormalities
Mother is hypertensive or has another significant co-morbidity
```
231
What is the difference between threatened miscarriage and antepartum haemorrhage?
Vaginal bleeding at < 24 weeks is threatened miscarriage.
| Vaginal bleeding at 24+ weeks is antepartum haemorrhage.
232
What are the causes of antepartum haemorrhage? (8)
Placental:
Placental abruption
Placenta praevia
Vasa praevia
```
Local causes:
Cervicitis
Cervical ectropion
Cervical carcinoma
Vaginal trauma
Vaginal infection
```
233
The most clinically important Rhesus antigens are C, D and E. They are coded on two adjacent genes on which chromosome?
Chromosome 1.
234
Which Rhesus antibodies cause haemolytic disease of the foetal and newborn (HDFN)?
Anti-D (most commonly)
| Anti-C (rarely)
235
Occurrence of HDFN from rhesus auto immunisation requires 3 things to happen - what are they?
1. A rhesus negative mother must conceive a baby who has inherited the rhesus-positive phenotype from the father.
2. Foetal cells must gain access to the maternal circulation in sufficient volume to provoke a maternal antibody response.
3. Maternal antibodies must cross the placenta and cause immune destruction of red cells in the foetus.
236
Why does rhesus disease not affect the first pregnancy?
Because the primary immune response is usually weak and consists mostly of IgM which does not cross the placenta. In the subsequent pregnancies, B cells produce a much larger response with IgG antibodies which do cross the placenta.
237
What are the potential sensitising events for rhesus disease? (5)
```
Miscarriage
Termination
Antepartum haemorrhage
Invasive prenatal testing (CVS, amniocentesis, cordocentesis)
Delivery
```
238
Which test is used to identify the proportion of foetal cells in the maternal blood, allowing calculations of the seize of foeti-maternal transfusion and the amount of extra anti-D required in cases of potential rhesus isoimmunisation?
The Kleihauer test.
239
What are the signs of foetal anaemia (e.g. caused by HDFN)? (6)
```
Polyhydramnios
Enlarged foetal heart
Ascites and pericardial effusions
Hyperdynamic foetal circulation
Reduced foetal movement
Abnormal CTG with reduced variability and eventually a sinusoidal trace
```
240
Which scans can we use to assess foetal anaemia?
Middle cerebral artery Doppler scans (peak velocity measurement).
241
What are the routes of administration for foetal blood transfusions in cases of foetal anaemia? (4)
Into umbilical vein at point of cord insertion
Into intrahepatic vein
Into peritoneal cavity
Into foetal heart
242
Multiple pregnancy accounts for what proportion of live births?
3%
243
What proportion of successful IVF procedures result in multiple pregnancy?
20%
244
How is multiple pregnancy classified?
Number of foetuses: Twins, triplets etc.
Number of fertilised eggs: Zygosity
Number of placentae: Chorionicity
Number of amniotic cavities: Amnionicity
245
Which supplements should be offered to women with multiple pregnancy and why?
Iron, folic acid and vitamin B12, because they are at higher risk of anaemia.
246
What proportion of twin pregnancies result in spontaneous birth before 37 weeks?
60%
247
Why might the death of one monochorionic twin result in death or handicap of the co-twin?
Acute hypotension due to placental avascular anastomoses between the 2 circulations.
248
Twin-to-twin transfusion syndrome:
Cause
Diagnostic criteria
What is the name of the staging system?
Cause: Unbalanced vascular anastomoses in monochorionic twins, with more AV connections in one direction than the other. Changes in hydrostatic and osmotic forces will occur resulting in TTTS.
Diagnostic criteria (via USS):
Single placenta mass (i.e. monochorionic)
Concordant gender
Oligohydramnios with maximum vertical pool < 2cm in one sac and polyhydramnios in other sac (> 8cm)
Discordant bladder appearances
Haemodynamic and cardiac compromise
What is the name of the staging system?
Quintero Staging.
249
What is twin anaemia polycythaemia sequence (TAPS)?
A rarer, chronic form of TTTS in which a large inter-twin haemoglobin difference occurs, leading to anaemia in one twin and polycythaemia in the other. It can be differentiated from TTTS as oligohydramnios polyhydramnios sequence is not seen.
250
What is mirror syndrome?
A combination of foetal hydros and maternal pre-eclampsia.
251
How are TTTS and TAPS treated?
```
Amnioreduction
Septostomy
Selective feticide
Fetoscopic laser ablation of vascular anastomoses (definitive treatment between 16 and 26 weeks)
Above 26 weeks, consider delivery
```
252
In twin pregnancies, if external cephalic version fails to turn a transverse foetus, what can be tried?
Internal podalic version
253
Define preterm labour.
Onset of labour < 37 weeks gestation.
254
In labour, what causes the changes in the structure of the cervix? (4)
Breakdown of collagen
Changes in proteoglycan concentration
Infiltration of leukocytes and macrophages
Increase in water content
255
In labour, what causes increased myocetrial activity?
Activation of cassette of contraction-associated proteins (CAPs) converts myometrium from a quiescent to a contractile state. CAPs include gap junction proteins, oxytocin and prostanoid receptors, enzymes for PG synthesis and cell signalling proteins.
256
Which hormone maintains uterine quiescence?
Progesterone.
257
What do we use Progesterone receptor antagonist RU486 for?
To induce labour.
258
What are the 2 functions of the oxytocin/oxytocin receptor (OTR) system in the pregnant uterus?
Stimulation of contractions
Production of prostaglandins
NOTE: There is no increase in there production of oxytocin associated with the onset or progression of labour but the sensitivity of the myometrium to oxytocin at term increases due to increased OTR expression.
259
Which enzyme is the rate limiting step in prostaglandin synthesis?
PGHS-2.
260
What is the dominant site of prostaglandin synthesis in pregnancy?
The amnion.
261
What is the mean site of prostaglandin action in pregnancy?
The myometrium.
262
The enzyme responsible for prostaglandin metabolism is expressed by the chorion - what is its name?
15-hydroxyprostaglandin dehydrogenase (PGDH). Its expression falls with the onset of labour, facilitating transfer of PGs from the amnion to the myometrium (which the chorion lies between).
263
What condition is classically associated with painless premature cervical dilatation, and suggested by a history of painless second trimester pregnancy loss?
Cervical weakness.
264
What proportion of pregnancies delivered after PPROM are complicated by infection?
33%
265
Chorioamnionitis (infection of the foetal membranes) is associated with foetal brain damage due to an inflammatory response - this can cause ______ ______.
Periventricular leukomalacia.
266
What are the causes of preterm labour? (5)
```
Cervical weakness
Chorioamnionitis
Uterine Mullerian anomalies
Haemorrhage
Stress
```
267
How can antepartum haemorrhage and placental abruption lead to preterm labour?
Acute bleeding leads to thrombin release which directly stimulates myocetrial contraction.
268
Define placental abruption.
Separation of the placenta from the wall of the uterus during pregnancy, especially when it occurs prematurely.
269
What can be tested to determine who is and who is not in preterm labour?
Cervicovaginal fluid level of foetal fibronection (fFN) - this is a glycoprotein found in the cervicovagiunal fluid, amniotic fluid, placental tissue and in the interface between the chorion and decidua. It acts as a glue at the maternal-foetal interface, and its presence in the cervicovaginal fluid between 22-36 weeks is a predictor of preterm delivery.
270
In preterm labour, tocolytics may be given to delay delivery long enough for corticosteroid administration - why do we want to administer corticosteroids?
For neonatal lung function, to reduce the incidence of respiratory distress syndrome.
271
What are the first choice tocolytics in preterm labour?
```
Calcium channel blockers (e.g. nifedipine)
OTR antagonists (e.g. atosiban)
```
272
What are beta-agonists (ritodrine, salbutamol, terbutaline) given for in preterm labour?
They mediate myocetrial relaxation by stimulating cAMP production. This delays delivery but does not improve outcome, and they have significant maternal side-effects such as pulmonary oedema.
273
What is magnesium sulphate given for in preterm labour?
It inhibits uterine contraction by decreasing frequency of depolarisation of smooth muscle by modulating calcium uptake, binding and distribution in smooth muscle cells.
274
NSAIDs (indomethacin) can be given to delay delivery in preterm labour, but what are their adverse foetal side-effects?
They inhibit prostaglandins, causing premature closure of the ductus arteriosus, which can cause persistent pulmonary hypertension.
Indomethacin is also associated with increase risk of necrotising enterocolitis ands neonatal renal dysfunction.
275
How do CCBs (e.g. nifedipine) relax the contraction of the myometrium in preterm labour?
They bind to L-type calcium channels and reduce intracellular calcium levels.
276
Atosiban (an OTR antagonist) is a competitive antagonist of oxytocin and _____ ___ receptors within the myometrium. Is results in dose-dependent inhibition of uterine contractility and oxytocin-mediated PG release.
Vasopressin V1a.
277
Which 2 corticosteroids are recommended in preterm labour?
Betamathasone
| Dexamethasone
278
Which antibiotic is the prophylactic of choice in PPROM?
