Obstetrics

Question 1

Why is the principal cause of resistance to insulin during pregnancy?

Answer 1

Pregnancy related hormones act as antagonists to insulin receptors

Question 2

What are the 3 hormones responsible for transient insulin resistance in pregnancy?

Answer 2

Glucagon
Cortisol
Human placental lactogen

Question 3

How does does the maternal body usually counteract the increased levels of glucagon, cortisol and HCG in pregnancy?

Answer 3

By secreting increased amounts of insulin

Question 4

For patients with pre existing type 1 and type 2 diabetes what will be the likely management during pregnancy?

Answer 4

Type 1 - increase amount of insulin

Type 2 - may need to switch to insulin as pregnancy progresses

Question 5

If a patient has pre-existing diabetes what is the risk to the foetus if it is poorly controlled?

Answer 5

25% risk of congenital abnormality

Question 6

What additional assessments are made for women with pre-existing diabetes?

Answer 6

Retinopathy

Nephropathy

Question 7

How is the folate acid dose adjusted for women with pre existing diabetes and why?

Answer 7

Increased to 5mg daily (from preconception to 12 weeks)

increased risk of neural tube defects with DM compared to general population

Question 8

For women with pre existing DM, how would you alter their ACEi/statins?

Answer 8

Stop them

Question 9

In additon to folate, what other medication is routinely prescribed to women with pre existing DM?

Answer 9

Aspirin 75mg daily

increased risk of PET in DM

Question 10

What happens to the scan interval for women with pre existing DM, what are they looking for?

Answer 10

increased to every 2-4 weeks

Detect SGA or macrosomic baby

Question 11

What is the commonest congenital abnormality and what is done to detect this?

Answer 11

Cardiac

fetal echo at 18 weeks

Question 12

What happoens with regard to induction of labor for women with pre existing DM?

Answer 12

IOL 37-38 weeks

Question 13

7 maternal risks of pre existing DM?

Answer 13

Pre eclampsia 
Hypoglycaemia 
Retino/nephropathy
Infection
Birth trauma 
induction of labour
caesarean section

Question 14

7 fetal risks associated with pre existing DM

Answer 14

Miscarriage 
Congenital malformation
Still birth (x5)
Macrosomia (x2)
Neonatal hypoglycaemia 
Neonatal death (x4)
Obesity and diabetes in later life

Question 15

How is maternal glucose controlled during labour?

Answer 15

Infusion pump on a sliding scale to keep below 7mmol/l

Question 16

What complications can occur with fetal insulin following delivery how can this be countered ?

Answer 16

risk of hypoglycaemia as foetus no longer in hyperglycaemic environment
Early feeding

Question 17

For mothers with type 2 DM, what medication should they resume if breast feeding?

Answer 17

Metformin

Glibenclamide

Question 18

What are the 5 at risk groups for gestational diabetes?

Answer 18

BMI above 30kg/m2
Previous macrosomic baby above 4.5kg
previous gestational diabetes 
first degree relative with diabetes
Family origin - south asian, black carribean, middle eastern

Question 19

If a mother is identified as at risk of DM, when will her screening take place?

Answer 19

24-28 weeks

Question 20

What is the gold standard for diagnosing gestational DM and what are the levels?

Answer 20

Oral glucose tolerance test
A fasting plasma glucose level ≥ 5.6 mmol/l
A 2-hour plasma glucose level ≥ 7.8 mmol/l

Question 21

what are the 4 maternal risks of gestational diabetes?

Answer 21

Birth trauma
induction of labour
caesarean section
diabetes in later life

Question 22

What are the3 foetal/neonatal risks of gestational diabetes?

Answer 22

Macrosomia
neonatal hypoglycaemia
obesity/diabetes in later life

Question 23

What are the tow measurements that define pre eclampsia?

Answer 23

Systolic > 140 on 2 occasions

Urine protein;creatanine ratio (PCR) >30

Question 24

What are the trimesters of pregnancy?

Answer 24

0-12
13-26
27-birth

Question 25

What are the normal blood pressure changes during pregnancy?

Answer 25

Blood pressure initially falls Stabilises in second trimester reaches pre pregnancy levels by term

Question 26

Why are hypertensive women at <20 weeks gestation considered to have pre existing hypertension?

Answer 26

because blood pressure initially falls in pregnancy so they would need to have an already increased BP to counter thsi

Question 27

How might essential hypertension in women initially be masked?

Answer 27

Drop in BP during T1 may take BP below threshold

Question 28

What are the 7 risks associated with Risk related to pre-existing hypertension?

Answer 28

``` Superimposed pre-eclampsia Placental Abruption fetal growth restriction Intra cerebral haemorrhage Maternal cardiac failure intracranial haemmorhage maternal death ```

Question 29

What are the defining terms of pregnancy induced hypertension?

Answer 29

systolic >140 on 2 separate occasions At >20 weeks gestation No proteinuria

Question 30

Definition of pre-eclampsia?

Answer 30

``` BP >140/90 On TWO separate occasions more than FOUR HOURS apart AND Significant PROTEINURIA >20 weeks gestation ```

Question 31

Limits of mild/moderate and severe pre-eclampsia?

Answer 31

>140 >150 >160 or <160 but with >2 severe signs

Question 32

8 signs/symptoms of severe pre-eclampsia?

Answer 32

``` Severe headache and visual disturbance Epigastric pain Brisk reflexes and Clonus Papilloedema Left upper quadrant tenderness (liver) Platelets: <100 x 109/l Alanine amino transferase: >50 IU/l Creatinine: >100 mmol/l. ```

Question 33

What 5 blood tests would you do in pre eclampsia?

Answer 33

``` FBC, U&E, Uric acid, LFT (clotting) Decrease Hb Platelets: <100 x 109/l ALT: >50 IU/l Creatinine: >100 mmol/l Raised uric acid ```

Question 34

How does time of onset of pre-eclampsia affect the outcomes?

Answer 34

Usually better outcomes if >36 weeks gestation Significant increase maternal /perinatal M+M if <33 weeks

Question 35

What is the most common cause of death associated with pre-eclampsia?

Answer 35

Intracranial haemorrhage has been found to be the most common cause of death (50%)

Question 36

What is the pathophysiology of pre-eclampsia?

Answer 36

Reduction on blood flow to intervillous space Poorly perfused placenta