You are on page 1of 128

1. RCGP curriculum 3.

06 - Women’s Health External links NICE 2008 Antenatal care guidelines A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following: Blood group: A Rhesus negative What is the most appropriate management regarding her rhesus status? A. Give first dose of anti-D at 28 weeks B. No action required unless antenatal vaginal blood loss C. Give first dose of anti-D as soon as possible D. Give anti-D just prior to delivery E. No action required

Rhesus negative woman - anti-D at 28 + 34 weeks NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks

Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend: 1. 10 antenatal visits in the first pregnancy if uncomplicated 2. 7 antenatal visits in subsequent pregnancies if uncomplicated 3. women do not need to be seen by a consultant if the pregnancy is uncomplicated

Gestation 8 - 12 weeks (ideally < 10 weeks)

Purpose of visit Booking visit 2. general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes 3. BP, urine dipstick, check BMI Booking bloods/urine  FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies  hepatitis B, syphilis, rubella  HIV test is offered to all women  urine culture to detect asymptomatic bacteriuria

10 - 13 weeks

Early scan to confirm dates, exclude multiple pregnancy

11 - 13+6 weeks 16 weeks

Down's syndrome screening including nuchal scan Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan Routine care: BP, urine dipstick, symphysis-fundal height (SFH) Routine care: BP, urine dipstick, SFH Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above Routine care as above Second dose of anti-D prophylaxis to rhesus negative women Information on labour and birth plan Routine care as above Check presentation - offer external cephalic version if indicated Information on breast feeding, vitamin K, 'babyblues' Routine care as above Routine care as above

18 - 20+6 weeks 25 weeks (only if primip) 28 weeks

31 weeks (only if primip) 34 weeks

36 weeks

38 weeks 40 weeks (only if

Low-molecular weight heparin C. Warfarin D. . Aspirin B.External links Australian goverment Prescribing in pregnancy A 26-year-old woman with a history of hypothyroidism and antiphospholipid syndrome becomes pregnant. Which one of the following is contraindicated in pregnancy? A. Levothyroxine E.primip) 41 weeks Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 1. The list below largely comprises of those known to be harmful. Prescribing in pregnant patients Very few drugs are known to be completely safe in pregnancy. Most women are switched to low-molecular weight heparin for the duration of the pregnancy. Unfractionated heparin Warfarin is contraindicated in pregnancy.

ACE inhibitors. 3. 5. angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents The majority of antiepileptics including valproate. carbamazepine and phenytoin are known to be potentially harmful. The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk 2.Women’s Health External links NICE 2008 Antenatal care guidelines Theme: Routine antenatal care . 2.see the link. Antibiotics 1. tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies Other drugs 1. 3. 4. 2. 4. 6.Some countries have developed a grading system .06 .RCGP curriculum 3.

16 weeks F.20+6 weeks G. 7 . 28 weeks I.20+6 weeks 3. 25 weeks H. 38 weeks For each of the following components of routine antenatal care select the gestation when it should occur 2. Anomaly scan 18 .12 weeks C. 8 .13+6 weeks . 14 -15 weeks E.A. 34 weeks J.13+6 weeks D. 11 .8 weeks B. 18 . Down's syndrome screening where nuchal scanning is available 11 .

3.g. haemoglobinopathies hepatitis B. 2. smoking. rubella HIV test is offered to all women . Booking visit 8 . antenatal classes BP. check BMI 2.4. syphilis. red cell alloantibodies. 10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated Gestation 8 . vitamin D. 2. 3. blood group. rhesus status. general information e. folic acid. alcohol. diet.12 weeks (ideally < 10 weeks) Purpose of visit Booking visit 1.12 weeks Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. urine dipstick. FBC. They recommend: 1. Booking bloods/urine 1.

urine dipstick. If Hb < 10.13+6 weeks 16 weeks 18 .4. SFH Second screen for anaemia and atypical red cell alloantibodies. urine culture to detect asymptomatic bacteriuria 10 .5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 11 . urine dipstick. exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood results.20+6 weeks 25 weeks (only if primip) 28 weeks 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus .13 weeks Early scan to confirm dates. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan Routine care: BP. symphysis-fundal height (SFH) Routine care: BP.

Hydatidiform mole . vitamin K. Placental abruption B.06 . 'babyblues' Routine care as above Routine care as above Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 38 weeks 40 weeks (only if primip) 41 weeks 3.negative women Information on labour and birth plan 36 weeks Routine care as above Check presentation . Ectopic pregnancy C.RCGP curriculum 3.offer external cephalic version if indicated Information on breast feeding. Threatened miscarriage D.Women’s Health Theme: Bleeding in pregnancy A.

On examination blood pressure is 90 / 60 mmHg Placental abruption 2. Her last period was 8 weeks ago. Vasa praevia F. Bloody show H.E. She has not yet had any antenatal care despite suffering from severe vomiting. A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding. On examination her cervix is tender to touch . A 31-year-old woman presents with painless vaginal bleeding at 15 weeks gestation. On examination the uterus is large for dates Hydatidiform mole 3. A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Missed (delayed) miscarriage I. Inevitable miscarriage For each one of the following scenarios select the most likely diagnosis: 1. Placenta praevia G.

heavy bleeding and crampy.Ectopic pregnancy Bleeding in pregnancy The table below outlines the major causes of bleeding during pregnancy. conditions such as sexually transmitted infections and cervical polyps should be excluded. Complete miscarriage . The table below outlines the key features of each condition: Spontaneous abortion Threatened miscarriage . lower abdo pain.complete or incomplete depending or whether all fetal and placental tissue has been expelled.painless vaginal bleeding typically around 6-9 weeks Missed (delayed) miscarriage . Incomplete miscarriage . Antepartum haemorrhage is defined as bleeding after 24 weeks 1st trimester Spontaneous abortion Ectopic pregnancy Hydatidiform mole 2nd trimester Spontaneous abortion Hydatidiform mole Placental abruption 3rd trimester Bloody show Placental abruption Placenta praevia Vasa praevia Alongside the pregnancy related causes.little bleeding .light vaginal bleeding and symptoms of pregnancy disappear Inevitable miscarriage .

Women’s Health External links . hyperemesis. Shoulder tip pain and cervical excitation may be present Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e. tense uterus* with normal lie and presentation.women with placenta praevia may haemorrhage 4. Tender. Fetal heart may be distressed Vaginal bleeding.g. Non-tender uterus* but lie and presentation may be abnormal Rupture of membranes followed immediately by vaginal bleeding. no pain.RCGP curriculum 3. Fetal bradycardia is classically seen Hydatidiform mole Placental abruption Placental praevia Vasa praevia *vaginal examination should not be performed in primary care for suspected antepartum haemorrhage .Ectopic pregnancy Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. The uterus may be large for dates and serum hCG is very high Constant lower abdominal pain and. woman may be more shocked than is expected by visible blood loss.06 .

The following results were obtained: Time (hours) Blood glucose (mmol/l) 0 2 7. Start metformin + advice about diet / exercise B. What is the most appropriate action? A.NICE 2008 Management of diabetes in pregnancy SIGN Management of diabetes in pregnancy Postgraduate Medical Journal DKA in pregnancy You review a 28-year-old woman who is 26 weeks pregnant.1 11. Advice about diet / exercise + self-monitor glucose levels .2 There have been no other antenatal problems and her anomaly scan was normal. Start metformin + advice about diet / exercise + self-monitor glucose levels C. She has just had a routine glucose tolerance test as her BMI is 34 kg/m^2.

4. black Caribbean and Middle Eastern) Screening for gestational diabetes 1. if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. . It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes 1. Start insulin + advice about diet / exercise + selfmonitor glucose levels E. 2. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian. Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy. 3. 5. gestational diabetes.D. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes 2. Advise weight loss + start metformin Most women (around 80%) with gestational diabetes can be managed with a combination of diet and self-monitoring. BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.5 kg or above. 3.

and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including fourchamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Management of gestational diabetes 1. .RCGP curriculum 3. 5. 2. 2. 3. weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents.Women’s Health External links NICE 2008 Antenatal care guidelines 3. apart from metformin.g. 4. 5. 6. 4. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check 5. responds to changes in diet and exercise in around 80% of women oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008 Management of pre-existing diabetes 1.06 .

Which one of the following statements regarding routine antenatal care is incorrect? A. 3. The early ultrasound scan and nuchal scan should not be done at the same time E. All women are offered a HIV test D. 2. They recommend: 1. Women are screened twice during pregnancy for anaemia Many centres now perform the early ultrasound scan and nuchal scan at the same time Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. NICE recommend 10 antenatal visits in the first pregnancy if uncomplicated B. Women do not need to be seen by a consultant if the pregnancy is uncomplicated C. 10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated Purpose of visit Gestation .

