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This booklet in Obstetric is intended for last minute revision before taking a

This booklet in Obstetric is intended for last minute revision before taking a

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    Long case examination for phase iii medical students usmkk Long case examination for phase iii medical students usmkk Document Transcript

    • 2009/2010 2009 Long Case Examination for Phase III Medical Students (Obstetric Cases) List and Answer to Commonly Asked Questions by Lecturers Muhamad Na’im B Ab Razak University Science Malaysia jacknaim@gmail.com www.jacknaimsnotes.blogspot.com
    • Open Notes to My friends In the name of Allah, The Most gracious and the Most Merciful: Assalamu’alaikum wbt, May Peace and Blessing of GOD be upon all of you Dear friends, I would like to take this opportunity to thank you for inspiring me a lot during our journey in medical school. This notes is my way of replying your kindness and favor in helping me to survive the challenging life of medical school. Lot of cry and tears, but yet we still able to laugh together! All thanks to the seniors who have been doing a great job by compiling the entire commonly asked question during an exam. I just add some spice to their effort by providing an answer to the questions through this little book. If there is any mistake in this book, do not hesitate to inform me. InsyaALLAH I will try my best to correct it and updating this book. Whatever you read in this book, please double check with current management and ask opinion from lecturers. This book mainly reserves to be used for last minutes revision and not as reference. Please keep on reading text book and enhance your knowledge through journals. It is our duty as a Muslim to keep on updating our knowledge Hopefully, all of us may become a great and outstanding Muslim doctor someday. Pray for me that I may pass my undergraduate study and successfully pursuit my dream to become an emergency specialist. Sincerely yours, Jacknaim
    • Oath Of USM Medical Student’s Graduation Day In the name of God, We seek from you: The ability to be truthful, honest modest, Merciful and objective in our dealings The fortitude to admit our mistakes, to amend our ways and to forgive The wisdom to comfort and counsel all our patients Towards well being, peace and harmony regardless of their Social status, race and religion The ability to understand that our profession is sacred, Dealing with your most precious gifts of life and intellect We promise to devote our lives in serving mankind, Poor or rich, Literate or illiterate, Irrespective of race and religion With Patience and tolerance, With virtue and reverence, With knowledge and vigilance, And with Your love in our heart
    • The Oath Of the Muslim Doctor I swear by God ...The Great To regard God in carrying out my profession To protect human life in all stages and under all circumstances, doing my utmost to rescue it from death, malady, pain and anxiety. . To keep peoples' dignity, cover their privacies and lock up their secrets... To be, all the way, an instrument of God's mercy, Extending my medical care to near and far, Virtuous and sinner and friend and enemy. To strive in the pursuit of knowledge and. harnessing it for the benefit but not the harm of Mankind. To refer my teacher, teach my junior, And be brother to members of the Medical Profession. Joined in piety and charity. To live my Faith in private and in public, Avoiding whatever blemishes me in the eyes of God, His Apostle and my fellow Faithful. And may God be witness to this Oath.
    • Long Case Examination for Phase III Medical Students University Science Malaysia Important and Common Cases Needs to be Covered in Obstetric Section. 1) Normal labour 2) False labour 3) Unsure of Date 4) Induction of Labour 5) Caesarian Section 6) Pregnancy Induce Hypertension 7) Pre eclampsia 8) Hypertension in Pregnancy 9) Diabetes Mellitus in pregnancy 10) Gestational Diabetes Mellitus 11) Oligohydramnios 12) Polyhydramnios 13) Reduced Fetal Movement 14) Threatened pre term labour 15) Premature birth. 16) Post Date 17) Post Term 18) PPROM 19) PROM 20) Placenta previa 21) Unstable lie 22) Breech presentation 23) Multiple pregnancy 24) Heart disease in pregnancy 25) Anemia in pregnancy 26) Fibroids 27) Anti phospholipids syndrome 28) Teenage pregnancy And We have enjoined on man (to be good) to his parents: in travail upon travail did his mother bear him, and in years twain was his weaning: (hear the command), "Show gratitude to Me and to thy parents: to Me is (thy final) Goal [Q31:14]]
    • Long Case Examination for Phase III Medical Students University Science Malaysia Anti tetanus toxoid Macrosomic baby (page 18) Type of immune (page 36) Management (page 16, 17) When to give (page 36) MOGTT, when to do (page 15) MOGTT, Indication (page 16) Anemia in pregnancy (page 44,45) Shoulder dystocia (page 18) Spontaneous vaginal delivery ((page 18) Breech presentation (page 36) Weight gain in pregnancy (page 15) Causes and complication Mode of delivery Heart disease in pregnancy (page 40, 41, 42, 43) Candidosis Aspirin, IV Drug (page 24) Contraindication for pregnancy (page 43) Failure (page 40) Caesarian section (page 9) Eisenmenger syndrome (page 41) Anterior abdominal wall layer (page 10) Warfarin (page 41) Impending scar rupture (page 10) Preparation pre op and post op (page 9) Episiotomy Pfannensteil scar (page 32) Definition (page 4) Trial of scar (page 9) Layer cut (page 4) Cervix Fibroids (page 46) Normal cervical length (page 3) cervical effacement (page 1) Hypothyroidism (page 50) cervical dilatation in nulli vs multiparity (page 1) Labour Bishop score (page 1, page 3) Cervical cerclage (page 26) Braxton Hicks contraction (page 2) definition of labour (page 5) Chorioamnionitis Discharging patient in latent phase of Common organism (page 8) labour (page 3) Management (page 8) engagement (page 4) Show (page 5) Diabetes Melitus in pregnancy True vs false labour (page 2) GDM (page 15) Management of active phase of labour Complication of GDM (page 16) (page 2) Diagnosis and level of sugar control (page Mechanism of labour (page 4) 15) Screening test (page 15) Induction of labour Diabetogenic hormone (page 15) definition (page 7) Hydrocephalus (page 19) Indication (page 7)
    • Long Case Examination for Phase III Medical Students University Science Malaysia Mehtod (page 7) Ultrasound placenta (page 6) Oligohydramnios (page 20) Premature labour (page 24) Parity Definition Pseudoprimid (page 5) Premature contraction (page 25) Grand multiparity (page 26) Management Great grand multiparity (page 49) Reduce fetal movement (page 22, 23) Polyhydramnios (page 21) Tocolytic Fetal kick chart Post date (page 27) Tradisional medicine (page 23) Post term (page 28, 29) PPROM (page 30) Twin pregnancy (page 37, 38, 39) Fever Classification Positive findings complication Management Physical examination Twin to twin transfusion reaction PROM (page 31) Unsure of date (page 7) Placenta Neagele's rule (page 7) seperation, sign and symptoms (page 2) Comfirmation of date Placenta previa (page 32, 33) Unstable lie (page 34, 35) Prostin Causes Complication (page 7) Complication dose (page 8) Management Instruction to patient (page 8) Mode of delivery with presence of contaction pain (page 1, page 3) Uterus Pregnancy induced hypertension support (page 4) definition (page 11) Essential hypertension (page 14) Management (page 11) Pre eclampsia (page 12) Impending eclampsia (page 13) Magnesium sulphate (page 13)
    • Long Case Examination for Phase III Medical Students University Science Malaysia 25 years old Malay lady, G1P0 at 37W+ 2/7 are admitted because of contraction pain but not associated with show or leaking. Questions 1) How do you access the favorable of cervix? 2) What is cervical effacement? 3) Are there any differences if the cervix is 1 cm dilated in primid vs. Multipara who presented with contraction pain at term? Image from: Joan Pitkin et al, Obstetrics and 4) Can we induce the labour with Prostin Gynaecology: An Illustrated colour Text with the present of recorded contraction pain? Differences if the cervix is 1 cm dilated in primid vs. Multipara who presented with Answer contraction pain at term? Cervical score In HUSM, we used Modified Bishop Score. Nulliparous women have small external os at Cervix is favorable if Bishop score > 5 cervix center. In multiparous woman, cervix is bulkier and the external os has a more slit like appearance. Therefore, dilatation of 1 cm is significant in primid and not in multigravida. In multiparous, it is usually normal if cervix dilatation is 1 cm. Diagnosis of false labour should be made if it did not progress. Role of Prostin in the presence of recorded contraction pain. Recorded contraction pain is by evidence of CTG reading plus typical history of contracting Mnemonics: DiCoLePoS (Dilatation, pain. consistency, length, Position and Station) [Credited to Dr Ramli Ibrahim, HUSM] Once it present, Prostin should never being use as it will predispose mother to uterine hyper Cervical Effacement stimulation and cause fetal distress to the baby. Cervical changes prior to onset of labour where cervix become shorter, softer and moves from its Other mode of induction of labour should be position in the posterior vaginal fornix towards considered. anterior vaginal fornix [Joan Pitkin et al, Obstetrics and Gynaecology: An Illustrated colour Text] 1
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: G1P0, Post EDD, currently in labour (VE Impression: Patient is already in active phase of 5cm) first stage of labour. Post date patient who are already in labour will Question: not change the management and spontaneous a) Patient is a primid, never experience vaginal delivery should be expected except there before, how are you going to ask her in is indication for caesarian section or Hx whether it is a true labour. instrumental deliveries. b) How to manage this patient General management Notes: A Braxton Hicks contraction is a normal 1) Transfer patient to Labour room irregular uterine contraction starts occurring 2) FBC and GSH from fourth months of pregnancy. It acts as preparation for uterus to contract properly later. First stage of labour 1) Review history and problems True vs. False Labour pain 2) Abdominal exam and VE +ARM 1) Timing of contractions 3) Starts partogram False Labor: Often are irregular and do not 4) Review patient after 4H since cervix is get closer together <6cm (if >6cm VE when full dilatation True Labor: Come at regular intervals and as is expected) time goes on, get closer together. Contractions 5) Monitor last about 30-70 seconds. a) Maternal BP, PR, Uterine contraction 2) Change with movement b) 4H temperature False Labor: contractions stop in association c) FHR auscultation/ CTG with walking or change in position. True Labor: Contractions continue, despite Second stage of labour movement or changing positions 1) Leave patient for 30 minutes if no pushing contraction. Notify MO if not 3) Strength of contractions deliver after 1H of active pushing False Labor: Contractions are usually weak 2) Episiotomy and do not get much stronger (may be strong first, then get weaker) Third stage of labour (30 Minutes) True Labor: Contractions steadily increase 1) Syntometrine (Oxytoxin 5U+ in strength ergometrine 0.5 mg) IM 2) Delivery of placenta by controlled cord 4) Pain of contractions traction False Labor: contractions are usually only 3) Repairing of episiotomy wounds felt in the front of the abdomen or pelvic region True Labor: Contractions usually start in the Signs of placenta separation lower back and move to the front of the - Uterus contract and fundus become abdomen. Referred pain from uterus felt at the globular and firm buttock. - Small gush of blood flow out - Lengthening of umbilical cord. Management of this patient 2
    • Long Case Examination for Phase III Medical Students University Science Malaysia 28 years old Malay lady, G1P0 at 38W + 5/7 Before, any decision to discharge this patient, days POA was admitted because of contraction few measures needs to be look at. pain. There is no show or leaking liquar.Below 1) If the contraction pain starts to subside is her Bishop score on admission. 2) Pre discharge vagina examination did not show any cervical progression 3) No Pre labour ruptures of membrane. 4) CTG has been performed and reactive 5) Baby is not in mal presentation. 6) Patient can easily come back to hospital if anything happen. a) Short distance b) Access to transportation c) People to take care of her. 7) With advice that patient must come to hospital if any PROM or show or if the contraction become strong and in close intervals. Questions Induction of labour 1) Comment on the Bishop score 2) What is the normal length of the cervix - Induction with prostin is not indicated as in non pregnant lady? contraction is already there. It will only 3) If this patient requested to be increase risk for uterine hyper discharged, can you allow that? Support stimulation and abruptio placenta. your answer. - ARM could be done if cervical 4) Will you induce this patient for labour? dilatation more than 3 cm. Bishop Score Based on assessment on Bishop Score, patient is already in latent phase of labour as evidence of os is dilated. However the cervix is not favorable for labour yet. Normal cervix length for non pregnant lady 3.5 CM Requested to be discharged This patient is in the latent phase of labour. In primid, the latent phase could be as short as one day but may extend up to one week. 3