Erythromycin 250mg 4/day for 10 days.
279
Pregnancies complicated bye PPROM before 23 weeks are associated with which condition in the foetus?
Pulmonary hypoplasia.
280
PPROM is diagnosed through clinical history and demonstration of what?
A pool of liquor on the vagina on speculum examination.
281
Why is tocolysis contraindicated in PPROM?
Due to increased risk of maternal and foetal infection in patients with PPROM.
282
There is a direct relationship between what and the risk of preterm delivery?
Cervical length.
283
Which 2 interventions can be used to prevent preterm delivery?
Progesterone (IM hydroxyprogesterone caproate)
| Cervical cerclage
284
What are the 3 circumstances when cervical cerclage is performed?
History indicated cerclage - following multiple mid-trimester losses or preterm deliveries.
Ultrasound indicated cerclage - when the cervix shortens (usually < 25mm) in a women with a history of cervical surgery or previous preterm birth.
Rescue cerclage - when the cervix is dilating in the absence of contractions.
285
What treatment can be considered if transvaginal cerclage fails?
Transabdominal cerclage.
286
How can PPROM be diagnosed is pooling of amniotic fluid is not observed on speculum examination?
Insulin-like growth factor binding protein-1 test or alpha-microglobulin-1 test of vaginal fluid.
287
Rescue cervical cerclage should not be offered to women with any of... (name 3).
Signs of infection
Active vaginal bleeding
Uterine contractions
288
If clinical assessment suggests that a woman is in preterm labour, at what stage do you start treatment immediately, and at what stage do you consider transvaginal ultrasound to confirm diagnosis?
Start treatment if < 29+6 weeks
| Use transvaginal USS if 30+ weeks, and if cervical length < 15mm start treatment
289
Which drug can be given for neuroprotection in preterm labour?
Magnesium sulphate.
290
How is hypertension classified (mild, moderate, severe)?
```
Mild = 140-149 systolic, 90-99 diastolic
Moderate = 150-159 systolic, 100-109 diastolic
Severe = >= 160 systolic, >= 110 diastolic
```
291
What are the 3 hypertensive conditions of pregnancy?
Non-proteinuric pregnancy-induced hypertension (gestational hypertension)
Pre-eclampsia
Chronic hypertension
292
Define non-proteinuric pregnancy-induced hypertension (gestational hypertension).
Hypertension that arises for the first time in the second half of pregnancy in the absence of proteinuria. It is not associated with adverse outcomes and seldom requires treatment.
293
Why is chronic hypertension often masked in the first trimester?
Because there is a physiological fall in blood pressure that occurs due to peripheral vasodilation.
294
Pre-Eclampsia:
Definition
How common is it?
Risk factors
Definition: Hypertension of at least 140/90mmHg recorded on at least 2 separate occasions and at least 4 hours apart and in the presence of at least 300mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the 6th postpartum week.
How common is it?
It complicates 2-3% of all pregnancies.
```
Risk factors:
First pregnancy
Previous pre-eclampsia
Age 40+
10 years or more since last baby
BMI obese
Family history of pre-eclampsia
Multiple pregnancy
```
295
Explain the pathophysiology of pre-eclampsia.
NOTE: It can occur in pregnancies lacking a foetus (molar pregnancies) and in the absence of a uterus (abdominal pregnancies).
1. Genetic predisposition
2. Abnormal immunological response
3. Deficient trophoblast invasion
4. Hypoperfused placenta
5. Circulating factors
6. Vascular endothelial cell activation
7. Clinical manifestations of disease
296
How does pre-eclampsia effect the cardiovascular system, leading to generalised oedema?
In pre-eclampsia, there is marked peripheral vasoconstriction which leads to hypertension. This, combined with loss of endothelial cell integrity, leads to increased vascular permeability. This causes generalised oedema.
297
Which lesion of the renal system is specific to pre-eclampsia? How is it associated with proteinuria?
Glomeruloendotheliosis - this is associated with impaired glomerular filtration and selective protein loss (albumin and transferrin) leading to proteinuria. This leads to reduction in plasma oncotiw pressure which exacerbates oedema.
298
Pre-eclampsia is associated with _______ fibrin deposition and ______ platelet count.
Pre-eclampsia is associated with increased fibrin deposition and reduced platelet count.
299
The impacts of pre-eclampsia on the liver can present as HELLP syndrome. What does this stand for?
(H)aemolysis
(E)levated (L)iver enzymes
(L)ow (P)latelets
300
How does HELLP syndrome usually present? Which complications is it associated with? (3)
Presentation:
Epigastric pain
Nausea and vomiting
Complications:
Acute renal failure
Placental abruption
Stillbirth
301
Define eclampsia.
Presence of tonic-clonic convulsions in a woman with pre-eclampsia and in the absence of any other identifiable cause. This is likely due to vasospasm and cerebral oedema.
NOTE: It is heavily associated with FGR.
302
What are the classic symptoms of pre-eclampsia?
Frontal headache
Visual disturbance
Epigastric pain
Vague 'flu-like' symptoms
303
Why is epigastric tenderness worrying in pre-eclamspia?
It suggests liver involvement (HELLP syndrome).
304
What is the most common cause of maternal death in pre-eclampsia?
Cerebral haemorrhage.
305
What is the drug of choice for treatment of hypertension in pre-eclampsia?
Labetalol (alpha-blocker). IV hydralazine can also be used in severe cases.
NOTE: Nifedipine (CCB) has a rapid onset of action but can cause a severe headache which mimics worsening disease.
306
What is the drug of choice for treatment and prevention of convulsions in pre-eclampsia?
IV magnesium sulphate.
307
Which drug can be used to try and prevent pre-eclampsia? It modestly reduces the risk in high-risk women.
Low-dose aspirin (75mg daily).
308
Which drug (which can be used during delivery) should be avoided in patients with pre-eclamspia because it significantly increases BP?
Ergometrine.
309
Which antihypertensive drugs should be discontinued in pregnant women due to concerns over teratogenicity and negative effects on foetal growth?
ACE inhibitors, ARBs, atenolol and chlorothiazide.
310
What are the preferred drugs to treat chronic hypertension in pregnancy (> 150/100mmHg). (3)
NOTE: Below this BP, it is usually unnecessary to treat.
Labetalol
Nifedipine
Methyldopa
311
Foetal growth restriction (FGR):
Definition
Causes
Definition: Failure of a foetus to achieve its genetic growth potential.
Causes:
Reduced foetal growth potential (aneuploidies, single gene defects e.g. Seckel's syndrome, structural abnormalities e.g. renal agenesis, intrauterine infections)
Reduced foetal growth support (maternal or placental factors such as poor placental perfusion or undernutrition).
312
Which type of FGR is associated with uteroplacental insufficiency and why?
Asymmetrical - because reduced oxygen transfer to the foetus causes hypoxia, and the brain is relatively spared in comparison with abdominal girth and skin thickness.
313
What are the risk factors for FGR?
```
Multiple pregnancies
History of FGR
Current heavy smokers
Current drug users
Underlying conditions e.g. hypertension, diabetes etc.
SFH smaller than expected
```
314
Significant proteinuria is diagnosed if protein : creatinine ratio is ________ or a validated 24 hour urine collection shows ________.
Significant proteinuria is diagnosed if protein : creatinine ratio is > 30mg/mmol or a validated 24 hour urine collection shows > 300mg protein.
315
Regarding hypertension in pregnancy, do not offer birth before _____ weeks to women with gestational hypertension whose blood pressure is ______.
Regarding hypertension in pregnancy, do not offer birth before 37 weeks to women with gestational hypertension whose blood pressure is < 160/110mmHg.
316
Offer birth to women with pre-eclampsia before 34 weeks and after a course of corticosteroids if...(name 2).
Severe hypertensive develops refractory to treatment
| Maternal or foetal indications develop as specific in the consultant plan
317
What foetal monitoring should be performed when the mother has chronic hypertension?
Ultrasound foetal growth, amniotic fluid volume assessment and umbilical artery doppler velocimetry between 28-30 weeks and 32-34 weeks.
Only do CTG if activity is abnormal.
318
What foetal monitoring should be performed when the mother has mild or moderate gestational hypertension?
Ultrasound foetal growth, amniotic fluid volume assessment and umbilical artery doppler velocimetry if diagnosis is confirmed at < 34 weeks.
Only do CTG if activity is abnormal.
319
What foetal monitoring should be performed when the mother has severe gestational hypertension or pre-eclampsia?
Do CTG at time of diagnosis - if normal, do not repeat more than weekly. Repeat if woman reports change in foetal movement, there is PV bleeding, abdominal pain or deterioration in maternal condition.
320
What foetal monitoring should be performed when the mother is at high risk of pre-eclampsia?
Ultrasound foetal growth, amniotic fluid volume assessment and umbilical artery doppler velocimetry starting at 28-30 weeks.
321
What is the dosing of magnesium sulphate in women with pre-eclampsia?
Leading dose of 4g given IV over 5 mins, followed by infusion of 1g/hour for 24 hours.
