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1
Q

Why cant you give nitrofurantoin to pregnanct women in their 3rd trimester?

what are the alternative Abs for treating a UTI?

A

It increases the risk of haemolytic anaemia in the baby

Amoxicillin or ceftriaxone

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2
Q

why is ibruprofen contraindicated in pregnancy?

A

crosses the placenta and increases the risk of kidney problems in baby

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3
Q

Lithium risks to the baby

A

Ebsteins anomaly
congenital heart defect where the tricuspid valve is in the wrong place resulting in abnormally large RA and small RV

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4
Q

Which anti-epileptics are CI in pregnancy and why

A

sodium valporate and carbamazepine

teratogenic and can result in spina bifida

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5
Q

what are the risks of taking SSRIs in pregnancy

A

1st trimester -> congenital heart defects

3rd trimester -> inc risk of persistent pulmonary hypertension in the newborn

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6
Q

UKMEC3 scenarios

A

> 35 and smokes <15/day
wheelchair bound/ immobility
BMI >35
FHx of VTE in 1st degree relatives <45
current gallstones
carrier of BRCA1/2 gene
controlled HPTN

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7
Q

UKMEC4 scenarios

A

> 35 and smokes >15/day
uncontrolled HPTN
history of breast cancer
history of VTE
History of stroke or IHD
migraine with aura
breastfeeding and postpartum <6weeks
positive antiphospholipid antobodies
major surgery

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8
Q

Drugs considered safe in breastfeeding

A

Antibiotics: penicillins, trimethoprim, cephalosporins

anti-epileptics: sodium valporate, carbamazepine

anti-depressants: TCAs

antipsychotics

glucocorticoids

thyroxine

asthma: salbutamol, theophyllines

b-blockers

warfarin/heparin

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9
Q

Drugs contraindicated in breastfeeding

A

antibiotics: chloramphenicol, ciprofloxacin, sulphonamides, tetracycline
Lithium
benzodiazapines
aspirin
carbimazole
methotrexate
sulphonyureas
amiodarone

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10
Q

risks to mother and fetus in epilepsy during pregnancy

A

mother:
increased plasma volume may mean lesser effect of medications and inc risk of seizures

lowered seizure threshold with excessive tiredness and hyperemesis

fetus:
increased risk of congenital abnormalities with anti-epileptic drugs. risk increases with multiple meds
esp valporate and carbamazepine

risk of fetal hypoxia in prolonged seizures

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11
Q

management of epilepsy in pregnancy

A
  • MDT management with obstetrician and neurologist
  • aim for a single drug regime with wither lamotragine or phenytoin

-5mg folic acid preconception-12weeks to minimise neural tube defects

-monitor of drug plasma levels

-detailed anomaly scan and fetal echo at 18-20 weeks for cardiac abnormalities

-serial growth scans every 4 weeks from 28-36wks gestation

-vitamin K at 36 weeks and IM to baby at birth as anticonvulsants can inhibit clotting factor production

-anticonvulsant medication deemed safe in breast feeding

counselling:
- advise to take medication as risk of fetal hypoxia if have a prologed fit
- if last fit was >2yrs then could consider stopping medication
- advise to take showers over baths to reduce risk of drowning if have a fit

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12
Q

Exposure to chicken pox when pregnant

A

if mother has had chickenpox in the past then she is ok

if cant remember then test for VZ Ig

if non-immune:
<20 weeks, >20wks and NO rash –> VZIG (effective for up to 10days post contact)
- avoid contact with other pregnant women and neonates for 4 weeks

> 20 weeks presenting with a rash –> oral acyclovir (800mg 5 a day for 7 days)
avoid contact with other pregnant women and neonates until all the lesions have crusted over

-arrange referral to fetal medicine specialist
-post natal neonatal ophthalmic examination
-if infection occurs at term, planned delivery should be delayed until 7 days post clearance of lesions (allows passive transfer of Abs to fetus)

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13
Q

conselling about obesity in pregnancy

A

Preconception:
-Lifestyle/diet and exercise advice
-5mg folic acid –>12wks

risks of obesity in pregnancy:
maternal:
- increased risk of GDM (2-3 fold) (OGTT offered at 24-28wks)