    • Long Case Examination for Phase III Medical Students University Science Malaysia 23 years old Malay lady at 39W+3/7 POA Mechanism of labour was transferred into ward from labour room because of contraction pain associated with Changes in position of the fetal head during show on the day of admission. No leaking of passage through the birth canal in the vertex presentation. liquor reported and fetal movement was good. (EDFIERE!) Questions 1) Engagement 1) Types of pelvis 2) Descent 2) What is engagement 3) Flexion 3) Outline the mechanism of labour 4) Internal rotation 4) What is the layer cut during the 5) Extension episiotomy procedure? 6) External rotation 5) The structures supporting the uterus. 7) Expulsion What is episiotomy and layer cut during the procedures? Episiotomy is a surgical cut that is made to the perineum during the pushing stage of labour. Layers of cutting: 1) Skin 2) Subcutaneous tissue 3) Vaginal mucosa 4) Bulbospongiosus muscle 5) Deep and superficial transverse perineal muscle Engagement Descent of the biparietal diameter of the fetal Support of the Uterus head below the plane of the pelvic inlet. Clinically, if the lowest portion of the occiput is 1) Tone of levator ani muscle at or below the level of the maternal ischial 2) Perineal body spines (station 0), engagement has usually taken 3) Ligaments place. Engagement can occur before the onset of a. Transverse cervical or cardinal true labor, especially in nulliparous patients [The ligament John Hopkins Manual of Gynecology and b. Pubocervical Obstetrics 3rd ed.] c. Sacrocervical 4
    • Long Case Examination for Phase III Medical Students University Science Malaysia 36 years old Malay lady, G3P0 at 37 weeks of Differential diagnosis pregnancy was admitted to ward after noticing - In labour spotting blood mixing with mucous on her - False labour underpants after waking up from sleep. The - PROM same event occurs two times in ward. However, - Bleeding from PP or Placenta abruptio. there is no recorded abdominal pain. - Discharge from urinary tract infection - Trauma to the perineal region. Question 1) What is mature pseudo primid? Management to this patient 2) What is labour 3) Terminology for blood mixing with 1) Full history and physical examination mucous a) Correct dating of pregnancy 4) Differential diagnosis b) Elicit any risky pregnancy 5) Management to this patient. c) Eliminating the differential diagnosis. Answer d) It is important to exclude PROM as patient at term and chorioamnionitis Mature pseudo primid could be disastrous for fetus. - Mature means age of mother > 35 years 2) Observation of vital sign old 3) Fetal kick chart (some doctor - Pseudo primid means patient has been recommend this) and labour progression pregnant but never deliver the baby. chart (LPC) - The term ‘mature’ should alert the 4) Speculum examination to access the doctor in carefully managing this patient cervix and excludes PROM, infection. because of many complication can occur 5) Assessment of fetal well being (CTG in this age group. Furthermore, this and ultrasound) could be her last pregnancy 6) Blood investigation (FBC to look for evidence of infection) Labour 7) Urine FEME to exclude UTI. - Process by which fetus is expelled from 8) Observe the patient in wards for 2-3 the uterus and into the outside world. days. If patient is stable and the labour - Three stages of labour does not progress, then the diagnosis is a) 1st stage- onset of contraction till false labour. Patient can be safely full dilatation of cervix discharge and ask her to come back b) 2nd stage- full dilatation of cervix till again once the sign and symptoms of delivery of fetus labor starts. c) 3rd stage- delivery of placenta 9) If patient in labour, then proceed with - Sign and symptoms of labour includes the management for labour abdominal contracting pain, show (discharging blood mixing with mucous), gushing of clear fluid (liquor) 5
    • Long Case Examination for Phase III Medical Students University Science Malaysia Notes on U/S about placenta Placental thickness judged subjectively Vascularity But if measure at midposition or cord insertion 2-4 cm = normal Very vascular – has 2 blood supplies Blood from fetus through 2 (sometimes 1) Grade 0 umbilical arteries through umbilical cord 1.Late 1st trimester-early 2nd trimester from fetal hypogastric arteries to placenta 2.Uniform moderate echogenicity 3.Smooth chorionic plate without indentations 1 umbilical vein carries blood back to fetal left portal vein Grade 1 1.Mid 2nd trimester –early 3rd trimester (~18-29 Blood from mom through branches of wks) uterine arteries through the myometrium 2.Subtle indentations of chorionic plate (arcuate arteries) through the basilar plate 3.Small, diffuse calcifications (hyperechoic) (spiral arteries) into the placenta randomly dispersed in placenta The two circulations intertwine in the Grade 2 placenta but do not mix 1.Late 3rd trimester (~30 wks to delivery) Exchange of oxygen and nutrients occurs 2.Larger indentations along chorionic plate over the large vascular surface area 3.Larger calcifications in a “dot-dash” configuration along the basilar plate Maternal venous channels in the placenta are hypoechoic or anechoic spaces called Grade 3 venous lakes (usually small, but can be 1.39 wks – post dates large) 2.Complete indentations of chorionic plate through to the basilar plate creating Anatomy on US “cotyledons” (portions of placenta separated by the indentations) Inner border of placenta against the uterine 3.More irregular calcifications with significant wall has the combined hypoechoic shadowing myometrium and interposed basilar layer = 4.May signify placental dysmaturity which can hypoechoic band called the decidua basalis cause IUGR (contains maternal blood vessels) 5.Associated with smoking, chronic hypertension, SLE, diabetes Outer surface abutting the amniotic fluid = chorionic plate (chorioamniotic membrane) Sources: = bright specular reflector http://www.learningradiology.com/notes/gunote s/placentapage.htm 6
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Unsure LMP/ Unsure of Date to pregnancies at gestations greater than the legal definition of fetal viability (24 weeks). Questions a) Neagele’s rule Divided into mechanical (Sweep & scratch, b) Investigation ARM,) and pharmacological (IV Syntocinon, c) Management Prostin). d) Induction of labour e) Complication of Prostin Others; breast stimulation, relaxin, hyaluronidase, sexual intercourse, acupuncture, Neagele’s rule homeopathic method 1) Sure of date 2) Menstrual cycle is regular of 28 days (ovulation occur 14 days prior to the Indication for IOL next menses) 1) Fetal 3) Not on any form of hormonal a) IUGR contraception within 3 months b) PIH/PE 4) Not lactating within 2 months c) GDM at 38w d) Post EDD Investigation e) Twin at term 1) Cardiatocography (CTG) to access fetal f) Hx of unexplained APH well being g) Transverse oblique/unstable lie 2) Ultrasound for physical biometry of the h) Hemolytic disease baby, and amniotic fluid index i) Fetal abnormality incompatible with life (anencephaly) 2) Maternal Management a) Medical disorder aggravated by 1) Confirmation of the date of pregnancy pregnancy like DM, SLE, PE, Renal a) Early ultrasound scan (<20w) disease. b) 1st UPT positive (6-8w) b) IUD with risk of DIC c) Quickening c) Spontaneous/ PROM>24h d) Uterine size correspond to d) Abruption of placenta pregnancy e) Onset of signs and symptom of pregnancy Complication of prostin f) Conception date 1) Failed IOL (require c-sec) 2) Bishop score (>5 is favorable) 2) Uterine hyper stimulation 3) Elicit any medical problem. 3) Uterine rupture. 4) Fetal distress. Induction of labour 5) C/I in patient with asthma/glaucoma An intervention designed to artificially initiate 6) Abruptio placenta uterine contractions leading to progressive dilatation and effacement of the cervix and the birth of the baby. The term is usually restricted 7
    • Long Case Examination for Phase III Medical Students University Science Malaysia 27 years old Malay lady, G2P1 at 38 weeks of In woman whom deliver more than two babies pregnancy was admitted to ward because of (not grand Multipara) and 1 caesarean section PROM more than 24 hours. She was council for scar, the dose for each cycle is 1.5 mg. induction of labour. If labour is not progress after the second dose, Question then it is considered as failed induction [NICE 1) Common organism causing Guidelines] and emergency C-sec will be done. chorioamnionitis in PROM and how to HUSM did not follow this guidelines and IOL manage. with prostin is based on clinical experience. 2) Dose of Prostin 3) Instruction to the patient before inserting Some might consider failed induction after the the Prostin third dose, 6 hours after the second dose. (Controversy) Answer Notes: Prostin is contraindicated if presence of Common organism causing chorioamnionitis uterine contraction to avoid uterine hyper in PROM and how to manage? stimulation. 1) Risk of getting infection arises after 12 Instruction to patient before inserting the hours of PROM. Prostin 2) Antibiotic prophylaxis should be given based on common isolated organism 1) Ask the patient to urinate first because which is group B Streptococcus (IV she needs to lie on bed for one hour Penicillin) 2) Ask the patient to lie down on bed for 3) Chorioamnionitis is more dangerous to one hour fetus as compared to mother 3) Ask the patient to inform the doctor if 4) IOL should be suggested to the mother the contraction pain is strong. if PROM > 24 hours. 90% of patient 4) Do CTG after one hour to access uterine with ruptured membrane will deliver the contraction and any evidence of fetal baby within 24 hours. distress 5) If chorioamnionitis develop, patient 5) After one hour, do the VE to access the should be covered with antibiotic cervical dilatation. against GBS, gram negative and 6) If cervix is more than 3 cm, remove the anaerobes. residual Prostin and sent patient to labour room. Dose of Prostin 7) If less than that, and suspect uterine Notes: I suppositories equals to 3 mg. hyper stimulation, remove the residue Prostin as well and send patient to In primid, we can insert 1 suppository and labour room and monitor with CTG. access the Bishop score 6 hours later. If cervix is KIV tocolytic agents (salbutamol). If favorable, then we may proceed with artificial fetal distress, emergency cs. rupture of membrane. If not, second dose of 8) If CTG normal, patient can regain her Prostin may be given. activity. Recheck cervical score 6 hour later. 8
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 3 Previous C-sec scars 3) To cover the surgery a) Consent form signed Question b) Baseline blood investigation (FBC, a) Investigation GSH, LFT, BUSE/Creat) b) Management c) Blood cross match (2U Pack cell) c) Post op-acute management d) IV ampicillin 1g stat for prophylactic Trial of Scar e) Bladder catheterization Notes: According to ACOG guidelines on f) Pre med (IV Ranitidine 50mg in 10 vaginal birth after Caeserean Section, trial of ml by slow injection, IV Maxalon scar is not recommended in patients at high risk 10 mg by slow injection, Sodium for uterine rupture. One of the contraindication citrate 30 ml orally) including this case. 4) Anesthetist with at least one year experience 1) Two prior uterine scars and no vaginal 5) Ideally use regional block except contra deliveries indicated (major placenta previa, local 2) Previous classical or T-shaped incision skin sepsis, severe heart disease, or extensive transfundal uterine surgery coagulation disorder, severe fetal 3) Previous uterine rupture distress, cord prolapsed, eclampsia) 4) Medical or obstetric complication that 6) Present of obstetrician. precludes vaginal delivery 7) Reduce risk of thromboembolic 5) Inability to perform emergency cesarean phenomenon after surgery delivery because of unavailable surgeon, a) Early ambulation anesthesia, sufficient staff, or facility b) Anti embolic stocking/Flowtron c) Anti coagulant for high risk cases. Notes: The management of this patient should [The practical Labour Suite Management- Dr Adibah Ibrahim] emphasize more on caesarean section and anticipating in possibility of uterine rupture. It Post op management also includes advice for tubal ligation. (Practice 1) Recovery area (one to one observation until in Malaysia to do BTL after 4 Caesarian patient has airway control, cardio respiratory Section) stability and can communicate) 2) In wards (1/2hly observation RR, HR, BP, Investigation pain and sedation) for 2H, then hourly if stable Fetal investigation 3) Intrathecal opiods- hourly observation for RR, - Ultrasound (AFI, Estimated fetal Sedation and pain scores for 12h for weight, exclude placenta previa, accrete diamorphines and 24h for morphines) or abruptio, biometry) 4) For epidural opiods and patient-controlled - CTG analgesia with opiods (hourly monitoring during CS, plus 2h after discontinuation) Maternal (preparation for C-sec) 5) Post natal care (analgesic, monitor wound 1) For patient in labour (fluid diet and T. healing, signs of infection) Ranitidine 150 mg q.d.s) 6) consider CS complication (endometritis, 2) Patient at high risk of anesthetic( sips of thromboembolism, UTI, urinary tract trauma) water+ IV fluid if indicated) [NICE Guidelines on Caesarian Section] 9