322
The safety of which antihypertensives is uncertain whilst breastfeeding? (3)
ARBs
ACE inhibitors
Amlodipine
323
Why is diagnosis of pre-eclampsia difficult in patients with CKD?
Because they may have pre-existing hypertension and proteinuria.
324
What are the complications of dialysis in pregnancy? (4)
Preterm delivery
Polyhydramnios
Pre-eclampsia
Caesarian delivery
325
Pregnancy is generally considered safe how many years after renal transplant?
2 years post-transplant.
326
Give 4 immunosuppressant drugs that are safe to use in pregnancy.
Tacrolimus
Azathioprine
Ciclosporin
Prednisolone
NOTE: Screening for GDM is necessary with prednisolone and tacrolimus.
327
Which 2 immunosuppressants should be avoided in transplant recipients considering pregnancy?
Mycophenolate
| Sirolimus
328
Poor glycemic control is associated with increased risk of congenital abnormalities - specifically which 2 types?
Neural tube defects
| Cardiac anomalies
329
What pre-meal glucose levels should be targeted before considering trying for pregnancy if you have diabetes mellitus?
4-7mmol/L.
330
All women with diabetes should be offered _________ from 12 weeks gestation until delivery.
low dose (75mg) aspirin.
331
Management of diabetes mellitus in pregnancy.
MDT approach
Blood glucose monitoring 7x/day (before and 1 hour after meals) - Pre-meal target < 5.3 mmol/L, 1 hour post-prandial target < 7.8 mmol/L.
Renal and retinal screening
Foetal anomaly scan at 19-20 weeks with assessment of cardiac outflow tracts
Serial growth scans to diagnose macrosomia and polyhydramnios
Aim for vaginal delivery between 38-39 weeks
332
What happens to insulin resistance throughout pregnancy?
It increases - so women with diabetes will be required to increase dose of metformin or insulin during second half of pregnancy.
333
What are the NICE recommendations for diagnosis of GDM?
Diagnose GDM if:
Fasting blood glucose > 5.6mmol/L
2-hour OGTT (75g glucose) > 7.8mmol/L
334
Screening with fasting blood glucose or HbA1c should be offered at what stage after delivery in order to rule out T2DM in a mother who had GDM?
6-13 weeks after delivery.
335
What happens to TSH and free T4 in the first trimester of pregnancy?
TSH falls
| Free T4 rises (and then falls over the remainder of the pregnancy)
336
In pregnant women with hypothyroidism, thyroid replacement therapy should be continued throughout pregnancy with a target TSH of what?
TSH < 4mmol/L.
337
Suboptimal thyroid replacement therapy is associated with... (name 2)
...developmental delay and pregnancy loss.
338
Why is radioactive iodine contraindicated in pregnancy?
It destroys the foetal thyroid.
339
Which drugs should be used to treat hyperthyroidism in pregnancy? (2)
Carbimazole
Propylthiouracil
NOTE: Lowest acceptable dose in order to avoid foetal hypothyroidism.
340
What 2 cautions should you be aware of when treating hyperthyroidism with propylthiouracil and carbimazole in pregnancy?
Use lowest acceptable dose in order to avoid foetal hypothyroidism.
Check maternal WCC regularly due to risk of agranulocytosis.
341
What are the risks of uncontrolled thyrotoxicosis in pregnancy? (3)
Increased risk of miscarriage
Preterm delivery
FGR
342
How is thyroid storm managed in pregnancy? (4)
Propylthiouracil
High-dose corticosteroids
Beta-blockers (to block peripheral effects)
Rehydration
343
How are severe and mild hyperparathyroidism managed in pregnancy?
```
Severe = parathyroidectomy
Mild = adequate hydration and low calcium diet
```
344
What are the risks of hyperparathyroidism in pregnancy? (4)
Increased rates of miscarriage
Intrauterine death
Preterm labour
Neonatal tetany
345
What are the risks of hypoparathyroidism in pregnancy? (3)
Increased risk of second trimester miscarriage
Foetal hypocalcaemia
Neonatal rickets
346
How is hypoparathyroidism treated in pregnancy? (3)
Vitamin D
Oral calcium supplements
Regular monitoring of calcium and albumin
347
Hyperprolactinaemia is an important cause of infertility. What is it usually caused by?
A benign pituitary adenoma.
348
How are pituitary adenomas and their effects managed?
Microadenomas are treated with bromocriptine and cabergoline (dopamine agonists), but these are stopped in pregnancy unless there is evidence of growth.
Macroadenomas may require surgery or radiotherapy at some point, but they do not usually cause problems during pregnancy so should just be monitored.
349
What happens to the pituitary gland during pregnancy?
Enlarges by 50%.
350
What are the risks of Cushing's syndrome in pregnancy (it is rare because most affected women are infertile)? (3)
Pre-eclampsia
Preterm delivery
Stillbirth
351
How is Conn's syndrome diagnosed?
High aldosterone and hypokalaemia.
| Enlargement of adrenals can be seen on CT or USS.
352
Why might cortisol levels be erroneously normal in a pregnant woman with Addison's disease?
Because there is an increase in cortisol-binding globulin during pregnancy.
353
How is a phaeochromocytoma diagnosed?
24-hour urine catecholamines and adrenal imaging.
354
Why is C-section the preferred mode of delivery in women with a phaeochromocytoma?
Because this prevents the sudden increases in catecholamines associated with vaginal delivery.
355
What classification is used to assess level of heart failure?
NYHA classification.
356
At what stages in pregnancy is an echocardiogram usually performed?
Booking appointment and at 28 weeks.
357
Why should prophylactic antibiotics be given during labour to any woman with a structural heart defect?
To avoid bacterial endocarditis.
358
Why might the speed of the second stage of labour be increased with elective forceps or ventouse delivery if the mother has cardiac conditions?
This reduces maternal effort and therefore the requirement for increased cardiac output.
359
In women with CVD, active management of the third stage of labour should involve syntocinon alone - why is ergometrine not used?
Because it causes vasoconstriction which may lead to hypertension and heart failure.
360
How is acute heart failure typically managed in pregnant women (same in non-pregnant women)? (5)
```
Sit up
Oxygen
Diamorphine
Furosemide
GTN
```
361
What is the main primary cause of myocardial infarction in the postpartum period?
Coronary artery dissection.
362
Mitral stenosis treatment should aim to reduce heart rate during pregnancy - how do we do this? (4)
Bed rest
Oxygen
Beta-blockade
Diuretic therapy
363
What is the treatment of choice for mitral stenosis post-delivery?
Balloon mitral valvotomy.
364
Which type of drugs should be avoided in pregnant women with severe asthma?
Bronchoconstrictors (ergometrine and prostaglandin F2alpha).
365
Maternal cystic fibrosis is associated with increased risk of... (name 2)
...Prematurity and FGR.
366
Risk of congenital abnormalities is increased by _____ in a baby whose mother is treated with anticonvulsants during pregnancy?
2-3x
367
What are the main groups of congenital abnormalities associated with use of antiepileptic drugs? (3)
Neural tube defects
Facial defects
Cardiac defects
368
Which antiepileptic drug should be avoided in pregnant women unless they are unresponsive to other drugs?
Valproate.
369
How is epilepsy managed in pregnancy?
Reduce dose of antiepileptic drugs as much as possible
Reduce to mono therapy if possible
5mg folic acid daily to reduce risk of NTDs
370
Pregnant women with MS have no higher risk of complications, but they will have a higher relapse rate in the first ____ months postpartum.
3 months.
371
Bell's palsy incidence increases ___ fold in the ____ trimester of pregnancy. It can be managed using corticosteroids and antivirals.
Increases 10 fold in the 3rd trimester.
372
Pregnant women with sickle cell anaemia should receive _________ preconception, and ________ from daily early pregnancy to delivery.
High dose folate (5mg) preconception.
Low-dose aspirin (75mg) daily from early pregnancy to delivery.
373
Pregnant women with sickle cell disease are at increased risk of (name 6).
```
Miscarriage
Sickle cell crisis
Pre-eclampsia and eclampsia
FGR
Premature labour
Thromboembolic disease
```
374
Which supplements should be offered to pregnant women with thalassaemia?
Iron and folate.
375
How common is gestational thrombocytopenia?
NOTE: Other causes (e.g. autoimmune) should be ruled out before diagnosing gestational thrombocytopenia?
7-8% of pregnancies.
376
Autoimmune thrombocytopenia (in pregnancy):
Pathophysiology
Platelet count below what level indicates high-risk of maternal haemorrhage?
Management
Pathophysiology: Autoantibodies are produced against platelet surface antigens, leading to platelet destruction by the reticuloendothelial system.
Platelet count below what level indicates high-risk of maternal haemorrhage?
< 50x10^9/L
Management:
Serial monitoring of platelet count
Consider treatment if count falls below 50x10^9/L approaching 37 weeks
Corticosteroids - suppress platelet autoantibodies
IVIG - can be given to achieve more rapid rise in platelet count
377
Antigens against which factors in the clotting cascade increase during pregnancy? (2)
Factor 8C
| von Willebrand factor
378
How can women at significant risk of postpartum haemorrhage be man aged during labour and delivery?
