WOMEN'S HEALTH 1 - Obstetrics Flashcards

Question

Outline what would happen in a medical abortion - when do they most commonly happen?

Answer 1

most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments: Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue) 1 – 2 day later Mifepristone is an anti-progestogen medication that blocks the action of progesterone, **halting the pregnancy and relaxing the cervix**. Misoprostol is a prostaglandin analogue, meaning it **binds to prostaglandin receptors and activates them.** Prostaglandins soften the cervix and **stimulate uterine contractions.** From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.

Answer 2

Prime cervix with medciiens - same as the ones used in medical abortion - **Misoprostal and mifepristone** and osmotic dilators that absorb fluid and open cervical canal There are two options for surgical abortion: Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)

Answer 3

The period from placental delivery to 6w after birth - the post-natal period. the period of about six weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition.

Answer 4

Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progesterone) Increase of prolactin - as placenta is delivered

Answer 5

Involution of the uterus. **uterus returning to pre pregnant state** Decidua sheds as lochia. - **decidua -maternal uterine tissue** Lactation.

Answer 6

Gravidity = total number of pregnancies regardless of outcome, Parity = total number of pregnancies carried over the threshold of viability (24w)

Answer 7

ncreased blood volume, increased cardiac output, increased stroke volume, increased heart rate, Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre) Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm Maternal blood volume up 30%, mostly in 2nd half red cells up 20% but plasma up 50% → Hb falls Low grade increase in coagulant activity rise in fibrinogen and Factors VII, VIII, X Biochemical changes calcium requirements increase during pregnancy especially during 3rd trimester + continues into lactation increased intra-gastric pressure, decreased gut motility, increased fibrinogen and clotting factors, increased total T3 T4 levels, increased uterine size

Answer 8

There is muscle ischaemia, autolysis and phagocytosis -> involution of the uterus. - becomes fibrous tissue - more prone to rupture in future prengancies If can still feel uterus above belly button after a couple of days, be concerned eg Endometrisus

Answer 9

1. Lochia rubra. 2. Lochia serosa. 3. Lochia alba. RSA Generally lasts 4-6 weeks

Answer 10

Colostrum.

Answer 11

- Protein rich. - Vitamin A. - NaCl. - GF's. - Antibodies. - Lactoferrin.

Answer 12

Baby suckles -> nipples send impulses to brain -> prolactin is released from the ant.pituitary -> milk is produced by lactocytes -> oxytocin is released from the post.pituitary -> myoepithelial contraction -> milk ejection. – Oxytocin –> stimulates milk ejection from the breast as well as uterine contractions Anterior first (Prolactin), then posterior (Oxy)

Answer 13

Maternal: – Faster uterine involution, bonding, contraception, – Protection from breast/ovarian/endometrial cancer. Infant: – Lower incidence of diarrhoea, necrotising enterocolitis (NEC), – Lower incidence of otitis media and respiratory tract infections Milk contains all the nutrients the infant needs (except vitamin D and K) up till 6 months of age.

Answer 14

1. Infection. 2. Haemorrhage. 3. Fatigue. 4. Anaemia. 5. Back pain. 6. Haemorrhoids.

Answer 15

1. Sepsis. 2. Sever haemorrhage. 3. Pre-eclampsia. 4. VTE. 5. Prolapse. 6. Incontinence. 7. Depression.

Answer 16

1. Obesity. 2. Anaemia. 3. Diabetes. 4. Amniocentesis/invasive procedures .Impaired immunity/ immunosuppressant medication 5. Prolonged spontaneous rupture of membranes Group A Strep infection in close contacts / family members History of pelvic infection History of group B Strep infection

Answer 17

1. Endometritis. 2. Skin infections. 3. Pyelonephritis. 4. Chorioamnionitis. 5. Pneumonia.

Answer 18

Post-partum haemorrhage: >500ml estimated blood loss after **birth of baby.**

Answer 19

>1500ml blood loss and continuing to bleed/signs of shock. For a woman of 70kg a blood loss of more than 40% of her total blood volume (2,800mls) is generally regarded as life threatening Either primary - within first 24 hours (most often immediately after delivery) or secondary - After 24 hours and up to 12 weeks post delivery

Answer 20

Tone (uterine atony most commonly) Trauma (large baby) Thrombus (clots) Tissue (fibroids) – In addition, it can be caused by abnormalities of the placenta (placenta previa/accrete) *Uterine atony = soft and weak uterus after childbirth. It happens when your uterine muscles don’t contract enough to clamp the placental blood vessels shut after childbirth*

Answer 21

Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 22

1st line –> Apply bimanual compression (pressure aims to compress uterine arteries) with fundal massage – 2nd line is medical management –> IV syntocinon/Syntometrine (oxytocin) 10 units or IM ergometrine (strong vasoconstrictor) – You can also use IM Carboprost (Haemobate) (prostaglandin which aids uterine contraction) **avoid in asthama!** Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding If still bleeding take to operating theatre for surgical approaches. – 1st line is Bakri balloon tamponade (also called intra-uterine Bakri catheter)–> used if uterine atony is main cause – If uncontrolled, B-lynch suture or uterine artery embolism – If still not controlled –> ligate internal branch of the internal iliac artery – Last resort is hysterectomy

Answer 23

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Answer 24

Investigations involve: Ultrasound for retained products of conception Endocervical and high vaginal swabs for infection Management depends on the cause: Surgical evaluation of retained products of conception Antibiotics for infection

Answer 25

1. Increasing gestational age. 2. Obesity. 3. Smoking. 4. C-section. 5. Family history. 6. Immobility. 7. Multiple pregnancy e.g. twins. 8. Previous VTE.

Answer 26

The risk is greatest just after giving birth, in the post partum period.# Pregnant woman with a previous VTE history: LMWH throughout pregnancy until 6 weeks postnatal enoxaparin

Answer 27

LMWH. eg Enoxaparin or Dalteparin TED stockings. Pregnant woman with a previous VTE history: LMWH throughout pregnancy **until 6 weeks postnatal**

Answer 28

Doppler ultrasound TOM TIP: The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Answer 29

Women with suspected pulmonary embolism require: Chest xray ECG CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan. VQ scan - inhale isotpes and compare the ventilation and perfusion of the lungs - In PE will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue.

Answer 30

Women with a massive PE and haemodynamic compromise need immediate management by an experienced team of medical doctors, obstetricians, radiologists and others. treat with **LMWH first (eg enoxaparin)** then investigate to rule in/out ***Unfractionated heparin*** Thrombolysis Surgical embolectomy

Answer 31

Accidental dural puncture -> CSF leakage and decreased pressure in fluid around the brain.

Answer 32

Lying flat! Simple analgesia Fluids and caffeine?? **Epidural blood patch** - *injecting a bit of patients own blood into epidural sapce to stop leak of CSF*

Answer 33

Sepsis is a condition where the body launches a large immune response to an infection, causing large **systemic inflammation** and affecting the functioning of the organs of the body Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.

Answer 34

Chorioamnionitis Urinary tract infections

Answer 35

Chorioamnionitis is an infection of the chorioamniotic membranes (what makes up the sac that surrounds the embryo) and amniotic fluid. E coli is most common

Answer 36

(3Ts white with sugar) Temperature <36 or >38 degrees Tachycardia -Heart rate > 90bpm (PN) Tachypnoea - Respiratory rate > 20bpm WCC >12 or <4 x 109/l Hyperglycaemia >7.7mmol Low blood pressure Altered consciousness Reduced urine output

Answer 37

Bloods cultures Urine output Fluid Resuscitation Antibiotics Lactate Oxygen piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin. Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.