    • Long Case Examination for Phase III Medical Students University Science Malaysia 26 years old Malay lady, housewife, G2P1 at 38 4) Forceps application and breech extraction weeks of gestation with second husband and once full cervical dilatation achieves history of previous caesarean section was 5) Elective caesarean section admitted because of c-sec scar tenderness. 6) Explore the genital tract after difficult or instrumental delivery Questions 7) Blood FBC and GSH 1) S&S of impending scar rupture 2) Management for patient come with Once the ruptured occur impending scar rupture 3) Elicit the scar tenderness on PE 1) Secure the ABC. 02 100%, 3L/min increase 4) The anterior abdominal wall layer cut oxygenation to tissue if hemorrhage occurs. during the c-sec operation. 2) 2 large bore IV line 3) Blood transfusion and shock management Uterine scar rupture 4) Emergency laparatomy 5) Delivery of fetus and placenta A complete uterine rupture is a tear through the 6) Exploration of the rupture site thickness of the uterine wall at the site of a prior a) Try to repair the lesion cesarean incision. b) Hysterectomy of not salvageable 7) Internal iliac artery ligation in case of broad Patient might present with: ligament hematoma because uterine artery is usually retracted and difficult to be identified. 1. Fetal distress evidence by abnormalities 8) Vaginal repair if there is cervical tear in fetal heart rate 2. Vaginal bleeding Layer cut through caesarean section 3. Sharp onset of pain at the site of (Pfannenstiel approach) previous scar 4. Sharp pain between contractions 1) Curved transverse cut just below hair 5. contraction become less intense (finally border lead to atony) a) skin 6. Diminished baseline uterine pressure b) superficial fascia (Camper and 7. Abdominal tenderness Scarpa) 8. Recession of the presenting fetal part c) Rectus sheath (contains fascia of 9. Hemorrhage EO, IO and TM) 10. shock 2) Vertical incision for access into lower Management to impending scar ruptures abdomen Management a) Separation of rectus abdominis muscle in midline Prophylactic management b) Dividing of the fascia transversalis c) periperitoneal fat tissue 1) Close monitoring for woman with high risk of d) peritoneum uterine rupture 2) Early detection of causes of obstructed labour 3) Use Oxytoxin with caution 10
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: PIH being, abnormal surveillance basic blood test (BP and urine dipstick at least Questions 3X per week, weekly PE profile and a) Differential diagnosis CTG.) b) Management 6) Starts anti hypertensive when diastolic c) Drugs (SE&MOA) BP > 90 mmHg d) Drugs contraindicated in PIH a) T. Methyldopa 250 mg tds to max dose of 3g/day or Definition b) T. labetolol 100 mg tds to max 300 BP more than or equal to 140/90 mmHg in mg tds previously normotensive patient, @ A rise in 7) IM dexamethasone 12 MG 12 hourly for systolic BP of > 30 mmHg or diastolic BP > 15 two doses for expectant prem delivery. mmHg compared with pre-conception or first trimester value in two recording of at least 4H In case of severe PE apart 1) Manage in hospitals 2) Close monitor BP 4Hly, reflex, clonus Differential diagnosis 3) Check fundus - Chronic hypertension (long or before 20w) 4) Twice weekly(or more based on - Pre eclampsia (>20W+new onset proteinuria) severity) PE, CTG, biophysical profile - PE with superimposed chronic HPT and doppler New onset or A) acutely worsen proteinuria, B) 5) Anti-hypertensive but aim for 20-25 sudden increase in BP, C) thrombocytopenia or reduction only and not normal by using D) elevated liver enzymes after 20 week hydrallazine or labetolol gestation in women with pre existing HPT - Gestational HPT (after 20w without In labour proteinuria) 1) BP stabilization 2) Watch for fluid overload (monitor UO) Management 3) Seizure prophylaxis in severe PE 1) if detected <20W, must exclude molar 4) Epidural analgesic is the best pregnancy by US and after exclusion, 5) Oxytoxin only to augment labour. being investigate for primary or 6) Never allow woman with severe PE to secondary HPT push excessively. If BP high, consider 2) If pre existing HPT during Booking, instrumental delivery. should be managed by obs+internist 7) C/I to ergometrine/syntometrine in third 3) Every other day BP check at local clinic stage due to hypertensive effect. if BP is first high during any ante natal check up. 4) Investigation for PE profile (platelet Drugs contraindicated for PIH includes ACE count, uric acid, serum creatinine level, inhibitor and ARB as it can cause renal AST, urine albumin). If PE is diagnosed, dysgenesis of the baby. then it should be repeated once a week 5) If BP sustained at >100mg/ >25 increment mmHg or clinical suspicious of IUGR, poor maternal-feternal well 11
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 41/M/F, G1P0 at 29W+2d POA 5) PE profile twice a week (severe PE) or High blood pressure and proteinuria 3+ once a week(mild PE) compose of a) Platelet count (decrease) Question b) Uric acid (1st indication of renal a) Investigation and reason impairment) b) Treatment plan c) Sr Creatinine level (renal function) c) Time of delivery and why? d) Liver enzyme, AST (liver damage) e) Urine albumin as mention in above. My impression: High blood pressure with 6) Clotting study if platelet < 100 x 106/l proteinuria could lead to Pre eclampsia which is 7) Input/output Fluid Chart. worrisome due to serious complication. 8) CTG for fetal well being. Therefore, PE should be ruled out first before 9) Serial ultrasound measurements of fetal considering other condition that may falsely give size, umbilical artery Doppler and liquor positive result to proteinuria like UTI volume PE is defined as: Treatment plan Hypertension unique to pregnancy, diagnosed after 20W of gestation and associated with new Mild PE onset proteinuria; Eclampsia if seizure occurs. T. Methyldopa 250mg tds, max 3g/day or T. Labetolol 100 mg tds, max 300mg tds If woman already having pre existing HPT but Or, Tab. Nifedipine 10 mg tds stat dose after 20W she develops new onset proteinuria, sudden increase in BP, thrombocytopenia or Severe PE elevated liver enzymes, then PE with IV hydrallazine start 5mg, double if no effect superimposed on chronic hypertension must until 35mg. change drug if fails or be suspected. IV Labetolol start 10 mg, double if no effect until max 300mg/day) HELLP (Hemolysis, Elevated liver enzyme, low platelet) is a variant of PE with involvement of ** MgSo4 slow infusion 4g 10-15 minutes. liver giving rise to tender epigastric pain, and Maintenance dose IV ig/hour finally DIC. When to Deliver Investigation 1. Delivery is definitive treatment if mother life 1) Repeat Dipstick testing within 6H is compromised. (Very high uncontrolled BP, PE shows by urinary albumin platelet <100, AST>150 iU/L >300mg/24 hour@ >1g/l in 2 random 2. Can wait until term if well controlled and fetal urine 6 hour a part. is not compromised. 1+ = 0.3 g/l, 2+ = 1 g/l and 3+ = 3 g/l. 3. If gestation >34W, then delivery after 2) 24 Hour proteinuria to see severity of stabilization is recommended PE. Severe PE >5000mg/24 hr. 4. In this case, prolong delivery for 24 Hr to give 3) BP should be checked every 15 minutes steroid injection for lung maturity until women are stable. Then, [RCOG Guideline No. 10(A) March 06] 4) Close monitoring of BP (at least 4Hourly) + reflex, clonus. 12
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 19/M/F, G1P0 at 32W of pregnancy 1g/h for at least 24h after last seizure or delivery diagnosed with pre eclampsia at 28W of Add 4 vials (10g) to 50cc of normal saline & run gestation. at 5cc/h Question If further fits occur give a further slow IV dose furth a) Signs and symptoms of impending of 2g & continue the maintenance infusion eclampsia b) Magnesium sulphate Contraindications for Magnesium Sulfate: Cardiac failure Signs and symptoms of impending eclampsia Acute renal failure 1) Headache 2) N & V Drug monitoring: 3) Visual Disturbances Clinical 4) Right upper quadrant pain 1) Patellar reflex: 5) Progressively oedema (non dependant) - After completion of loading dose 6) Frothy urine (proteinuria - Half hourly whilst on maintenance infusion maintenanc - use elbow reflex if epidural in situ Magnesium sulphate 2) Respiratory rate: should be >16/min Magnesium sulfate is superior to other AED 3) Hourly urine output: should be >25ml/h (phenytoin, diazepam). (urine output is critical as serum Mg level depends on renal excretion) Indications: 1) Eclampsia 4) Pulse Oximetry : must remain >90% 2) Fulminating severe PE either: a) Severe hypertension (MAP: >125 Serum Mg level should be checked when: mmHg, SBP: >170 mmHg, DBP: >110 Oliguria (<25ml/h) mmHg); OR Respiratory rate <16/min b) Hypertension with proteinuria (BP: Pulse oximetry <90% >180/90 mmHg, proteinuria: Continuing fit >0.3g/24h), AND one of the following: i. Clonus (>3 beats) Toxicity (therapeutic range: 2-4 mmol/l @ 4-8 2 ii. Severe persistent headache mg/dl) iii. Visual disturbance Loss of patella reflex iv. Epigastric pain Weakness v. Platelet count <100 x 103/dL Nausea Feeling of warmth 5mmol/l Protocol for use of Magnesium Sulfate: Flushing (5ml vial contain 2.5g MgSO4 ~0.5g/ml) Double vision Slurred speech Loading Dose – 4g Magnesium Sulfate Muscle paralysis 6-7 mmo/l 8ml (4g) + 12ml 0.9% saline IV over minimum Respiratory arrest of 10 - 15 minutes Cardiac arrest >12 mmol/l [Labor suite Management by Dr Adibah Ibrahim] Maintenance Dose 13
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 34/M/L, G2P1 C/C-High blood pressure Investigation Dx- Essential hypertension. 1) ECG 2) Urine dipstick test Question: Hx and Pe only 3) Fasting Lipid profile 4) BUSE and creatinine, Essential hypertension -Primary elevation of blood pressure without Management known causes which can be ameliorated only by lifelong pharmacological therapy [Kumar& Non pharmacological Clark 6th edition] 1. Lifestyle medication with light exercise. 2. Reduce the intake of salt and fat. Risk factor - Genetic Pharmacological - Low birth weight 1. Stop ACE inhibitor and ARBs. Atenolol - Environmental factor can cause IUGR and Labetolol is a) Obesity relatively contraindicated in Asthmatic b) Alcohol intake patient. c) Sodium intake 2. T. Methyldopa 250mg tds, max 3g/day d) Stress or e) Smoking 3. T. Labetolol 100 mg tds, max 300mg tds - Humoral mechanism (insulin resistance) or 4. Tab. Nifedipine 10 mg tds stat dose Cardiac output rises in pregnancy, however there ** Do not give Methyl dopa together is relative greater fall in peripheral resistance, with Nifedipine. therefore BP in pregnant woman is usually low 5. High calcium supplementation of 1.5 than those not pregnant [Kumar& Clark 6th g/day to prevent PE edition] 6. Avoid Combined vitamins C and E (in the form of tocopherol from soybean) as Important history to be elicited it may cause IUGR 1) Risk factor to develop pre eclampsia Others measurement 1. Routine ante natal check up. a. existing chronic medical disorders such 2. Advise patient to come immediately to as obesity, hypertension, diabetes hospital if develop signs and symptoms mellitus, renal disease, connective tissue of impending PE. disease and thrombophilia, 3. Urinary Dipstick to screen new onset of b. Previous history of preeclampsia or proteinuria. eclampsia or IUGR or unexplained 4. CTG and ultrasound to monitor fetal stillbirth well being. c. Family history of preeclampsia or 5. Re assurance to the patient. eclampsia, and 6. Can allow delivering via SVD unless d. Extremes of reproductive age (below 20 there is indication for C-Sec. or above 40 years old) 14
    • Long Case Examination for Phase III Medical Students University Science Malaysia 25 Years Old Malay lady, Nurse, G1P0 at date b) 2 hour post glucose load: 7-8 + 5/7 was admitted to wards because of mmol/L contraction pain and URTI. Patient also was 2) Level of blood glucose control: Blood investigated for GDM because of excessive Sugar Profile (4-6 mmol/L) and Serum weight gain during 21 week of pregnancy. HBA1c concentration (< 6.5%) Questions Screening test for GDM before performing the 1) What Is GDM? MOGTT 2) How do you diagnose GDM 3) Screening test for GDM a) Random blood sugar (> 11.1 mmol/L) 4) When to do MOGTT b) Urinary glucose level (≥ 1+ on more 5) Name the diabetogenic hormone in than one occasion or ≥ 2+ on one pregnancy occasion) 6) What is normal weight gain in c) Mini Glucose Tolerance Test (> 7.8 pregnancy? mmol/L) Answer When to do MOGTT What is GDM? 1) Candidates for MOGTT is offered for this test at 16-18 weeks of pregnancy A syndrome of glucose intolerance appears 2) If normal, then repeat at 26-28 weeks of during pregnancy and usually disappears after pregnancy. If it negative, then no need pregnancy is terminated. It affects 7% of all to re-do it as HPL diabetogenic effect pregnancy. starts to plateau even though it’s serum level continue to increase It is a metabolic disorder of multiple aetiology proportionally. characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein Diabetogenic hormone in pregnancy metabolism resulting from defects in insulin secretion, insulin action, or both. a) Human Chorionic Somatomammotropin (HCS) or formerly known as Human Previously, it is categorized into impaired Placental Lactogen (HPL) glucose tolerance test and GDM based on fasting b) Estrogen (stimulate production of and 2 hour post glucose load in MOGTT. prolactin) However, current guidelines stated that GDM c) Progesterone includes impaired glucose tolerance test. d) Cortisol Notes: In GDM, besides of anti-diabetogenic Diagnosing Diabetes Mellitus and the level of hormone, there will be increased in insulin blood sugar control degradation by placental enzymes 1) Diagnose: Based on MOGTT Normal weight gain in pregnancy Normal level of MOGTT is a) Fasting: 5-6 mmol/L 1) First 5 months: 0.5 kg/months 2) Followed with: 0.5 kg/ week. 15