2. syphilis. urine dipstick.8 . exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood results. haemoglobinopathies hepatitis B. Booking bloods/urine 1. diet. vitamin D. alcohol. antenatal classes BP. FBC.12 weeks (ideally < 10 weeks) Booking visit 1.13+6 weeks 16 weeks 18 . urine dipstick. blood group. symphysis-fundal height (SFH) 11 . check BMI 2. general information e.20+6 weeks 25 weeks (only if primip) .g. 4. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan Routine care: BP. folic acid. rhesus status. rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 . 3. smoking.13 weeks Early scan to confirm dates. red cell alloantibodies.

5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women Information on labour and birth plan Routine care as above Check presentation . SFH Second screen for anaemia and atypical red cell alloantibodies. vitamin K. 'babyblues' Routine care as above Routine care as above Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 36 weeks 38 weeks 40 weeks (only if primip) 41 weeks . If Hb < 10. urine dipstick.offer external cephalic version if indicated Information on breast feeding.28 weeks Routine care: BP.

Hypertension in pregnancy . A urine dipstick shows is normal. Normal physiological change E. This is confirmed with ambulatory blood pressure monitoring. She is now 15 weeks pregnant.External links NICE 2010 Hypertension in pregnancy A 36-year-old woman presents for a routine antenatal review. The raised ambulatory blood pressure readings exclude a diagnosis of whitecoat hypertension. Her blood pressure in clinic is 154/94 mmHg. Pre-eclampsia B. There is no significant past medical history of note.6. On reviewing the notes it appears her blood pressure four weeks ago was 146/88 mmHg. Pregnancy-induced hypertension C. Note the use of the term 'pre-existing hypertension' rather than essential hypertension. White-coat hypertension D. What is the most likely diagnosis? A. Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) do not occur before 20 weeks. Raised blood pressure in a 36-year-old female is not that common and raises the possibility of secondary hypertension. Pre-existing hypertension This lady has pre-existing hypertension.

3g / 24 hours) Oedema may occur but is now less commonly used as a criteria . no oedema Occurs in around 5-7% of pregnancies Pre-eclampsia A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria. and continues to fall until 20-24 weeks after this time the blood pressure usually increases to prepregnancy levels by term Hypertension in pregnancy in usually defined as: 1. 2. blood pressure usually falls in the first trimester (particularly the diastolic). no oedema Pregnancy-induced hypertension in association with proteinuria (> 0. also known as gestational hypertension) Hypertension (as defined above) occurring in the second half of pregnancy (i. in normal pregnancy: 1. after 20 weeks) No proteinuria.The classification of hypertension in pregnancy is complicated and varies.e. 2. systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic After establishing that the patient is hypertensive they should be categorised into one of the following groups Pre-existing hypertension Pregnancy-induced hypertension (PIH. Remember.

Which one of the following complications is she at an increased risk of developing? A. Polyhydramnios B. polyhydramnios . Pregnancy-induced hypertension D. Neonatal hyperglycaemia E.25%.15%.Occurs in 3-5% of pregnancies and is more common in older women Resolves following birth (typically after one month). 2. possibly due to fetal polyuria preterm labour . associated with polyhydramnios Neonatal complications . Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life Occurs in around 5% of pregnancies 7.Question stats A 29-year-old pregnant woman is diagnosed as having gestational diabetes at 22 weeks gestation. Postnatal depresion Pregnancy: Diabetes – Complications: Maternal complications 1. Antepartum haemorrhage C.

g.RCGP curriculum 3. 10 . 3.8 weeks B. 6. 8 .13 weeks D.12 weeks C. 14 -15 weeks E.1. 4. 8.06 . 5.Women’s Health External links NICE 2008 Antenatal care guidelines Theme: Routine antenatal care A. CNS and CVS malformations (hypertrophic cardiomyopathy) stillbirth hypomagnesaemia hypocalcaemia shoulder dystocia (may cause Erb's palsy) 8. sacral agenesis. macrosomia (although diabetes may also cause small for gestational age babies) hypoglycaemia respiratory distress syndrome: surfactant production is delayed polycythaemia: therefore more neonatal jaundice malformation rates increase 3-4 fold e. 7. 9. 7 . 16 weeks . 2.

First screen for anaemia and atypical red cell alloantibodies 8 .12 weeks 6. 18 . They recommend: .13 weeks 5. 28 weeks I.20+6 weeks G. First dose of anti-D prophylaxis to rhesus negative women 28 weeks Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. 38 weeks For each of the following components of routine antenatal care select the gestation when it should occur 4. 34 weeks J. 25 weeks H.F. Early scan to confirm dates 10 .

folic acid. syphilis. blood group. 3. alcohol. 3. diet. 10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated Gestation 8 . check BMI 2. vitamin D. 2. exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood 11 . rhesus status. haemoglobinopathies hepatitis B. rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 .13 weeks Early scan to confirm dates. FBC. 4. red cell alloantibodies. 2.1. Booking bloods/urine 1. smoking.13+6 weeks 16 weeks . urine dipstick. antenatal classes BP. general information e.g.12 weeks (ideally < 10 weeks) Purpose of visit Booking visit 1.

If Hb < 10. urine dipstick. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick 18 . symphysis-fundal height (SFH) Routine care: BP.offer external cephalic version if indicated Information on breast feeding. vitamin K. urine dipstick.results. 'babyblues' 36 weeks .5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women Information on labour and birth plan Routine care as above Check presentation .20+6 weeks 25 weeks (only if primip) 28 weeks Anomaly scan Routine care: BP. SFH Second screen for anaemia and atypical red cell alloantibodies.

38 weeks 40 weeks (only if primip) 41 weeks Routine care as above Routine care as above Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 9.Women’s Health External links NICE 2008 Management of diabetes in pregnancy SIGN Management of diabetes in pregnancy Postgraduate Medical Journal DKA in pregnancy A 25-year-old Asian woman who is 26 weeks pregnant has an oral glucose tolerance test (OGTT).06 . A recent ultrasound shows that the fetus is large for dates.RCGP curriculum 3. The following results are obtained: . This was requested due to a combination of her ethnicity and a background of obesity.

BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.2 What is the most appropriate management? A. Start insulin B. Give advice about a diabetic diet + repeat OGTT in 4 weeks D.2 14. Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy. Start insulin + aspirin Insulin should be started straight away given the blood glucose levels and evidence of macrosomia. 2. Give advice about a diabetic diet C. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes 1. Start gliclazide E.Time (hours) Blood glucose (mmol/l) 0 2 9. Some endocrinologists would consider using either metformin or glibenclamide but gliclazide (option D) is not mentioned in the NICE guidelines. gestational diabetes.5 kg or above. .

NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008 Management of pre-existing diabetes 1. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian.3. 6. apart from metformin. 5. 3. responds to changes in diet and exercise in around 80% of women . 4. 5. black Caribbean and Middle Eastern) Screening for gestational diabetes 1. 3. and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including fourchamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Management of gestational diabetes 1. 2. 4. if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes 2. weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents.

2.g. She request medication to help relieve the nausea. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check 10- RCGP curriculum 3. 3. Urine dipstick shows no evidence of ketones.06 .Women’s Health External links NICE 2008 Antenatal care guidelines A 23-year-old female primip presents during the 10th week of pregnancy complaining of persistent nausea. Metoclopramide C. What is the most appropriate drug to prescribe? A. oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e. Ondansetron B. 5. Domperidone D. Aprepitant . 4.

2. Promethazine Vomiting in pregnancy: antihistamines are first-line Antenatal care: specific points NICE issued guidelines on routine care for the healthy pregnant woman in March 2008 Nausea and vomiting 1.E. natural remedies . as found in the Healthy Start multivitamin supplement' particular care should be taken with women at risk (e. Alcohol 1. Asian.ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE antihistamines should be used first-line (BNF suggests promethazine as first-line) Vitamin D 1. obese.g. poor diet) 2. NICE recommend 'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding' 'women may choose to take 10 micrograms of vitamin D per day. NICE recommend women should avoid alcohol during the first trimester . 3.

Tender. 5. shock out of keeping with visible loss pain constant tender.06 . No pain D. if women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week 11RCGP curriculum 3. 3. Shock out of keeping with visible blood loss Antepartum haemorrhage: determining cause Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks pregnancy. Normal lie and presentation C. Which one of the following features would point towards a diagnosis of placenta praevia rather than placenta abruption? A. 2. tense uterus* normal lie and presentation fetal heart: absent/distressed .2. Distressed fetal heart E.Women’s Health A 28-year-old woman 27 weeks into her first pregnancy presents with vaginal bleeding. prior to delivery of the fetus Distinguishing placental abruption from praevia: Placental abruption: 1. tense uterus B. 4.

