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Obstetrics DR S MOOSA FY1SBA 1 A 28-year-old woman presents to her obstetrician at 10 weeks gestation with complaints of nausea, vomiting, and breast tenderness. She has missed her last menstrual period. What is the most likely cause of her symptoms? A) Ectopic pregnancy B) Threatened miscarriage C) Normal physiological changes of pregnancy D) Hyperemesis gravidarum E) Ovarian hyperstimulation syndromeSBA 2 Amelia Pott, a 23 year old female attends her GP on the 25 April following a positive pregnancy test. She th is keen to know when the baby will be due. Her last menstrual period was on the 10 of April, she has regular menstrual cycles. What is her estimated date of delivery? 1. 7 December 2. 7 Jan 3. 18 December 4. 19 Jan 5. 17 Jan Naegels rule 1.First, determine the first day of your last menstrual period. 2.Add 1 year and 7 days to that date. 3.Next, count back 3 calendar months from that date 10 of April 17 of April th 17 Jan It is prudent for the obstetrician to get a detailed menstrual history, including duration, flow, previous menstrual periods, and hormonal contraceptives. Therefore, please mention that information! SBA 3 found that she had stage 2 hypertension following an ambulatory reading of 150/95 mmHg. Sinceher GP then, her blood pressure has been managed by 10mg ramipril daily. Today, her sitting blood pressure is 135/85 mmHg. What is the most appropriate action? A. Switch to methyldopa B. Continue ramipril C. Switch to labetalol D. Switch to amlodipine E. Stop ramipril and monitor blood pressureHypertension in pregnancy Pre-existing hypertension Pregnancy-induced hypertension Pre-eclampsia (PIH, also known as gestational hypertension) A history of hypertension before pregnancy or an Hypertension (as defined above) occurring in Pregnancy-induced hypertension in elevated blood pressure > 140/90 mmHg before 20 the second half of pregnancy (i.e. after 20 association with proteinuria (> 0.3g / 24 weeks gestation weeks) hours) No proteinuria, no oedema No proteinuria, no oedema Oedema may occur but is now less commonly used as a criteria Occurs in 3-5% of pregnancies and is more common Occurs in around 5-7% of pregnancies in older women Occurs in around 5% of pregnancies Resolves following birth (typically after one If a pregnant woman takes an ACE inhibitor or month). Women with PIH are at increased risk angiotensin II receptor blocker (ARB) for pre-existing of future pre-eclampsia or hypertension later in hypertension this should be stopped immediately and life alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review SBA 4 A nurse informs you of Rosemary John, a 28-year-old woman who is 24 weeks pregnant. He says that she has a blood pressure reading of 155/90 mmHg. Her previous blood pressure 2 days ago was 152/85 mmHg. She was previously healthy prior to becoming pregnant. What is the first line management in this situation? A. Hydralazine B. Urgent delivery of the foetus C. Lifestyle interventions D. Oral labetalol E. IM steroid injections SBA 5 Sophia Hodgekinson, aged 36, visits her GP upon discovering her pregnancy. She has a history of depression and is presently using sertraline. What course of action would you recommend concerning her medication? A. Stop sertraline as it can lead to congenital heart diseases B. Stop sertraline as it can lead to the development of ASD C. Stop sertraline as it can cause low birth weight D. Continue sertraline E. Stop sertraline as it can lead to preterm labour SBA 6 A 25-year-old woman undergoes a vaginaldelivery at 39 weeks gestation, followed by a physiological third stage of labour.Shortly after, she loses 600ml of blood. Help is called for, and an ABCDE assessment is made. IV access compressed to stimulate contractionshowever, she continues to lose blood.erised, and the uterus has been The patient'sonly medical history includes asthma, and she does not have any known coagulopathy. What is the most appropriate next step in her management? A. IM carboprost B. IV carboprost C. IV oxytocin D. IV tocolytics E. Intrauterine balloon tamponade PPH blood loss of > 500 ml • PPH is a life-threateningemergency - senior members of staff should be involved immediately Surgical: if medical options fail to control the bleedingthen surgical options will need to be urgentlyconsidered • ABC approach • the RCOG state that the intrauterine balloon • two peripheral cannulae, 14 gauge tamponadeis an appropriate first-line €˜surgical' • lie the woman flat interventionfor most women where uterineatony is the only or main cause of haemorrhage • bloods includinggroup and save • other options include: B-Lynch suture, ligation of the • commence warmed crystalloid infusion uterine arteries or internal iliac arteries • if severe, uncontrolledhaemorrhage then a hysterectomy • mechanical is sometimes performedas a life-savingprocedure • palpate the uterine fundusand rub it to stimulate contractions • catheterisation to prevent bladderdistension and monitor urine output • medical • IV oxytocin: slow IV injection followed by an IV infusion • ergometrine slow IV or IM (unless there is a history of hypertension) • carboprost IM (unless there is a history of asthma) • misoprostol sublingual • there is also interest in the role tranexamic acid may play in PPH SBA 7 Which one of the following drugs is contra-indicated whilst breast feeding? A. Warfarin B. Cephalosporins C. Aspirin D. Tricyclic antidepressants E. ChlorpromazineThe following drugs should be avoided: •antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides •psychiatric drugs: lithium, benzodiazepines •aspirin •carbimazole •methotrexate •sulfonylureas •cytotoxic drugs •amiodarone SBA 8 For Olivia, a 27-year-old woman in her 36th week of pregnancy with her first child, who is currently in a breech presentation, what is the most suitable course of action? A. Provide reassurance that the baby is likely to turn to a cephalic presentation before delivery. B. Refer for external cephalic version. C. Admit for induction of labor and a trial of vaginal delivery. D. Refer for radiological pelvimetry. E. Admit for a cesarean section. Breech presentations Management if < 36 weeks: many fetuses will turn spontaneously •around 60%.eech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of •weeks in multiparous womenould be offered from 36 weeks in nulliparous women and from 37 •if the baby is still breech then delivery options include planned caesarean section or vaginal delivery Information to help decision making - the RCOG recommend: early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.' •breech presentation delivered at term is influenced by how the baby is born.' of babies with a RCOG absolute contraindications to ECV ▪antepartum hemorrhage within the last 7 days ▪abnormal cardiotocography ▪major uterine anomaly ▪ruptured membranes ▪multiple pregnancy SBA 9 A woman complains of severe itching at 34 weeks gestation. The itching started 2 weeks previously and has been preventing her from sleeping. She is itchy all over her body, especially in her hands and feet. She has not noticed any rashes. Her mother reports similar symptoms when she was pregnant with her 2nd child. She is otherwise well. What is the most appropriate action? A. Dermatology referral B. Give topical steroids C. Check uric acid levels D. Check renal function E. Check liver function tests Pregnancy:jaundice Intrahepatic cholestasis of pregnancy Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester. It is the most common liver disease of pregnancy. Features •pruritus, often in the palms and soles •no rash (although skin changes may be seen due to scratching) •raised bilirubin Management •ursodeoxycholic acid is used for symptomatic relief •weekly liver function tests •women are typically induced at 37 weeks Complications include an increased rate of stillbirth. It is not generally associated with increased maternal morbiditySBA 10 Which of the following is a risk factor for placenta previa? A) Nulliparity B) Advanced maternal age C) Smoking during pregnancy D) Previous cesarean section E) Maternal obesitySBA 11 A 26-year-old pregnant woman presents to the emergency room at 34 weeks gestation with cesarean sections. On examination, her blood pressure is 90/60 mmHg, heart rate is 120 bpm, and fetal heart rate monitoring shows signs of fetal distress. What is the most likely diagnosis? A) Placental abruption B) Ectopic pregnancy C) Uterine rupture D) Placenta previa E) Ruptured ovarian cystSBA 12 A 35-year-old pregnant woman at 34 weeks gestation presents to the emergency room with sudden onset of shortness of breath, chest pain, and tachycardia. On examination, her blood pressure is 100/70 mmHg, heart rate is 130 bpm, and oxygen saturation is 90% on room air. Fetal heart rate monitoring shows no abnormalities. What is the most likely diagnosis? A) Pulmonary embolism B) Myocardial infarction C) Pneumonia D) Asthma exacerbation E) Anxiety attackSBA 13 During a routine prenatal visit, a pregnant woman at 32 weeks gestation complains of feeling dizzy and light-headed when lying on her back. She reports improvement in symptoms when turning onto her left side. What is the most likely explanation for her symptoms? A) Placenta previa B) Aortocaval compression syndrome C) Gestational hypertension D) Spinal cord compression E) HypoglycemiaSBA 14 A 30-year-old woman presents to the labor and delivery unit with persistent vaginal bleeding after delivering her baby. She gave birth vaginally 30 minutes ago. On examination, the uterus is boggy and larger than expected for the postpartum period. What is the most likely diagnosis? A) Uterine atony B) Retained placenta C) Placenta previa D) Placental abruption E) Uterine rupture