  • increased risk of VTE (9fold)(consider prophylactic LMWH during pregnancy and after)
  • increased risk of gestational HPTN (2-3 fold)
  • inc risk of PPH (2fold)

-vitamin D deficiency –> supplementation

fetal:
- congenital abnormality (60% inc risk) eg NTD
- prematurity (20% inc risk)
- macrosomia and shoulder dystocia (3fold)
- stillbirth (2fold)

advice:
- hospital birth
- encourage vaginal birth but advise on possible complications and risk of EMCS
- weight loss throughout pregnancy

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14
Q

managament for GDM

A

diagnosis
fasting>5.6, 2hr post OGTT >7.8

  • joint antenatal and diabetes clinic 1 week after diagnosis and then every 2 weeks

-self BM measurements before and after each meal. aim for <5.6 preprandial and <7.8 post prandial

1st line (fasting <7mmol) - lifestyle changes

2nd line (targets not met 2 weeks after lifestyle changes) - metformin

3rd line (targets not met with lifestyle and metformin)
- insulin

NB: if fasting glucose >7 at diagnosis offer insulin straight away

birth no later than 40+6wks

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15
Q

drugs CI in pregnancy

A

ACEi, ARBs, thiazides, ibruprofen

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16
Q

High and moderate risk RFs in pre-eclampsia

A

HIGH RISK
previous pregnancy with pre eclampsia or HPTN
pre-existing maternal conditions (HPTN, DM, SLE, renal disease)

MODERATE RISK
primigravid
age >40
pregnancy interval >10 years
BMI >35
FH of pre-eclampsia
multiple pregnancy

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17
Q

when to offer aspirin in pregnancy

A

pre-eclampsia prophylaxis:
1 high risk RF or 2 moderate risk RF

Offer from12/40 GA until delivery

75-150mg OD

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18
Q

when to admit someone with high BP

A

severe HPTN >160/100
symptoms- eg. headache, dizziness, changes in vision, abdo pain
reduced fetal movements
abnormal bloods- deranged LFTs, U&Es, low Plts, anaemia

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19
Q

Management of someone admitted to the ward with signs of pre-eclampsia

A

MONITOR
- BP every 30 mins
- urine dip daily
- bloods (FBC, U&Es, LFTs)
- CTG

MEDICATION
- IV labetelol
- steroids if <34 weeks
- severe PET: MgSO4 –> delivery within 24hrs

DELIVERY
-aim for 37weeks
- maternal choice of delivery but advise on labour ward
- conitinuous BP 4x day for at least 24hrs
- 1-2day BP for 2 weeks post discharge

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20
Q

first degree tear

A

Tear limited to the superficial perineal skin or vaginal mucosa only

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21
Q

second degree tear

A

Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)

Stitch on ward by midwife

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22
Q

third degree tear

A

3a: extends to perineal muscles, fascia and less than 50% of the anal sphincter

3b: extends through the perineal muscles, fascia and more than 50% of the anal sphincter- but the internal sphincter remains intact

3c: Extends through the perineal muscles, fascia and the external and internal anal sphincter. The anal mucosa is intact

repair in theatre by reg

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23
Q

Fourth degree tear

A

Perineal skin, muscle, anal sphincter and anal mucosa are torn

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24
Q

Management of toxoplasmosis in pregnancy

A

PREVENT: avoid contact with cats/ kittens, raw meat, wash hands after touching soil

INVESTIGATIONS
infection suspected send maternal blood sample to specialised toxoplasmosis lab
if +ve then amniocentesis >14wks

TREATMENT
refer to fetal medicine unit for USS every 2 weeks
mother- spiromycin (2-3g OD for 3 weeks)
baby- sulfadiazine, pyrimethamine, folonic acid for 1 year