Answer 38

Is when a pregnancy is is implanted outside the uterus, the most common site fallopian tube. **(specifically the ampulla)** **most dangerous if in the the isthmus** Can also occur at the entrance to the fallopian tube, ovary, cervix or abdomen

Answer 39

Previous ectopic pregnancy **Previous PID** Previous surgery to the fallopian tubes Black ethnicity **Intrauterine devices!!** Older age Smoking Endometriosis The **progesterone only pill is a risk factor** because it slows the passage of the ovum through the fallopian tube. *in 1/3 of ectopic pregnancies, there will be no risk factors*

Answer 40

typically presents around 6 – 8 weeks gestation. Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. can be asymptomatic Missed period Constant lower abdominal pain in the right or left iliac fossa Shoulder tip pain (referred pain from the diaphragm) Vaginal bleeding Lower abdominal or pelvic tenderness Cervical motion tenderness (pain when moving the cervix during a bimanual examination) 18.5%

Answer 41

Serum HCG - pregnancy test BhCG <63% increase over 48h FBC, clotting, - to see if haemodynamically stable A transvaginal ultrasound scan - gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign A mass representing a tubal ectopic pregnancy **moves separately to the ovary.** *(a corpus luteum will look similar to this, but will move with the ovary)* Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”) = so is not diagnostic of an ectopic serum b-HCG can also be performed

Answer 42

When a women has a positive pregnancy test and there is no evidence of pregnancy on an ultrasound scan

Answer 43

it is **important to obtain a baseline and repeat beta hCG in 48hrs.** In an intrauterine pregnancy hCG will double every 48 hours, it won’t in an miscarriage or ectopic pregnancy . Once levels are above 1500 should be able to see on USS A fall of more than 50% is likely to indicate a miscarriage

Answer 44

Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service. All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy. 3 options Expectant management (awaiting natural termination, conervative) Medical management (methotrexate) Surgical management (salpingectomy or salpingotomy) *(Methotrexate: must be stopped at least 6 months before conception in both men and women)*

Answer 45

Follow up needs to be possible to ensure successful termination Patient must be clincally stable and pain free The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain **HCG level < 1000 IU / l** - repeat hCG on day 2, 4, 7 - should fall my 15% within 7 days , repeat weekly unitl IUL is <20

Answer 46

Methotrexate is highly teratogenic (harmful to pregnancy). It is given as an intramuscular injection into a buttock. Give if size is <35mm No fetal Heartbeat **hCG <1,500IU/L** can only be done if the patient is willing to attend follow-up. Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. Vaginal bleeding Nausea and vomiting Abdominal pain Stomatitis (inflammation of the mouth)

Answer 47

Pain Adnexal mass > 35mm Visible heartbeat **HCG levels > 5000 IU / l** Laparoscopic salpingectomy = remove affected fallopian tube - is first-line for women with no other risk factors for infertility Laparoscopic salpingotomy - used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube - just remove ectopic pregnancy *around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)*

Answer 48

Miscarriage is the spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.# Occurs in 20% of pregnancies

Answer 49

the fetus is no longer alive, but no symptoms have occurred

Answer 50

Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive Inevitable miscarriage – vaginal bleeding with an open cervix

Answer 51

Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus

Answer 52

Abnormal foetal development. Uterine abnormality. Incompetent cervix. Placental failure. Multiple pregnancy. Think structures (uterus, placenta, cervix not working properly)

Answer 53

Age >30. Smoking. Excessive alcohol consumption. Uterine surgery. Poorly controlled diabetes.

Answer 54

Transvaginal USS. Serum hCG.

Answer 55

missed miscarriage = oral mifepristone. 48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed incomplete miscarriage = a single dose of misoprostol (vaginal, oral or sublingual) women should be offered antiemetics and pain relief a pregnancy test should be performed at 3 weeks Vaginal misoprostol. *(helps stimulate uterine contractions, to make sure everything is delivered)* If there is evidence of infection and haemodynamic instability in the context of a miscarriage, surgical intervention with **vacuum aspiration** would be an appropriate surgical management Manual vacuum aspiration. Counseling and support.

Answer 56

Monozygotic: identical twins (from a single zygote) Dizygotic: non-identical (from two different zygotes)

Answer 57

Monoamniotic: single amniotic sac Diamniotic: two separate amniotic sacs Monochorionic: share a single placenta Dichorionic: two separate placentas The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Answer 58

on the booking ultrasound scan. Ultrasound is also used to determine the: Gestational age Number of placentas (chorionicity) and amniotic sacs (amnionicity) Risk of Down’s syndrome (as part of the combined test)

Answer 59

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Answer 60

Risks to the fetuses and neonates: Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Answer 61

occurs when the fetuses share a placenta. one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Answer 62

Pre-eclampsia Sepsis Shoulder Dystocia Gestational diabetes

Answer 63

PCOS. Miscarriage. Infertility.

Answer 64

Glucose tolerance decreases with increasing gestation after the first trimester Largely due to anti-insulin hormones secreted by the placenta in normal pregnancy (human placental lactogen, glucagon and cortisol)

Answer 65

Normal women show an approx. doubling of insulin production from the end of the first trimester to the third trimester Likely to underlie the increased insulin requirements of women with existing diabetes Lead to the development of abnormal glucose tolerance in gestational diabetes - where there is insufficient insulin secretion to compensate for the insulin resistance

Answer 66

Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth. Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes (first-degree relative)

Answer 67

**Oral Glucose Tolerance Test** An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours. screening is offered at **24-28 weeks,** Normal results are: Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l Results higher than this suggest gestational diabetes remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.

Answer 68

The initial management suggested by the NICE guidelines (2015) is: **Fasting glucose less than 7 mmol/l (5.6-7): trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin** Fasting glucose above 7 mmol/l: start insulin ± metformin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin Gestational diabetes is treated with **short-acting**, but not longer-acting SC insulin . Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.

Answer 69

Monitoring for pre-eclampsia with regular BP and urine checks Regular fetal growth scans (usually 28, 32 and 36 weeks) – to assess fetal size, growth velocity and enable delivery planning Timing of delivery – induction of labour or planned caesarean section For uncomplicated GDM – delivery by 40+6 For complicated GDM – 37 – 38+6 Intrapartum care Fetal monitoring Hourly monitoring of blood glucose May need variable rate insulin infusion to maintain blood glucose

Answer 70

Aspirin 150mg once daily from 12 weeks until delivery – to reduce risk of pre-eclampsia Folic acid 5mg ideally from preconception (or as early as possible) until 14 weeks Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required. Aspirin should be stopped before delivery, as it is contraindicated in breast feeding

Answer 71

macrosomia and neonatal hypoglycaemia. macrosomia poses a risk of shoulder dystocia

Answer 72

congenital malformations Intrauterine growth restriction macrosomia =maternal hyperglycaemia causes fetal hyperglycaemia as glucose crosses the placenta, foetus secretes more insulin that promotes growth An increase in foetal blood glucose brings about a hyperinsulinaem ia in the foetus, leading to increased fat deposition.