Factor concentrate
Tranexamic acid
Desmopressin (increases levels of factor 8 and vWF)
379
Untreated coeliac disease is associated with what in pregnancy? (2)
Spontaneous miscarriage
| FGR
380
What risks are associated with IBD during pregnancy? (3)
Increased rate of C-section
Preterm labour
SGA
381
Which drug used to treat IBD is contraindicated in pregnancy?
Methotrexate.
382
What should be used to manage a flare up of IBD during pregnancy?
Steroids.
383
What is the most common cause of jaundice in pregnant women?
Viral hepatitis.
384
Acute viral hepatitis in the first trimester is associated with what?
Increased risk of spontaneous miscarriage.
385
Which form of viral hepatitis is most likely to lead to fulminant hepatic failure in pregnancy?
Hepatitis E - it most common in the 4rd trimester in primigravida.
386
What is the risk of foetal transmission if the mother has hepatitis B?
20-30%.
387
Autoimmune hepatitis is diagnosed on _____ _____ and associated with ____ and ____.
Diagnosed on liver biopsy.
Associated with ASMA and ANA.
388
How do hormonal changes increase the risk of gallstones in pregnancy?
Increased oestrogen - leads to increased cholesterol secretion and supersaturation of bile.
Increased progesterone - leads to decreased small intestinal motility.
389
Women with SLE who suffer with ____ ____ are at highest risk of adverse outcomes.
Women with SLE who suffer with lupus nephritis are at highest risk of adverse outcomes.
390
Which condition is antiphospholipid syndrome associated with (although it may be a primary condition)?
SLE.
391
Antiphospholipid syndrome:
Associations (2)
Clinical features (3)
Diagnostic requirements
Associations:
Anticardiolipin antibodies
Lupus anticoagulant (APS is associated with SLE)
Clinical features:
Arterial or venous thrombosis
Foetal loss after 10 weeks gestation
3+ miscarriages at < 10 weeks gestation, or delivery < 34 weeks due to FGR or pre-eclampsia
Diagnostic requirements:
Positive antibody titres on 2 occasions, 2-3 months apart.
392
Antiphospholipid syndrome management in pregnancy.
Low-dose aspirin beginning before 12 weeks gestation
Renal studies including 24-hour urine collection for protein
Monitor blood pressure
Serial ultrasonography to assess foetal growth, umbilical artery doppler and liquor volume
If pharmacological treatment is required, steroids, azathioprine, sulfasalazine and hydroxychloroquine are safe
NSAIDs until week 32
393
In pregnant women with antiphospholipid syndrome, if pharmacological treatment is required, which drugs are considered safe?
Steroids
Azathioprine
Sulfasalazine
Hydroxychloroquine
394
Some mothers with SLE will have anti-Ro/La antibodies which cross the placenta - what 2 conditions can this cause in the foetus?
Neonatal lupus
| Congenital heart block
395
Which dermatological signs are normal during pregnancy? (3)
Increased pigmentation
Spider naevi
Pruritus without rash
396
What is pemphigoid gestationis and how is it managed?
Pemphigoid gestationis is a rare pruritic autoimmune bullous disorder in which lesions begin on the abdomen and progress to widespread clustered blisters sparing the face.
Management: Topical and oral steroids.
397
What is polymorphic eruption of pregnancy?
A self-limiting pruritic inflammatory disorder usually presenting in the third trimester. It often begins one the lower abdomen involving striae and extends to the thighs, buttocks, legs and arms, sparing the umbilicus, face, hands and feet.
It has no impact on pregnancy.
398
What are prurigo of pregnancy and how are they managed?
Common excoriated papule on the extensor limbs, abdomen and shoulders. They are more common in atopic individuals and start around 25-30 weeks, resolving after delivery.
Management: Topical steroids and emollients.
399
What is pruritic folliculitis of pregnancy?
A condition in which the patient has pruritic follicular eruption with papule and pustules mainly affecting the trunk (looks similar to acne). It usually starts in the 2nd and 3rd trimester, and resolves within weeks of delivery.
400
(Maternal) Rubella:
Type of virus
Mode of transmission
Clinical features of congenital Rubella syndrome (5)
Type of virus: Togavirus.
Mode of transmission: Droplet.
```
Clinical features of congenital Rubella syndrome:
Sensorineural deafness
Congenital cataracts
Blindness
Encephalitis
Endocrine problems
```
401
(Maternal) Syphilis:
Causative organism
Screening tests used in pregnancy
Management
Causative organism: Treponema pallidum.
Screening tests used in pregnancy (offered for all pregnant women):
1. Treponemal tests (detect specific treponemal antibodies):
EIAs
Treponema pallidum haemagglutination assay (TPHA)
Fluorescent treponemal antibody-absorbed test (FTA-abs)
2. Non-treponemal tests (non-specific antibodies):
Venereal disease research laboratory (VDRL) test
Rapid plasma reagin test (RPR)
Management:
Benzathine penicillin - prevents congenital syphilis
402
What is a Jarish-Herxheimer reaction?
A reaction that may occur with treatment of maternal syphilis as a result of the release of proinflammatory cytokines in response to dying organisms. It presents with worsening symptoms and fever for 12-24 hours after starting treatment, and may be associated with uterine contractions and foetal distress.
403
```
(Maternal) Toxoplasmosis:
Causative organism
Route of transmission
Features seen in severely affected infants (4)
Diagnostic tests
Treatment
```
Causative organism: Toxoplasma gondii.
Route of transmission: Faecal-oral (cat faeces, soil, uncooked meat).
```
Features seen in severely affected infants:
Ventriculomegaly
Microcephaly
Chorioretinitis
Cerebral calcification
```
Diagnostic tests:
Sabin Feldman Dye Test
Amniocentesis and PCR of amniotic fluid
Treatment: Spiramycin to reduce incidence of transplacental infection.
404
```
(Maternal) Cytomegalovirus (CMV):
Type of virus
Route of transmission
Proportion of women who are seropositive by the time they become pregnant
Features seen in the foetus (6)
```
Type of virus: DNA herpes virus.
Route of transmission: Droplets.
Proportion of women who are seropositive by the time they become pregnant: 60%.
```
Features seen in the foetus:
Growth restriction
microcephaly
Intracranial calcification
Ventriculomegaly
Ascites
Hydrops
```
NOTE: May present later in infants with blindness, deafness or developmental delay.
405
(Maternal) Chickenpox:
Causative virus
Route of transmission
Prophylaxis and management
Causative virus: Varicella zoster virus (VZV).
Route of transmission:
Droplets
Direct personal contact
Prophylaxis and management:
VZIG given after exposure of a non-immune pregnant woman
Aciclovir (800mg 5/day for 7 days) if patient presents within 24 hours of onset of rash and is > 20 weeks
406
Characteristics of congenital varicella syndrome.
Skin scarring in a dermatomal distribution
Eye defects (microphthalmia, chorioretinitis, cataracts)
Hypoplasia of the limbs
Neurological abnormalities (microcephaly, cortical atrophy, mental restriction, dysfunction of bladder and bowel sphincters)
407
Under which circumstances should a neonate be given VZIG?
If birth occurs within 7 days of onset of the rash or the mother develops chickenpox within 7 days of delivery.
408
```
(Maternal) Parvovirus:
Causative virus
Route of transmission
What can it cause in children?
What can it cause in foetuses/how is this managed?
```
Causative virus: Parvovirus B19.
Route of transmission: Droplets.
What can it cause in children?
Slapped cheek syndrome (aka fifth disease/erythema infectiosum).
What can it cause in foetuses/how is this managed?
Aplastic anaemia, leading to hydrops due to high output cardiac failure and liver congestion. This can be treated in utero with transfusions.
409
```
(Maternal) Listeria:
Causative organism
How much higher is the incidence of Listeria infection in pregnant women than non-pregnant?
Route of transmission
Management
```
Causative organism: Listeria monocytogenes (Gram-positive).
How much higher is the incidence of Listeria infection in pregnant women than non-pregnant?
18x higher.
```
Route of transmission:
Contaminated food (e.g. unpasteurised milk, soft cheese) - cooking or freezing kills it, but it survives cool environments such as refrigeration.
```
```
Management:
IV antibiotics (ampicillin 2g every 6 hours).
```
410
(Maternal) Listeria:
Proportion of affected pregnancies that result in miscarriage or stillbirth
Proportion of affected pregnancies that result in premature delivery
Proportion of affected pregnancies that result in neonatal mortality (due to respiratory distress, fever, sepsis or neurological symptoms)
Proportion of affected pregnancies that result in miscarriage or stillbirth: 20%.
Proportion of affected pregnancies that result in premature delivery: 50%.
Proportion of affected pregnancies that result in neonatal mortality (due to respiratory distress, fever, sepsis or neurological symptoms): 38%.
411
Meconium staining of the amniotic fluid may raise suspicion of which perinatal infection?
Listeria.
412
```
Neonatal herpes:
Caused by which herpes viruses? (2)
Subgroups (3)
When is risk of infection greatest?
Management
```
Caused by which herpes viruses?