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25
management of Rubella in pregnancy
not routinely screened for in the UK anymore RF- unvaccinated mother INVESTIGATIONS serum IgM- active infection serum IgG- previous immunity TREATMENT Refer to fetal medicine unit for 1-2weekly monitoring
26
Management of CMV in pregnancy
INVESTIGATIONS serology, signs of CMV infection on USS TREATMENT Refer to fetal medicine for regular check ups no prenatal treatment available valganciclovir PO 8g OD to baby at birth for 6 months
27
management of HIV in pregnancy
Routinely screened for at booking INVESTIGATIONS (if known positive) Viral load and CD4 count every 2-4 weeks F/U every 1-2 weeks MANAGEMENT joint HIV and obstetrician care maternal ART ASAP PEP to baby immediately at birth- zidovudine for 2-4 weeks AT DELIVERY viral load <50copies/mL- vaginal delivery ok >50copies/mL- C/S advised NO BREASTFEEDING
28
Management of HSV in preganancy
painful genital ulcer- high risk when first occurrence INVESTIGATIONS swab of ulcer for PCR TREATMENT 1st-2nd trim- 400mg aciclovir TDS for 5 days + 400mg OD from 36wks- delivery --> vaginal okay 3rd trim- 400mg aciclovir TDS until delivery --> C/S advised if vaginal give IV aciclovir intrapartum and to baby
29
management of HBV in pregnancy
joint ID/hepatologist and obstetrician care maternal tenofovir baby at birth - HBIg within 24hrs + HB vaccine at birth, 4 weeks and 12 months
30
management of listeriosis in pregnancy
admission to hospital IV amoxicillin 2g every 6 hours for 14days
31
Managament of a UTI in pregnancy
asymptomatic or symptomatic - 50mg nitro QDS for 7 days not resolved after 48hrs or near term: amoxicillin 500mg TDS for 7 days or cefalexin 500mg BD for 7 days
32
management of syphilis in pregnancy
Refer to GUM IM benzylpenicillin BD for 14 days
33
Complications of toxoplasmosis infection in pregnancy
In vitro IUGR intracranial calcification hydrocephalus or microcephalus birth CHD blindness -chorioretinitis neurological defects
34
complications of CMV infection in pregnancy
At birth: hepatitis hepatosplenomegaly microcephaly SGA Long term sensory neural hearing loss neurological disabilities
35
complications of rubella infection in pregnancy
infection <12wks- discuss TOP as severe congenital defects likely 12-20- some form of defect likely >20wks- unlikely at delivery: microcephaly cataracts CHD: PDA, VSD, PS sensory neural hearing loss long term: learning disabilities DM thyroiditis
36
complications of listeria monocytogens infection in pregnancy
paralysis seizures cerebral palsy learning difficulties blindness CHD renal problems
37
complications of VZV infection in pregnancy
maternal: pneumonitis encephalitis hepatitis death (rare) baby:
38
complications of parvovirus B19 infection in pregnancy
hydrops fetalis
39
complications of syphilis in pregnancy
Hutchinson teeth, blindness, deafness, rashes
40
describe the antenatal screening for downs
Who would it be offered to? - offered to all women - high risk: increased age, FHx - includes screen for pataus and edwards - all free on NHS When would it be offered NIPT- (private:7-10 weeks, NHS: offered if higher risk after integrated test)- maternal blood 1. 10-13 weeks: combined test- looks at the chance of having T21/18/13. maternal age, bHCG, PAPP-A and NT (>3.5) (CRL needs to be between 45-84mm to be eligible) 2. 15-20: Quadruple screen InhibinA, BHCG, UE3, AFP 3. Integrated test- combines the results of the combined and quadruple test ((NB: smoking can affect the results, the quadruple test has a higher false positive result than the combined and the intesgrated has the lowest false positive result) 4. CVS- 11-14wks 5. Amnioscentesis 15-20 interpretation of the results
41
Obesity in pregnancy managament
BMI >35 - OGTT at 24-28 weeks - Vitamin D 10mg OD - 5g folic acid preconception -12 weeks - anaestetic review - higher risk of marosomia, GDM, dystocfia, PPH - post-natal thromboprophylaxis
42
physiological changes in pregnancy
- marked increase in fibrinogen - increase in fVII,X and XII - stroke volume increases by 30 - plasma volume increases disproportionately to red cell mass resulting in relative anaemia - rise in AFP - soft systolic flow murmur due to dilation across tricuspid valve
43
effects of warfarin in pregnancy