Answer 73

* **hypoglycaemia** * **respiratory distress syndrome** – more common as lung maturation is delayed * **hypertrophic cardiomyopathy** – hypertrophy of the cardiac septum occurs in some infants. It regresses over several weeks but may cause heart failure from reduced left ventricular function * **polycythaemia** (venous haematocrit >0.65) – makes the infant look plethoric. (plethora = polycythaemia of newborns)**

Answer 74

It has **multifactorial aetiology** Genetic factors – can run in families 40%-60% have a genetic component Foetal factors – low birth weight is associated with hypertension Obesity High alcohol Alcohol intake Insulin intolerance Lack of physical activity Metabolic Syndrome X *cluster of conditions, such as high insulin levels, glucose intolerance, low levels of HDLs, central obesity*

Answer 75

○ Renal e.g. CKD ○ Endocrine e.g. Conn’s syndrome, acromegaly, Cushing’s syndrome ○ Coarctation of the aorta ○ Pre-eclampsia occurring during third trimester of pregnancy

Answer 76

Hypertension - Causes arteries to common less compliant, and narrowing of the lumen Can lead to Hyaline arteriosclerosis, which is protein deposition in the arterial wall, Lead to atherosclerosis and aneurysms forming - stroke Endothelial damage = CAD, ACS

Answer 77

ACE-Inhibitor e.g. Ramipril (or angiotensin receptor blocker e.g. candesartan if contraindicated e.g. due to cough)

Answer 78

calcium channel blocker e.g. amlodipine

Answer 79

ACE-inhibitor + CCB Or if afro Caribbean - CCB and ARB/ACEi or Thiazide like Diuretic

Answer 80

ACEi, eg Ramipril

Answer 81

eg Candesartan It's given instead of an ACE-inhibitor, if a ACE-i is contraindicated. You give ACE-i to anyone who is younger than 55, or not Black afro Caribbean, or someone with Diabetes at any age .

Answer 82

A patient with high BP which is diagnosed **prior to pregnancy or before week 20 of pregnancy** Their high BP is **not resolved** postpartum.

Answer 83

New high BP after 20w gestation and resolves after giving birth. There is no proteinuria or end organ damage

Answer 84

Pre-eclampsia is defined as **new-onset BP ≥ 140/90 mmHg** after ***20 weeks*** AND ≥ 1 of proteinuria, organ dysfunction Pre-eclampsia features a triad of: Hypertension Proteinuria Oedema Can also see Severe headache, visual disturbance, clonus, liver tenderness, abnormal liver enzymes,. plate count low Eclampsia is when seizures occur as a result of pre-eclampsia.

Answer 85

Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels. Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction

Answer 86

High-risk factors are: Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease Moderate-risk factors are: Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia GIve aspirin for either 1 high risk or 2 low risk factors

Answer 87

Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling) Oedema Reduced urine output Brisk reflexes

Answer 88

The NICE guidelines (2019) advise a diagnosis can be made with a: Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies) Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed . Since pre-eclampsia is being considered the GP should refer the patient to the nearest obstetric emergency department.

Answer 89

**Aspirin** is used for prophylaxis against the development of pre-eclampsia. It is given from ***12 weeks gestation until birth to women with:*** A single high-risk factor Two or more moderate-risk factors *aspirin is CI in breastfeeding btw*

Answer 90

High risk factors hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension Moderate first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy

Answer 91

Labetolol is first-line as an antihypertensive Nifedipine (modified-release) is commonly used second-line (needs to be rapidly acting) Treat coagulation defects, Check bloods, eg platelet, renal and liver magnesium sulphate if hyperreflexia (also prevents seizures in pregnant woman w eclampsia) **Respiratory rate is the most important parameter to monitor when administering magnesium sulphate for eclampsia, as it can cause respiratory depression** Planned early birth may be necessary if the blood pressure cannot be controlled, or decline in liver or renal function ***(monitor these closely)*** ^**This should resolve the pre eclampsia** Corticosteroids should be given to women having a premature birth to help mature the fetal lungs. Limit fluid intake as low protein, so extra fluids can cause oedema

Answer 92

Fetal growth restriction. Preeclampsia affects the arteries carrying blood to the placenta Preterm birth. Placental abruption. hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome. Eclampsia. Stroke Renal Failure oligohydramnos

Answer 93

Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate ***(4g vein over 15 minutes, followed by an infusion of 1g/hour maintained for 24 hours)*** is used to manage seizures associated with pre-eclampsia. **any seizure in a pregnant woman are always eclampsia until proven otherwise** **Respiratory rate** is the most important parameter to monitor when administering magnesium sulphate for eclampsia, as it can cause respiratory depression - **reverse with Calcium Gluconate**

Answer 94

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics: Haemolysis Elevated Liver enzymes Low Platelets

Answer 95

2-fold increase in iron requirements -> micro-cytic aneamia. B12/folate deficiency -> macrocytic anaemia. During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentratio

Answer 96

Booking bloods > 110 g/l 28 weeks gestation > 105 g/l Post partum > 100 g/l

Answer 97

Low MCV may indicate iron deficiency Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy Raised MCV may indicate B12 or folate deficiency

Answer 98

iron replacement (e.g. ferrous sulphate 200mg three times daily). not anaemic but low ferritin - supplementary iron. . Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). -Intramuscular hydroxocobalamin injections All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily *Women on antiepileptics, who try to conceive, should receive folic acid 5mg instead of 400mcg OD* Diabetics, those with thalasseamia trait, coeliac disease also need 5mg of folic acid as well as do obese pregnant women (>30BMI) folic acid daily until the 13th week of pregnancy, **(for the first trimester only)**

Answer 99

Asymptomatic (50%) Malodorous, purulent discharge from the urethra, cervix, vagina,3 to 5 days after exposure (40% to 60%) Simultaneous urethral infection (70% to 90%) Infection of the pharynx (10% to 20%) Gonococcal conjunctivitis (can rapidly lead to blindness) Polyarthritis Later on, can cause intermenstraul bleeding, pain when weeing, and lead to PID - which can lead to problems with fertililty

Answer 100

Male - urine, or urethreal swab if discharge - Female - Swab of endocervical cannal Rectum NAAT testing for both if not Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs Culture on **Gonococcus agar**

Answer 101

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 102

Women without chorioamnionitis Use Benzylpenicillin. Women with chorioamnionitis Use Benzylpenicillin plus gentamicin plus metronidazole. Gentamicin = Aminoglycoside (For gram neg) Metronidazole = For anaearobic cover

Answer 103

Mother - Can be Asymptomatic Preterm labor Chorioamnionitis PID For neonate - Conjunctivitis Pneumonia

Answer 104

1-week oral doxycycline (a tetracycline) Pregnant – oral erythromycin (14 days) or oral azithromycin - (macrolides)

Answer 105

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria.

Answer 106

Primary syphilis **involves a painless ulcer called a chancre at the original site of infection** Secondary syphilis Latent syphilis *symptoms disappear and the patient becomes asymptomatic despite still being infected.* Tertiary syphilis Neurosyphilis occurs if the infection involves the central nervous system

Answer 107

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 108

ypically starts after the chancre has healed, with symptoms of: Maculopapular rash **Condylomata lata** (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 109

. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep **intramuscular dose of benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis. **(in pregnancy, women who are allergic to penicillin should undergo penicillin desensitization and then be treated with penicillin)**

Answer 110

- Stillbirth * Maculopapular rash * Hepatosplenomegaly * Cardiovascular anomalies * Sensorineural deafness

Answer 111

during or relating to the period of about six weeks after childbirth (known as the puerperium) during which the mother's reproductive organs return to their original non-pregnant condition.

Answer 112

Endometritis C - Section infection Mastitis Breast engorgement Necrotising fasicitis Psychiatric issues

Answer 113

infection of the endometrium that often invades the underlying myometrium. Risk factors Miscarriage (when fetal tissue is left behind) C - Section Prolonged rupture of membranes, multiple vaginal examinations,

Answer 114

Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding. It occurs most commonly 5–10 days after delivery.

Answer 115

The first line is IV Clindamycin and Gentamicin Clindamycin is a lincosamide , gentamicin an Aminoglycoside .