6. Shock in proportion to visible loss No pain Uterus not tender* Lie and presentation may be abnormal Fetal heart usually normal Coagulation problems rare Small bleeds before large *vaginal examination should not be performed in primary care for suspected antepartum haemorrhage . anuria Placenta Praevia 1. coagulation problems beware pre-eclampsia. Which one of the following antihypertensives is she most likely to be commenced on? . Her blood pressure is 162/94 mmHg. DIC. 3.06 .women with placenta praevia may haemorrhage 12RCGP curriculum 3. 6. 2. 7. 7. She has been monitored for the past few weeks due to pregnancy-induced hypertension but has now developed proteinuria. 5.Women’s Health External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy You admit a woman who is 34 weeks pregnant to the obstetric ward. 4.

Moxonidine B. intracerebral Cardiac failure Multi-organ failure Risk Factors . Nidedipine E. 2. 5. Labetalol D. intra-abdominal. intrauterine growth retardation Eclampsia Haemorrhage: placental abruption.3g / 24 hours). Methyldopa Labetalol is first-line for pregnancy-induced hypertension Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0. 4. Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems 1.A. Atenolol C. 3. Fetal: prematurity.

4. Nifedipine and hydralazine may also be used Delivery of the baby is the most important and definitive management step.1. 2. abnormal liver enzymes or HELLP syndrome Management 1. 4. The timing depends on the individual clinical scenario 2. 9. 3. 7. 3. 3. Consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold Oral labetalol is now first-line following the 2010 NICE guidelines. Hypertension: typically > 170/110 mmHg and proteinuria as above Proteinuria: dipstick ++/+++ Headache Visual disturbance Papilloedema RUQ/Epigastric pain Hyperreflexia Platelet count < 100 * 106/l. 8. 7. 5. . 5. 8. 6. 6. > 40 years old Nulliparity (or new partner) Multiple pregnancy Body mass index > 30 kg/m^2 Diabetes mellitus Pregnancy interval of more than 10 years Family history of pre-eclampsia Previous history of pre-eclampsia Pre-existing vascular disease such as hypertension or renal disease Features of severe pre-eclampsia 1. 2.

see the link. Antibiotics to avoid: . Erythromycin C.Women’s Health External links Australian goverment Prescribing in pregnancy A woman who is 24-weeks pregnant presents with a productive cough. Cefaclor The BNF advises avoiding quinolones in pregnancy due to arthropathy in animal studies Prescribing in pregnant patients Very few drugs are known to be completely safe in pregnancy.06 . The list below largely comprises of those known to be harmful.13- RCGP curriculum 3. On examination crackles can be heard in the left base and a decision is made to give an antibiotic. Ciprofloxacin B. Which one of the following is least suitable to prescribe? A. Cefalexin E. Co-amoxiclav D. Some countries have developed a grading system .

16 weeks gestation B. 2. 4. Most common between 12 . 4. 2.06 .1. 5. carbamazepine and phenytoin are known to be potentially harmful. angiotensin II receptor antagonists Statins Warfarin Sulfonylureas Retinoids (including topical) Cytotoxic agents The majority of antiepileptics including valproate. Tetracyclines Aminoglycosides Sulphonamides and trimethoprim Quinolones: the BNF advises to avoid due to arthropathy in some animal studies Other drugs 1. 3. The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk 14RCGP curriculum 3. ACE inhibitors. Wernicke's encephalopathy is a recognised complication . Affects around 4% of pregnant women C. 3.Women’s Health Which one of the following statements regarding hyperemesis gravidarum is correct? A. 6.

4. antihistamines should be used first-line (BNF suggests promethazine as first-line) admission may be needed for IV hydration Complications 1. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Associations 1. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*. 3. Ondansetron is first-line in women after 12 weeks gestation E. 3. 4. 2. 5.D. multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity Smoking is associated with a decreased incidence of hyperemesis Management 1. Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis . 2. Commonly associated with hypothyroidism Hyperemesis gravidarum Hyperemesis gravidarum describes excessive vomiting during pregnancy. 2.

2ºC and she has diffuse suprapubic tenderness. She complains of a persistent pink vaginal discharge which is 'smelly'. Urine dipstick shows blood ++. Admit to hospital E.06 . Arrange urgent ultrasound to exclude retained products + send MSSU + start oral co-amoxiclav D. On vaginal examination the uterus feels generally tender. On examination her pulse is 90 / min. Arrange urgent ultrasound to exclude retained products + send MSSU + take high vaginal swab B. She needs to be admitted for intravenous antibiotics. temperature 38. fetal: small for gestational age.Women’s Health A 24-year-old woman presents 8 days after giving birth. Send MSSU + take high vaginal swab + start oral co-amoxiclav + metronidazole C. . likely secondary to endometritis. Send MSSU + take high vaginal swab + start oral co-amoxiclav This woman by definition has puerperal pyrexia. pre-term birth *and in very rare cases beyond 20 weeks 15RCGP curriculum 3.5. What is the most appropriate management? A. Examination of her breasts is unremarkable.

if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours) 16RCGP curriculum 3. 2. Causes: 1. 3.06 . 5.Women’s Health External links NICE 2010 Hypertension in pregnancy A 24-year-old female who is 10 weeks in to her first pregnancy presents for review. Systolic + diastolic rises by < 10 mmHg .Puerperal pyrexia Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. Falls in first half of pregnancy before rising to prepregnancy levels before term B. 4. What normally happens to blood pressure during pregnancy? A. endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism Management 1. Her blood pressure today is 126/82 mmHg.

blood pressure usually falls in the first trimester (particularly the diastolic). and continues to fall until 20-24 weeks after this time the blood pressure usually increases to prepregnancy levels by term Hypertension in pregnancy in usually defined as: 1. Doesn't change Hypertension in pregnancy The classification of hypertension in pregnancy is complicated and varies. 2. also known as gestational hypertension) Hypertension (as Pre-eclampsia A history of Pregnancy-induced . Remember. Systolic + diastolic falls by < 10 mmHg D. Systolic > 140 mmHg or diastolic > 90 mmHg Or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic After establishing that the patient is hypertensive they should be categorized into one of the following groups Pre-existing hypertension Pregnancy-induced hypertension (PIH. in normal pregnancy: 1.C. 2. Rise in first half of pregnancy before falling to prepregnancy levels before term E.

no oedema Occurs in 3-5% of pregnancies and is more common in older women defined above) occurring in the second half of pregnancy (i. karyotype available after 3 .e. no oedema Occurs in around 5-7% of pregnancies Resolves following birth (typically after one month). karyotype available after 3 weeks B. The Down's syndrome screening tests have indicated she is at high risk and the midwives have discussed the option of an amniocentesis. Performed at 16 weeks. after 20 weeks) No proteinuria.hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria.3g / 24 hours) Oedema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies 17- RCGP curriculum A pregnant woman comes to see you for advice. Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life hypertension in association with proteinuria (> 0. Which one of the following best describes the timing of an amniocentesis? A. Performed at 13-14 weeks.

karyotype available after 3 weeks E. karyotype after 3 weeks Some laboratories are now able to detect Down's syndrome using fluorescence in-situ hybridization (FISH) in 2 days. karyotype available after 3 weeks D. karyotype available after 3 days Amniocentesis: performed at 16 weeks. The karyotype results typically take 3 weeks. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions. Performed at 14-15 weeks. Performed at 16 weeks. It is known the karyotype may be wrong in 1/1000 cases due to maternal cells being present Conditions which may be diagnosed . for example if > 35 years old. Performed at 14-15 weeks. but full karyotyping takes 3 weeks Amniocentesis Amniocentesis is a procedure used in prenatal diagnosis. Amniocentesis is usually performed at 16 weeks and the risk of fetal loss is 0.days C.5-1%. Around 20 ml of fluid is removed by transabdominal needle under ultrasound guidance. It may be offered after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk.

This is her first pregnancy. Admit for caesarean section Breech presentation . Reassure mother baby will most likely turn to a cephalic presentation prior to delivery B. Refer for radiological pelvimetry E.1. 2. Her baby is known to currently lie in a breech presentation. neural tube defects (raised AFP levels in the amniotic fluid) chromosomal disorders inborn errors of metabolism 18- RCGP curriculum External links RCOG External cephalic version guidelines RCOG Breech presentation guidelines A woman who is 36 weeks pregnant is reviewed. What is the most appropriate management? A. Admit for induction of labour and trial of vaginal delivery D. 3. Refer for external cephalic version C.

Cord prolapse is more common in breech presentations Management 1. 5. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women if the baby is still breech then delivery options include planned caesarean section or vaginal delivery 3.the RCOG recommend: .In a breech presentation the caudal end of the fetus occupies the lower segment. A footling breech. CNS malformation. 4. Information to help decision making .g. 2. A frank breech is the most common presentation with the hips flexed and knees fully extended. 3. Uterine malformations. 2. chromosomal disorders) Prematurity (due to increased incidence earlier in gestation) 1. where one or both feet come first with the bottom at a higher position.this has a success rate of around 60%. 2. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. fibroids Placenta praevia Polyhydramnios or Oligohydramnios Fetal abnormality (e. is rare but carries a higher perinatal morbidity .Risk factors for breech presentation 1. if < 36 weeks: many fetuses will turn spontaneously if still breech at 36 weeks NICE recommend external cephalic version (ECV).