teratogenic most in 1st trim but also CI in 2nd and 3rd 1st vertebral calcinosis nasal hypoplasia brachydactyly later cerebral deformities eye problems
44
Mx of PE in pregnancy
Ix: ECG, CXR FBC, U&Es, clotting screen, LFTs USS of leg if DVT suspected V/Q scan or CTPA 80mg enoxaparin (LMWH) BD
45
cut off for normal protein creatinine ratio
<30
46
when should a fetal pole and heart beat be detected on USS
6 weeks
47
causes of secondary amenorrhoea
Pregnancy thyroid disorders anorexia/ low BMI hyperprolactinaemia (prolactinoma, dopamine antagonist drugs) PCOS POI sheehans syndrome
48
Causes of primary amenorrhoea
Turners hypogonadism hypopituitarism low BMI CAH
49
Investigations for amenorrhoea
primary- examine genitalia, sex hormones, height and weight, karyotyping secondary urine pregnancy test TFTs Prolactin LH/FSH androgens medication review MRI brain
50
when should anti-D injections be given in the antenatal period?
weeks 28 and 34 and any sensitising event such as trauma, antenatal bleed, amnioscentesis, CVS, ECV, delivery
51
types of breech and how common is it
20% babies breech at 28 weeks. by term most of these move to cephalic spontaneously and only 3% are left as breech. flexed (complete) - both legs flexed at the hip and knees and baby apears to be 'crossed legged' extended (frank) - both legs flexed at the hips and extended at the knees (so legs are straight up) - most common footling - one or both legs extended at the hip so the foot is presenting first - most dangerous to deliver
52
Management of breech at >37
counselling Understand the mothers wishes. is she very keen for a vaginal delivery or C/S ECV - try to move the position of the baby from the outside of abdomen - give anti-D to Rh-ve mothers - approx 50% success rate (slightly less if first baby, more if not) risks: fetal distress, placental abruption --> emergency C/S 1/200 chance - Contraindications: ruptured membranes, multiple pregnancy(except for second twin), placenta praevia, PV bleed, footling breech breech vaginal delivery - must be in hospital 4/10 will need an EMCS - hands off approach - continuous CTG - risk of fetal hypoxia/ distress
53
RFs for breech and complications
- polyhydramnios/ oligohydramnios - obstructive fibroids - low lying placenta - multiparity complications - chord prolapse
54
differentials for menorrhagia
dysfunctional uterine bleeding fibroids adenomyosis endometriosis (more dysmenorrhoea than menorrhagia) bleeding disorders hypothyroidism obesitty
55
indications for taking 5mg folate preconception-12weeks
anti-epileptic drugs BMI >30 coeliac diabetes thalassaemia traits
56
what are the different types/ severities of spina bifida
Spina bifida occulta Incomplete fusion of the vertebrae, but with no herniation of the spinal cord May be visible only as a small tuft of hair overlying the site Meningocele Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF Visible prominence at the site, but usually covered by skin Myelomeningocele Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord. Usually accompanied by other defects such as hydrocephaly or Chiari malformation Visible prominence at the site, with exposed meninges
57
causes of polyhydramnios
GDM/ DM fetal renal problems oesophageal atresia twin twin transfusion syndrome diaphragmatic hernia chromosomal abnromalities
58
complications of polyhydramnios
maternal increased risk of needing C/S increased pressure so hightened sx eg. GORD, urinary sx, stretch marks respiratory distress fetal chord prolapse breech/ unstable lie PROM Preterm labour abruption
59
features of a partogram and when is it used
In active stage of first stage of labour (>6cm dilated) Time Temp BP Urine (K, G, P, B) - all every 4 hrs HR- maternal (every 30mins) and fetal Contractions (check every hr, measure no of contractions in 10 minutes) Dilation- PV exam every 4 hrs aiming for 1cm/hr in prim, 2cm/hr in multiparous. failure to progress if half that rate Station- in relation to ischial spine Liquor- blood stained: abruption, clear: SROM, meconium stained Position- of anterior fontanelle Moulding- of fontanelles Caput Drugs given Oxytocin rate
60
reassuring CTG features
Baseline rate- 110-160bpm variability - 5-25bpm accelerations inc in HR by >15bpm for >15seconds decels- non or early
61
non-reassuring CTG features
baseline rate 100-109bpm or 161-180bpm variability <5bpm for 30-50mins or >25bpm for 15-25 mins variable decelerations with shoulder accelerations prolonged decels for 3-5minutes