HSV1
HSV2
Subgroups:
Localised to skin, eye and mouth
Localised to CNS disease (encephalitis alone)
Disseminated infection with multiple organ involvement
When is risk of infection greatest?
When the mother acquires primary genital herpes within 6 weeks of delivery.
Management:
Aciclovir (400mg tds)
If infection occurs in 3rd trimester and is primary, C-section is advised mode of delivery
413
(Maternal) Group B Streptococcus can cause sepsis in neonates - when is it usually spread from mother to child?
It is a vaginal commensal that is spread between the time of rupture of the membranes to delivery.
414
What is the most common cause of severe early-onset (within 7 days of delivery) infection in newborns?
Group B Streptococcus.
415
```
(Maternal) Chlamydia:
Causative organism
When does transmission from mother to child occur?
What can it cause in infants?
Management
```
Causative organism: Chlamydia trachomatis.
When does transmission from mother to child occur?
During delivery.
What can it cause in infants?
Conjunctivitis and pneumonia.
Management:
Azithromycin or erythromycin (tetracyclines should be avoided during pregnancy).
416
(Maternal) Gonorrhoea:
Causative organism (and Gram-positive or negative?)
When does mother-to-child transmission occur?
What can it cause in the neonate?
Management
Causative organism:
Neisseria gonorrhoeae - Gram-negative diplococcus.
When does mother-to-child transmission occur?
At delivery.
What can it cause in the neonate?
Ophthalmia neonatorum.
Management:
Cephalosporins.
417
(Maternal) HIV:
When is planned vaginal delivery possible (C-section is the norm in patients with HIV)?
What should women with high viral load be given when undergoing planned C-section or when they present with spontaneous rupture of the membranes?
When is planned vaginal delivery possible (C-section is the norm in patients with HIV)?
When the mother has a viral load of <50 copies/mL at 36 weeks gestation.
```
What should women with high viral load be given when undergoing planned C-section or when they present with spontaneous rupture of the membranes?
IV azidothymidine (AZT).
```
418
Management of neonates born to a mother with HIV.
Clamp cord as soon as possible and bathe baby immediately after birth
Advise against breastfeeding
Give infant azidothymidine for 4-6 weeks after birth
419
How should HIV be diagnosed in neonates?
Direct viral amplification by PCR (normally carried out at birth, 3 weeks, 6 weeks and 6 months).
NOTE: Neonates will test positive for HIV antibodies due to passive transfer from the mother.
420
Hepatitis B transmission is 95% preventable through which 2 interventions?
Vaccination (vaccine is given at birth, 1 month and 6 months)
Immunoglobulin (at birth)
421
Which hepatitis C treatments are contraindicated in pregnancy? (2)
Interferon
| Ribavirin
422
What proportion of women who deliver vaginally will have some degree of perineal trauma?
85%.
423
What proportion of women who deliver vaginally will have perineal trauma requiring suturing?
60-70%.
424
How is perineal trauma (during delivery) classified?
First degree - injury to perineal skin only.
Second degree - injury to perineum involving muscles but not anal sphincter.
Third degree:
IIIa - < 50% of EAS torn.
IIIb - > 50% of EAS torn.
IIIc - Both EAS and IAS torn.
Fourth degree - lacerations involve the perineal fascia and muscles, both the EAS and IAS, and the rectal mucosa.
NOTE: 3rd and 4th degree tears are grouped together and called obstetric anal sphincter injuries (OASIs).
425
What symptom is seen with external anal sphincter incompetence? What symptom is seen with internal anal sphincter incompetence?
```
EAS = faecal urgency.
IAS = faecal incontinence.
```
426
Episiotomies are used in what proportion of spontaneous vaginal deliveries in the UK?
10%.
427
Episiotomy is performed in which stage of labour?
Second - to enlarge the vulval outlet and assist vaginal birth.
428
In an episiotomy, the incision can midline or...
...at an angle (60 degree) from the posterior end of the vulva (this is called a mediolateral episiotomy).
429
What are the pros and cons of midline vs mediolateral episiotomy?
Midline episiotomy results in less bleeding, quicker healing and less pain, but there is an increased risk of extension to involve the anal sphincter (OASI).
430
What are the potential complications of episiotomy? (4)
Infection
Haemorrhage
Dyspareunia
Incontinence (urinary or faecal)
431
What proportion of deliveries in the UK are assisted with instruments (ventouse or forceps)?
10-15% (this rate is higher in nulliparous women (30%)).
432
What are the indications for instrumental delivery?
Foetal - suspected foetal compromise (CTG pathological, abnormal pH or lactate on foetal blood sampling, thick meconium).
Maternal:
Nulliparous women - lack of continuing progress for 3 hours with regional anaesthesia, or 2 hours without regional anaesthesia.
Multiparous women - lack of continuing progress for 2 hours with regional anaesthesia, or 1 hours without regional anaesthesia.
Maternal exhaustion, vomiting or distress.
Medical indications to avoid prolonged pushing or valsalva (e.g. cardiac disease, spinal cord injury).
433
How is operative vaginal delivery classified?
Outlet
Low
Mid
High
(based on position of foetal head).
434
Why should ventouse not be used < 34 weeks?
Because of high risk of cephalhaematoma and intracranial haemorrhage.
435
Under which circumstances should ventouse not be used? (4)
< 34 weeks
Face presentation
Breech presentation
Before full dilatation of the cervix
436
What are the pros of ventouse vs forceps? (4)
Lower risk of pelvic floor trauma
Lower risk of anal sphincter injury
Less likely to need maternal regional or general anaesthesia
Less likely to cause significant perineal pain at 24 hours
437
What are the cons of forceps vs ventouse? (2)
Higher rusk of lacerations and facial palsy.
438
What are the cons of ventouse vs forceps? (3)
Higher failure rate of vaginal delivery
Higher risk of cephalhaematoma and cerebral haemorrhage
Higher risk of retinal haemorrhage
439
Compare C-sections with instrumental delivery (pros and cons).
```
C-section = higher risk of major haemorrhage and need to stay in hospital > 5 days.
Instrumental = higher risk of foetal trauma.
```
440
Which forms of pelvis make operative vaginal delivery more difficult? (3)
Anthropoid (narrow)
Android (male/funnel-shaped)
Platypelloid (elliptical)
441
Which forms of analgesia are preferred for:
Forceps delivery
Rigid cup ventouse
Soft cup ventouse
Forceps delivery - regional anaesthesia.
Rigid cup ventouse - pudendal block with perineal infiltration.
Soft cup ventouse - perineal infiltration with local anaesthetic.
442
What position is the patient usually in for operative vaginal delivery?
The lithotomy position.
443
What can be attempted if vacuum delivery fails?
Low-pelvic forceps.
444
Soft vs rigid cups for ventouse.
Soft cups are more likely to fail, but cause less scalp injury.
445
In ventouse delivery, the centre of the cup should be placed over the flexion point. Where is this?
At the vertex, which is on the sagittal suture 3cm anterior to the posterior fontanelle and 6cm posterior to the anterior fontanelle.
446
During ventouse delivery, what should the operating suction pressure be?
0.6-0.8 kg/cm^2
447
What should the maximum time from application of a suction cup (ventouse) to delivery be?
15 minutes.
448
In forceps delivery, non-rotational forceps should be used when the head is OA with no more than 45 degrees deviation to the left or right. Give 2 examples of non-rotational forceps.
Neville-Barnes
| Simpson
449
Give an example of rotational forceps.
Kielland
450
Define Caesarian section.
A surgical procedure where incisions are made through a woman's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies.
451
What proportion of babies in the UK are delivered by C-section?
25-30%.
452
How are emergency C-sections classified?
Category 1 - Immediate threat to life of woman or foetus.
Category 2 - No immediate threat to life of woman or foetus.
Category 3 - Requires early delivery.
Category 4 - At a time to suit the woman and maternity services.
453
What are the 4 major indications for C-section (responsible for > 70%)?
Previous C-section
Malpresentation (mainly breech)
Failure to progress labour
Suspected foetal compromise
454
What is tocophobia?
Irrational fear of childbirth.
455
What position is used for C-sections?
Left lateral tilt - this minimises aorto-caval compression and reduces the incidence of hypotension and reduced placental perfusion.
456
What are the 2 incision options for a C-section?
Pfannenstiel incision
Transverse suprapubic incision (no curve)
NOTE: Vertical excision may be used in cases of extreme maternal obesity, suspicion of other intra-abdominal pathology or where access to the uterine fundus is required.
457
What type of uterine incision is used in > 95% of C-sections and why?
Lower uterine segment transverse incision - due to ease of repair, reduced blood loss and low incidence of dehiscence or rupture in subsequent pregnancies.
NOTE: A classical C-section incision incorporates the upper uterine segment with a vertical incision.
458
One a foetus is delivered by C-section, an oxytocic agent is administered - which agent/dose is often used and why is an oxytocic agent given?
5 IU syntocinon IV
| To aid uterine contraction and placental separation.