Answer 116

This is a condition that refers to inflammation of the breast – It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus

Answer 117

Erythematous, tender, swollen area of breast – Systemic upset with fevers, chills and fatigue – 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied – If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days

Answer 118

Caused by vascular and lymphatic stasis May occur on days 2–4 postpartum in women who are not nursing or at any time if breastfeeding is interrupted. Management conservatively with ice packs and painkillers

Answer 119

Trichomonas vaginalis - its type of parasite classed as a protozoan, and is a single-celled organism with flagella Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.

Answer 120

Trichomonas can increase the risk of: Contracting HIV by damaging the vaginal mucosa Bacterial vaginosis Cervical cancer Pelvic inflammatory disease Pregnancy-related complications such as preterm delivery. Premature rupture of fetal membranes Can lead to prem baby and low birthweight

Answer 121

The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell. Itching Dysuria (painful urination) Dyspareunia (painful sex) Balanitis (inflammation to the glans penis) Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis

Answer 122

Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis. The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope). Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative. A urethral swab or first-catch urine is used in men. Treatment is with metronidazole.

Answer 123

pre-term premature rupture of membrane, maternal chorioamnionitis, intrauterine growth retardation low birth weight baby pre-eclampsia.

Answer 124

Testing for bacteria in the urine of asymptomatic patients is not recommended as it may lead to unnecessary antibiotics. Pregnant women are an exception to this rule, due to the adverse outcomes associated with infection. Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth. Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S).

Answer 125

Urinary tract infection in pregnancy requires 7 days of antibiotics. The antibiotic options are: Nitrofurantoin (avoid in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin

Answer 126

Mothers that have previously had chickenpox are immune and safe. When in doubt, IgG levels for VZV can be tested. A positive IgG for VZV indicates immunity. Chickenpox exposure in pregnancy - first step is to check antibodies

Answer 127

historically, exposure has been managed through the timely administration of varicella zoster immunoglobulin (VZIG). However, the guidance has changed due to a national/international VZIG shortage. **oral aciclovir** (or valaciclovir) is now the first choice of PEP for pregnant women at any stage of pregnancy antivirals should be given at day 7 to day 14 after exposure, not immediately When the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation. **consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash if the woman is < 20 weeks the aciclovir should be 'considered with caution'**

Answer 128

**T**oxoplasma Gondii **O**ther -Parvovirus B19, VZV, Zika, Syphilis **R**ubella **C**ytomegalovirus, Chlamydia, Coxsackie Virus **H**erpes Simplex 2, HIV, Hepatitis B

Answer 129

This is the term used to describe an abnormally low level of amniotic fluid during pregnancy – It is characterised by having less than <500ml at 32-36 weeks and amniotic fluid index (AFI) <5th percentile Prevalence: Rare in early pregnancy, common in postterm pregnancies (12% to 25% at 41 weeks).

Answer 130

Causes: – Low production of foetal urine –> Renal agenesis (Potter’s syndrome), dysplastic kidney, obstructive uropathy – Poor Placental diffusion –> Pre-eclampsia – Leakage of amniotic fluid –> Premature rupture of membranes - **Causes 50% or oligohydramnios** Other causes include congenital infection, fetal cardiac defects, neural tube defects, twin–twin transfusion syndrome, and non-steroidal antiinflammatory drugs

Answer 131

– Abnormal lie and development – ***Poor respiratory development*** –> amniotic fluid is needed for maturation of the alveoli, so infants are born with severe respiratory distress – Foetal muscle contractures (as amniotic fluid allows the fetus to move its limbs in utero) Amniotic band syndrome (adhesions between the amnion and fetus causing serious deformities, including limb amputation) or musculoskeletal deformities due to uterine compression (such as clubfoot) may develop in some cases.

Answer 132

Diagnosis: – Ultrasound is investigation of choice (shows level <5th centile) Management: – Increase maternal hydration - amniofusion (the introduction of normal saline via an intrauterine catheter placed through the partially dilated cervix during labour to stop cord compression)

Answer 133

This is the term used to describe an abnormally high level of amniotic fluid during pregnancy – It is used when the amniotic fluid index is above the 95th centile for gestational age – It causes over-distension of the uterus which can lead to preterm labour and other complications

Answer 134

– It is idiopathic in the majority of cases Maternal Diabetes, as amniotic fluid is dependent on degree of glycemic control, and **macrosomia** (big babies produce more urine) – Twin-to-twin transfusion syndrome –> leads to oligohydramnios for one and polyhydramnios for the other – Decreased swallowing of fluid –> foetal oesophageal/duodenal atresia or CNS abnormalities _ hydrops fetalis (foetal heart failure)

Answer 135

Signs and Symptoms * Uterine size larger than normal for stage of pregnancy * Dyspnea (especially when lying on back (supine)) * Premature labor * Difficulty palpating fetal parts or hearing fetal heart tones refractory edema of the lower extremities and vulva. * Diagnosis. Polyhydramnios should be suspected if the fundal height is significantly more than expected for gestational age. Diagnose wit It is defined via US as a total amniotic fluid volume >2L

Answer 136

Antacids to relieve heartburn and nausea for the mother Nonsteroidal anti-inflammatory drugs **(indomethacin)** can decrease fetal urine production, but may cause premature closure of the fetal ductus arteriosus. Removal of fluid by amniocentesis is only transiently effective.

Answer 137

Lie - the relationship between the long axis of the fetus and the mother. Presentation - the fetal part that first enters the maternal pelvis. Position – the position of the fetal head as it exits the birth canal.

Answer 138

Prematurity Multiple pregnancy Uterine abnormalities (e.g fibroids, partial septate uterus) Fetal abnormalities Placenta praevia - the placenta partially or wholly blocks the neck of the uterus Primiparity (first child)

Answer 139

Cephalic vertex presentation is the most common and is considered the safest Other presentations include breech, shoulder, face and brow

Answer 140

Longitudinal, transverse or oblique

Answer 141

**external cephalic version** (ECV) is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. C section delivery if unsuccessful It has an approximate success rate of 50% in primiparous women and 60% in multiparous women.

Answer 142

Breech – attempt ECV before labour, vaginal breech delivery or C-section Brow – a C-section is necessary Face - chin is anterior (mento-anterior) a try normal labour then C section chin is posterior (mento-posterior) then a C-section is necessary Shoulder – a C-section is necessary

Answer 143

– Complete –> this is where the complete caudal end of the fetus is in the lower segment - Frank –> this is the most common where buttocks occupy the lower segment – Footling –> this is the most dangerous form where the foot is in the pelvis

Answer 144

– Mother –> Malformations of the uterus, large fibroids, previous uterine surgery – Pregnancy –> Placenta Praevia, poly/oligohydramnios, prematurity

Answer 145

If <36 weeks: – No action is required yet as many foetuses will turn spontaneously to cephalic presentation If >36 weeks: – 1st line is external cephalic version (ECV) to turn baby into cephalic presentation – It is offered at **36 weeks for 1st time mothers and 37 weeks for multiparous women** – However, this cannot be **offered if there are multiple pregnancies or ruptured membranes** If unsuccessful: – Offer elective Caesarean section or vaginal breech delivery if breech postion was discovered when shes in the second stage of labour (fully dilated)

Answer 146

a) insufficient uterine contractions (so can just give syntocinon) b) Cephalopelvic disproportion (so givng syntoncinon isnt gonna help, need C section)

Answer 147

- because after birth - uteris becomes fibrous tissue - more prone to rupture in future prengancies

Answer 148

When the size of pelvis cant allow the foetus to pass through the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large fetus, an unfavorable orientation of the fetus, or a combination of these factors

Answer 149

In the case of a fetus being too large, some obstetricians recommend induction of labour for earlier delivery. Diagnosis of CPD in active labour will usually result in a Caesarian section