62
pathological CTG
baseline rate <100 or >180 variability <5bpm for >50mins or >25bpm for >25mins variable decels with no shouldering prolonged decels for >5mins failure to return to BRa sinosoidal biphasic W shape
63
causes of fetal tachycardia
hypoxia hyperthyroidism chorioamnionitis fetal/maternal anaemia
64
causes of fetal bradycardia
prolonged cord compression cord prolapse hypothyrodism epidural/ spinal anaesthesia maternal seizure 100-120 could be normal for post dates
65
causes of reduced variability
fetal sleeping (no longer than 40mins) acidosis fetal tachycardia drugs- opiates, benzos, MgSo4 prematuriy congenital heart disease
66
mechanism of early decelerations
uterine contracture causes increased ICP in fetus leading to increase vagal tone which lowers the HR
67
causes of variable decelerations
oligohydramnios umbilical cord compression
68
causes of late decelerations
maternal hypotension PET uterine hyperstimulation
69
causes of sinosoidal rhythm
severe fetal hypoxia severe fetal anaemia feta/ maternal haemorrhage
70
why is hypotension an absolute CI to epidural?
the epidural will cause peripheral vasodilation and worsen pre existing hypotension most anaethesists will pre load pt with 1L IV fluids before giving epidural
71
absolute contraindications for epidural anaesthesia in pregnancy
maternal refusal allergies to anaesthetic agents sytemic infection skin infection by epidural site bleeding disorders platelet cout <80000 uncontrolled hypotension
72
relative CI to epidural
HOCM aortic stenosis mitral stenosis
73
where does the pudendal nerve arise from and what are the branches of the pudendal nerve and what do they innovate
S2,3 and 4 perineal nerve -> perineal muscles and perineal skin inferior anal nerve --> external anal sphincter, perianal skin dorsal nerve of the clitorus --> urethral sphincter
74
physiology of fetal circulation after birth
occlusion of the umbilical vessels --> reduces venous return back to the right side of the heart --> reduces right sided arterial pressure --> closure of foramen ovale. As the fetus starts to breath the pulmonary circulation pressure lowers --> right ventricular output increases The pulmonary artery vasodilates to allow the new low pressure right sided system to develop increased flow through pulmonary system leads to more venous return to the left side of the heart --> increased pressure on left side of heart --> closure of the ductus arteriosus
75
difference between urge and stress incontinence
urge- detrusor overactivity and bladder oversensitivity causes leakage of urine stress- increased abdo floor pressure vs decreased pelvic pressure causes leakage of urine on coughing/ laughing/ sneezing/ heavy lifting
76
investigations for incontinence
- abdo/ pelvic exam - speculum/ bimanual - kegel test - urine dip and MSU - bladder diary for 3 days (noting exactly when it happens and any triggers) - bladder scan- post void residual volume - referral to urodynamics
77
management of urge incontinence
1. lifestyle changes - avoid caffeine - lose weight if BMI >30 modify fluid intake 2. bladder retraining exercises (minimum 6 weeks) 3. anticholinergics - eg. oxybutynin (not in >80/ frail), tolterodine, mirabegron
78
management of stress incontinence
1. lifestye changes - avoid caffeine 2. pelvic floor exercises (refer to physiotherapy) - 8 contractions, 3x a day for a minimum of 3 months 3. surgical - colposuspension - autologous rectal facia sling
79
Pathophysiology of PMS
symptoms occuring in the luteal phase of menstrual cycle casued by high progesterone eg. mood swings, bloating, tearfullness, irritability, breast tenderness, abdo pain (all progesterone problems)
80
management of PMS
1. psychosocial - exercise - sleep hygiene - CBT - vit B6 2. bio - COCP - mirena coil - SSRIs eg. citalopram - oestrodiol patches - GnRH analogue + HRT 3. surgical -hysterectomy
81
Management of PCOS
weight loss metformin COCP trying to conceive wt loss +/- metformin clomifene
82
sensitising events in Rh- woman requiring anti D
vaginal bleeding <12 weeks if heavy, painful or persistent PV bleeding >12 weeks ruptured ectopic pregnancy TOP ERPC amniocentesis or CVS antenatal haemorrhage ECV intra uterine death post delivery at 28 and 34 weeks abdominal trauma
83