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 28/M/F, G3P2 at 28W P.O.A admitted in Neonate view of uncontrolled blood sugar level. a) Congenital abnormalities Diagnosed as GDM at 26W P.O.A. Previous b) Shoulder dystocia, birth asphyxia & traumatic pregnancy also complicated with GDM and birth macrosomic baby requiring LSCS. Positive c) Hypoglycemia – fetal islet cell hyperplasia family history of DM on maternal side. d) Jaundice e)Respiratory distress syndrome – Questions hyperinsulinaemia diminished surfactant a) Complication of GDM production b) Indication for MOGTT f) Hypocalcaemia and hypomagnesaemia c) Management to this patient Indication for MOGTT Complication of GDM 1) Significant glycosuria on 2 or more Maternal occasions during pregnancy a) Hypertension, ↑ incidence of pre- 2) Maternal obesity (i.e. maternal weight eclampsia (if a/w nephropathy) >80 kg or BMI >27 at booking) b) ↑ incidence of infection – UTI, 3) Family history of diabetes in first-degree vulvovaginitis etc relatives c) Polyhydramnios 4) Previous big baby (weighing >4 kg) d) Pre-term labour 5) Women >35 years old e) Coronary artery disease 6) Previous unexplained stillbirths, f) Thromboembolic disease recurrent abortions, birth defects g) Risk of caesarean delivery 7) Previous history of gestational diabetes 8) Polyhydramnios in current pregnancy Fetus 9) Big baby in current pregnancy 1. Early pregnancy 10) Congenital abnormality a) Spontaneous abortion b) Congenital anomalies → 40% of perinatal Management for this patient death in diabetic pregnancies My point of view: This patient was diagnosed as c) Cardiac defects GDM at 26W of pregnancy. Now is her 28W of d) Neural tube defects pregnancy and her blood sugar level is e) Renal anomalies uncontrolled. Obviously DM diet is not working. f) Caudalregression synd (rare) Therefore, I see the role of giving insulin injection to her. 2. Later pregnancy a) Macrosomia Therefore for this current admission, BSP should b) Polyhydramnios be done after giving insulin injection to look for c) IUGR (intrauterine growth restriction) the blood sugar level and further adjustment of d) Unexplained intrauterine death. May be insulin dosage. secondary to: Chronic hypoxia Pregnancy shouldn’t be allowed beyond 38W Polycythemia due to risk of unexplained IUD. Lactic acidemia Ketoacidosis 16
    • Long Case Examination for Phase III Medical Students University Science Malaysia 36 years old Malay lady, teacher, G4P3 at 37W Caesarean section + 6/7 was admitted to wards for further 1) This is possibly a best option but this management in view of will put patient in high risk category for next pregnancy which is 2 caesarean 1) Establish DM for three years. scars with no successful VBAC. Previously on OHA but now changed to 2) If patient wish to pregnant again, she insulin. However, blood sugar is will require caesarean section for the uncontrolled. Currently there is no following pregnancy. complication of DM develops. 2) Last pregnancy is by caesarian section Management for this patient because of transverse lie. Antenatal 1) Fetal surveillance with ultrasound for Questions biophysical profile and CTG. 1) Option of mode of delivery and pre 2) Blood sugar profile with adjustment of requisite for it. insulin dosage. 2) Management for this patient. 3) Diabetic diet Answer Intrapartum 1) Management based upon modes of Patient with uncontrolled diabetes mellitus delivery either chooses induction of should not be allowed to proceed with labour with spontaneous vaginal pregnancy beyond 38 weeks of pregnancy. delivery or caesarean section. 2) Patient should be started on DKI Therefore, it is crucial to determine the correct regimes (5% dextrose solution with 1 date of pregnancy to avoid pre term delivery. gram KCL) together with sliding scale Furthermore, fetus of diabetic mother is insulin infusion. If patient go for c-sec, associated with delay lung maturity. morning dose of insulin should be omitted. Mode of delivery 3) Presence of senior obstetrician to In this patient, mode of delivery should be standby in case any complication occur. balanced between benefit and risk. The decision 4) Pediatrician needs to be informed should always be discussed with the patient. regarding this case. Spontaneous vaginal delivery with induction of Post partum labour. 1) Baby should be observed in NICU for 1) Should be done carefully if using 24 hours before discharged. Prostin because of history of c-sec with 2) After the delivery, insulin can be stop no successful VBAC. Dosage is 1.5 mg and patient may continue taking OHA. for each cycle. Membrane sweeping 3) Referral to internal medicine team for could be considered. further management 2) Need to elicit the lie of the fetus in 4) Advise for contraception. cephalic presentation. 5) Counseling on blood sugar control if 3) Excludes macrosomic baby. patient wish to get pregnant again 17
    • Long Case Examination for Phase III Medical Students University Science Malaysia 35 Years old Malay lady, G1P0 at 37W + 5/7 b) > 4,250 g = elective caesarean section with gestational Diabetes Mellitus was admitted Notes: Ultrasound is specific for determination of for review for intrapartum management estimated fetal weight but only with sensitivity of 60- 70% at term. There will be a + of 500 mg Questions discrepancy of estimated and real fetal weight. 1) What should you elicit before allowing Macrosomic baby of diabetic vs. non diabetic patient to deliver by vagina delivery? mother 2) What is macrosomic baby? 3) Are there any differences between Macrosomic baby of non diabetic mother is at macrosomic baby who is belonging to low risk for developing shoulder dystocia as diabetic mother and non diabetic compared to baby of diabetic mother. This is due mother? to present of excessive fat tissue growth at 4) If this patient keen on SVD even though shoulder region in baby of diabetic mother. The the estimated fetal weight is 4 Kg and disproportionate excessive growth of the the labour is complicated with shoulder shoulder will predispose them to the risk of dystocia, what would be your shoulder dystocia during SVD. management? Steps in managing Shoulder dystocia Answer 1) Call for help, inform senior obstetrician and pediatric colleague Before allowing diabetic mother deliver via 2) Experienced obstetrician should be SVD, few thing needs to be excluded first. present during second stage of labour 1) The size of baby is not macrosomic 3) Mc Roberts’ maneuvers (Flexion and 2) Cephalic presentation abduction of the maternal hips, 3) Longitudinal lie positioning the maternal thighs on her 4) Not a candidate for Caesarean section abdomen) a) Major placenta previa 4) If not successful, apply suprapubic b) Footling or flexion breech pressure together with Mc Roberts c) 2 previous c-sec scar without prior (External suprapubic pressure is applied normal delivery in a downward and lateral direction to d) Unstable lie push the posterior aspect of the anterior e) Any obstruction to descending of shoulder towards the fetal chest ) fetus (fibroid, ovarian cyst, 5) If fail, proceed with Wood-Corkscrew Cephalopelvic disproportion) Maneuvers (The hand is placed behind the posterior shoulder of the fetus. The shoulder is rotated progressively 180° in Macrosomic Baby a corkscrew manner so that the impacted For undergraduate level, macrosomic is the anterior shoulder is released. estimated weight of fetus > 4 kg. However, it is 6) If still fail, then deliver the posterior arm further classified into categories first. a) 4,000 - 4,250 g (discuss with patient 7) If fail, do Zavanelli maneuvered (push regarding mode of delivery) the baby back) and prep for emergency C-sec 18
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: DM with hydrocephalus baby 2) Observation of fetal condition through serial ultrasound. Check for any Question abnormality like spina bifida (associated a) H(x) and P(e) with hydrocephalus) b) Investigation and management 3) 30 minutes CTG monitoring for fetal condition. History 4) FBC and GSH for the mother 1) Regarding DM 5) Blood sugar profile, Hba1c level of the a) Since when? Pre existing or during mother. this pregnancy 6) Check for any complication of diabetes b) Any history of macrosomic baby, mellitus. Polyhydramnios or unexplained IUD during previous pregnancy? Management c) Are there family risk factor? d) Is MOGTT done? (normally early 1) Prenatal pregnancy and repeated at24-28w in a) Pre term delivery is unlikely in this case; high risk group in which initial test therefore corticosteroid injection is not is negative) needed. e) Now on diabetic diet, OHA, or b) Admit the patient at obstetric wards to insulin. observe the blood sugar level. Starts f) Ever being admitted due to DM with diabetic diet. If fails, starts insulin. complication like hypoglycaemia, c) Inform the pediatrician and neonatal diabetic foot. neurosurgeon regarding delivery of baby g) Any complaint of DM complication and next intervention. (most likely like heart disease, peripheral caesarian section at 38-39w to prevent vascular disease, diabetic head entrapment) nephropathy, diabetic retinopathy. d) Counseling to the patient regarding the baby condition. Congenital abnormality 2) Regarding hydrocephalus in DM is low. On next pregnancy should a) How did the patient know that? take folic acid to reduce risk of Through US (usually diagnosed hydrocephalus. after >24w)? Who confirmed it? e) Termination of pregnancy is against b) Did mother took/compliance to folic medical ethics and Islamic law. Only acid? fetus which is dead in vitro or no chance c) Did previous baby having of living can be terminated. congenital anomaly? 2) Intrapartum d) The weight of the baby? a) Prep for C-sec e) P(e) for unstable lie. 3) Post natal 1) Check CBS of the baby and mother Investigation 2) Admit baby to the NICU for further 1) Find the causes of hydrocephalus. management. TORCHES? Bleeding? Edward 3) Counsel mother to control diabetes and took syndrome? folic acid before next pregnancy 19
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Oligohydramnios In the term or post-term gestation, oligohydramnios is frequently associated with Question thick meconium (a/w Meconium Aspiration), a) Complication of oligohydramnios deep decelerations in the fetal heart rate, and b) How to detect the dysmaturity syndrome. One team reported c) Management a 13-fold increase in perinatal mortality rate (to 57/1,000) when the sonogram showed Definition amniotic fluid volume to be marginal, and a 47- Reduce in AFI <5 based on ultrasound fold increase (to 188/1,000) with severe [additional of vertical amniotic fluid pocket oligohydramnios. depths volume in four quadrant.] Some specialist may consider AFI <8 as oligohydramnios (AP In 62 cases of second-trimester Dr Nik Hasliza). oligohydramnios, another team reported a 43% perinatal mortality rate, with lethal pulmonary Amniotic fluid production hypoplasia complicating 33% of cases. If A) Production of amniotic fluid is from amniotic fluid was essentially absent 1. Inward transfer of solute across the ("anhydramnios"), 88% had lethal outcomes, amnion with water following passively in compared with 11% of those with moderate fluid early gestation. reductions. 2. Water transport across the highly permeable skin of the fetus during the first Diagnosis half of gestation (keratinization of skin at - Via ultrasound 22-25W) 3. Baby's urination (first starts at 8-11W Management and is major source of production. it is Other Investigation recycled when baby swallows it) 1) intrauterine instillation of dye to 4. Secretion of large volumes of fluid each diagnose PROM [confirm if the dye is day by the fetal lungs after second half of found in the vagina]-not practically done gestation (2nd source) 2) Furosemide test to visualize fetal B) Increase amniotic fluid from 8-43W bladder gestation linearly until 32W (700-800 mL- Both test not practically done constant until term) Others -C) After 40W, declines at rate 8% per 1) Amnioinfusion of 200 ml Normal saline week until 300ml at 42W (not practically done) 2) Maternal rehydration.(controversial) Causes 3) frequent fetal biophysical testing and 1) PROM or PPROM appropriately timed delivery 2) fetal urinary tract anatomy (renal and 4) Rule out fetal structural and ureter most common) chromosomal anomalies 3) Uteroplacental insufficiency 5) Earlier delivery in baby incompatible 4) Pulmonary hypoplasia with life. Complication Notes: risk of fetal asphyxia and death is high in IUGR 20