' 'Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born. Enquiry about pregnancy related problems E. Which one of the following is not indicated as part of her routine assessment? A. However. Symphysis-fundal height measurement D. 'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.' 19RCGP curriculum External links NICE 2008 Antenatal care guidelines A woman who is 28-weeks pregnant presents for antenatal review.1. She is well and has had no pregnancy related problems to date. auscultation of the fetal heart may provide reassurance. Urine dipstick B. 2. . Blood pressure C. Auscultation of the fetal heart Routine auscultation for the fetal heart is not recommended by NICE. the guidelines suggest that when requested by the mother.

They recommend: 1. syphilis. check BMI Gestation 8 . 4. diet. urine dipstick. general information e. exclude multiple pregnancy .Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. haemoglobinopathies hepatitis B. FBC.13 weeks Early scan to confirm dates. 2. smoking.12 weeks (ideally < 10 weeks) 2. 3. red cell alloantibodies. blood group. folic acid. Booking bloods/urine 1.g. 10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated Purpose of visit Booking visit 1. vitamin D. 3. rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 . 2. rhesus status. alcohol. antenatal classes BP.

If Hb < 10. urine dipstick.11 .5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 18 . If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan Routine care: BP. vitamin K. symphysis-fundal height (SFH) Routine care: BP.20+6 weeks 25 weeks (only if primip) 28 weeks 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women Information on labour and birth plan Routine care as above Check presentation . urine dipstick.13+6 weeks 16 weeks Down's syndrome screening including nuchal scan Information on the anomaly and the blood results.offer external cephalic version if indicated Information on breast feeding. 'baby- 36 weeks . SFH Second screen for anaemia and atypical red cell alloantibodies.

The scan has reportedly shown increased nuchal translucency. Cystic fibrosis . which one of the following is most associated with this finding? A.blues' 38 weeks 40 weeks (only if primip) 41 weeks Routine care as above Routine care as above Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 20- RCGP curriculum External links Fetal Ultrasound Good link on hyperechogenic bowel A woman who is 12 weeks pregnant presents as she is concerned following a recent antenatal scan. Renal agenesis B. Other than Down's syndrome.

Polyhydramnios D. 2. Down's syndrome congenital heart defects abdominal wall defects Causes of hyperechogenic bowel: 1. Causes of an increased nuchal translucency include: 1. 2. Cytomegalovirus infection E. 3. Ultrasound in pregnancy A nuchal scan is performed at 11-13 weeks. 3.C. Congenital heart defects Next question A knowledge of fetal abnormalities is specifically mentioned in the Women's Health curriculum statement. cystic fibrosis Down's syndrome cytomegalovirus infection 21RCGP curriculum External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy .

Epigastric pain C. 5. fetal: prematurity. intracerebral cardiac failure multi-organ failure Risk factors . intrauterine growth retardation eclampsia haemorrhage: placental abruption. Reflexes difficult to elicit D. Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems 1. A low platelet count may indicate the patient is developing HELLP syndrome Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0. Headache B. 3. intra-abdominal.3g / 24 hours).Which one of the following clinical features would be least consistent with a diagnosis of severe pre-eclampsia? A. Low platelet count E. Papilloedema Severe pre-eclampsia is associated with hyperreflexia and clonus. 4. 2.

consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease Features of severe pre-eclampsia 1. 8. 5. 5. 6. abnormal liver enzymes or HELLP syndrome Management 1. 4. 7. The timing depends on the individual clinical scenario 2. 2. . 9. 4. 3.1. 3. 7. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. 8. 3. hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l. 2. 6.

06 .Women’s Health External links RCOG Chickenpox in pregnancy guidelines Department of Health Green-top guidelines A woman who is 14 weeks pregnant presents as she came into contact with a child who has chickenpox around 4 days ago. Varicella zoster vaccination E. Varicella zoster immunoglobulin B. No action required C. IV aciclovir D. Varicella zoster vaccination + varicella zoster . Blood tests show the following: Varicella IgM Negative Varicella IgG Negative What is the most appropriate management? A.22- RCGP curriculum 3. She is unsure if she had the condition herself as a child.

if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. microcephaly and learning disabilities 3. Shingles is reactivation of dormant virus in dorsal root ganglion. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure 2. a syndrome now termed fetal varicella syndrome Fetal varicella syndrome (FVS) 1. risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks features of FVS include skin scarring. eye defects (microphthalmia). Management of chickenpox exposure 1. . limb hypoplasia. 2.if not immune give VZIG The negative IgG indicates no previous exposure to chickenpox Chickenpox exposure in pregnancy Chickenpox is caused by primary infection with varicella zoster virus. In pregnancy there is a risk to both the mother and also the fetus.immunoglobulin Chickenpox exposure in pregnancy .

consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash 23RCGP curriculum 3. Brie and Stilton E. There is no past medical history of note and this is her first pregnancy.potential risk to developing fetus C. Advise to increase milk and soft-cheese consumption e. Await booking bloods for confirmation of vitamin D levels D. Should be avoided . What is the most appropriate advice to give? A.Women’s Health External links NICE 2008 Antenatal care guidelines A 27-year-old woman has just found out she is pregnant.06 . Advise her she can take supplements if she wishes but this is not part of routine NHS antenatal advice .g. She asks for advice about vitamin D supplementation.3. Offer vitamin D supplementation if she feels her diet is inadequate B.

NICE recommend 'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding' 'women may choose to take 10 micrograms of vitamin D per day. NICE recommend women should avoid alcohol during the first trimester if women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week 24RCGP curriculum 3. 3. obese.g. Alcohol 1. 2. as found in the Healthy Start multivitamin supplement' particular care should be taken with women at risk (e.Soft-cheese should be avoided during pregnancy due to the risk of Listeria Antenatal care: specific points NICE issued guidelines on routine care for the healthy pregnant woman in March 2008 Nausea and vomiting 1. natural remedies .Women’s Health The chance of a 45-year-old mother giving birth to a child with Down's syndrome is approximately: .06 . poor diet) 2. 2. Asian.ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE antihistamines should be used first-line (BNF suggests promethazine as first-line) Vitamin D 1.

1 in 100 E.1/1.000 at 30 years then divide by 3 for every 5 years Down's syndrome: epidemiology and genetics Risk of Down's syndrome with increasing maternal age 1. 1 in 30 D. 3. risk at 30 years = 1/1000 35 years = 1/350 40 years = 1/100 45 years = 1/30 One way of remembering this is by starting at 1/1. 1 in 5 B.e. 2. 1 in 500 Down's syndrome risk . 1 in 10 C.A. 4.000 at 30 years and then dividing the denominator by 3 (i. 3 times more common) for every extra 5 years of age Cytogenetics: Mode % of cases Risk of recurrence .

5% if father is translocation carrier Robertsonian translocation (usually onto 14) 5% Mosaicism 1% The chance of a further child with Down's syndrome is approximately 1 in 100 if the mother is less than 35 years old. Nuchal translucency + B-HCG + alpha-feto protein .06 . If the trisomy 21 is a result of a translocation the risk is much higher 25- RCGP curriculum 3. B-HCG + alpha-feto protein + oestradiol B.Women’s Health External links NICE 2008 Antenatal care guidelines What is the current recommended antenatal screening tests for Down's syndrome in the UK? A.Non-disjunction 94% 1 in 100 if under mother < 35 years 10-15% if mother is translocation carrier 2.

13+6 weeks if women book later in pregnancy either the triple* or quadruple test** should be offered between 15 . unconjugated oestriol. B-HCG + pregnancy associated plasma protein A E.20 weeks 2. 3. the combined test is now standard: nuchal translucency measurement + serum B-HCG + pregnancy associated plasma protein A these tests should be done between 11 . B-HCG + alpha-feto protein D. Nuchal translucency + B-HCG + pregnancy associated plasma protein A Down's . human chorionic gonadotrophin **alpha-fetoprotein. human chorionic gonadotrophin and inhibin-A 26External links Australian goverment Prescribing in pregnancy . unconjugated oestriol.antenatal screening: Nuchal translucency + B-HCG + pregnancy associated plasma protein A Down's syndrome: antenatal testing NICE issued guidelines on antenatal care in March 2008 including advice on screening for Down's syndrome: 1. *alpha-fetoprotein.C.

Some countries have developed a grading system . Methyldopa D. Which one of the following medications should be avoided? A. tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies Other drugs . Prescribing in pregnant patients Very few drugs are known to be completely safe in pregnancy. ACE inhibitors such as lisinopril are known teratogens and most be avoided. Hydralazine B.see the link.A 39-year-old woman who has recently been diagnosed with hypertension comes for review. Lisinopril When prescribing this woman should be treated as if she were pregnant given the absence of effective contraception. 4. Antibiotics 1. The list below largely comprises of those known to be harmful. 2. Nifedipine C. 3. Labetalol E. She is sexually active but does not currently use any form of contraception other than barrier methods.

