Antenatal care

What is the level of growth discordance in MCDA twins that would prompt fetal medicine referral?

>25% fetal growth discordance

If one of the MCDA twins died, what is the chance of death and neurological complications in the second twin?

• death 15%

• neurological complications 26% (therefore do fetal brain MRI after 4 weeks)

When should screening for TTTS and fetal growth discordance start in MCDA?

TTTS - at 16/40

Fetal growth discordance - at 20/40

In MCDA what should the growth discordance be to diagnose fetal growth discordance?

More than 20%

According to last MBRRACE what is the maternal mortality rate overall vs black women?

overall 12.8 in 100,000

black 34 in 100,000

What is the incidence of placenta praevia?

If one prev CS?

1 in 200

1 in 160

What is the success rate of Bakri balloon in PPH?

75-80%

What is the cut off for cervical length in placenta praevia?

if <31mm x16 higher chance of EMCSW

What are the risks of placenta praevia?

MOH 21%

hysterectomy 11%

hysterectomy if prev CS 27%

bladder injury 6%

VTE 3%

What are the T and lambda signs?

T - monochorionic diamniotic

Lambda - dichorionic

What is the rule of cervical length management in multiple pregnancy and its management?

Measure of cervical length is offered once in multiple pregnancy at 16-20 weeks

if <25mm offer progesterone rather than stitch

What percentage of monochorionic twins will experience fetal growth restriction or TTS?

15% for both

What is the expected number of selective termination cases fetal medicine units should do for multiple pregnancy

15 cases pre year with 2 operators

When should patients with multiple pregnancies pregnancies have FBC checked?

booking

20-24/40

28/40

At what gestational age should women give up smoking to have the same effect as non smoker?

What is the maximum length of time a nicotine patch should be worn a day?

prior to 16/40

16 hours a day

What are the most common cause of death in pregnancy?

• direct early

• direct late

• indirect early

• indirect late

• direct early - VTE

• direct late - suicide

• indirect early - cardiac

• indirect late - malignancy

definition of maternal mortality rate vs maternal mortality ratio

maternal mortality rate - per 100,000

maternal mortality ratio - per 100,000 live births

What is the rate of compression to ventilation in neonatal resuscitation?

3 compressions to 1 ventilation

30 of these cycles in 1 minute

What are the side effects of neonatal steroids?

hypoglycaemia

reduced birth weight

psychosis

Difference in dexamethasone vs betamethasone dosing in antenatal care

dexamethasone - 12mg and 12mg 12 hours apart

betamethasone - 12mg and 12mg 24 hours apart

What is the appropriate follow up for a patient who refused IOL for post dates?

x2 weekly CTG

ultrasound for AFI

What is the incidence of breech?

3-5%

What is the mortality in vaginal breech vs CS vs SVD?

vaginal breech 2 in 1000

SVD 1 in 1000

CS 0.5 in 1000W

What is the rate of breech babies will turn to cephalic by term?

What is the rate ECV baby will turn back to breech?

8% and 3&

Still birth rate

2 in 1000 although some say 3

BMI for

• 1 point for antenatal VTE

• aspirin

• OGTT

• growth scans for obesity

• 1 point for antenatal VTE >30

• aspirin >35

• OGTT >30

• growth scans for obesity >35

Target Hb in pregnancy and post partum?

first trimester - 110

from 28/40 - 105

post partum - 100

What is the incidence of placenta accreta?

What is the risk of PA after CS

1 in 300

inrceases by 7 fold after every CS

What is fetal blood volume at term?

100ml/kg

Best diagnostic tool for placenta accreta

ultrasound with colour doppler

Definition of minor, major and massive APH

minor - <50ml

major 50-1000ml

massive >1000ml

If patient has placental abruption what is the chance she is going to have another one?

What about two?

1 abruption - 4.4%

2 abruptions - 25%

What is the mode of action of ergometrine, carboprost and misoprostol? What are the doses?

ergometrine

• alpha adrenoreceptor and dopamine agonist

• 500mcg

carboprost

• PFG2

• 250mcg every 15 min max 2mg

misoprostol

• PGE2

• 800mcg

risk of uterine perforation in surgical management of miscarriage vs in surgical evacuation of retained products of conception post partum

SMM 1 in 1000

ERPC post partum 1.5%

Tests included in combined test

• NT

• biochemical - HCG, PAPPa

• maternal age

Tests included in quadruple test

• HCG

• inhibin A

• oestrodiol oe3

• AFP

Sensitivity and false +ve in combined and quadruple tests

combined

• sensitivity 90%

• false +ve 5%

quadruple

• sensitivity 70%

• false +ve 5%

Sensitivity and false +ve in NIPT?

sensitivity 99%

0.1% false positive

contraindications to NIPT?