459
What are the intraoperative complications of C-section? (4)
Haemorrhage
Caesarian hysterectomy (most common indication = uncontrollable maternal haemorrhage)
Placenta praevia
Organ damage (bowel damage, bladder injury, ureter damage)
460
What are the post-operative complications of C-section? (3)
Infection
Venous thromboembolism
Psychological impact
461
What proportion of women with a previous C-section achieve vaginal delivery?
Up to 70%.
462
What are the 2 delivery options for women who previously delivered by C-section?
Elective repeat C-section (ERCS)
| Attempted vaginal birth after C-section (VBAC)
463
What does the acronym TOLAC stand for in obstetrics?
Trial of labour after Caesarian
464
Define puerperium.
The 6-week period following completion of the 3rd stage of labour.
465
What is uterine involution?
The process by which the postpartum uterus (1kg) returns to its pre-pregnancy stage (< 100g).
466
During uterine involution, which hormone speeds up muscle autolysis in women who are breastfeeding?
Oxytocin.
467
What are the signs of delayed uterine involution? (7)
```
Artefact
Full bladder
Retained products of conception (or clots)
Uterine infection
Fibroids
Broad ligament haematoma
```
468
How many weeks after delivery would you expect the internal os to be fully closed?
2 weeks.
NOTE: The external os may remain open permanently, giving a 'funnel-shape' to the parous cervix.
469
What is lochia?
Blood-stained uterine discharge comprising of blood and necrotic decidua.
470
What are the 3 types of lochia?
Lochia rubra - red coloured during the first few days after delivery (gradually changes to pink).
Lochia serosa - becomes serous by the 2nd week.
Lochia alba - scanty yellow-white discharge lasting for 1 month.
471
Why should you avoid codeine when providing analgesia to patients with perineal tears?
It causes constipation (and may also cause drowsiness in breastfed babies).
472
What is the most common cause of spontaneous opening of repaired perineal tears and episiotomies?
Infection.
473
In patients given regional anaesthesia during delivery, the bladder may take up to 8 hours to regain sensation. During this time, 1L of urine may be produced, which can damage the detrusor muscle. What does this cause?
A hypocontractile bladder, which can lead to overflow incontinence.
474
When should a formal assessment of bladder function be made after delivery?
6 hours (at least 300mL of urine should have been passed).
475
Women who have undergone a repair of a 3rd or 4th degree perineal tear should be treated with which drugs to avoid constipation?
Lactulose and ispaghula husk (fybogel) or methylcellulose for 2 weeks.
476
All women who have had a C-section should have what measured postoperatively (ideally at day 2-3)?
Haemoglobin - treat mild-moderate anaemia with iron tablets and severe with blood transfusions.
477
What proportion of eclamptic fits happen postnatally?
Nearly 50%.
478
During the puerperium, women with hypertension should continue antenatally prescribed antihypertensives with the aim of keeping BP below what?
150/100 mmHg. Antihypertensives should be continued for 1-2 weeks postnatally.
479
Define secondary postpartum haemorrhage.
Fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery.
480
What are the 2 most common causes of secondary postpartum haemorrhage, and how might you differentiate between them?
Endometritis and retained placental tissue.
Endometritis will present with a closed internal os and retained placental tissue with present with an open internal os.
481
Other than endometritis and retained placental tissue, give some causes of secondary PPH. (3)
Hormonal contraception
Bleeding disorders (e.g. von Willebrand's disease)
Choriocarcinoma (rare)
482
Obstetric palsy (aka traumatic neuritis):
Definition
Features (5)
Pathophysiology
Definition: A condition in which both lower limbs develop signs of motor and/or sensory neuropathy following (usually prolonged or obstructed) delivery.
```
Features:
Sciatica
Footdrop
Paraesthesia
Hypoaesthesia
Muscle wasting
```
Pathophysiology:
Proximal nerve damage is caused as the lumbosacral plexus and nerve tracks are stretched and compressed by the foetal head.
483
Symphysis pubis diastasis:
Definition
Associations (3)
Definition: Spontaneous separation of the symphysis pubis.
Associations:
Forceps delivery
Rapid second stage of labour
Severe abduction of the thighs during delivery
484
Define puerperal pyrexia.
Temperature > 38 degrees on any 2 of the first 10 days postpartum, exclusive of the first 24 hours.
485
In the first 24 hours postpartum, what should be suspected if there is a spiking temperature associated with wheezing, dyspnoea or evidence of hypoxia following general anaesthetic?
Aspiration pneumonia (Mendelson's syndrome).
486
Define puerperal sepsis.
Genital tract infection following delivery.
487
What is the most common cause of necrotising fasciitis in a patient with puerperal sepsis?
Clostridium perfringens.
488
What is meant by 'the pinks'?
Elevated mood, a feeling of excitement, overactivity and difficulty sleeping during the first 24-48 hours after delivery.
489
What proportion of women experience baby blues in the first 2 weeks after delivery?
80%.
490
What proportion of women suffer from some form of depression in the first year after delivery?
10-15%.
491
Which scale is a screening test for postnatal depression?
The Edinburgh Postnatal Depression Scale.
492
When does puerperal psychosis most commonly present?
On the 5th day postpartum.
493
What is the risk of recurrence of puerperal psychosis in future pregnancies?
50% - for this reason, women with previous history of puerperal psychosis should be considered for prophylactic lithium.
494
What is colostrum?
Yellowish fluid secreted by the breast that can be expressed as early as the 16th week of pregnancy (replaced by milk during the second postpartum day) - it has an important role in protection against infection.
495
Which vitamin is not found in breast milk?
Vitamin K
496
What are the major constituents of breast milk?
```
Lactose
Protein (lactalbumin, lactoglobulin and caseinogen)
Fat
Water
All vitamins except vitamin K
```
497
Which hormone stimulates milk synthesis?
Prolactin.
498
Which hormones causes expulsion of milk from the breasts?
Oxytocin - it causes contractions of the myoepithelial cells lying longitudinally along the lactiferous ducts.
499
Breastfeeding is contraindicated with which drugs? (5)
```
Aspirin (at doses of 300mg or more)
Amiodarone
Lithium
Anticancer drugs (antimetabolites)
Radioactive substances
```
500
How can suppression of lactation be achieved? (2)
Fluid restriction
| Tight bra
501
What are the boundaries of the pelvic inlet?
Anteriorly - upper border of the pubic symphysis.
Laterally - upper margin of the pubic bone.
Posteriorly - promontory of the sacrum.
502
What are the normal transverse and anteroposterior diameters of the pelvic inlet?
```
Transverse = 13.5cm
Anteroposterior = 11.0cm
```
503
What is the normal angle of the pelvic inlet (in comparison with the horizontal)?
60 degrees.
504
Define 'midpelvis'.
The area bounded anteriorly by the middle of the pubic symphysis, laterally by the pubic bones, the obturator fascia and the inner aspect of the ischial bone and spines, and posteriorly by the junction of the second and third sections of the sacrum.
505
The midpelvis is almost round. What is the normal diameter?
12cm.
506
Why is it important that the ischial spines are palpable vaginally? (2)
To assess descent of the present part on vaginal examination (station zero is the level of the ischial spines).
To provide a local anaesthetic pudendal nerve block (for ventouse or forceps delivery).
507
What are the boundaries of the pelvic outlet?
Anteriorly - lower margin of the pubic symphysis.
Laterally - descending ramps of the pubic bone, ischial tuberosity and the sacrotuberous ligament.
Posteriorly - last piece of the sacrum.
508
What are the normal transverse and anteroposterior diameters of the pelvic outlet?
```
Transverse = 11.0cm
Anteroposterior = 13.5cm
```
509
What are the 4 different shapes of pelvis?
Gynaecoid
Android
Anthropoid
Platypelloid
510
Which shape of pelvis is most favourable for labour?
Gynaecoid.
511
Which shape of pelvis is most common?
Gynaecoid.
512
Which 2 shapes of pelvis predispose to failure of rotation?
Android and platypelloid.
513
What is the pelvic floor formed of?
The 2 levator ani muscles.
514
What are the four membranous sutures of the vault in the foetal skull? They are soft and unossified at the time of labour.
Sagittal
Frontal
Coronal
Lambdoidal
515
The anterior fontanelle (aka bregma) is at the junction of which sutures?
Sagittal, frontal and coronal.
516
The posterior fontanelle is at the junction of which sutures?
Sagittal and lambdoidal.
517
With regards to the foetal skull, what is the vertex?
The area bounded by the two parietal bones and the anterior and posterior fontanelles.
518
Is it preferable to have an occipito-anterior (OA) or an occipito-posterior (OP) position for spontaneous vaginal birth?
OA.
519
What is the attitude of the foetal head?
Attitude refers to the degree of flexion and extension of the upper cervical spine.
520
The sebmento-bregmatic diameter is from the chin to the anterior fontanelle (9.5cm) and is referred to as the face presentation. If there is even more extension of the head so that the diameter is around 13cm, what is it called?
Mento-vertical diameter is around 13cm and this presentation is known as 'brow' presentation. It is not usually possible for the head to pass through the pelvis in this position.
521
Which substances are responsible for the increase in intracellular calcium ions that stimulate contractions in labour? (2)
Prostaglandins
| Oxytocin
522
What stimulates the formation of gap junction between myocetrial cells in the uterus term?