5. 2. 3. 4. carbamazepine and phenytoin are known to be potentially harmful.1. angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents The majority of antiepileptics including valproate.Women’s Health External links NICE 2010 Hypertension in pregnancy Which one of the following statements is not correct regarding hypertension in pregnancy? A. An increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic suggests hypertension B. Pre-eclampsia occurs in around 5% of pregnancies C. Urine dipstick showing protein + is consistent with gestational hypertension D.06 . A rise in blood pressure before 20 weeks suggests . The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk 27RCGP curriculum 3. ACE inhibitors. 6.

in normal pregnancy: 1. With gestational hypertension the blood pressure rises in the second half of pregnancy Proteinuria suggests pre-eclampsia Hypertension in pregnancy The classification of hypertension in pregnancy is complicated and varies. also known as gestational hypertension) Hypertension (as defined above) occurring Pre-eclampsia A history of hypertension before Pregnancy-induced hypertension in . systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic After establishing that the patient is hypertensive they should be categorised into one of the following groups Pre-existing hypertension Pregnancy-induced hypertension (PIH. Remember.pre-existing hypertension E. blood pressure usually falls in the first trimester (particularly the diastolic). and continues to fall until 20-24 weeks after this time the blood pressure usually increases to prepregnancy levels by term Hypertension in pregnancy in usually defined as: 1. 2. 2.

Which one of the following conditions is not part of the differential diagnosis? A. Tracheo-oesophageal fistula .3g / 24 hours) Oedema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies 28- RCGP curriculum 3. no oedema Occurs in 3-5% of pregnancies and is more common in older women in the second half of pregnancy (i. Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life association with proteinuria (> 0.Women’s Health A woman who is 34 weeks pregnant is found to have an amniotic fluid volume of 440 ml. Pre-eclampsia C. after 20 weeks) No proteinuria. no oedema Occurs in around 5-7% of pregnancies Resolves following birth (typically after one month).pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria.06 . Premature rupture of membranes B.e.

D. premature rupture of membranes fetal renal problems e.g. Tracheo-oesophageal fistula is associated with polyhydramnios. 3. Oligohydramnios In oligohydramnios there is reduced amniotic fluid. 2. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile. Her first pregnancy was complicated by gestational . 5.Women’s Health External links NICE 2008 Management of diabetes in pregnancy SIGN Management of diabetes in pregnancy Postgraduate Medical Journal DKA in pregnancy A 29-year-old woman has just found out she is pregnant for the second time. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia 29RCGP curriculum 3.06 . Causes: 1. Intrauterine growth restriction An amniotic fluid volume of 440ml indicates oligohydramnios. Renal agenesis E. 4.

5 kg or above. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian. BMI of > 30 kg/m^2 previous macrosomic baby weighing 4. Do oral glucose tolerance test at 16-18 weeks E. Do fasting glucose at booking visit Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy.diabetes. 4. 3. gestational diabetes. Do oral glucose tolerance test at booking visit D. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes 1. black Caribbean and Middle Eastern) Screening for gestational diabetes 1. Start insulin B. 2. Following her first pregnancy she was told she was no longer diabetic. What is the most appropriate management? A. Start metformin and do oral glucose tolerance test at 12-14 weeks C. 5. if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal .

women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. 3. 5. 6. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check 3. and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including fourchamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy Management of gestational diabetes 1. 4. . 3. 2. 5. responds to changes in diet and exercise in around 80% of women oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008 Management of pre-existing diabetes 1. 2.g.2. weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents. apart from metformin. 4.

continue breast feeding Breast feeding problems Mastitis Mastitis affects around 1 in 10 breast feeding women. Clindamycin for 7 days. if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection'. Co-amoxiclav for 7 days. The BNF advises to treat 'if systemically unwell. What is the most appropriate management? A. . stop breast feeding D. This has been getting worse for the past three days and feeding is now painful. She has developed a warm. If left untreated.30- Question stats A new mother who is 4 weeks post-partum presents for review. red tender patch to on the right breast just lateral to the areola. She saw the midwife yesterday who helped with positioning but this has not improved matters. This generally requires incision and drainage. Co-amoxiclav for 7 days. Flucloxacillin for 14 days. The first-line antibiotic is flucloxacillin for 10-14 days. Breast feeding or expressing should continue during treatment. mastitis may develop into a breast abscess. Flucloxacillin for 7 days. On examination she has mastitis of the right breast with no obvious abscess. if nipple fissure present. continue breast feeding C. stop breast feeding E. continue breast feeding B.

Carrying twins Smoking is associated with a decreased incidence of hyperemesis gravidarum Hyperemesis gravidarum Hyperemesis gravidarum describes excessive vomiting during pregnancy. Hyperemesis gravidarum . Trophoblastic disease C. Obesity B. She is now having difficulty keeping down fluids and a dipstick of her urine shows ketones ++. Smoking D.Women’s Health A 23-year-old woman who is 10 weeks pregnant presents with severe vomiting.06 .31- RCGP curriculum 3. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Nulliparity E. Which one of the following is not associated with an increased risk of this condition? A.

naila@yahoo. pre-term birth *And in very rare cases beyond 20 weeks dr.is most common between 8 and 12 weeks but may persist up to 20 weeks*.Applied Knowledge Test .My account .com . Associations      Multiple pregnancies Trophoblastic disease Hyperthyroidism Nulliparity Obesity Smoking is associated with a decreased incidence of hyperemesis Management   Antihistamines should be used first-line (BNF suggests promethazine as first-line) Admission may be needed for IV hydration Complications      Wernicke's encephalopathy Mallory-Weiss tear Central pontine myelinolysis Acute tubular necrosis Fetal: small for gestational age.

Down's syndrome E.32- RCGP curriculum 3. Which one of the following is associated with a low alpha-feto protein level? A.Women’s Health Search Go A pregnant woman has serum alpha feto-protein levels measured.06 . Gastroschisis C. Meningocele B. Multiple pregnancy D. Anencephaly AFP   Raised in neural tubes defects Decreased in Down's syndrome Alpha feto-protein Alpha-fetoprotein (AFP) is a protein produced by the developing fetus .

24 weeks .com . presuming an uncomplicated pregnancy with no change in the estimated date of delivery? A. myelomeningocele and anencephaly) Abdominal wall defects (omphalocele and gastroschisis) Multiple pregnancy Decreased AFP Down's syndrome Trisomy 18 Maternal diabetes mellitus dr.Applied Knowledge Test .Women’s Health Search Go External links Civil Aviation Authority Fitness to fly guidelines A pregnant woman asks for advice about flying.Increased AFP Neural tube defects (meningocele.06 .My account 33RCGP curriculum 3.naila@yahoo. What is the latest time in her pregnancy that she may fly.

severe symptomatic valvular disease: should not fly uncomplicated myocardial infarction: may fly after 7-10 days complicated myocardial infarction: after 4-6 weeks coronary artery bypass graft: after 10-14 days percutaneous coronary intervention: after 5 days Respiratory disease . uncontrolled cardiac arrhythmia.B.up to 36 weeks Fitness to fly The Civil Aviation Authority (CAA) has issued guidelines on air travel for people with medical conditions.pregnancy . Cardiovascular disease      unstable angina. 28 weeks C. uncontrolled hypertension. 36 weeks E. 32 weeks D. please see the link provided. decompensated heart failure. 38 weeks Fitness to fly .

the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air.com .Applied Knowledge Test .naila@yahoo. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray Pregnancy   most airlines do not allow travel after 36 weeks for a single pregnancy and after 32 weeks for a multiple pregnancy most airlines require a certificate after 28 weeks confirming that the pregnancy is progressing normally Surgery     travel should be avoided for 10 days following abdominal surgery laparoscopic surgery: after 24 hours colonoscopy: after 24 hours following the application of a plaster cast.My account . the majority of airlines restrict flying for 24 hours on flights of less than 2 hours or 48 hours for longer flights Haematological disorders  patients with a haemoglobin of greater than 8 g/dl may travel without problems (assuming there is no coexisting condition such as cardiovascular or respiratory disease) dr.  pneumonia: should be 'clinically improved with no residual infection' pneumothorax: absolute contraindication.

Women’s Health Search Go External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy A 38-year-old female develops hypertension in the third trimester of her first pregnancy. Intracerebral haemorrhage B.34- RCGP curriculum 3. Pulmonary oedema C. Fetal intrauterine growth retardation Transverse myelitis is not associated with pre-eclampsia Pre-eclampsia . Fetal prematurity D. Which one of the following complications is least associated with this condition? A.5g protein. Transverse myelitis E. A 24 hour urine collection shows 0.06 .

intrauterine growth retardation eclampsia haemorrhage: placental abruption. intracerebral cardiac failure multi-organ failure Risk factors          > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease Features of severe pre-eclampsia  hypertension: typically > 170/110 mmHg and proteinuria as above . Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems      fetal: prematurity. intra-abdominal.Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours).