    • Long Case Examination for Phase III Medical Students University Science Malaysia 35 years old Malay lady, G3P2 at 26W POA moderate (AFI 30.1-35) and severe (AFI >35) was admitted for further management after she [Naser Omar et al] persistently worried about her current pregnancy because her belly was too big Causes of polyhydramnios compared to previous pregnancy 1) 60% is idiopathic Questions 2) Maternal causes 1) What is polyhydramnios and how do a) Gestational diabetes mellitus you grade them? 3) placental abnormalities (placental 2) What is the causes of polyhydramnios abruption, placenta accreta) 3) How do you manage this patient? 4) Fetal factor a) congenital anomalies ( anencephaly, Answer hydrocephalus, spina bifida, tracheoesophageal fistula, duodenal atresia, hydrops fetalis and many more) b) Multiple pregnancy 95th percentile c) chromosomal abnormalities such as Down's syndrome and Edwards Mean value syndrome 5) Skeletal dysplasia and syndrome. 5th percentile 6) others like chorioangioma of the placenta Management to this patient Source:http://emedicine.medscape.com/article/40485 6-overview 1) Reassure the mother 2) Excludes the causes of polyhydramnios a) This patient should be offered to do MOGTT Polyhydramnios b) Ultrasound examination and proceed to Doppler and full scan if Polyhydramnios may be defined as an amniotic necessary fluid index above the 95th centile for gestational 3) Assessment of fetal well being age [Moore& Cayle]. a) Access while doing ultrasound + CTG. Previously, it is defined when the deepest 4) Treat the underlying causes vertical pool is more than 8 cm, but currently 5) Treat the hydramnios based on measurement on 4 quadrant > 25. a) Mild & Moderate: Indomethacin or (Based on ultrasound) sulindac b) Severe: Amnioreduction It complicates approximately 0.4-3.5 % of 6) Corticosteroid if anticipating pre term pregnancies and it can be divided into three delivery. groups: mild (amniotic fluid index 25-30), 21
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 32/M/F, G2P1, decreased fetal movement Tocolysis has also been advocated for the management of intrapartum fetal distress, Question impaired fetal growth, pre term labour and to 1) H(x) and P(e) facilitate external cephalic version at term 2) Management of decrease fetal movement MgSO4 3) Use of tocolytic (function/type) 1. works as membrane stabilizer, 4) Fetal kick chart (indication and competitive inhibition of Ca; therapeutic component) at 4-7 mEq/L 2. SE: flushing, nausea, lethargy, pulm Reduce fetal movement? Baby goes through edema normal sleep cycle. As long as baby moves 3. Toxicity: cardiac arrest (tx: calcium every couple of hour, then it’s fine. gluconate), slurred speech, loss of patellar reflex (@ 7 -10), resp problems History (@15-17), flushed/warm (@9-12), Exclude Abruptio placenta muscle paralysis (@15-17), hypotonia -Decreased fetal movement, abdominal pain, (@10-12) bleeding after 22w -shocks, tender uterus, fetal distress/absent fetal Nifedipine heart sound 1) calcium channel blocker: 10 mg q 6 h; se: nausea and flushing Exclude fetal distress -Decreased/absent fetal movement, abnormal B2 agonist fetal heart rate 1. ritodrine/ terbutaline - Thick meconium stained fluid 2. dec. uterine stimulation; may cause DKA in hyperglycemia, pulm edema, Other history n/v, palpitations (avoid with h/o cardiac - What did patient do? Working mother seems to disease or if vaginal bleeding) 0.25 mg perceive less fetal movement. sq q 20-30 min x 3 then 5 mg q 4 po - Any history of trauma? - Elicit maternal medical illness Indomethacin/prostaglandin synthesis inhibitor 1. 50 mg po/100 mg pr SE: premature PE and investigation closure of PDA in an 1) Auscultation of fetal heart rate and hour,oligohydramnios confirmation with ultrasound. 2) CTG monitoring for ½ hour. Fetal kick chart 3) Umbilical artery Doppler ultrasound in 1) Screening by caregivers to alert them about high risk cases. their fetal condition which might compromised. This will aid early intervention to reduce Tocolysis perinatal mortality. The administration of medications to stop 2) Routine or done in women with increased risk uterine contractions during premature labor of complication in baby 3) Decision of management shouldn’t be made based on fetal kick chart. 22
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Reduce fetal movement about decrease in fetal movement as compared with multi para. Question 2) Identification of maternal risk factor a) Regarding traditional medicine, how to which might contribute to perinatal advice patient mortality. b) Line of thinking to get diagnosis - age, smoking, overweight/obesity, c) Management. previous stillbirth or neonatal death Traditional medicine 3) What actually the causes of reduce or A doctor has no right to order patient to stop absent fetal movement? taking traditional medicine. However, lack of a) Placenta Abruptio study and information between interaction of b) Intra uterine growth restriction traditional medicine and modern medicine may c) Syndromic baby cause few un-expected side effect. d) Placenta insufficiency. e) Mother’s perception. Furthermore, few manufacturers being dishonest by adding some ‘hidden’ ingredient inside their 4) Investigation to support diagnosis product which may cause serious side effect in reaction to certain drugs. Therefore, as a doctor Management we can advise patient to 1. Choose either taking only traditional or 1) Take full history and elicit risk factor modern medicine or not combining that might compromise fetal condition. them. 2) Fetal well being assessment 2. Suggest to them to stop traditional (recommended by NICE guideline) medicine while pregnant because afraid CTG, Ultrasound. of unexpected side effect with 3) Fetal kick chart (not recommended by prescribed medicine. NICE and others as it will cause more 3. Avoid herbal base traditional medicine. anxiety to the mother.) however, some 4. Use alternative traditional medicine that says it is better than doing nothing. known scientifically not harmful like 4) If CTG or ultrasound shows fetal honey. compromise, admit patient to the wards and do serial monitoring of fetal Line of thinking to get the diagnosis condition 1) Is mother really paying full attention 5) Re assures the mother. about fetal movement 6) Patient can be safely discharge after a) Fetal movement is rather perception fetal monitoring shows normal result in of woman. Busy mother tends to three consecutive days. Discharge feel less fetal movement. patient with b) Working in busy environment may a) TCA at antenatal wards weekly or cause less perception of fetal twice weekly movement. b) To come again to ward if reduce c) A woman which is first time fetal movement pregnant may become too anxious c) Instruction to use fetal kick chart. about fetal condition and notice 23
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Premature labour with PV Bleeding glucose tolerance, osteoporosis and depression of fetal/maternal adrenals Questions 2) Tocolytic a) 4 drugs in management of premature Nifedipine labour - calcium channel blocker: 10 mg qds; b) Drugs for candidiasis - se: nausea and flushing c) Function, complication and monitoring B2 agonist of the drugs - ritodrine/ terbutaline d) Doses of drugs - dec. uterine stimulation; may cause DKA in hyperglycemia, pulm edema, Definition of preterm n/v, palpitations (avoid with h/o cardiac 1) Onset of labour after the gestation of viability disease or if vaginal bleeding) 0.25 mg i.e 24 weeks and before 37 completed weeks of sq q 20-30 min x 3 then 5 mg q 4 po pregnancy. 2) The onset labour may be determined by 3) Antibiotic therapy documented uterine contractions and rupture - For women at risk of preterm delivery membranes or documented cervical change with because of PPROM, prophylactic an estimated length of less than 1 cm and/or antibiotics delay delivery and reduce cervical dilatation of more than 2 cm. maternal and neonatal infective morbidity. Types - Not recommended in risk of preterm but a) Threatened (uterine contraction without with intact membranes cervical changes) - Erythromycin 500mg qds plus co- b) Actual/establish (uterine contraction+ cervical amoxyclav (Augmentin) 375mg tds for changes) 7 days OR clindamycin 150mg qds for 7 Additional: occurs in around 7% of all days. pregnancies and is a major cause of infant mortality and morbidity. [Scottish guidelines] Drug for candidiasis in pregnancy Survival rate: 23 w 0-8% 24w 15-20% Imidazoles are best but pregnant women may 25w 50-60% 26-28w 85% 29w 90% need longer (7 not 4 day) courses. Thrush is a common vaginal infection in pregnancy causing Drugs in management of premature labour itching and soreness. There is no evidence that 1) Corticosteroid therapy this yeast infection harms the baby. Antifungal - Betamethasone, 12mg, IM, 24 hours creams are effective. Imidazoles (such as apart. clotrimazole) are more effective than older - In USM, Dexamethasone, 12 MG, IM, treatments such as nystatin and hydrargaphen. 12 hours apart. Longer courses (7 days) cured more than 90% of - Function is to increase lung maturity. women whereas standard (4 day) courses only Usage of corticosteroid below 24w is no cured about half the cases. [Cochrane Database beneficial since pneumocyte not develop of Systematic Reviews, Issue 4, 2009] yet. Also not recommended >34W. - Possible long-term effects on cognitive or neurological development, impaired 24
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 33 years old, G3P2 present at 24W+5D 4) Re assure the patient POA with premature contraction. No history of 5) Give IM Dexamethasone 12mg bds, 12 hours UTI, Vaginal discharge, trauma. apart. 6) Keep patient nil by mouth and anticipate for Question caesarian section. A) How to differentiate premature 7) Hydrate patient adequately with 2 pints NS contraction and true labour contraction and 3 pints D5% B) Management of this patient 8) Take blood for investigation including FBC, C) How to discharge this patient GSH. 9) Urine dipstick (nitrogen, albumin= indicate Premature contraction UTI) and Urine FEME. Uterine contraction after the gestation of 10) Allocate possible causes of premature viability. i.e 24W and before 37 completed contraction. weeks of pregnancy. It could progress to 11) Monitor 4 hourly BP, 20 minutes CTG premature labour. 12) Inform Pediatrician regarding patient's condition and keep in view to book for It is called threatened pre term labour if ventilator. contraction is not associated with cervical 13) Monitor the labour progression by labour dilatation. progression chart. 14) Ultrasound examination for fetal well being. If it is associated with cervical dilatation, hence 15) Administer tocolytic for example Nifedipine it is termed as Establish Pre term labour. 5mg (some specialist give 10 mg) 16) Observe patient for one day. if contraction Characteristic of a true labour subside, discharge patient to ante natal wards for 1) At term further observation. 2) Come at regular interval i.e once in one 17) If contraction subsides for two consecutive hour and finally can goes to once in five days in ante natal wards, then patient can be minutes near labour. discharged 3) The timing of each contraction is last about 30-70 seconds Discharging the patient 4) The intensity of pain increase by time. 1) After no contraction within 2 days in ante Pain is at the back due to referred pain natal wards of cervix. 2) Ensure that patient already took 5) The pain does not relief by walking or dexamethasone. changing in posture. 3) CTG reactive. 6) Presence of show and liquor. 4) Follow up at ante natal clinic within 2 weeks. 5) Fetal Kick Chart (some protocol say it is not Management of this patient indicated) 1) Obtain full history and perform relevant physical examination. 2) Admit patient to premature room in labour room. 3) Inform the case to MO in charged 25
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 42/M/F G11P7+3A at 36/52 with history fetal, placenta abnormalities (PE, Anruptio of 5 premature deliveries, electively admitted for placenta, PP), multiple pregnancy, Medical removal of cervical cerclage condition like Hypertension, DM and anemia, aneuploidy and fetal anomalies, increase Questions maternal mortality. [The older obstetric patient, a) Risk of grandmultiparae Current Obstetrics & Gynecology (2005) 15, b) Risk of pregnancy at old age 46–53] c) How to prevent PPH in this patient d) Indications of cervical cerclage Cervical cerclage e) When to do and remove cervical cerclage. Cervical cerclage is a procedure in which sutures are inserted around the cervix in women Grandmultiparae suspected to have cervical weakness. This is Definition: a woman who has had five or more thought to prevent cervical dilatation and pregnancies resulting in viable fetuses. Great membrane exposure, thus helping the uterus to grand multipara if > 10 retain the pregnancy in women who are prone to miscarrying, mostly in the mid-trimester. The results showed high in incidence of anemia [Cervical cerclage, Current Obstetrics & (80%). Cesarean section (38% vs 35%), Gynaecology (2006) 16, 306–308] inversion of uterus (0.2% vs nil) and rupture of uterus (0.2% vs nil), hypertension and PIH Cervical cerclage can be classified as an elective superimposed on chronic hypertension (12.5- procedure (based on previous history and/or 25% vs 8-14%). The incidence of postpartum investigation), a selective procedure (based on hemorrhage, abruptio placentae, preterm labour, evidence obtained by ultrasound examination obstructed labour, puerperal sepsis and wound that shows shortening of the cervix) or an infection was also high in grand multi parous emergency procedure (when the cervix is dilated group. There were 9 maternal deaths out of 1000 with the membranes seen or bulging via the cases of study group as compared to 4 deaths in cervical os). control group. Similarly the perinatal mortality rate was 180/1000 births as compared to An elective procedure is performed around 12– 150/1000 in para 2-4. [Grand Multiparity: Still 14 weeks’ gestation (Dr Amir HUSM-16W) an Obstetric Risk Factor,Khadija H Asaf. Pak J after confirming fetal viability. The TAC is Obstet Gynaecol May 1997;10(1,2):24-8] performed around the same time. Emergency cerclage is performed when the cervix is noted Pregnancy at old age to be dilating.[Cervical cerclage, Current an age over 35 years for the ‘elderly Obstetrics & Gynaecology (2006) 16, 306–308] primigravida’(FIGO, 1958)Improvements in women’s general health have led to this term It is removed when term is achieved or tending to be reserved for pregnancies in women premature contraction (Dr Amir HUSM) at or above 40 years of age.[Current Obstetrics & Gynaecology (2005) 15, 46–53] Risk of pregnancy at old age: Miscarriage, ectopic pregnancy, chromosomal disorder in 26