Answer 150

Uterine rupture refers to a full-thickness disruption of the uterine muscle and overlying serosa. It typically occurs during labour, and can extend to affect the bladder or broad ligament. There are two main types: Incomplete – uterine serosa (perimetrium) surrounding the uterus remains intact.. In this case, the uterine contents remain within the uterus. Complete – complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Answer 151

Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 152

Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Answer 153

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 154

There are 3 stages. in the third trimester, before Labor starts , a woman might have a **plug of mucus and blood fall out of the opening to the cervix** sometimes called the bloody shell other times the **amniotic sac might rupture** sometimes called water breaking either of these can trigger the onset of Labor - this releases loads of prostaglandins which stimulate labour

Answer 155

Braxton Hicks contractions are irregular, mild uterine contractions that can occur during pregnancy, often called "practice contractions." They are typically painless, do not increase in intensity or frequency, and do not lead to labor. They can go away with changing postion/movements, true contractions wont

Answer 156

The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner from front to back). Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. (can take 24 hours in primgravida) Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. (can take 4-6 hours in primigravida) (examination every 4 hours) Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 157

The second stage of labour lasts from 10cm dilatation of the cervix to delivery of the baby The success of the second stage depends on “the three Ps”: power, passenger and passage.

Answer 158

Size: particularly the size of the head as this is the largest part. Attitude: the posture of the fetus. For example, how the back is rounded and how the head and limbs are flexed. Lie: the position of the fetus in relation to the mother’s body: Presentation: the part of the fetus closest to the cervix:

Answer 159

The third stage of labour is from the completed birth of the baby to the delivery of the placenta. Can be done naturally/physiologically or Active management from Dr or Midwife ==>involves giving a dose of intramuscular oxytocin to help the uterus contract and expel the placenta. Careful traction is applied to the umbilical cord to guide the placenta out of the uterus and vagina.

Answer 160

Descent Obstetricians describe the position of the baby’s head in relation to the mother’s ischial spines during the descent phase. Descent is measured in centimetres, from: -5: when the baby is high up at around the pelvic inlet 0: when the head is at the ischial spines (this is when the head is “engaged”) +5: when the fetal head has descended further out

Answer 161

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section key complicaiton of AROM - amniotic fluid embolism

Answer 162

. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

Answer 163

Prematurity is defined as birth before 37 weeks gestation Babies are considered non-viable below 23 weeks gestation. Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival.

Answer 164

**Fetal fibronectin** is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely If the fetal fibronectin test result is positive (concentration more than 50 ng/ml), preterm labour should be diagnosed and treatment offered.

Answer 165

Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation) Prophylactic antibiotics should be given to prevent the development of chorioamnionitis==> **Erythromycin** antibioticsfor 10 days following premature preterm rupture of membranes, or until the woman is in established labour, whichever is sooner. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 166

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac Clinical assessment includes a speculum examination to assess for cervical dilatation. Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour. More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length

Answer 167

Fetal monitoring (CTG or intermittent auscultation) Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth *Administering steroids can cause hyperglycemia in diabetics, and therefore close attention should be paid to the blood glucose measurements. Hyperglycaemia in the mother can cause adverse outcomes for the fetus, which is why extra care must be taken. Hourly blood glucose measurements must be taken, and additional insulin given as required.*

Answer 168

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. - Inhibits myometrium contractions Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated. It is only used as a short term measure (i.e. less than 48 hours).

Answer 169

The lungs and brain are most likely to be affected as these develop in the 3rd trimester.

Answer 170

Intra-amniotic infection 50 Multiple gestation 40 Placental abruption 35 Third trimester vaginal bleeding 10 Second trimester vaginal bleeding 2 Prior preterm delivery 2–5 numbers are relative risk

Answer 171

Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes before the onset of labor.

Answer 172

Preterm PROM (PPROM) refers to PROM at <37 weeks. Prolonged PROM refers to PROM >24 hours and is associated with an increased risk of intra-amniotic infection Previous PROM, infection, smoking, vaginal bleeding during pregnancy, amniocentesis, polyhydramnios, multiple pregnancy, cervical insufficiency.

Answer 173

A history of Gush of fluid causing a woman to be constantly wet On speculum exam Pooling of fluid in posterior vaginal fornix. Or Absence of vaginal discharge. 1 A pool of vaginal fluid 2 Fluid turns nitrazine paper blue (pH of amniotic fluid is 7.0–7.7 compared with vaginal pH of 4.5) 3 Microscopic 'ferning' of vaginal fluid (refers to crystallization of amniotic fluid on drying) Note: bimanual examinations should be avoided (because they promote ascending intraamniotic infection)

Answer 174

* Urine analysis and culture for UTI/asymptomatic bacteriuroia * Cervical test or culture for C. trachomatis/N. gonorrhoea * Vaginal tests for bacterial vaginosis (BV) and trichomoniasis * Introital/rectal culture for group B streptococcus (GBS) **Basically just loads of tests for microbes!**

Answer 175

For both Both expectant management (watchful waiting) and an induction of labor (artificially stimulating labor) are considered in this case. 90% of women start labor on their own within 24 hours, and therefore it is reasonable to wait for 12–24 hours as long as there is no risk of infection Antibiotics if needed to prevent group B streptococcus (GBS) transmission. - **benzylpenicillin** - if - Known Maternal GBS Colonization or GBS Bacteriuria in the current pregnancy. Previous Baby with Neonatal GBS Disease. If GBS status is unknown and there are additional risk factors (e.g., fever, prolonged rupture of membranes >18 hours, or preterm PROM).

Answer 176

Benzylpenicillin is the antibiotic of choice for GBS prophylaxis Intravenous and Intrapartum (aka during labour)

Answer 177

Watchful waiting (expectant management) - Tocolytics to prevent the beginning of labor Magnesium sulfate infusion for 24–48 hours to allow maximum efficacy of corticosteroids for fetal lungs and also confer benefit to fetal brain and gut before delivery One time dose of corticosteroids (two separate administrations, 12–24 hours apart) before 34 weeks Antibiotics if needed to prevent GBS transmission Administering steroids can cause hyperglycemia in diabetics, and therefore close attention should be paid to the blood glucose measurements. Hyperglycaemia in the mother can cause adverse outcomes for the fetus, which is why extra care must be taken. Hourly blood glucose measurements must be taken, and additional insulin given as required.

Answer 178

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, **Happens after rupture of the fetal membranes** Causes foetal hypoxia in 2 ways = can get compressed, or when exposed to the outside temperature, can lead to vasospasm and subsequent hypoxia

Answer 179

Malpresentation (breech, transverse lie), polyhydramnios, small fetus, prematurity. **50% of patients with an umbilical cord prolapse will have undergone artificial rupture of membranes.**

Answer 180

Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis. 50% of patients with an umbilical cord prolapse will have undergone artificial rupture of membranes.

Answer 181

Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby. Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm).

Answer 182

When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section. Can insert fluid into baldder via catheriter if at home

Answer 183

ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery A single dose of co-amoxiclav is recommended after instrumental delivery to reduce the risk of maternal infection.

Answer 184

The decision to perform an instrumental delivery is based on the clinical judgement of the midwife or obstetrician. Some key indications are: Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions there is an increased risk of requiring an instrumental delivery when an epidural is in place for analgesia.