06 .       proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l.Applied Knowledge Test .com .Women’s Health Search Go External links NICE 2008 Antenatal care guidelines .My account 35RCGP curriculum 3. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario dr. abnormal liver enzymes or HELLP syndrome Management    consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines.naila@yahoo.

previous macrosomic baby. Screening for haemoglobinopathies Antenatal care: routine glucose testing no longer recommended Surprisingly perhaps. family history. NICE now recommends that blood glucose is only checked to those considered at risk (e. Hepatitis B E. They recommend:    10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated . Blood glucose D. Syphilis B. Asian ethnicity) Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. HIV C. as a matter of routine. to women during the booking visit for antenatal care? A. which one of the following tests should not be offered.g.According to recent NICE guidelines. obesity.

rhesus status.Gestation 8 .g. red cell alloantibodies. rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 . vitamin D. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan 11 . exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood results. blood group. antenatal classes BP. folic acid. diet.13+6 weeks 16 weeks 18 . smoking. urine dipstick. haemoglobinopathies hepatitis B. syphilis.20+6 weeks .13+6 weeks Early scan to confirm dates. check BMI Booking bloods/urine     FBC.12 weeks (ideally < 10 weeks) Purpose of visit Booking visit   general information e. alcohol.

offer external cephalic version if indicated Information on breast feeding.25 weeks (only if primip) 28 weeks Routine care: BP. urine dipstick. vitamin K. If Hb < 10. 'babyblues' Routine care as above Routine care as above Discussion about options for prolonged pregnancy 36 weeks 38 weeks 40 weeks (only if primip) . SFH Second screen for anaemia and atypical red cell alloantibodies. symphysis-fundal height (SFH) Routine care: BP.5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women* Information on labour and birth plan Routine care as above Check presentation . urine dipstick.

Blood tests reveal the following: TSH < 0.com .Women’s Health Search Go A 29-year-old female who is 14 weeks into her first pregnancy is investigated for excessive sweating and tremor.41 weeks Routine care as above Discuss labour plans and possibility of induction *The evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). Carbimazole + thyroxine . For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' dr.06 . Immediate surgery B.05 mu/l T4 188 nmol/l What is the most appropriate management? A.My account 36RCGP curriculum 3.Applied Knowledge Test .naila@yahoo.

Radioiodine Propylthiouracil is traditionally taught as the antithyroid drug of choice in pregnancy. Carbimazole has rarely been associated with aplasia cutis of the neonate Pregnancy: thyroid problems In pregnancy there is an increase in the levels of thyroxinebinding globulin (TBG).often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester . It also has the advantage of being excreted to a lesser extent than carbimazole in breast milk.C. Propylthiouracil E. This approach was supported by the 2007 Endocrine Society consensus guidelines. This causes an increase in the levels of total thyroxine but does not affect the free thyroxine level Thyrotoxicosis Untreated thyrotoxicosis increases the risk of fetal loss. maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy. Surgery at start of third trimester D. It is also recognised that activation of the TSH receptor by HCG may also occur . Despite this some endocrinologists use carbimazole and the BNF states both drugs may be used in pregnancy.

Applied Knowledge Test .naila@yahoo.com .My account 37RCGP curriculum 3.Women’s Health Search .06 .helps to determine risk of neonatal thyroid problems block-and-replace regimes should not be used in pregnancy radioiodine therapy is contraindicated Hypothyroidism Key points     thyroxine is safe during pregnancy serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum some women require an increased dose of thyroxine during pregnancy breast feeding is safe whilst on thyroxine dr. This approach was supported by the 2007 Endocrine Society consensus guidelines maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation .Management      propylthiouracil has traditionally been the antithyroid drug of choice.

1 to 2 units once or twice per week throughout pregnancy B. If then chooses to drink 1 to 2 units once or twice per week E. If then chooses to drink less than 7-14 units per week Antenatal care: specific points NICE issued guidelines on routine care for the healthy pregnant woman in March 2008 Nausea and vomiting  Natural remedies . If then chooses to drink 1 to 4 units no more than twice per week C.Go External links NICE 2008 Antenatal care guidelines A pregnant woman asks for advice about alcohol consumption during pregnancy. Avoid first trimester. 1 to 2 units once per week throughout pregnancy D. Avoid first trimester.ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE . Which one of the following is in line with current NICE guidelines? A. Avoid first and second trimester.

Women’s Health Search Go External links .06 .g. Antihistamines should be used first-line (BNF suggests promethazine as first-line) Vitamin D    NICE recommend 'All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding' 'Women may choose to take 10 micrograms of vitamin D per day. Asian.com . obese. poor diet) Alcohol   NICE recommend women should avoid alcohol during the first trimester If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week dr.My account 38- RCGP curriculum 3. as found in the Healthy Start multivitamin supplement' Particular care should be taken with women at risk (e.Applied Knowledge Test .naila@yahoo.

NICE 2010 Hypertension in pregnancy A 37-year-old woman presents for review. She is 26 weeks pregnant and has had no problems with her pregnancy to date. Gestational hypertension D. Urine dipstick reveals the following: Protein negative Leucocytes negative Blood negative What is the most appropriate description of her condition? A. Moderate pre-eclampsia B. Normal physiological change in blood pressure E. Pre-existing hypertension Hypertension in pregnancy The classification of hypertension in pregnancy is complicated and varies. Mild pre-eclampsia C. Remember. in normal pregnancy:  Blood pressure usually falls in the first trimester (particularly the diastolic). and continues to fall until 20-24 weeks . Blood pressure is 144/92 mmHg. a rise from her booking reading of 110/80 mmHg.

 After this time the blood pressure usually increases to prepregnancy levels by term Hypertension in pregnancy in usually defined as:   Systolic > 140 mmHg or diastolic > 90 mmHg Or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic After establishing that the patient is hypertensive they should be categorized into one of the following groups Pre-existing hypertension Pregnancy-induced hypertension (PIH. also known as gestational hypertension) Hypertension (as defined above) occurring in the second half of pregnancy (i. after 20 weeks) No proteinuria. no edema Occurs in 3-5% of pregnancies and is more common in older Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours) Edema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies . no edema Occurs in around 5-7% of pregnancies Resolves following birth Pre-eclampsia A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria.e.

women

(typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

dr.naila@yahoo.com - Applied Knowledge Test - My account 39RCGP curriculum

3.06 - Women’s Health Search Go External links NICE 2008 Management of diabetes in pregnancy SIGN Management of diabetes in pregnancy Postgraduate Medical Journal DKA in pregnancy You are counselling a 23-year-old woman with type 1 diabetes mellitus who has just found out she is pregnant. She is concerned about the increased risk congenital malformations, particularly heart defects. Which one of the following best describes the screening that is currently offered?

A. No extra screening is offered B. Echocardiography at 6 weeks C. Scan at 34-36 weeks including four-chamber view of the heart and outflow tracts D. Echocardiography in the first week of life E. Scan at 18-20 weeks including four-chamber view of the heart and outflow tracts

Diabetes in pregnancy: detailed heart scan at 18-20 weeks

Pregnancy: diabetes mellitus Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes
    

BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.5 kg or above. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Screening for gestational diabetes

 

if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes

NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008 Management of pre-existing diabetes
     

weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including fourchamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Management of gestational diabetes

responds to changes in diet and exercise in around 80% of women

  

oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check

dr.naila@yahoo.com - Applied Knowledge Test - My account 40RCGP curriculum

3.06 - Women’s Health Search Go External links NICE 2008 Routine anti-D prophylaxis guidelines RCOG Use of Anti-D Immunoglobulin for Rh Prophylaxis In which one of the following situations would you not routinely give anti-D prophylaxis to a non-sensitised Rhesus negative mother? A. Amniocentesis at 16 weeks

For this reason the RCOG in . Spontaneous miscarriage at 10 weeks D. External cephalic version at 37 weeks C. Placental abruption at 26 weeks E.B. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention    test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). Ectopic pregnancy at 7 weeks Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies       along with the ABO system the Rhesus system is the most important antigen found on red blood cells.

as liver devoted to RBC production albumin falls) . will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood. chorionic villus sampling. fetal cells are resistant Affected fetus  oedematous (hydrops fetalis.  2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis . blood group & direct Coombs test Coombs test: direct antiglobulin .determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:        delivery of a Rh +ve infant.once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test . fetal blood sampling Tests    all babies born to Rh -ve mother should have cord blood taken at delivery for FBC. whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis.