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Post EDD + PIH (exact case is unknown For PIH so discussion is random) 1) For baby(similar to post EDD) 2) For mother Question a) Hourly BP monitoring a) Differential diagnosis b) PE Profile (platelet count, uric acid, b) Investigation serum creatinine level, Liver c) Management enzymes- AST, Urine albumin) Term Management for Post date and post Term Period of gestation 37 to 42 week Based on scientific evidence 1) Women with post term gestations who Post date have unfavorable cervices can either Post date is a term to describe any pregnancy undergo labor induction or be managed that goes beyond expected date of delivery (40 expectantly. W) but does not exceed term. 2) Prostaglandin can be used in post term pregnancies to promote cervical Current practice in HUSM and KKM is to avoid ripening and induce labor. the delivery of post term baby due to the 3) Delivery should be effected if there is increase perinatal morbidity and mortality evidence of fetal compromise or associated with post term. Therefore, induction oligohydramnios. of labour should be initiated if pregnancy goes beyond the post date. Based on expert experiences 1) Antenatal surveillance for post term Approach to this patient pregnancies between 41 weeks (287 days; EDD +7 days) and 42 weeks (294 1) Absolute treatment for PIH is the days; EDD +14 days) of gestation termination of pregnancy. because of evidence that perinatal 2) Post EDD itself is an indication for morbidity and mortality increase as induction of labour to prevent post term gestational age advances. delivery. 3) However, the exact POG needs to be 1. Twice-weekly testing with some established to avoid delivery of pre term evaluation of amniotic fluid volume baby. beginning at 41 weeks of gestation. A nonstress test and amniotic fluid volume Investigation assessment (a modified BPP) should be For Post EDD adequate. 1) Biophysical profile of the baby • Fetal tone Drug commonly use in PIH • Movement of the body or limbs a) Methyl dopa • breathing movement b) Labetolol • Amniotic fluid volume c) Nifedipine • Heart rate (CTG) analysis. d) Magnesium Sulphate (pre eclampsia) 2) Doppler ultrasound 27
    • Long Case Examination for Phase III Medical Students University Science Malaysia 31 years old Malay lady, G6P5 at date + 9/7 In this patient, we however need to go through a with 1 previous scar for transverse lie and 4 broad perspective before deciding the VBAC management for this patient. Patient’s problem is 1) What is post term? a) Post date 2) What is the complication of the post b) 1 previous c-sec with successful 4 term? VBAC (low risk patient) 3) In this patient, how will you manage her c) Grand multi para (deliver > 5 times) and give reasons. Therefore, risk and benefit on method of Post term delivery should be considered. A pregnancy that has extended to or beyond 42 weeks of gestation (294 days, or estimated date of delivery [EDD] +14 days) [ACOG Roughly, this is the overview of the guidelines] management. 1) Antenatal surveillance at 42 to 42 week Complication of the post term including at least non stress test and assessment of amniotic fluid volume. 1) To the baby 2) Estimating the fetal weight. a) Uteroplacental insufficiency 3) Considering the induction of labour b) Oligohydramnios causing cord a) Prostin and oxytocin is not a good compression syndrome choice. c) Meconium aspiration syndrome b) May consider membrane sweeping d) Intrauterine infection c) After excludes macrosomic baby, e) Macrosomia and complication related to breech presentation and severe it oligohydramnios. f) Fetal dysmaturity syndrome 4) If we considering Caesarian section g) Increased risk for neonatal a) Indicated if it is a macrosomic baby encephalopathy b) But this will put mother on higher risk on next pregnancy because of 2) To mother two c-sec scar and grand Multipara. a) Severe perineal injury if delivering big Risk of uterine atony and rupture is baby high b) Increase rate for caesarian section c) Advise on bi tubal ligation for the c) endometritis, thromboembolic disease, mother. hemorrhage. d) Indicated if breech presentation. d) Psychological (anxiety and frustration) e) Indicated in severe oligohydramnios for carrying the baby longer than 5) Present of senior MO and pediatrician expected. during delivery. Management for this patient Women with an uncomplicated pregnancy who reach 41 to 42 weeks’ gestation should be offered elective delivery [SOGC] 28
    • Long Case Examination for Phase III Medical Students University Science Malaysia A healthy 25-year-old nulliparous woman has such events. Contraction stress tests assessing an uncomplicated pregnancy at 42 weeks. fetal heart responses to oxytocic-induced Induction of labour is fully discussed, suggested contractions have largely gone out of use as the and declined. Evaluate the tests that may be high false-positive rate has led to a high level of arranged to monitor fetal health until labour intervention. They also take longer and are more begins. [Journal review] complicated to conduct than NSTs. Where the advice over induction is unacceptable The assessment of liquor volume that may be to the patient, various measures may be used to related to placental function and fetal health has review fetal health. Several tests are described become an accepted part of surveillance of for this situation, but the problem remains that women such as this. A measurement of the no test or group of tests has been shown to amniotic fluid index of less than 5 cm or of the improve the perinatal outcome. maximum vertical pocket depth of less than 2 cm (various other levels are quoted) suggest Fetal movement charts have long been used in fetal compromise and lead to a recommendation late pregnancy as a form of fetal monitoring. for delivery. The biophysical profile combines They require the woman to note the time taken an ultrasound assessment of fetal movements for 10 fetal movements. A large randomised- and tone, breathing movements and amniotic controlled trial (RCT), however, demonstrated fluid volume. This combination would seem to no reduction in fetal mortality compared with be the most appropriate, but a recent RCT the control group, and the use of these charts showed no advantage over CTG with amniotic may increase anxiety without a beneficial depth measurement. Doppler studies of effect. Various forms of fetal acoustic umbilical artery velocimetry have not been stimulation test have been developed using a shown to be of benefit in predicting outcome. transabdominal sound source and assessing the fetal reaction in terms of cardiotocograph (CTG) There are clearly considerable limitations in the changes and fetal movements. Although such value of all these tests in detecting fetal tests have the advantage of taking less time than compromise and enabling rescue, but NICE other tests, there is no evidence for an improved recommends twice-weekly CTG and perinatal outcome. measurement of amniotic pool depth, and this will remain the advice until further advice based The standard non-stress test (NST) using a on RCTs is available. The advice and its reasons CTG relies on the observation of two or more must be discussed with this woman, and a episodes of fetal cardio acceleration of 15 beats sensitive approach is most likely to lead to a or more occurring within 20 minutes of the onset compromise, although there remains a of the test. It is generally thought, and advised possibility that the woman will wish for no tests by the National Institute for Health and Clinical and will await nature’s decision. Excellence (NICE), that twiceweekly tests should be performed, although the optimum Simon G. Crocker Department of Obstetrics & scheme is not known. Furthermore, the NST Gynaecology Norfolk & Norwich University used alone has a low sensitivity. The most Hospital, Colney Lane, Norwich NR4 7UY, UK common cause of perinatal death in such cases is [OBSTETRICS, GYNAECOLOGY AND meconium aspiration due to an acute asphyxial REPRODUCTIVE MEDICINE 17:1,2007 event, and the NST is not adequate to preclude Published by Elsevier Ltd.] 29
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: PPROM 1) Clear watery and alkaline per vaginal discharge. (pH 7.1-7.3 compared with Question: vaginal pH 4.5-6.0) a) Symptoms of fever 2) Arborization (ferning) under b) Positive findings in PPROM microscopic visualization c) Ix and Mx 3) Oligohydramnios d) Causes of unstable lie [ACOG Practice Bulletin, VOL. 109, NO. 4, APRIL 2007] PPROM Symptoms of chorioamnionitis: High grade Membrane rupture that occurs before 37 weeks fever, maternal and fetal tachycardia, tender of gestation is referred to as preterm PROM uterus. Intraamniotic infection has been shown to be Investigation and management commonly associated with preterm PROM, **Based on period of gestation but basically especially if preterm PROM occurs at earlier gestational ages. In addition, factors such as low 1. Determination of gestational age, fetal socioeconomic status, second- and third- presentation, and well-being trimester bleeding, low body mass index less 2. Expeditious delivery in patient with than 19.8, nutritional deficiencies of copper and evident intrauterine infection, abruptio ascorbic acid, connective tissue disorders (eg, placenta, or evidence of fetal Ehlers–Danlos syndrome), maternal cigarette compromise smoking, cervical conization or cerclage, 3. swabs for diagnosis of Chlamydia pulmonary disease in pregnancy, uterine trachomatis and Neisseria gonorrhoeae overdistention, and amniocentesis have been if immediate delivery not indicated linked to the occurrence of preterm PROM 4. Group B antibiotic prophylaxis 5. CTG monitoring for umbilical cord The risk of recurrence for preterm PROM is compression or asymptomatic uterine between 16% and 32%. contraction. Fever Causes of unstable lie Fever is considered as temp above 100.40 (380C) 2. Prevention of head descending but feverish sensation may occur when body a) Cephalopelvic disproportion temp above 98.60 (370C) b) Fibroid c) Ovarian cyst Symptoms d) Placenta previa 1) Patient complaints of body become hot e) Uterine surgery and sweating (increase temperature and f) Multiple gestation diaphoresis) g) Fetal abnormality (anencephaly) 2) Can also a/w with tachycardia, altered h) Fetal neuromuscular disorder consciousness, chills & rigor, headache, muscle and joint pain. 3. Condition that permit free fetal movement Positive findings in PPROM a) Polyhydramnios (AFI>8) b) Uterine laxation 30
    • Long Case Examination for Phase III Medical Students University Science Malaysia 25 years old Malay lady, G3P2 at 40 weeks + Management 2/7 of pregnancy presented to you because of 1) Close observation of vital sign gushing of clear fluid from vagina for 1 day 2) Review patient regularly especially duration. However, there is no contraction pain palpation of uterus. a) Elicit uterine tenderness Questions b) Lie and presentation of the fetus 1) Differential diagnosis and further c) Estimated fetal weight. history to support your diagnosis 3) Assessment of fetal well being (CTG 2) What complication that should concern and ultrasound ) you that may occur to the mother and 4) Rehydrate the patient baby. 5) IV ampicillin as prophylaxis against 3) How do you manage this patient GBS (rate of infection rise after 12 hour rupture of membrane) Differential diagnosis 6) Corticosteroid is not indicated. 1) Pre labour rupture of membrane 7) Notify the pediatric team regarding the - Establish that the fluid is truly amniotic possibility to admit the baby because of fluid and not urine. infection. - Contraction pain 8) This patient should not be discharged - Liquor color and induction of labour should be discussed with patient if not deliver after 2) In labour >24 hour. Usually 90% of patient with - Contraction pain that become shorten in PROM will deliver within 24 hour. intervals Notes: 3) Bacterial vaginosis Student must be able to differentiate between the - Foul smelling discharge PPROM and PROM. - Itchiness of vagina - Yellow or cream color discharge PPROM is premature rupture of membrane. i.e; - Any systemic sign for infection. membrane rupture during the period of fetal viability (>24 W) but not reach term yet. Complication to look for 1) Chorioamnionitis Meanwhile, Prelabour rupture of membrane, Notes: chorioamnionitis must be PROM is the ruptured membrane before labour. anticipated in patient presented with The patient already at term. PPROM or PROM as it can cause death to the mother and fetus. In PPROM, the focus is 1) to prolong the pregnancy so that the chances for fetus to Beware sign and symptoms of survive remain high and 2) to prepare the baby chorioamnionitis for possibility to be delivered prematurely. a) Fever b) Maternal tachycardia In PROM, a focus should be stress on possible c) Tender uterus infection to the mother and also to the fetus. d) Fetal tachycardia Lung complication to the fetus is unlikely as lung maturation already completed. 31