dose of MgSO4 to be given in eclampsia
IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
84
what is important to monitor when giving MgSO4
reflexes respiratory rate O2 sats if resp depression occurs then calcium gluconate is the Rx
85
layers to cut through during a C/S from skin to uterus
Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
86
rokitasnky's protuberance is associated with which ovarian tumour?
mature teratoma
87
causes of increased nuchal translucency
Downs CHD abdominal wall defects
88
causes of hyperechogenic bowel
cystic fibrosis downs CMV infection
89
what should be measured in someone with suspected DVT/ PE started on LMWH in extremes of body weight (<50kg or >90kg)?
anti-Xa activity
90
what test is used to detect presence of fetal blood in maternal circulation and how does it work?
Kleihaur test adds acid to maternal blood sample- fetal blood is resistant
91
management of RFM >28 weeks
1. hand held doppler 2. if no HB detected then immediate USS - include: abdo circumference, amniotic fluid volume and estimated fetal weight 3. if HB present then CTG for 20 mins if no fetal movements established after 24 weeks then referral to maternal fetal medicine unit 70% of episodes of RFM will be isolated and result in normal uncomplicated pregnancy
92
factors associated with increased risk of miscarriage
Increased maternal age Smoking in pregnancy Consuming alcohol Recreational drug use High caffeine intake Obesity Infections and food poisoning Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes Medicines, such as ibuprofen, methotrexate and retinoids Unusual shape or structure of womb Cervical incompetence
93
normal lab findings in pregnancy
reduced urea reduced creatinine increased urinary proteins dilutional anaemia thrombocytopenia neutrophilia hypercoaguable raised D-dimer
94
missed pill rules
COCP 1 missed pill- take ASAP and no further action required 2 missed pill- take last one missed ASAP and barrier contraception until 7 days of consecutive pills UPSI in days 1-7 pack -> emergency contraception in days 8-14 -> no emergency contraception required days 15-21 -> continue rest of pack then go straight onto new pack omitting pill free week POP traditional- <3hrs late take ASAP and no further action, >3hrs take ASAP and barrier for 48hrs desogestrel (carazette) <12hrs late take ASAP and no further action >12 hrs take ASAP and barrier for 48hrs 2 missed pills- take one and barrier for 48hrs
95
Drugs/ scenarios a pt is on that would make the COCP non favourable
drug inducing drugs eg. rifampicin, carbamazepine as will lower the effectiveness of the pill lamotragine- as COCP reduces the effectiveness and will lower the seizure threshold women who have had bariatric ssurgery as effectiveness is reduced as less absorption
96
positives and negatives of the depo-provera injection
positives: - induces amenorrhoea so useful in pts with painful/ heavy periods - reduces pain in sickle cell crisis negatives: - small risk of wt gain - can cause irregular periods - can cause mood swings - small risk of reduced bone density - delayed return to fertility up to 1 year
97
dose release of progesterone with the implant
60/70mcg/ day --> year 3 25mcg/day
98
risks and benefits of inplanon
benefits - reversible - good for painful periods - can induce amenorrhoea - little/ no risk of VTE - good for obese, smokers, VTE RFs - nexplanon is radioopaque risks - can cause irregular bleeding -
99
late injection rules
up to 14 weeks 14 weeks +1 late --> 7 days barrier if UPSI --> emergency contraception + 7 days barrier NB: not ella one
100
positives and negatives of copper IUD
positives: - non hormonal - very effective contraception - lasts 5 years - not affected by any other medication negatives: - cause heavier, more painful periods - irregular bleeding
101
positives and negatives of copper IUS
positives: - makes periods lighter, less painful or stop altogether - very effective - lasts 5 years (mirena) - protective over endometrial cancer negatives: - some reports of acne, breast pain, headache (but lesser extent to systemic progesterone) - can cause irregular bleeding - can cause functional cysts
102
risk of expulsion, PID and perforation for IUD/IUSS
expulsion 1in 20 PID 1 in 100 up to 4-6 weeks post insertion perforation 1 in 1000

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