NOTE: This allows greater coordination of myocyte activity by facilitating the passage of various products of metabolism and electrical current between cells.
Prostaglandins.
523
In labour, dermatan sulphate is replaced by what in the cervix?
Hyaluronic acid - this increases the water content of the cervix, leading to softening/ripening so that when contractions begin, they bring about effacement and dilatation.
524
How does progesterone maintain uterine relaxation?
Suppressing prostaglandin production
Inhibiting communication between myocetrial cells
Preventing oxytocin release
525
Which hormone opposes the action of progesterone?
Oestrogen - prior to labour, progesterone receptors are down-regulated and oestrogen receptors are up-regulated.
526
What is the function of corticotrophin-releasing hormone (CRH) (made by the placenta) in labour?
Potentiates the action of prostaglandins and oxytocin on myocetrial contractility.
527
Production of oxytocin and cortisol by the foetus during labour stimulates what?
The conversion of progesterone to oestrogen.
528
What is the Ferguson reflex?
In labour, this is the phenomenon where pressure from the foetal presenting part against the cervix is relayed via a reflex arc and results in increased oxytocin (which stimulates contractions, increasing pressure on the cervix etc. in a positive feedback loop).
529
First stage of labour:
Definition
Sub-phases
Definition: time from diagnosis of labour to full dilatation of the cervix (10cm).
```
Sub-phases:
Latent phase (3-8 hours) - time between the onset of regular painful contraction and 3-4cm cervical dilatation.
Active phase (2-6 hours) - time between the end of the latent phase and full cervical dilatation (10cm).
```
530
What is effacement?
The process by which the cervix shortens and becomes incorporated into the lower segment of the uterus - it occurs in the latent phase of the first stage of labour.
531
Second stage of labour:
Definition
Sub-phases
Definition: time from full dilatation of the cervix to delivery of the foetus.
```
Sub-phases:
Passive phase (1-2 hours) - time between full dilatation and the onset of involuntary expulsive contractions.
Active phase (no longer than 2 hours) - pushing.
```
532
Third stage of labour:
Definition
How long should it last?
Definition: time from delivery of the foetus until complete delivery of the placenta and the membranes.
How long should it last?
Usually happens within minutes, but considered abnormal if lasting > 30 minutes.
533
What are the stages of the mechanism of labour (not stage 1, stage 2 and stage 3)? (8)
```
Engagement - when the widest part of the presenting part has passed through the pelvic inlet.
Descent.
Flexion (of the head).
Internal rotation.
Extension.
Restitution.
External rotation.
Delivery of shoulders and foetal body.
```
534
How many 5ths of the face must be palpable in order for the head to be described as 'engaged'?
< 2/5
535
What should the length of the cervix be at 36 weeks?
3cm
536
At around ___cm dilated, the cervix should be fully effaced.
At around 4cm dilated, the cervix should be fully effaced.
537
How can foetal metabolic acidosis occur during labour? How can this metabolic acidosis be detected?
With each contraction, placental blood flow and oxygen transfer are temporarily interrupted. This hypoxia leads to anaerobic respiration which can result in metabolic acidosis if prolonged. This causes a characteristic change in foetal heart rate (FHR) patterns which can be detected by auscultation or CTG.
538
A Pinard stethoscope can be used to listen to FHR during labour - when and how often should this be done during labour?
For at least 1 minute after a contraction.
Every 15 minutes in the first stage of labour.
Every 5 minutes in the second stage of labour.
539
What are the indications for continuous electronic foetal monitoring (EFM) via CTG during labour? (6)
Significant meconium staining of the amniotic fluid
Abnormal FHR detected by intermittent auscultation
Maternal pyrexia
Fresh vaginal bleeding
Augmentation of contractions with oxytocin infusion
Maternal request
540
What are the differences between a 'normal', 'suspicious' and 'pathological' CTG?
When doing a CTG you look at baseline rate, variability, accelerations and decelerations.
If all features are 'reassuring' = normal CTG
If 1 feature is 'non-reassuring' = suspicious CTG
If 2 or more features are 'non-reassuring' or if there is any 1 'abnormal' feature = pathological CTG
541
To avoid CTG leading to unnecessary intervention during labour (as they have a high false-positive rate), what can be used to measure foetal pH and base excess?
Foetal scalp blood sampling (FBS).
542
What is a partogram?
A graphic record of labour - it allows instant visual progress of labour based on rate of cervical dilatation compared with an expected normal (according to parity).
NOTE: It also shows frequency and strength of contractions, descent of the head, station, amount and colour of amniotic fluid draining and basic observation of maternal wellbeing.
543
During the first stage of labour, how often should vaginal examination be performed?
Every 4 hours (more often if midwife suspects that progress of labour is unusually slow or fast, or there are foetal concerns).
544
What should be given to women in the first stage of labour who have been given opioid analgesia?
Antacids.
545
What is the first sign that the patient has entered the second stage of labour?
The patient will feel an urge to push.
NOTE: The use of regional anaesthesia may interfere with this urge.
546
In all cases, the baby should be delivered within how many hours of reaching full dilatation?
4 hours.
547
What is crowning?
When the head of the baby no longer recedes between contractions. Once this occurs, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths.
548
At what stages should the Apgar score be calculated after delivery?
1 minute and 5 minutes.
549
When should initiation of breastfeeding be encouraged?
Within the first hour of life.
550
Which form of management (active or physiological) should be recommended to all women in the third stage of labour? Why?
Active - using controlled cord traction, because it reduces the incidence of postpartum haemorrhage form 15% to 5%.
551
Give a rare complication of active management of the third stage of labour with controlled cord traction?
Uterine inversion.
552
After completion of the third stage of labour by physiological management, what should the placenta be inspected for?
Missing cotyledons
A succenturiate lobe
NOTE: If Therese are suspected, examination under anaesthesia and manual removal of placental tissue (MROP) should be arranged.
553
What is meant by 'primary arrest' in labour, and what is the most common cause?
Primary arrest = poor progress in the active first stage of labour (< 2cm cervical dilatation per 4 hours).
Most common cause = insufficient uterine contractions.
554
What is meant by 'secondary arrest' in labour, and what are the possible causes (4)?
Secondary arrest = when progress in the active first stage is initially good but then slows or stops altogether, usually after 7cm dilatation.
```
Causes:
Insufficient uterine contractions
Malposition
Malpresentation
Cephalopelvic disproportion (e.g. android pelvis or persistent OP position)
```
555
How many contractions per 10 minutes are ideal in the first stage of labour?
4-5 contractions per 10 minutes.
556
If poor progress is identified in the first stage of labour and the cause is identified as dysfunctional uterine activity, what is the management?
1. Offer artificial rupture of the membranes.
2. If there is still no progress after 2 more hours, consider oxytocin infusion to augment contractions (if doing this, offer an epidural beforehand and use continuous EFM as there is a risk of foetal compromise).
3. If progress fails despite 4-6 hours augmentation with oxytocin, recommend C-section.
557
What is relative cephalopelvic disproportion?
Where there appears to be cephalopelvic disproportion because of malposition of the head. In reality, the pelvis is not too small and the head is not enlarged.
558
What abnormalities of the birth canal can cause poor progress in the first stage of labour? (3)
Pelvic dimensions that cause cephalopelvic disproportion (e.g. due to previous fracture)
Unsuspected fibroids
Cervical dystocia (cervix fails to dilate due to severe scarring or rigidity)
559
What is cervical dystocia?
Where the cervix is non-compliant and effaces but fails to dilate because of severe scarring or rigidity (usually due to previous cervical surgery).
560
Delay in the second stage of labour is diagnosed if delivery is not imminent after how long?
Nulliparous woman = 2 hours of pushing
| Parous woman = 1 hour of pushing
561
Secondary dysfunctional uterine activity is a common cause of second stage delay. What is it associated with (2), and how is it managed?
Associations:
Maternal dehydration and ketosis
Management:
If no mechanical problem is anticipated and the woman is primiparous, treat with rehydration and IV oxytocin.
If multiparous, perform full clinical assessment before considering oxytocin.
NOTE: Only use oxytocin towards the start of the second stage, so if you have waited to diagnose second stage delay then it may not be appropriate.
562
When should you be particularly concerned that meconium staining indicates foetal compromise?
When it is thick or tenacious.
| When it is dark green, bright green or black.
563
What should you do if meconium is seen in the liquor?
Start EFM with CTG - this may indicate foetal compromise.
564
What are the resuscitative manoeuvres that can be attempted if foetal compromise is suspected? (5)
```
Repositioning the mother
IV fluids
Reducing or stopping oxytocin
Correction of epidural-associated hypotension
Continue CTG observation
```
565
If CTG is pathological and there is suspected foetal compromise, carry out an immediate vaginal examination. If the cervix fully dilated, instrumental delivery may be possible. If the cervix is not fully dilated, what should you do?
Foetal blood sampling - if the result is normal, continue labour and repeat samples. If the result is abnormal, perform immediate C-section.
566
What can be used to resuscitate a foetus during labour, where the mother is dehydrated and ketotic?