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Placenta Previa Investigation to order 1) Transvaginal or Abdominal US Question 2) FBC, GSH, Rh compatibility a) Management 3) CTG b) Other name for low transverse scar c) Types of placenta previa d) Investigation to order Management e) Complication 1) Admission to ward for PP Major. f) How to differentiate between placenta 2) Bed rest and serial US as placenta previa and abruptio. migration can occur. 3) Transfuse blood if needed i.e Definition: symptomatic or near delivery, (target Hb Placenta implanted in the lower segment of the at delivery is at least 8) + haematinic. uterus, presenting ahead of the leading pole of 4) Tocolysis and corticosteroid if prem the fetus. It occurs in 2.8/1000 singleton delivery is anticipated pregnancies and 3.9/1000 twin pregnancies 5) Avoid Sexual intercourse [MARCH JOGC MARS 2007] 6) PP Minor can be allowed for SVD 7) Counseling to the patient. Grade. I Placenta Lateral Minor Complication: encroaches on the Antepartum lower uterine -APH (3rd trimester) and Cx of blood transfusion segment but does -Unstable lie not reach the - Perinatal death cervical os. - Pre term labour -Thromboembolism d/t prolongs bed rest. Thromboembolism II Placenta reaches marginal major if - Placenta abruption the margin of the posterior cervical os but located Intrapartum does not cover it. - Excessive bleeding during SVD - C- section and its complication (major PP) III Placenta partially covers the os. - Hysterectomy IV Placenta is Complete Major Post partum symmetrically -DIC implanted in the - Intra uterine adhesion lower uterine -Recurrent PP segment - Placenta accrete PP VS Placenta abruptio Other name for low transverse scar Association with pain: PP is painless Pfannenstiel (traditional) scar, Joel- -Cohen scar. US: abruptio shows Retro placental blood clot 32
    • Long Case Examination for Phase III Medical Students University Science Malaysia 21 Years Old Malay Lady, G1P0 at 36/52 + 4/7 Management for this patient was admitted since 30 Week POA after history 1) FBC to access the level of hemoglobin of sexual intercourse and strenuous activity. of this patient Currently, there are no more bleedings. 2) GSH as patient may lose lot of bloods Ultrasound reveals placenta previa type III during delivery. GXM 2 unit should be prepared before delivery. Questions 3) Tocolysis as bleeding in PP patient may 1) How to differentiate PP type III and PP also due to contraction of uterus (not the type IV on ultrasound lower segment) 2) What is the risk factor for placenta 4) Assessment of fetal well being previa 5) Complete bed rest and avoid any 3) Can this patient be discharged? excessive activity. 4) Management for this patient 6) Discuss with patient regarding caesarian section as mode of delivery. How to differentiate PP type III and PP type IV Prior to delivery, all women with on ultrasound placenta praevia and their partners PP type III- Placenta partially covers the os. should have had antenatal discussions PP type IV- Placenta is symmetrically implanted regarding delivery, hemorrhage, in the lower uterine segment possible blood transfusion and major surgical interventions, such as Risk factor for placenta previa hysterectomy, and any objections or - Multiple gestation queries dealt with effectively.[RCOG] - Previous caesarian section 7) To prepare the patient for caesarian - Uterine structure anomaly section. - Assisted conception - Dilation & Curettage Notes: 1) Trans vaginal ultrasound is safe in the Can this patient be discharged? presence of placenta praevia and is more No, accurate than trans abdominal ultrasound in locating the placenta Women with major placenta praevia who have [RCOG Guideline No. 27 previously bled should be admitted and managed 2) Placenta migration occurs during second as in patients from 34 weeks of gestation. and third trimester except in posteriorly [RCOG] located PP and present of C-sec scar. 3) A scan should be performed at 32 weeks All women at risk of major ante partum in case suspected PP major and 90% of hemorrhage should be encouraged to remain the patient who is diagnosed with PP close to the hospital of confinement for the major will remains so. duration of the third trimester of pregnancy 4) Elective caesarean section should be [Royal Australian and New Zealand College of deferred to 38 weeks to minimize Obstetricians and Gynecologists] neonatal morbidity. Women with placenta praevia who have bled tend to deliver earlier 33
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: 42/M/F G9P8 with unstable lie Management a) Causes of unstable lie 1) Admit patient to antenatal wards b) Management a) Daily observation for fetal lie c) Complication b) Provide active management to correct lie c) Provide immediate clinical assistance upon membrane rupture Unstable lie 2) Exclude factors contributing to unstable 1. Fetal lie and presentation repeatedly lie change at beyond 36/52 of gestation. 3) Expectant vs. Emergent management 2. by 36W, fetal movement is limited, fetal should present as cephalic) Expectant 3. Incident at 26/32 is 40%, at 30/52 is A) Daily observation for fetal lie 20% & at term is 3% B) Discharge if longitudinal lie for 3 consecutive days Causes of unstable lie C) Review patient in a week time 4. Prevention of head descending D) Wait for spontaneous labour i) Cephalopelvic disproportion j) Fibroid Active management k) Ovarian cyst l) Placenta previa A) Caeserean section m) Uterine surgery B) ECV n) Multiple gestation C) Stabilizing induction of labour o) Fetal abnormality (anencephaly) p) Fetal neuromuscular disorder Complication 5. Condition that permit free fetal movement 1) Cord prolapsed leading to fetal hypoxia/ c) Polyhydramnios (AFI>8) fetal death. d) Uterine laxation 2) Compound presentation 3) Uterine rupture History a) Make sure that the date is correct cause unstable lie is physiological <36/52. b) Find any risk factor associated with unstable lie. c) Elicit any problem during pregnancy 34
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Unstable lie Option for this patient Question: A) Passive management by observation a) Physical examination (abdomen) in hope that the lie will return to b) Level of exposure normal position during term. c) Clinical evidence of head and buttock B) Caeserean section d) Management for this patient C) ECV [Relative contraindication] e) Option for this patient Results vary from 30% up to 80% in f) What is unstable lie different series. Race, parity, uterine g) Causes of unstable lie tone, liquor volume, engagement of the breech and whether the head is Unstable lie palpable, and the use of tocolysis, 1. Fetal lie and presentation repeatedly all affect the success rate. change at beyond 36/52 of gestation. [Greentop] 2. by 36W, fetal movement is limited, fetal D) Stabilizing induction of labour should present as cephalic) 3. Incident at 26/32 is 40%, at 30/52 is Notes: B-D is active management. 20% & at term is 3% Complication Clinical evidence of head and buttock 1) Cord prolapsed leading to fetal hypoxia/ Head: Hard, round and ballotable fetal death. Buttock: Soft, broad and not ballotable. 2) Compound presentation 3) Uterine rupture Management Causes of unstable lie 1) Admit patient to antenatal wards Prevention of head descending a) Daily observation for fetal lie a) Cephalopelvic disproportion b) Provide active management to b) Fibroid correct lie c) Ovarian cyst c) Provide immediate clinical d) Placenta previa assistance upon membrane rupture e) Uterine surgery 2) Exclude factors contributing to unstable f) Multiple gestation lie g) Fetal abnormality (anencephaly) 3) Expectant vs Emergent management h) Fetal neuromuscular disorder Expectant Condition that permit free fetal A) Daily observation for fetal lie movement B) Discharge if longitudinal lie for 3 a) Polyhydramnios (AFI>8) days b) Uterine laxation C) Review patient in a week time D) Wait for spontaneous labour 35
    • Long Case Examination for Phase III Medical Students University Science Malaysia Case: Breech Mode and timing of delivery Questions a) Causes and complication of breech <28 weeks, weight <1 SVD b) Management, mode of delivery and time kg of delivery for breech. c) ATT- Type of immune 28-32 weeks, weight LSCS 1.0 - 1.5 kg Breech It is the most common type of malpresentation. 32-37 weeks Weight Depend on case Presentation of the fetal buttocks and feet in 1.5 – 2.5 kg 1) Assisted labour breech delivery for Incidence: 26W 40%, 30W 20%, term 3% Extended and Type: Extended, Flexed, Footling flexed 2) LSCS for footling Causes breech 1) Multiparous woman with lax uterus and > 37 weeks Preferably Caesarean abdomen section 2) Prematurity 3) Fetal structural anomalies; anencephaly, ATT hydrocephalus Tetanus vaccine is an inactivated toxin (toxoid) 4) Uterine anomalies; uterus bicornu, made by growing the bacteria in a liquid fibroids medium and purifying and inactivating the toxin. 5) Multiple gestation; twins Type II Immune response 6) Hydramnios; oligo or poly 7) Placenta previa It is administer once the quickening felt and can 8) Contracted maternal pelvis be repeated 2-3 months after first injection in 9) Pelvic tumours primid women as a booster injection. (Usually 5th and 7th months of pregnancy) Complication 1) PROM Notes: It is different from Anti tetanus human 2) Cord prolapsed [common in footling immunoglobulin which are preparation presentation and lesser in flexed breech containing IgG immunoglobulin derived from presentation] plasma of donors sensitized to tetanus toxoid. It 3) Difficulty in delivering the shoulder acts by The IgG antibodies acts to neutralize the 4) Difficulty in delivering the head[ may free circulating exotoxisn of clostridium tetani lead to intracranial bleeding d/t tear of and prevent its fixation in tissue and its tentorium or delay delivery of head can consequences. cause prolonged compression of cord and asphyxia] 5) Birth trauma such as fracture, viscera damage, Erb Duchenne paralysis, dislocation of hip joint. 36
    • Long Case Examination for Phase III Medical Students University Science Malaysia 35 years old Malay lady, G5P5 (1 pair twin) at b) Number of fertilized egg (zygosity; 26/52 of pregnancy was admitted to wards mono,di) because of premature contraction and twin c) Number of placenta (chorionicity) pregnancy. d) Number of amniotic cavity (amnionicity) Questions Complication of multiple pregnancies 1) What history that could give you idea that you are dealing with cases of To the mother multiple pregnancy? 1) Hyperemesis gravidarum and in fact all 2) How do you diagnosed multiple physiological response towards pregnancy through physical examination pregnancy will be exaggerated. 3) How do you classify multiple pregnancy 2) Exacerbation of chronic illness 4) Complication of multiple pregnancy 3) Severe anemia in pregnancy 4) DIC secondary to fetal death. Answer 5) Miscarriage 6) Preterm labour. Notes: Account for only 3% of all live births, 7) Polyhydramnios they responsible of a disproportionate share of 8) Pre eclampsia. perinatal morbidity and mortality 9) Placenta abruptio 10) Post partum hemorrhage. History 11) Higher risk for developing GDM - Accelerated weight gain Others: acute fatty liver, pulmonary - Hyperemesis gravidarum embolism - Sensation of moving of more than one fetus To the fetus - Infertility treatment by ovulation- 1) IUD of one fetus inducing agents or gamete/zygote 2) IUGR transfer 3) Fetal abnormality - family history of dizygotic twins 4) Pre term delivery Notes: certain race like Africa has higher risk 5) Low birth weight factor to have multiple pregnancies. 6) Acute respiratory distress syndrome. 7) Congenital abnormality (mental Physical examination retardation, Siamese twin, cerebral - Presence of more than 2 poles (need to palsy) excludes fibroid) Others: twin-to-twin transfusion syndrome, - Usually, the abdomen size is bigger than Twin reversed arterial perfusion (TRAP)/ corresponds date acardiac twinning - Polyhydramnios - Presence of two or more fetal heart sounds on pinnard auscultation. Classification of multiple pregnancies a) Number of fetus (twin, triplet, quadruplets) 37
    • Long Case Examination for Phase III Medical Students University Science Malaysia 29 Years old Malay lady, G1P0, twin pregnancy Management to this patient at 24/52 was admitted because of frothy color 1) Evaluation on severity of the pre urine and headache. eclampsia - Close monitoring of blood pressure (15 Questions minutes interval until BP stable) - Repeat Dipstick testing within 6H 1) What is your provisional diagnosis and - 24 hour urinary protein justify your answer? - PE Profile (platelet count, uric acid 2) What is twin to twin transfusion level, sr Creatinine level, liver enxyme) syndrome? - Clotting study if platelet < 100 x 106/l 3) Factors contributes to preterm delivery 2) Management of hypertension 4) How do you manage this patient? Mild PE T. Methyldopa 250mg tds, max Answer 3g/day or T. Labetolol 100 mg tds, max 300mg Provisional diagnosis tds Pre eclampsia Or, Tab. Nifedipine 10 mg tds stat - Occur at 24w of gestation. dose - Primigravida - Twin pregnancy Severe PE - Symptoms of impending pre eclampsia IV hydrallazine start 5mg, double if no effect until 35mg. change drug if (frothy urine suggestive of proteinuria fails or and headache.) IV Labetolol start 10 mg, double if no effect until max 300mg/day) Twin to twin transfusion syndrome ** MgSo4 slow infusion 4g 10-15 - Intrauterine blood transfusion from minutes. Maintenance dose IV donor twin to another recipient twin ig/hour - Donor twin has smaller size and anemic 3) Fetal surveillance - Recipient twin will be plethoric - CTG for fetal well being. - Only occur in monozygotic twin with - Biophysical profile (Ultrasound monochorionic placenta monitoring of fetal movement, fetal tone and fetal breathing, ultrasound Factors contributes to preterm delivery assessment of liquor volume with or without assessment of fetal heart rate) - Lower and upper genital tract infection - Uterine over distension 4) Anticipating in preterm delivery by - Cervical incompetence giving IM Dexamethasone, 12 MG, and - Maternal medical complications, 12 hours apart. maternal stress - Fetal, placental or uterine abnormalities 5) Others - Bed rest - Reduce physical activity - Reduce high cholesterol and salty diet. 38
