Pregnancy and Birth

Question 1

1. When the _________ implants on the uterine wall the inner cells develop into the _______ and the outer cells develop into the ________.
2. What is the placenta derived from?
3. Identify three features of oxygen supply of the fetus.

Answer 1

1. Blastocyst, Embryo, placenta
2. Trophoblast and decidual tissue
3. Fetal Hb have increased oxygen capacity, Higher Hb concentration in fetal blood, Bohr effect means fetal blood can carry more oxygen in low CO2 than high CO2.

Question 2

1. What is the effect of Human Chorionic Gonadotropin in pregnancy?
2. What about Human Placental Lactogen (Human Chorionic Somatomammotropin)?

Answer 2

1. Prevents involution of the corpus luteum and induces development of testis in males.
2. It is produced from around week 5 of pregnancy. It has growth hormone-like effects. It decreases insulin-sensitivity in the mother thus more glucose for baby. Also involved in breast development.

Question 3

1. Identify some cardiovascular changes that occur with pregnancy?
2. Identify some haematological changes.
3. What is the average weight gain in pregnancy.

Answer 3

1. Increased cardiac output, increased heart rate, BP drops during second trimester.
2. plasma volume increases, erythropoiesis increases, Hb decreased by dilution, iron requirement increases significantly (require supplements).
3. 11kg

Question 4

1. How many extra calories should a pregnant woman consume daily?
2. How are the stages of pregnancy divided on metabolic grounds?

Answer 4

1. 200kcal on average
2. 1st-20th week mothers anabolic phase, little extra nutritional demands.
   21st-40th week mothers catabolic phase, very high metabolic demands of unborn child.

Question 5

1. Why is Folic acid given to women trying to conceive and while pregnant?
2. What other supplements are used in pregnancy?

Answer 5

1. Reduces the risk of neural tube defects.

2. Vitamin D, Vitamin B, Iron supplements, Higher protein and higher energy diet.

Question 6

1. What is the technical name for childbirth?
2. During this the _________/_________ ratio alters, increasing excitability. _________ increases uterine contractions and excitability
3. What are Braxton-Hicks Contractions

Answer 6

1. Parturition
2. Oestrogen/progesterone, oxytocin
3. Contractions of the uterus felt in the 2nd and 3rd trimester that are also called false labour pains.

Question 7

1. What major hormone change is to be expected at the beginning of labour?
2. In labour, first of all the unborn child drops lower in the uterus. This stretches the ______. This stretching stimulates ________ release and uterine contractions. This hormone causes uterine contractions itself and also _________ release which causes further contractions.

Answer 7

1. Oxytocin increase which stimulates uterine contractions.

2. Cervix, Oxytocin, Prostaglandins.

Question 8

1. What are the three stages of labour?

Answer 8

1. 1st stage cervical dilation (8-24 hours), 2nd stage passage of fetus through birth canal (mins to 2hrs), 3rd stage expulsion of placenta.

Question 9

1. Both _________ and __________ inhibit milk production and so drop suddenly at birth. The hormone ______ stimulates milk production and increases from week ___ of gestation. Oxytocin controls the _________ reflex.

Answer 9

1. Oestrogen, progesterone, prolactin, week 5, milk let-down reflex.

Question 10

1. How do you determine the effectiveness of a screening test?
2. How is a woman’s due date calculated?

Answer 10

1. Sensitivity and specificity

2. Add 280 days from last menstrual period.

Question 11

1. What does CRL mean and what is it used to determine?

2. What is placental praevia?

Answer 11

1. Crown-Rump Length, used to determine gestational age

2. When the placenta is low lying in the uterus and covers all or part of the cervix. Detected on anomaly US scan.

Question 12

1. Name the three chromosome abnormality conditions that can be screened for in the first trimester
2. What is nuchal translucency and what is it associated with?

Answer 12

1. Downs syndrome (T21), Edwards syndrome (T18), Patau’s syndrome (T13)
2. the sonographic appearance of a collection of fluid under the skin behind the fetal neck in the first-trimester of pregnancy. When increased there is an increased likelihood of fetal abnormality.

Question 13

1. The risk of Down Syndrome increases with __________ _____.
2. What does Downs screening look like in second trimester?

Answer 13

1. Maternal age

2. Maternal age and investigating biochemical markers e.g. AFP, hCG, unconjugated oestrodiol.

Question 14

1. What does NIPT stand for?

2. What does it entail?

Answer 14

1. Non-Invasive Prenatal Testing

2. Detecting fetal DNA fragments in maternal blood samples.

Question 15

1. Name two diagnostic tests that can be performed 12/15 weeks into pregnancy.
2. When does Rh Hemolysis occur?
3. Under what conditions in pregnancy would Anti-D antibodies be given?