IV fluids.
567
What can be used to resuscitate a foetus during labour, where the mother is hypotensive secondary to an epidural?
Fluid bolus
| Consider vasoconstrictors such as ephedrine
568
What can be used to resuscitate a foetus during labour, where there is uterine hyperstimulation from excess oxytocin?
Stop oxytocin and consider tocolytic drugs e.g. terbutaline.
569
What can be used to resuscitate a foetus during labour, where there is venocaval compression and reduced uterine blood flow?
Turn woman onto left lateral position.
570
What is the normal pH of foetal blood?
7.25
NOTE: Anything < 7.20 is considered foetal compromise.
571
Significant metabolic acidosis is diagnosed when foetal blood base excess is what?
> -12 mmol/L
572
TENS may be used to provide pain relief during labour - how does it work?
Blocks pain fibres in the posterior ganglia of the spinal cord.
573
Why is epidural not ideal for women in the first stage of labour?
Because it limits mobility.
574
What are the indications and contraindications for epidural anaesthesia?
```
Indications:
Prolonged labour/oxytocin augmentation
Maternal hypertensive disorders
Multiple pregnancy
Selected maternal medical conditions
High risk of operative intervention
```
```
Contraindications:
Coagulation disorders
Local or systemic sepsis
Hypovolaemia
Logistical (insufficient staff)
```
575
What are the complications of epidural anaesthesia during labour? (9)
Accidental dural pressure
Leakage of CSF if the subarachnoid space is reach, causing a spinal headache
Bladder dysfunction (loss of awareness of needing to micturate)
Overdistension of the bladder causing damage and voiding problems
Hypotension
Accidental total spinal anaesthesia (injection into subarachnoid space)
Spinal haematoma
Drug toxicity
Short-term respiratory depression of the baby (epidural sultans contain opioids)
576
What are the signs of uterine rupture?
```
Severe lower abdominal pain
Vaginal bleeding
Haematuria
Cessation of contractions
Maternal tachycardia
Foetal compromise (often bradycardia)
```
577
What are the relative contraindications to VBAC?
Two or more previous C-section scars
Need for induction of labour
Previous labour outcome suggestive of cephalopelvic disproportion
Previous classical C-section (ABSOLUTE contraindication)
578
What is the most common reason for induction of labour in the UK?
Prolonged pregnancy (another common indication is pre-labour rupture of the membranes).
579
What are the 2 absolute contraindications for induction of labour?
Placenta praevia
| Severe foetal compromise
580
What is the Bishop Score?
A score used to quantify how far the process of cervical changes has progressed before induction of labour - high scores are associated with an easier, shorter induction process.
581
What is most commonly used to induce labour?
Prostaglandin E2 - this is often enough to induce labour but ARM and oxytocin may be used in addition.
582
What is membrane sweeping?
Insertion of a gloved finger through the cervix and its rotation around the inner rim of the cervix. This strops off the chorionic membrane and releases natural prostaglandins which help to induce labour.
583
What must be excluded before membrane sweeping is performed?
Placenta praevia.
584
Other than PGE2, what drugs can be used to induce labour? (2)
Mifepristone and misoprostol.
585
When is induction of labour said to have failed?
If ARM is still impossible after the maximum number of doses of prostaglandin have been given or if the cervix remains unaffected and < 3cm dilated after an ARM has been performed and oxytocin has been running for 6-8 hours with regular contractions.
586
What are the options of induction of labour fails? (2)
Rest period followed by attempting induction again
| C-section
587
What does MEOWS stand for?
Modified early obstetric warning system - it is a tool used to identify clinical deterioration of pregnant women.
588
Name 2 key causative organisms for puerperal sepsis.
Lancefield group A beta-haemolytic streptococcus
| E. coli
589
Define antepartum haemorrhage, and give the causes.
Definition - vaginal bleeding after 20 weeks gestation.
Placental causes:
Placental abruption
Placenta praevia
Foetal causes:
Vasa praevia
```
Maternal causes:
Vaginal trauma
Cervical ectropion
Cervical carcinoma
Vaginal infection/cervicitis
```
590
Placental abruption:
Definition
Preventative Measures
Clinical presentation
Definition: premature separation of the placenta from the uterine wall.
Preventative Measures:
Control BP
Avoid precipitants like cocaine and smoking
Clinical presentation:
Tense rigid abdomen
591
Placenta Praevia:
Definition
Warning signs
Presentation
Definition: a placenta covering or encroaching on the cervical os.
```
Warning signs:
Low lying placenta at 20 week anomaly scan
Maternal collapse
Feeling cold
Light-headedness
Painless vaginal bleeding
```
Presentation:
Painless vaginal bleeding (which may trigger preterm labour).
592
What test should be used in placenta praevia if the mother is RhD-negative, and what does it tell you?
Kleihauer test - checks how much of the foetal blood has leaked into the maternal circulation.
593
```
Vasa praevia:
Definition
Causes (2)
Presentation
Management
```
Definition: when the foetal vessels traverse the foetal membranes over the internal cervical os.
Causes:
Velamentous insertion of the umbilical cord
Vessels joining an accessory (succenturiate) placental lobe to the placenta
Presentation:
Spontaneous artificial rupture of the membranes accompanied by painless fresh vaginal bleeding from rupture of the foetal vessels.
Management:
Immediate C-section.
594
Postpartum haemorrhage:
Definition
Preventative measures
Most common cause
Definition: blood loss > 500mL following delivery.
Preventative measures:
Iron supplementation for low Hb levels
Prophylactic oxytocin agents for high-risk patients
Most common cause:
Uterine atony
595
Define major obstetric haemorrhage.
Blood loss > 2500mL, or requiring blood transfusion > 5 units red cells or treatment for coagulopathy.
596
```
Eclampsia:
Definition
Most common cause of death in patients with eclampsia
Prevention
Management
```
Definition: The occurrence of one or more generalised convulsions and/or coma in the setting of pre-eclampsia and in the absence of other neurological conditions.
Most common cause of death in patients with eclampsia:
Cerebral haemorrhage.
Prevention:
Magnesium sulphate for women with pre-eclampsia.
Management:
ABCDE approach
Magnesium sulphate - loading dose 4g, maintenance infusion of 1g/hour for 24 hours after delivery
597
What risks should you be aware of when administering magnesium sulphate?
It has a narrow therapeutic window, so overdose is possible. This can cause respiratory depression and cardiac arrest.
598
What is the antidote for magnesium sulphate overdose?
10ml 10% calcium gluconate (slow IV infusion).
599
Amniotic fluid embolism is a rare cause of maternal collapse, which causes _________ and __________. How is it usually diagnosed?
Amniotic fluid embolism is a rare cause of maternal collapse, which causes acute cardiorespiratory compromise and severe DIC.
It is usually diagnosed at post-mortem with the presence of foetal cells in the maternal pulmonary capillaries.
600
Umbilical cord prolapse:
Definition
Preventative measures (3)
Warning sign
Definition: descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes.
Preventative measures:
Transverse, oblique or unstable lie should have elective admission to hospital after 37 weeks to allow quick delivery if membranes rupture
Avoid artificial induction of labour when the presenting part is non-stable and/or mobile
Avoid upwards pressure on the presenting part during vaginal examination
Warning sign:
Foetal distress on CTG following artificial or spontaneous rupture of the membranes.
601
Management of umbilical cord prolapse.
Perform speculum and digital examination immediately
Prevent further cord compression by elevating the presenting part or filling the bladder
Avoid handling the cord as it can cause cord spasm
Reposition mother knee to chest or left-lateral position
Confirm foetal viability by CTG auscultation of foetal heart
Emergency C-section
602
Shoulder dystocia:
Definition
Management
Definition: vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has been unsuccessful in delivering the shoulders.
Management:
Drop level of bed and lay mother flat
McRoberts position - flex and abduct the legs at the hip
Suprapubic pressure
Consider episiotomy
Woods' screw/Reverse Woods' screw (manoeuvres)
Change position to all fours
Finally, consider symphiotomy, cleidotomy or Zavanelli manoeuvres
603
Shoulder dystocia - maternal (3) and foetal (3) complications.
Maternal:
Increased perineal trauma
Post-partum haemorrhage
Psychological trauma
Foetal:
Brachial plexus injury
Fractured clavicle or humerus
Hypoxic brain injury
604
How should suspected DVT be confirmed in pregnancy?
Compression duplex ultrasound (followed by magnetic resonance venography if USS is negative but clinical suspicion remains high).
605
What are the 4 degrees of uterine inversion?
1st degree - the inverted fundus extends to but not through the cervix.
2nd degree - the inverted fundus extends through the cervix but remains within the vagina.
3rd degree - the inverted fundus extends outside the vagina.
4th degree - total inversion, when the vagina and uterus are inverted.
606
If manual replacement fails to reverse uterine inversion, what can be done?
Hydrostatic replacement - running 2-3L of warm saline via tubing into the vagina using your hands to create a seal around the vulva.
607
How can uterine rupture be managed?
Urgent laparotomy
Vaginal examination
Foetus should be delivered ASAP (whichever route is quickest)