8 weeks B.naila@yahoo. 16 weeks F. 18 . 14 -15 weeks E. anaemia.20+6 weeks G.com . 11 . 25 weeks .    jaundice.My account 41RCGP curriculum 3. 7 . hepatosplenomegaly heart failure kernicterus treatment: transfusions.Women’s Health Search Go External links NICE 2008 Antenatal care guidelines Theme: Routine antenatal care A.12 weeks C. UV phototherapy dr. 8 .06 .Applied Knowledge Test .13+6 weeks D.

Nuchal scan 11 . Second screen for anaemia and atypical red cell alloantibodies 28 weeks 11.H.12 weeks Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. Urine culture to detect asymptomatic bacteriuria 8 . 34 weeks J. They recommend:   10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated . 38 weeks For each of the following components of routine antenatal care select the gestation when it should occur 10. 28 weeks I.13+6 weeks 12.

12 weeks (ideally < 10 weeks) Purpose of visit Booking visit   general information e. alcohol. blood group. rhesus status. vitamin D.g. smoking. folic acid. syphilis.13+6 weeks 16 weeks . If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick 11 .13+6 weeks Early scan to confirm dates. women do not need to be seen by a consultant if the pregnancy is uncomplicated Gestation 8 . rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 . haemoglobinopathies hepatitis B. urine dipstick. diet. check BMI Booking bloods/urine     FBC. exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood results. red cell alloantibodies. antenatal classes BP.

urine dipstick. If Hb < 10. 'babyblues' Routine care as above Routine care as above 36 weeks 38 weeks 40 weeks (only if .5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 31 weeks (only if primip) 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women* Information on labour and birth plan Routine care as above Check presentation . SFH Second screen for anaemia and atypical red cell alloantibodies. urine dipstick. symphysis-fundal height (SFH) Routine care: BP.offer external cephalic version if indicated Information on breast feeding.20+6 weeks 25 weeks (only if primip) 28 weeks Anomaly scan Routine care: BP.18 . vitamin K.

This is her first pregnancy.com .naila@yahoo. Pelvic examination .06 .Applied Knowledge Test . For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' dr.Women’s Health Search Go External links NICE 2008 Antenatal care guidelines A 23-year-old woman attends her antenatal booking appointment.My account 42RCGP curriculum 3.primip) 41 weeks Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction *the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). She thinks that she is 10 weeks pregnant. Assess body mass index B. Which one of the following is not routinely performed? A.

vitamin D. Hepatitis B testing Antenatal care: timetable NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. check BMI Booking bloods/urine  FBC. Check for red cell alloantibodies E. haemoglobinopathies . blood group. rhesus status.C. folic acid. Urine culture if dipstick urine normal D.g. urine dipstick. diet. smoking.12 weeks (ideally < 10 weeks) Purpose of visit Booking visit   general information e. red cell alloantibodies. antenatal classes BP. They recommend:    10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated Gestation 8 . alcohol.

exclude multiple pregnancy Down's syndrome screening including nuchal scan Information on the anomaly and the blood results. urine dipstick. SFH Second screen for anaemia and atypical red cell alloantibodies.5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women Routine care as above 11 .13+6 weeks Early scan to confirm dates.   hepatitis B.20+6 weeks 25 weeks (only if primip) 28 weeks 31 weeks (only if primip) . urine dipstick. symphysis-fundal height (SFH) Routine care: BP.13+6 weeks 16 weeks 18 . rubella HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 . If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick Anomaly scan Routine care: BP. syphilis. If Hb < 10.

Applied Knowledge Test .Women’s Health Search .offer external cephalic version if indicated Information on breast feeding.06 . For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' dr. vitamin K.com . 'babyblues' Routine care as above Routine care as above Discussion about options for prolonged pregnancy Routine care as above Discuss labour plans and possibility of induction 36 weeks 38 weeks 40 weeks (only if primip) 41 weeks *the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks).naila@yahoo.My account 43RCGP curriculum 3.34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women* Information on labour and birth plan Routine care as above Check presentation .

Hydrops fetalis may result if maternal anti-D antibodies cross the placenta D.Go External links NICE 2008 Routine anti-D prophylaxis guidelines RCOG Use of Anti-D Immunoglobulin for Rh Prophylaxis Which one of the following statements regarding the management of pregnant. Anti-D should be given following every termination of pregnancy Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies . non-sensitised Rhesus negative women is incorrect? A. Around 15% of mothers are Rhesus negative C. All Rhesus negative women should receive anti-D at 28 and 34 weeks E. External cephalic version does not require prophylaxis B.

The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention      test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis .determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:     delivery of a Rh +ve infant.once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test .      along with the ABO system the Rhesus system is the most important antigen found on red blood cells. whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy .

will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood. fetal blood sampling Tests    all babies born to Rh -ve mother should have cord blood taken at delivery for FBC.   external cephalic version antepartum haemorrhage amniocentesis. chorionic villus sampling. fetal cells are resistant Affected fetus      oedematous (hydrops fetalis. hepatosplenomegaly heart failure kernicterus treatment: transfusions. anaemia.Applied Knowledge Test . UV phototherapy dr.My account 44Go Search External links Australian goverment Prescribing in pregnancy . blood group & direct Coombs test Coombs test: direct antiglobulin . as liver devoted to RBC production albumin falls) jaundice.com .naila@yahoo.

Orlistat E. Paracetamol B. Aspirin C. Metformin is sometimes used in pregnancy although many diabetic women are converted to insulin for the duration of the pregnancy to try and maximise control and minimise complications. . The urinary hCG test is positive. Simvastatin D. Whilst orlistat is not a known teratogen it should be used with 'caution' in pregnancy according to the BNF and the benefits are very likely outweighed by risks.A 37-year-old woman with a history of type 2 diabetes mellitus and obesity presents after a late period. Her current medication is as follows: Orlistat 120mg tds Simvastatin 40mg on Aspirin 75mg od Metformin 1g bd Paracetamol 1g qds Aqueous cream prn Which one of her medications must be stopped straight away? A. Metformin Simvastatin is contraindicated in pregnancy and must be stopped immediately.

Some countries have developed a grading system . Antibiotics     tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies Other drugs       ACE inhibitors.see the link.My account 45RCGP curriculum 3. The list below largely comprises of those known to be harmful.Women’s Health Search .com .Applied Knowledge Test .naila@yahoo.06 .Prescribing in pregnant patients Very few drugs are known to be completely safe in pregnancy. carbamazepine and phenytoin are known to be potentially harmful. angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents The majority of antiepileptics including valproate. The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk dr.

Go External links NICE 2008 Management of diabetes in pregnancy SIGN Management of diabetes in pregnancy Postgraduate Medical Journal DKA in pregnancy Which one of the following statements regarding the management of diabetes mellitus during pregnancy is incorrect? A. A previous macrosomic baby is a risk factor for gestational diabetes B. Diabetes complicates around 1 in 40 pregnancies C. A higher dose of folic acid (5 mg/day) should be used D. Metformin is contraindicated E. Tight glycaemic control reduces complication rates There is increasing evidence that metformin is safe during pregnancy Pregnancy: diabetes mellitus

Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies Risk factors for gestational diabetes
    

BMI of > 30 kg/m^2 previous macrosomic baby weighing 4.5 kg or above. previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Screening for gestational diabetes

 

if a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal women with any of the other risk factors should be offered an OGTT at 24-28 weeks currently the same WHO diagnostic criteria are used as for non-pregnant patients. There is however increasing evidence that a lower threshold should be used as treating borderline patients improves both maternal and neonatal outcomes

NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008 Management of pre-existing diabetes

weight loss for women with BMI of > 27 kg/m^2

    

stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 18-20 weeks including fourchamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Management of gestational diabetes
 

  

responds to changes in diet and exercise in around 80% of women oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia) there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin hypoglycaemic medication should be stopped following delivery a fasting glucose should be checked at the 6 week postnatal check dr.naila@yahoo.com - Applied Knowledge Test - My account

46-

RCGP curriculum

3.06 - Women’s Health Search Go Which one of the following statements regarding preterm birth is incorrect?

It occurs in around 5-10% of pregnancies (6% of singletons. May be elective due to congenital abnormalities Preterm birth occurs in around 5-10% of pregnancies Preterm birth Preterm birth is defined as delivery of an infant before 37 weeks gestation. Diabetes mellitus is a risk factor E.A. Occurs in around 15-20% of pregnancies D. 45% of twins) Causes 123456789- Unexplained (30-40%) Multiple pregnancies (20-30%) Congenital abnormalities Antepartum haemorrhage Pre-eclampsia Cervical incompetence Diabetes mellitus Polyhydramnios Uterine abnormalities . Is defined as delivery of an infant before 37 weeks gestation B. Around 45% of twin pregnancies are premature C.