Answer 15

1. Amniocentesis and Chorionic Villus Sampling.
2. When a mother is Rhesus negative and the baby she carries is Rhesus positive. The mother develops rhesus antibodies that attack the babies red blood cells.
3. Given at 28 weeks if mother is Rhesus negative or if newborn is positive or after any sensitising event e.g. TOP.

Question 16

1. Name two conditions worth considering a risk assessment for in pregnant women.

Answer 16

1. Gestational diabetes, Pre-eclampsia.

Question 17

1. If a pregnant woman has risk factors for Pre-eclampsia what treatment should she receive?
2. When should CVS testing be allowed? What about Amniocentesis

Answer 17

1. Should take 150mg Aspirin daily from 12 weeks until 36 weeks.
2. Between 11-14 weeks, >15 weeks.

Question 18

1. What is meant by confined placental mosaicism?

Answer 18

1. Where fetal DNA in the placenta comes from the mother not the baby

Question 19

1. Most drugs pass the placenta apart from large ________ ______ drugs such as Heparin. Small, ______-soluble drugs cross more quickly.
2. Define teratogenic drugs

Answer 19

1. Molecular weight, lipid.

2. Drugs that cause physical/functional defects in the human embryo or fetus of a pregnant woman.

Question 20

1. Although anti-epileptic drugs ______ congenital abnormalities, there is even _______ risk without using them in pregnant epilepsy patients.
2. For diabetic patients ______ is safe but _______ is not. For hypertension _____, ______ and _______ should be avoided and Labetalol, ________ and __________ should be used.

Answer 20

1. Increase, greater

2. insulin, Sulphonylureas, ACE inhibitors, ARBs, Thiazide diuretics, nifedipine, methyldopa

Question 21

1. Name four common acute problems in pregancy.
2. Regardless of risk, all women who are pregnant, in labour or in the puerperium should be encouraged to mobilise and be adequately hydrated to prevent _______ __________. Those with significant risk factors should receive _____.

Answer 21

1. Nausea+Vomiting, UTI, Pain, Heartburn.

2. Venous thromboembolism, LMWH.

Question 22

1. _______ must not be used in pregnancy unless there is a pregnancy prevention programme
2. Identify some of the maternal risks of obesity

Answer 22

1. Valproate
2. increased risk of miscarriage, gestational diabetes, pre-eclampsia, thromboembolic disease, infection, labour and shoulder dystocia.

Question 23

1. Patients with obesity are considered to have a _____ risk pregnancy (red pathway).

Answer 23

1. High

Question 24

1. Define ‘Large for dates’ pregnancy.

2. Identify 6 possible causes of LFD.

Answer 24

1. Symphyseal-fundal height >2cm for Gestational age.

2. Polyhydraminos, wrong dates, diabetes, obesity, multiple pregnancy, fetal macrosomia

Question 25

1. What is fetal macrosomia? 2. How is it diagnosed? 3. What are the risks of Fetal Macrosomia?

Answer 25

1. A Large baby 2. USS EFW (Estimated Fetal Weight) >90th centile, USS AC (Abdominal circumference) >97th centile. 3. Anxiety for mother, Shoulder dystocia, Labour dystocia, PPH

Question 26

1. Identify the three muscles of the lateral aspect of the abdomen 2. Name the tendons that divide the rectus abdominus muscles transversely and vertically 3. Identify the two attachments of the Linea Alba.

Answer 26

1. External oblique, internal oblique and transverse abdominus. 2. Transversely- tendinous intersections vertically- Linea Alba 3. Xiphoid process to pubic symphysis

Question 27

1. What is the rectus sheath? 2. Where is it? 3. What nerves supply the abdominal wall muscles?

Answer 27

1. The combined aponeuroses of the anterolateral abdominal wall muscles. 2. Immediately deep to the abdominal superficial fascia. 3. 7th-11th intercostal nerves, subcostal, iliohypogastric, ilioinguinal.

Question 28

1. What arteries supply the rectus abdominus muscles? | 2. What arteries supply the anterolateral abdominal wall muscles?