Answer 185

only use forceps at full dilatation (10cm) (or you'll be pulling on the cervix ==> uterine rupture) Only when station is 0 or +1 Has to be occipital anterior position (determine the position by feeling for the suture lines) You must empty the bladder Membranes need to be ruptured Need to give lots of pain relief And make sure there are no signs of Cephalopelvic disproportion

Answer 186

Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve)

Answer 187

Injury to the femoral nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg. The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Answer 188

a cut in the area between the vagina and anus (perineum) during childbirth, to **make the opening of the vagina a bit wider**, allowing the baby to come through it more easily. Sometimes a woman's perineum may tear as their baby comes out. In some births, an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly. *Episiotomy is equivalent to a second-degree perineal laceration*

Answer 189

Cephalohaematoma with ventouse Facial nerve palsy with forceps The main complication for the baby is cephalohaematoma. This involves a collection of blood between the skull and the periosteum. The main complication for the baby is facial nerve palsy, with facial paralysis on one side. Forceps delivery can leave bruises on the baby’s face. Rarely the baby can develop fat necrosis, leading to hardened lumps of fat on their cheeks ***only use forceps whem mum is fully dilated at 10cm, or youll attach and pull the cervix**

Answer 190

First degree - tear within vaginal mucosa only.

Answer 191

Second degree - tear into sub-cutaneous tissue.

Answer 192

Third degree - laceration extends into external anal sphincter.

Answer 193

Fourth degree - laceration extends through external anal sphincter into rectal mucosa.

Answer 194

1. Primigravida. 2. Macrosomia and shoulder dystocia. 3. Forceps delivery. 1st degree - repair on own ] 2nd degree - suture on ward by midwife or suitably experieinced clinician 3rd and 4th degree - require repair in theatre by a suitably trained clinician

Answer 195

a large or abnormally positioned baby - **eg shoulder dystocia, or macrosomia** small pelvis - **if a girl is a teenager/young, malnutrition or lack of vit D exposure** problems with the birth canal - **FGM, tumors**

Answer 196

When **anterior shoulder** of the baby becomes stuck **behind the pubic symphysis** of the pelvis, after the head has been delivered It requires specific maneuvers to facilitate delivery. With babies head out, uterus will still be contracting, but baby will want to breathe - but it can't, because chest is compressed

Answer 197

1. Macrosomia. **(secondary to gestational diabetes, is most common cause)** 2. Maternal diabetes. 3. Post-maturity. 4. Obesity. 5. Prolonged labour. 6. Use of forceps/venoutse 7. IOL 8. Prolonged 1st/2nd stage of labour

Answer 198

HELPERR: ``` H - call for Help. E - evaluate for Episiotomy. **(often large one)** L - Legs in McRoberts. P - suprapubic Pressure. E - Enter pelvis. - Rubin’s maneuver or Wood’s Maneuver R - Rotational manoeuvres. R - Remove and deliver posterior arm. ```

Answer 199

McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Rubins manouvre = (press on the posterior shoulder to allow the anterior shoulder extra room) Woodscrew - putting a hand in the vagina and rotating the foetus 180 degrees in attempt to 'dislodge' the anterior shoulder from the symphysis pubis. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery

Answer 200

1. Vaginal tear. 2. PPH. 3. PTSD. 4. Bladder/uterine rupture.

Answer 201

1. Cerebral palsy. 2. Hypoxia. 3. Brachial plexus injury. 4. Fractured humerus/clavicle. Fits

Answer 202

Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels Myometrium, the middle layer that contains smooth muscle Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa) Usually the placenta attaches to the endometrium. This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby.

Answer 203

With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond There are three further definitions, depending on the depth of the insertion

Answer 204

Risk Factors Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 205

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond Placenta increta is where the placenta attaches deeply into the myometrium Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder A - I - P = alphabetical in terms of depth

Answer 206

Ideally, placenta accreta is diagnosed antenatally by ultrasound Patients may require additional management at birth due to the risk of bleeding and difficulty separating the placenta. This may include: Complex uterine surgery Blood transfusions Intensive care for the mother Neonatal intensive care The options during caesarean are: Hysterectomy with the placenta remaining in the uterus (recommended) Expectant management, leaving the placenta in place to be reabsorbed over time *If placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended.*

Answer 207

Prolonged Gestation Women with uncomplicated pregnancies should be offered IOL between 40+0 to 40+14 weeks’ gestation Premature Rupture of Membranes Maternal Health Problems *eg hypertension, pre-eclampsia, diabetes and obstetric cholestasis.* Fetal Growth Restriction *the second most common indication for induction of labour* Intrauterine Fetal Death

Answer 208

Cephalopelvic disproportion Major placenta praevia Vasa praevia Cord prolapse Breech presentation Triplet or higher order pregnancy Transverse lie Previous classical Caesarean section - Increased risk of emergency C section and uterine rupture

Answer 209

**Vaginal Prostaglandins**- act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus - **mainstay** **Amniotomy** where the membranes are ruptured artificially using an instrument called an amnihook. Give artificial oxytocin (Syntocinon) alongside will be to increase the strength and frequency of contractions. **Membrane sweep** - It is classified as an adjunct of IOL. Performing it increases the likelihood of spontaneous delivery. Done by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua. With amniotomy and membrane sweep, this process releases prostaglandins in an attempt to expedite labour

Answer 210

It's an assessment of ‘cervical ripeness‘ based on measurements taken during vaginal examination. Score of ≥ 8 – suggests the cervix is ripe or ‘favourable’ – this means that there is a high chance of a response to interventions made to induce labour (i.e. induction of labour is possible). Bishop score is **> 6 = amniotomy and an intravenous oxytocin infusion** is the preferred method of induction of labour if the Bishop score is **≤ 6 = Vaginal PGE2 or oral misoprostol** is the preferred method of induction of labour. It is checked prior to induction, and during induction to assess progress **(6 hours post-table/gel, 24 hours post-pessary):**

Answer 211

Dilation of cervix Length of Cervix Station (Position of top of head in relation to ischial spines) Consistency of cervix Position of cervix Failure of a cervix to ripen despite use of prostaglandins may result in the need for a caesarean section.

Answer 212

Maternal * Failed induction of labor * Failure to progress (labor dystocia) * Cephalopelvic disproportion Uteroplacental * Previous uterine surgery (classical cesarean) * Prior uterine rupture * Outlet obstruction (fibroids) * Placenta previa, large placental abruption Fetal * “Fetal distress”/non-reassuring fetal testing * Cord prolapse * Fetal malpresentation (transverse lie)

Answer 213

Placenta praevia is where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. Low-lying placenta is used when the placenta is within 20mm of the internal cervical os Placenta praevia is used only when the placenta is over the internal cervical os *Praevia directly translates from Latin as “going before”*

Answer 214

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) **Assisted reproduction (e.g. IVF)** *indeed, In a large Norwegian study in 2006 it was found that there was a six-fold higher risk of placenta praevia in singleton pregnancies conceived by assisted fertilisation compared with naturally conceived pregnancies.*

Answer 215

The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.**if low lying, resacn at 32 weeks to assess ** Many women with placenta praevia are asymptomatic. It may present with painless vaginal bleeding in pregnancy - **usually bright red** (antepartum haemorrhage). Bleeding usually occurs later in pregnancy (around or after 36 weeks). *placental abruption presents with pain, and dark red blood* can do a speculum, don't do a digital exam

Answer 216

repeat **transvaginal ultrasound scan at 32 and 36 weeks** Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os). As main complicaton is bleeding, may need Emergency caesarean section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy If mother is Rh negative and foeus is Rh postive, then give Anti D - to prevent mother sensitisation If a woman with known **placenta praevia goes into labour (with or without bleeding), an emergency caesarean** section should be performed

Answer 217

when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates.

Answer 218

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gestation; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 219

Sudden onset severe abdominal pain that is continuous **in third trimester** O/E - extreme pain and cold to touch Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating fetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Answer 220

Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage. Concealed abruption is opposed to revealed abruption, where the Fblood loss is observed via the vagina.