My account 47- RCGP curriculum 3.naila@yahoo.10- Infections e. which one is least suitable to use? A. She has developed pre-eclampsia with her current blood pressure being 156/104 mmHg and the urine dipstick reported as follows: Protein + Leucocytes negative Blood negative There is no oedema and the patient is otherwise asymptomatic. Labetalol .Applied Knowledge Test . Of the following drugs.com .g.06 . Pyelonephritis dr.Women’s Health Search Go External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy A 29-year-old woman who is 28 weeks pregnant is reviewed.

intracerebral cardiac failure multi-organ failure Risk factors . intrauterine growth retardation eclampsia haemorrhage: placental abruption.B. Hydralazine ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic. Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems      fetal: prematurity. Most clinicians would either use methyldopa or labetalol first-line in this situation Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Methyldopa E. Losartan D. intra-abdominal. Nifedipine C.

         > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease Features of severe pre-eclampsia         hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario . abnormal liver enzymes or HELLP syndrome Management    consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines.

Afro-Caribbean ethnicity D.dr.com . Macrosomia B. Prolonged labour E. Which one of the following is not a risk factor for primary post-partum haemorrhage? A.My account 48RCGP curriculum 3.Applied Knowledge Test . Polyhydramnios Post-partum haemorrhage .naila@yahoo.000 ml of blood shortly following a vaginal delivery. Pre-eclampsia C.Women’s Health Search Go External links RCOG Post-partum haemorrhage guidelines A 29-year-old woman loses around 1.06 .

uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure . Other causes include genital trauma and clotting factors Risk factors for primary PPH include*:          previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) Management      ABC IV syntocinon (oxytocin) 10 units or IV ergometrine 500 mcg IM carboprost other options include: B-Lynch suture. ligation of the uterine arteries or internal iliac arteries if severe.Post-partum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary Primary PPH    occurs within 24 hours affects around 5-7% of deliveries most common cause of PPH is uterine atony (90% of cases).

Can help detect neural tube defects . It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor **previously the definition of secondary PPH was 24 hours .Women’s Health Search Go Which one of the following statements regarding amniocentesis is incorrect? A.My account 49- RCGP curriculum 3. Is usually performed at 16 weeks C. Is performed under ultrasound guidance B.Applied Knowledge Test .6 weeks.com .Secondary PPH   occurs between 24 hours . Please see the RCOG guidelines for more details dr.12 weeks** due to retained placental tissue or endometritis *the effect of parity on the risk of PPH is complicated.06 .naila@yahoo.

5-1% Amniocentesis Amniocentesis is a procedure used in prenatal diagnosis. It is known the karyotype may be wrong in 1/1000 cases due to maternal cells being present Conditions which may be diagnosed    Neural tube defects (raised AFP levels in the amniotic fluid) Chromosomal disorders Inborn errors of metabolism dr.My account . Amniocentesis is usually performed at 16 weeks and the risk of fetal loss is 0.5-1%.000 cases E. It may be offered after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk. Around 20 ml of fluid is removed by trans-abdominal needle under ultrasound guidance.D. The karyotype results typically take 3 weeks. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions.naila@yahoo. Risk of fetal loss is 2-3% Amniocentesis: risk of fetal loss is 0. Karyotype may be wrong in 1 in 1.Applied Knowledge Test . for example if > 35 years old.com .

Breast feeding is safe whilst on thyroxine E. Untreated thyrotoxicosis increases the risk of premature labour Pregnancy: thyroid problems In pregnancy there is an increase in the levels of thyroxinebinding globulin (TBG). Increased levels of thyroxine-binding globulin are seen in pregnancy C. This causes an increase in the levels of total thyroxine but does not affect the free thyroxine level Thyrotoxicosis .06 .Women’s Health Search Go Which one of the following regarding the management of thyroid problems during pregnancy is incorrect? A.50- RCGP curriculum 3. Block-and-replace is preferable in pregnancy compared to antithyroid drug titration D. Maternal free thyroxine levels should be kept in the upper third of the normal reference range when treating thyrotoxicosis B.

This approach was supported by the 2007 Endocrine Society consensus guidelines Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism Thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation . HCG levels will fall in second and third trimester Management      Propylthiouracil has traditionally been the antithyroid drug of choice. It is also recognized that activation of the TSH receptor by HCG may also occur .My account .naila@yahoo.com . maternal heart failure and premature labor Graves' disease is the most common cause of thyrotoxicosis in pregnancy.Applied Knowledge Test .often termed transient gestational hyperthyroidism.helps to determine risk of neonatal thyroid problems Block-and-replace regimes should not be used in pregnancy Radioiodine therapy is contraindicated Hypothyroidism Key points     Thyroxine is safe during pregnancy Serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum Some women require an increased dose of thyroxine during pregnancy Breast feeding is safe whilst on thyroxine dr.Un-treated thyrotoxicosis increases the risk of fetal loss.

26 cm After 20 weeks. 15 . 22 .Women’s Health Search Go A pregnant woman presents for review. She is 24 weeks pregnant. symphysis-fundal height in cm = gestation in weeks Symphysis-fundal height The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres . 13 . What would be the expected symphysis-fundal height? A.06 . 18 .17 cm C.22 cm E.19 cm D. 17 .15 cm B.51- RCGP curriculum 3.

Women’s Health Search Go External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy Which one of the following is not a risk factor for the development of pre-eclampsia? A.g. Multiple pregnancy E. if 24 weeks then the a normal SFH = 22 to 26 cm dr.com . Multiparity . e. Body mass index of 34 kg/m^2 C.naila@yahoo.06 . Previous history of pre-eclampsia B.Applied Knowledge Test .It should match the gestational age in weeks to within 2 cm after 20 weeks. Age of 42 years D.My account 52RCGP curriculum 3.

Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems      fetal: prematurity.3g / 24 hours). intra-abdominal. intracerebral cardiac failure multi-organ failure Risk factors          > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease .No previous pregnancies is a risk factor for pre-eclampsia Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0. intrauterine growth retardation eclampsia haemorrhage: placental abruption.

abnormal liver enzymes or HELLP syndrome Management    consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines.naila@yahoo. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step.Applied Knowledge Test . The timing depends on the individual clinical scenario dr.com .Women’s Health Search Go .My account 53- RCGP curriculum 3.Features of severe pre-eclampsia         hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l.06 .

3g / 24 hours). Body mass index of 38 kg/m^2 B. Diabetes mellitus There is some evidence to suggest that pre-eclampsia is actually less common in smokers Pre-eclampsia Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0. Nulliparity E. A woman carrying twins D. Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Pre-eclampsia is important as it predisposes to the following problems . Smoking C.External links RCOG 2006 Management of severe pre-eclampsia/eclampsia NICE 2010 Hypertension in pregnancy Which one of the following is not a risk factor for the development of pre-eclampsia? A.

abnormal liver enzymes or HELLP syndrome . intra-abdominal. intracerebral cardiac failure multi-organ failure Risk factors          > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease Features of severe pre-eclampsia         hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l. intrauterine growth retardation eclampsia haemorrhage: placental abruption.     fetal: prematurity.

com .Women’s Health Search Go A woman who is 41 weeks pregnant has a biophysical profile.06 . Which one of the following is not assessed during this test? A. Fetal activity B.Applied Knowledge Test . Fetal breathing movements D. Fetal tone E. The timing depends on the individual clinical scenario dr. Amniotic fluid volume .Management    consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines.naila@yahoo.My account 54- RCGP curriculum 3. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step. Head circumference C.

Rhesus negative mothers who are sensitised where there is coexistent anaemia . Rhesus negative mothers who are sensitised C. Rhesus negative mothers who are not sensitised B.Biophysical profile A biophysical profile is an antenatal ultrasound test which assesses: 12345- Amniotic fluid volume Fetal tone Fetal activity Fetal breathing movements Reactivity of the heart 55- External links NICE 2008 Routine anti-D prophylaxis guidelines RCOG Use of Anti-D Immunoglobulin for Rh Prophylaxis You are reviewing the blood results for a pregnant woman. Which one of the following results would indicate the need for routine antenatal anti-D prophylaxis to be given at 28 weeks? A.

For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis .once sensitization has occurred it is irreversible . Rhesus positive mothers who are not sensitised Rhesus negative pregnancy A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies       along with the ABO system the Rhesus system is the most important antigen found on red blood cells.D. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks Prevention     test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). Rhesus positive mothers who are sensitised E.

UV phototherapy . anaemia. will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood. whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis. fetal blood sampling Tests    all babies born to Rh -ve mother should have cord blood taken at delivery for FBC. blood group & direct Coombs test Coombs test: direct antiglobulin. as liver devoted to RBC production albumin falls) jaundice.determines proportion of fetal RBCs present Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:        delivery of a Rh +ve infant. chorionic villus sampling. fetal cells are resistant Affected fetus      oedematous (hydrops fetalis. hepatosplenomegaly heart failure kernicterus treatment: transfusions. if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test .