Answer 28

1. Superior and Inferior Epigastric | 2. Subcostal and intercostal arteries.

Question 29

the ______ _____ cannot be palpated abdominally if normal sized and only arises out of the pelvis at around ___ weeks gestation. The uterine fundus can usually start to be palpated above the ____ ________ from 12 weeks gestation, by ____ weeks it reaches around the umbilicus and from here it grows at about ______per week until reaching near the ___________ at around 36 weeks. From this gestation onwards the fundal height may decrease as the head starts to descend into the maternal pelvis. From 20 weeks symphysiofundal height can be measured (from the symphysis to the fundus in cm) with the height in cm equalling the weeks in gestation +/- 3cm.

Answer 29

Uterine fundus, 12 weeks, pubic symphysis, 20 weeks, 1cm, xiphosternum.

Question 30

1. What is an LSCS 2. What needs sutured closed in a Caesarean section? 3. What is a Laparotomy? 4. What is the advantage/disadvantage of a laparotomy.

Answer 30

1. Lower Segment Caesarean Section 2. Layers to stitch closed: Uterine wall with visceral peritoneum** Rectus sheath Skin 3. A vertical midline excision 4. Adv: relatively bloodless, Disadv: increased chance of wound complications.

Question 31

1. What are the two types of hysterectomy? | 2.

Answer 31

1. Abdominal and vaginal hysterectomy. | 2.

Question 32

1. Define Polyhydraminos 2. What is the USS diagnostic advice? 3. Identify some causes of polyhydraminos.

Answer 32

1. Excess of amniotic fluid 2. Amniotic fluid index of >25cm (AFI), deepest pool >8cm (DPV) 3. Maternal diabetes, Fetal abnormality (anomaly, twin pregnancy, Hydrops fetalis, viral infection), Idiopathic.

Question 33

1. Identify 4 clinical features of Polyhydraminos | 2. Identify 4 possible signs of polyhydraminos

Answer 33

``` 1. Abdominal discomfort Pre-labour rupture of membranes Preterm labour Cord prolapse 2. LFD Malpresentation Tense shiny abdomen Inability to feel fetal parts ```

Question 34

1. Define zygosity 2. Define chorionicity 3. Define Monozygotic/dizygotic 4. What are the following abbreviations: DCDA, MCDA, MCMA 5. How can chorionicity be determined?

Answer 34

1. The genetic make-up of the unborn child. 2. Number of placenta of the pregnancy 3. Monozygotic- splitting of a single fertilised egg (common). Dizygotic- fertilisation of two separate eggs by two separate sperm. 4. Dichorionic Diamniotic, Monochorionic Diamniotic, Monochorionic Monoamniotic. 5. Ultrasound scan.

Question 35

1. What is exaggerated morning sickness a sign of? 2. Identify some of the complications associated with monochorionic twins 3. Define TTTS

Answer 35

1. Multiple pregnancy 2. Single Fetal Death, Selective Growth Restriction, Twin Anaemia-Polycythaemia sequence, Absent or reversed EDV, Twin-to-twin Transfusion Syndrome. 3. Syndrome with artery-vein anastomoses, Donor twin perfuses the recipient twin.

Question 36

1. When and how should MCMA twins be delivered? | 2. Identify some of the effects of diabetes on pregancy

Answer 36

1. Deliver by C-section at 32-34 weeks 2. Increases insulin requirements N&V can precipitate DKA Ketosis more common Diabetic retinopathy worsens especially after rapid control of diabetes Diabetic Nephropathy can worsen

Question 37

1. Gestational diabetes? Whats that eh? 2. What causes it? 3. How is it diagnosed? 4. What are the diagnostic values for Gestational diabetes?

Answer 37

1. diabetes that develops during pregnancy & usually goes away after giving birth.  2. Placental hormones e.g. Human Placental Lactogen, Cortisol. 3. An OGTT. 4. Fasting >=5.1 mmol/l 2 hour >=8.5 mmol/l

Question 38

1. What is the definition of Small for Gestational Age (SGA)? 2. What about low birth weight (LBW)? 3. What about Fetal Growth Restriction (FGR)?

Answer 38

1. Infant born with birth weight below 10th centile. 2. Birthweight <2500g 3. Failure to achieve genetic potential for growth, implies pathology restricting growth.

Question 39

1. Identify the three categories of causes of SGW | 2. How is SGW diagnosed?

Answer 39

1. Maternal, Fetal and placental abnormality. 2. Midwife measures SFH at each appointment and charts growth with this. USS with measurement of AC and EFW charts growth.

Question 40

1. What is an Umbilical Artery Doppler used for? 2. What else should be observed with the doppler? 3. By when should a SGW baby be delivered ideally?

Answer 40

1. Measurement of placental blood flow to fetus. 2. Middle cerebral artery, Ductus arteriosus. 3. By 37+6 weeks.