• triplets

• cancer

• organ transplant

• blood transfusion in the last 4 months

Can combined / quadruple / NIPT tests be done in twins/triplets?

Twins

• all tests ok but sensitivity reduced

Triplets

• only maternal age and NT

How many CVS/amnio should a person do a year to maintain competency?

20 a year

What are the complications if CVS / Amnio are done too early in gestation?

CVS - limb and facial malformations

Amnio - talipes

Risk of miscarriage in CVS/Amnio - within what period of time should a miscarriage take place to be related to the procedure

0.5% (1% in twins)

within 14 days

risk of down syndrome depending on maternal age

20yo - 1 in 1500

30yo - 1 in 900

35yo - 1 in 300

40yo - 1 in 100

45yo - 1 in 50

Features of Edwards and Patau

Edwards

• choroid plexus cysts

• rocker bottom feet

• strawberry skull

Patau

• polydactyly

• holoprocencephaly

which genetic condition is cystic hygroma more common in ?

Turners syndrome

Meckel Gruber genetic condition presentation

polycystic kidneys

encephalocele

Causes of echogenic bowel

• normal

• trisomy 21

• cystic fibrosis

• meconium

• CMV

What is the presentation and management of coxsackie virus in pregnancy

Presentation

• type A hand foot mouth disease

• type B hepatitis, myocarditic

Management - reassurance, symptomatic

What is the risk of transmission of toxoplasmosis in different trimesters? When is it most dangerous?

1st trimester risk is 10% however most likely 85% to have congenital malformation

2nd trimester 25%

3rd trimester 85%

What is the treatment regime for TB?

6 months total

• first 2 months - rifampicin + isoniazid + pyrazinamide + ethambutanol + pyridoxine (B6)

• last 4 months - rifampicin + isoniazid + pyridoxine (B6)

Why is streptomycin not advised in pregnancy for TB?

cranial nerve 8 palsy in baby - deafness and balance

What is the first line treatment for uncomplicated malaria falciparum vs non falciparum

falciparum - quinine and clindamycin

non falciparum - chloroquine

for 7 days

What is an important side effect of quinine to monitor for?

hypoglycaemia

Prophylactic medication for chloroquine resistant malaria? what is the contraindication?

Mefloquine

• contraindicated in epilepsy

• use malarone

How should a baby of malaria positive mum be tested

microscopy thick and thin every week for 4 weeks

Symptoms / signs of primary / secondary and tertiary syphilis

Primary - chancre painless ulcer

secondary - malaise, mucocutaneous rash, condylomata lata

tertiary - neurological, MSK, cardiac

what is condylomata lata

warty lesions in secondary syphilis

Test results of false positive and false negative syphilis and causes

False positive

• autoimmune reaction eg SLE

• EIA - VDLR+ PRP+

False negative

• protozone reaction

  • EIA+ VDLR- PRP-

Jarisch- Herxheimer reaction

occurs in 45% when starting treatment for syphillis

management is symptom relief

Treatment of syphillis - and in penicillin allergy

first/second trimester

• benzathine penicillin 2.3MU IM single dose

third trimester

• benzathine penicillin 2.3MU IM two doses weekly

penicillin allergy - ceftriaxone 500mg IM daily for 10 days

Patient with high risk of SGA but normal uterine dopplers should have growth scans from what gestational age

from 32/40 every 4 weeks

Patient with high risk of SGA with abnormal uterine dopplers should have growth scans from what gestational age

from 24-28+6 every 4 weeks

For patients with fetal growth restriction (<3rd centile or <10th with abnormal dopplers) when should they be delivered

between 37 and 37+6

TFT results in

• hypothyroidism

• subclinical hypothyroidism

• isolated hypothythyroidism

• hypothyroidism T4 low TSH high

• subclinical hypothyroidism - T4 normal TSH high

• isolated hypothythyroidism - T4 low TSH normal

Goal TSH level in hypothyroidism

TSH < 2.5mU/L

Advised daily iodine intake in pregnancy and breastfeeding

Daily 250 micrograms, should not exceed 500 micrograms

Postnatally when should a woman revert to pre conception levothyroxine dose?

2 weeks post partum and check TFT at 6 weeks

Gestational thyrotoxicosis

seen in hyperemesis

temporary

management is supportive