Answer 221

There are no reliable tests for diagnosing placental abruption. It is a clinical diagnosis!! - Ultrasound can be useful in excluding placenta praevia, nut not that helpful (only 2% seen on USS) Avoid doing Digital vaginal exam, as can worise bleeidng look for risk factors and hvae high index of suspicion Tends to be normal - Normal (longitudinal lie and cephalic presentation).

Answer 222

2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4-6 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally There is an increased risk of stillbirth so it's recommended to deliver at 37-38 weeks. Active management of the third stage is recommended. where the foetus is viable, under 36 weeks of gestation, and not exhibiting distress, it is recommended that corticosteroids be administered to enhance foetal lung maturation. As per the **RCOG guidelines**: In women presenting with APH before 37+0 weeks of gestation, where there is no **maternal or foetal compromise and bleeding has settled**, there is ***no evidence*** to support elective premature delivery of the foetus.

Answer 223

Vasa praevia is a condition in which the fetal vessels are exposed, **outside the protection of the umbilical cord or the placenta**. The fetal vessels travel **through the chorioamniotic membranes,** and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, **particularly when the membranes are ruptured during labour and at birth.** This can lead to dramatic fetal blood loss and death. No major maternal risk , but **major fetal risk**

Answer 224

Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes. Risk factors Low lying placenta IVF pregnancy Multiple pregnancy

Answer 225

Ideally picked up on ultrasound during pregancy - when membranes rupture - Present as an antepartum haemorrhage, Painless!! It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes

Answer 226

For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend: Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs.

Answer 227

Bleeding from anywhere in the genital tract after 24w gestation.

Answer 228

placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality. Can also be unexplained

Answer 229

cervical ectropion, infection and vaginal abrasions from intercourse or procedures.

Answer 230

Spotting = Stains, streaking, or spotting of blood Minor Haemorrhage = Less than 50mL Major Haemorrhage = 50-1000mL without signs of circulatory shock Massive Haemorrhage = Greater than 1000mL with or without signs of circulatory shock

Answer 231

Premature labour/delivery Blood transfusion *(formation of antibodies)* Acute tubular necrosis (+/- renal failure) DIC PPH! ITU admission ARDS (secondary to transfusion) Fetal morbidity (hypoxia) and mortality Foetal growth restriction

Answer 232

Happens when rhesus anitgens on surface of mother and foetus RBC aren't compatabile If mother is rhesus D negative, and fetus is Rhesus D postive, **foetal blood can cross placenta** and enter mothers bloodstream ==> Mother will recognise the rhesus D antigen as foreign and produce antibodies to it ==> **(mother becomes sensitised to rhesus D antigens)** Usually not a problem in inital pregnacy If pregnant again, **mothers anti-D antibodies can cross the placenta**. If that fetus is rhesus positive, these **antibodies attach themselves to the red blood cells of the fetus** and causes the immune system of the fetus to attack its own red blood cells

Answer 233

Keilhauer test - blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream. to see if mum has been sensitised

Answer 234

Phototherapy – Expose to ultraviolet light, converts unconjugated bilirubin to a conjugated form that is easier for the infant to clear. Immunoglobulin therapy

Answer 235

Anti-D prophylaxis can be given. This destroys Rh+ IgG and so no RBC are attacked.

Answer 236

1. Miscarriage. 2. Abortion. 3. Amniocentesis. 4. Placental abruption. 5. During delivery.

Answer 237

Anti-D! There is a risk of sensitisation.

Answer 238

85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally.

Answer 239

Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.

Answer 240

Female Age > 35 Menstrual disorder Previous abdominal / pelvic surgery Previous PID / STD Abnormal pelvic examination Male Previous genital pathology Previous urogenital surgery Previous STD Systemic Illness Abnormal genital examination

Answer 241

Sperm problems (30%) Ovulation problems (25%) Tubal problems (20%) Uterine problems (10%) Unexplained (25%) 40% of infertile couples have a mix of male and female causes.

Answer 242

There is some general lifestyle advice for couples trying to get pregnant: The woman should be taking 400mcg folic acid daily Aim for a healthy BMI Avoid smoking and drinking excessive alcohol Reduce stress as this may negatively affect libido and the relationship Ensure smears are up to date Aim for intercourse every 2 – 3 days Avoid timing intercourse

Answer 243

Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS) Chlamydia screening Semen analysis Female hormonal testing (see below) Rubella immunity in the mother

Answer 244

1. PCOS. 2. Miscarriage. 3. Infertility. 4. Obstetric complications. Lower ART success

Answer 245

Ovulation / ovarian function / ovarian reserve Semen Quality Tubal Patency (+ Uterus)

Answer 246

Serum LH and FSH on day 2 to 5 of the cycle Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle). Anti-Mullerian hormone Thyroid function tests when symptoms are suggestive Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea

Answer 247

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development. High LH may suggest polycystic ovarian syndrome (PCOS).

Answer 248

A rise in progesterone 7 days before end of cycle indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone. Ideally, (length of cycle minus 7 days) peak luteal progesterone levels should be 10ng/ml or higher Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Answer 249

What It Is: OHSS involves an exaggerated response of the ovaries, leading to excessive growth of ovarian follicles and fluid leakage from the blood vessels into the abdominal and other body cavities. It can range from mild to severe. caused by fertilitiy treatment bHCG injections Ascties, D, and V , decreased urine output, enlarged ovaries

Answer 250

Young age Polycystic ovary syndrome (PCOS) High doses of fertility medications (gonadotropins) Elevated estrogen levels during treatment Previous history of OHSS Use of hCG to trigger ovulation Treatment of OHSS: Mild Cases: Rest, hydration, pain relief, and monitoring. Moderate to Severe Cases: Hospitalization Intravenous fluids to restore balance Paracentesis (draining fluid from the abdomen) if needed LMH Avoidance of hCG injections and freezing embryos for later use

Answer 251

<5m/ml. Further testing may include endocrine tests and karyotyping e.g. klinefelters.

Answer 252

1. HSG (hysterosalpingogram) imaging. 2. HyCoSy (Hysterosalpingo-contrast-sonography). 3. Laparoscopy.

Answer 253

The options when anovulation is the cause of infertility include: Weight loss for overweight patients with PCOS can restore ovulation Clomifene may be used to stimulate ovulation Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects) Gonadotropins may be used to stimulate ovulation in women resistant to clomifene Ovarian drilling may be used in polycystic ovarian syndrome Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

Answer 254

Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH. Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

Answer 255

Mild - Intrauterine Insemination (IUI) - Moderate abnormality - IVF Severe – Intracytoplasmic Sperm Injection (ICSI) For Azoospermia : Surgical Sperm Recovery Donor Insemination

Answer 256

The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include: Tubal cannulation during a hysterosalpingogram Laparoscopy to remove adhesions or endometriosis In vitro fertilisation (IVF)

Answer 257

Stimulated Intrauterine Insemination (SIUI) In Vitro Fertilisation (IVF) - Intracytoplasmic Sperm Injection (ICSI) - Surgical Sperm Recovery (PESA/TESE) - Embryo Freezing Donor insemination - Donor Egg - Donor Embryo - Host Surrogacy

Answer 258

Ovarian stimulation -> egg collection -> insemination -> fertilisation check -> embryo culture -> embryo transfer -> luteal support.

Answer 259

To avoid multiple pregnancy.

Answer 260

1. Multiple pregnancy. 2. Miscarriage. 3. Ectopic pregnancy. 4. Foetal abnormality.

Answer 261

1. Increasing age -> reduced egg quality. 2. Successive cycles/longer duration infertility. 3. Obesity. 4. Environmental factors e.g. smoking, alcohol, caffeine.

Answer 262

1. Endometrial polyps. 2. Fibroids e.g. sub-mucous will significantly affect pregnancy rates. 3. Adhesions.

Answer 263

1. Intermittent auscultation using a pinard stethoscope or a hand held doppler. 2. Continuous monitoring: cardiotocography (CTG). Doppler Scanner is first line to establsih a babys heart beat as is v quick and easy to use

Answer 264

Operation Two transducers are placed on the abdomen to get the CTG readout: One above the fetal heart to monitor the fetal heartbeat One near the fundus of the uterus to monitor the uterine contractions The transducer above the fetal heart monitors the heartbeat using Doppler ultrasound. The transducer above the fundus uses ultrasound to assess the tension in the uterine wall, indicating uterine contraction.

Answer 265

Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops

Answer 266

Sepsis Maternal tachycardia (> 120) Significant meconium Pre-eclampsia (particularly blood pressure > 160 / 110) Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain

Answer 267

reassuring, non-reassuring and abnormal | >180 bpm.

Answer 268

Reassuring 110 – 160 Non-reassuring 100 – 109 or 161 – 180 Abnormal Below 100 or above 180

Answer 269

Reassuring 5 – 25 Non-reassuring Less than 5 for 30 – 50 minutes or More than 25 for 15 – 25 minutes Abnormal Less than 5 for over 50 minutes or More than 25 for over 25 minutes

Answer 270

An increase in the baseline HR by 10-15 bpm.

Answer 271

The presence of accelerations is reassuring.

Answer 272

Decelerations are non-reassuring. Foetal hypoxia causes them due to a lack of oxygen to the unborn baby, causes the foetal heart rate to decelerate because the baby's body recognizes the low oxygen levels and tries to compensate by slowing down the heart rate in an attempt to conserve oxygen and maintain vital functions.

Answer 273

Early decelerations are seen just before a uterine contraction. They may be due to foetal head compression.

Answer 274

Late decelerations are seen just after uterine contraction. They may be due to placental insufficiency and are often more sinister.

Answer 275

When there is a mixture of early and late decelerations.

Answer 276

- Normal: everything is normal and accelerations are present. Suspicious: a single non-reassuring feature Pathological: two non-reassuring features or a single abnormal feature Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

Answer 277

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression (given an overall impression of the CTG and clinical picture)

Answer 278

. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. *thought to be caused by increased oestrogen and progesterone levels* The condition resolves after delivery of the baby. it's relatively common (1% pregnant women) Happens in the 3rd trimester

Answer 279

Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester. Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet. Fatigue Dark urine Pale, greasy stools Jaundice ***^Post Hepatic symptoms, as blockage of outflow*** Importantly, there is no rash associated with obstetric cholestasis. If a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.

Answer 280

Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis Importantly, there is no rash associated with obstetric cholestasis. If a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.

Answer 281

Obstetric cholestasis will cause: Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids *It is normal for alkaline phosphatase (ALP) to increase in pregnancy. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.*

Answer 282

Emollients (i.e. calamine lotion) to soothe the skin Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching) Ursodeoxycholic acid, (Ursodiol) to lower toxic bile acids Vitamin K can be given if doctors are worried about low Vit and PT time, as is a Fat solubale vitiman so needs bile in the gut to be absorbed =Can increase the chance of a stillbirth - So IOL is offered usually 37-38 weeks gestation - Only if LFT's/bile acids are significantly deranged IOL IS NOT RECCOMMNEDED BEFORE 37 WEEKS

Answer 283

Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation According to the Royal College of Obstetricians and Gynaecologists (RCOG), a discussion should take place with women regarding induction of labour after 37+0 weeks of gestation. However, in most cases, IOL is best avoided unless there are significantly deranged LFT's/bile acid levels. Women should be informed that the case for intervention (after 37+0 weeks of gestation) may be stronger in those with more severe biochemical abnormality (transaminases and bile acids). Induction of labour is not advised nor recommended at earlier gestation periods (prior to 37 weeks) hence, 34, 35, and 36 weeks is the incorrect answer.

Answer 284

after 28 weeks - do CTG, and can think about IOL Before then - Just have a listen for foetal heart sounds Babies sleep for no more than 90 mins should have established patterns of mveoments by 28 weeks Need to compare with whats normal for that individual mum and baby reduced moements -= baby is tired

Answer 285

Category 1: An immediate threat to the life of the mother or baby. This includes conditions like suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia, or persistent fetal bradycardia. Category 1 C-sections are considered emergencies and should be **performed within 30 minutes.** Category 2: A maternal or fetal compromise that is not immediately life-threatening. Should be **perfomred within 75 minutes** Category 3: An early birth is needed, but there is no immediate risk to the mother or baby. Category 4: A birth that is scheduled to suit the mother or healthcare provide

Answer 286

having an estimated foetal weight (EFW) or birth weight **below the 10th percentile for gestational age**. maternal - smoking, poor nutrition, conditions like hypertension, diabetes, CKD, **torch** infections, very young mother Placental insufficines - Preeclampsia, placenta praevia Foetal factors - Trisomy 21, 18 and 13 - Turners syndrome - Intraauterine infections, like TORCH

Answer 287

A) Abdominal circumference less than the 10th centile for gestation Abdominal circumference (AC) is the most sensitive ultrasound parameter for detecting fetal growth restriction or SGA. It reflects fetal size, particularly the liver and abdominal fat stores, which are most affected by reduced nutrient supply or placental insufficiency. A fetal abdominal circumference below the 10th centile is a strong indicator of SGA, and it is commonly used to define and diagnose SGA.

Answer 288

previous uterine rupture or classical caesarean scar

Answer 289

8 - 12 weeks (ideally < 10 weeks) Booking visit general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes BP, urine dipstick, check BMI Booking bloods/urine FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies hepatitis B, syphilis HIV test is offered to all women urine culture to detect asymptomatic bacteriuria

Answer 290

10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy 11 - 13+6 weeks Down's syndrome screening including nuchal scan *(confirm dates just before you get down)*

Answer 291

18 - 20+6 weeks = Anomaly scan *(leave home and get wierd at 18)* ***can ideally pick up placenta praevia here if present*** BP, urine dipstick, symphysis-fundal height (SFH) First dose of anti-D prophylaxis to rhesus negative women at 28 weeks Second dose of anti-D prophylaxis to rhesus negative women* 34 weeks

Answer 292

Any three of: ethnicity (specified), booking BMI, pre-existing medical conditions such as **hypertension,** past obstetric history of hypertension or**pre-eclampsia** social history including **smoking or taking other drugs** Accept “multiple pregnancy, previous IUGR

Answer 293

The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis of hyperemesis gravidarum: RCOG 5% pre-pregnancy weight loss dehydration electrolyte imbalance Thyroid function tests are not helpful for diagnosis because they are often transiently abnormal in women with this condition. Sometimes women with hyperemesis can mimic biochemical hyperthyroidism as hCG, at high levels, can stimulate TSH receptors haematocrit in the FBC, raised transaminases and lowered albumin in the LFTs, lowered potassium, sodium and metabolic hyperchloremic alkalosis in the U+Es and ketones in the urine

Answer 294

simple measures rest and avoid triggers e.g. odours bland, plain food, particularly in the morning ginger P6 (wrist) acupressure first-line medications antihistamines: oral cyclizine or promethazine phenothiazines: oral prochlorperazine or chlorpromazine second-line medications oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. if ondansetron is used then these risks should be discussed with the pregnant woman oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days admission may be needed for IV hydration

WOMEN'S HEALTH 1 - Obstetrics Flashcards

(319 cards)