    • Long Case Examination for Phase III Medical Students University Science Malaysia Multiple Pregnancies Summary of recommendation from Clinical Management Guidelines for Obstetrician- Gynecologists Number 56, October 2004 Level B Evidence Tocolytic agents should be used judiciously in Cerclage, hospitalization, bed rest, or home multiple gestations uterine activity monitoring has not been studied in high order multiple gestations, and, therefore Women with high-order multiple gestations should not be ordered prophylactically. There should be queried about nausea, epigastric pain currently is no evidence that their prophylactic and other unusual 3rd-trimester symptoms use improves outcome in these pregnancies because they are at increased risk to develop HELLP syndrome, in many cases before Because the risks of invasive prenatal diagnosis symptoms of preeclampsia have appeared. procedures such as amniocentesis and chorionic villus sampling are inversely proportional to the The higher incidence of gestational diabetes and experience of the operator, only experienced hypertension in high-order multiple gestations clinicians should perform these procedures in warrants screening and monitoring for these high-order multiple gestation. complication. Women should be counseled about the risks of Level C (expert opinion) high order multiple gestation before beginning ART The national Institutes of Health recommends that women in preterm labor with no Management of discordant growth restriction of contraindication to steroid use be given one death of one fetus in a high-order multiple course of steroids regardless of the number of gestations should be individualized, taking into fetuses consideration the welfare of the other fetus (es) 39
    • Long Case Examination for Phase III Medical Students University Science Malaysia 36 years old Malay lady, housewife, G5P4 at 2. Prop up the patient 45o. 30W+ 5/7 POA with known history of chronic 3. Oxygen 100% 3L/min via nasal prong rheumatic heart disease and on single drug 4. Intravenous access. therapy presented with sudden onset shortness 5. Take the blood for arterial blood gas of breath on the day of admission, cannot lie flat (ABG). on night and reduce effort tolerance. There was 6. 12 lead ECG. no sign and symptoms suggestive of lung 7. Intravenous furosemide, 40 – 80 mg stat infection. Currently she is not in labour and and maintenance. fetal movement is good. 8. Intravenous digoxin and intravenous diamorphine 2.5 – 5 mg slowly – Questions depending on medical request. 1) What sign and symptoms that you would like to elicit to suggest that this is Further management: a case of heart failure 1. Admit the patient to antenatal ward. 2) How do you manage this patient 2. Carry out all the investigations as mentioned above. Answer 3. Continue oxygenation. 4. Prop up the patient 45o. Sign and symptoms of heart failure 5. Close monitoring of Cardiac symptoms: exertional dyspnoea, a) vital signs orthopnea, paroxysmal nocturnal dyspnoea, b) input output chart dyspnoea at rest, acute pulmonary edema, chest c) Cardiotocography ( CTG ) pain, palpitation. 6. Continue IV furosemide. May change to tablet form when necessary. Non cardiac symptoms: anorexia, nausea, weight 7. Tab slow potassium. loss, bloating, fatigue, weakness, oliguria, 8. Consider IM dexamethasone 12 mg b.d, nocturnal, and cerebral symptoms 6 hours apart to anticipate pre term delivery. Physical examination: Clubbing, prolong 9. Should be managed together with capillary refilling, weak, rapid, and thready medical team. pulse, tachycardia, diaphoresis, pallor, Advice on discharge: peripheral cyanosis with pallor and coldness of the extremities, pulmonary rales, edema, 1. Semi bed rest at home and avoid hepatomegally, pleural effusion, ascites, vigorous activity cardiomegally, murmurs. 2. Regular follow up at combined clinic. 3. If the patient develops any symptoms of Management to this patient urinary tract infection, upper respiratory Acute management tract infection or chest infection, come early to the hospital. Similar to managing non pregnant patient where 4. Advise to deliver in the hospital. the aim is to stabilize the patient 5. Admit when the patient at term OR admit earlier if the patient has symptoms 1. Secure the ABC – airway, breathing and of HF. circulation. 40
    • Long Case Examination for Phase III Medical Students University Science Malaysia 29 years old Malay lady, G3P2 at 27/52 W POA withstand stress of normal labour. The with mitral valve prolapses (not in failure) same thing goes for Induction of labour. 3. Patient should be placed on high risk Questions category with present of senior 1) What is Eisenmenger’s syndrome obstetrician and consultation from 2) How do you manage this patient cardiologist. 4. Close monitoring of vital signs, CTG Answer and oxygen saturation. Each patient must be attended by one staff nurse or Heart disease complicates approximately 1% of all mid wife pregnancy with chronic rheumatic heart disease is 5. Patient must be in prop up position with the commonest cause in Malaysia apart from oxygen is freely available. congenital heart disease, cardiomyopathies, 6. Pain management – in form of epidural myocarditis and coronary artery diseases. anesthesia (if the patient has no contraindication) or opiates. Eisenmenger’s syndrome 7. Prophylactic antibiotic to give adequate Pulmonary hypertension secondary to protection: Ampicillin or Gentamicin or uncorrected congenital heart disease Amoxicillin characterized with right-to-left shunting and the 8. Prolonged second stage labour must be associated cyanosis assisted 9. Syntocinon is used in third stage of Management to this patient labour instead of ergometrine or syntometrine. Antenatal 1. Should be managed in combined clinic. Management of postpartum: 2. Advice on 1. Adequate rest for maternal. a) Avoid doing vigorous activities 2. Encourage breast feeding unless she b) Avoid from getting infection – i.e. cannot cope with it. good oral hygiene, treat UTI or 3. Continue oral antibiotic for 5 days. URTI. 4. Adequate anti coagulant prophylaxis i.e 3. Medication – T.frusemide, hematinic, warfarin to prevent deep vein folic acid and anticoagulant prophylaxis thrombosis and thromboembolism. i.e. LMWH 5. Discussion about family planning. 4. Come to the hospitals if develops any Based on symptoms of heart failure, UTI, URTI a. Severity of the heart disease or chest infection b. Completed family 5. Advise to deliver in the hospital. 6. Admit when the patient at term OR Methods: admit earlier if the patient has symptoms a. Hormonal contraception - COC will of HF. increase risk of TE. b. IUCD should be discouraged due to Management of intrapartum: risk of infection. 1. Aim for SVD c. Sterilization 2. C-sec if any obstetric problem or in view of cardiologist that patient cannot 41
    • Long Case Examination for Phase III Medical Students University Science Malaysia 19 Years old Malay lady, G2P0+1(abortion) at microcephaly, optic atrophy, and blindness, 39 W POA with history of chronic rheumatic seizures, Dandy-Walker syndrome, and focal heart disease with mitral valve replacement, cerebellar atrophy),absent or non-functioning infective endocarditis and completed treatment kidneys, anal dysplasia, deafness, hemorrhagic and history of overwafarinization at 15W POA complications, premature births, spontaneous currently admitted for elective heparin infusion abortions, stillbirths, and death Questions How to access functional cardiac status during 1) Should warfarin be used in pregnancy pregnancy 2) How to access functional cardiac status during pregnancy 3) Why do you think this patient admitted for heparin infusion? Answer Should warfarin be used in pregnancy? Warfarin (Coumadin®) is an oral anticoagulant that inhibits synthesis of vitamin K–dependent clotting factors, including factors II, VII, IX, and X, and the anticoagulant proteins C and S [Shirin Abadi et al] Literature suggests a strong association between maternal warfarin use and fetal adverse effect [Shirin Abadi et al] If possible, warfarin therapy should be avoided during pregnancy. If warfarin therapy is Clinical Practice Guideline on "Management of essential, it should be avoided at least during the Heart failure", KKM first trimester (because of teratogenicity) and from about 2 to 4 weeks before delivery to Why do you think this patient admitted for reduce risk of hemorrhagic complications heparin infusion? [Shirin Abadi et al] Pregnancy itself predispose patient to risk of thromboembolism. Furthermore, this patient has Using warfarin between 6 and 12 weeks’ been on prosthetic mitral valve which further gestation is associated with “fetal warfarin increases the risk of thromboembolism. syndrome,” which is most commonly manifested by nasal hypoplasia, stippled epiphyses, limb Unfractionated heparin or low molecular weight deformities, and respiratory distress heparin could be substituted when appropriate because these agents do not cross the placenta Other complication includes central nervous and are considered the anticoagulant drugs of system abnormalities (mental retardation, choice during pregnancy. [Shirin Abadi et al] 42
    • Long Case Examination for Phase III Medical Students University Science Malaysia 38 Years old Malay lady, housewife, due to any structural or functional cardiac G9P6+2(abortion) at 12/52 POA and known conditions [Hunt SA et al] case of Mitral Valve Prolapse with mild Mitral regurgitation for more than 10 years According to European Society of Cardiology, HF is a syndrome whereby the patient should Questions have the following features; typically shortness 1) Type of murmur in mitral regurgitation of breath at rest or exertion, and/fatigue sign, and stenosis and Pathophysiology signs of fluid retention and objective evidence of 2) What is heart failure? an abnormality of the structure or function of the 3) Contraindication for pregnancy in heart heart at rest. disease There have been a confusing in defining the type Types of murmur and Pathophysiology of heart failure especially involving the acute or chronic state. Furthermore, many clinicians use Mitral regurgitation it interchangeably to refer to severity of the - Pan systolic murmur disease. Therefore, the ESC guidelines have - Occur when ventricles leak to a lower come across with new definition which chamber or vessel because there is distinguishes between new onset HF, transient pressure gradient from the moment HF and chronic HF. ventricle begin to contract. - Blood then flow and murmur begin at New onset HF is self-explanatory and refers to beginning of first heart and continue first presentation. until the pressure equalize - Other causes of pan systolic murmur Transient HF refer to symptomatic HF over a include tricuspid regurgitation, VSD, limited time period, although long-term and Aortopulmonary shunts. treatment may be indicated, for examples; patient with mild Myocarditis with nearly Mitral stenosis complete recovery, patient with MI who needs - Mid diastolic murmur. diuretic in CCU but not require it in long term - Begin later in diastolic and may be short treatment or transient HF caused by ischemia or extend right up to first heart sound. that resolve with revascularization - Due to impairs flow during ventricular filling either because of stenosis, or Meanwhile chronic heart failure is a persistent obstruction by tumor mass (atrial heart failure with stable, worsening or myxoma) decompensated state. - Can also due to Austin Flint murmur of aortic regurgitation and Carey Coombs Contraindication for pregnancy murmur of acute rheumatic fever,. 1) Pulmonary hypertension 2) Eisenmenger’s Syndrome What is Heart failure? 3) Aortic dilatation > 4cm and this should be suspected in Marfan syndrome Heart failure is a syndrome manifesting as the 4) Mother on warfarin treatment. inability of the heart to fill with or eject blood 5) Severe cyanotic heart disease with low oxygen saturation and high hematocrit 43
    • Long Case Examination for Phase III Medical Students University Science Malaysia 18 years old Malay lady, G1P0 at 32/52 POA 6) Excludes the differential diagnosis of was admitted because of severe lethargy, lethargy, shortness of breath and light- shortness of breath and light-headedness. headedness a) Cardiovascular problem Questions b) Respiratory tract infection 1) Define anemia c) Multiple pregnancy 2) Common cause of anemia in pregnancy d) Diabetes mellitus 3) Management to this lady 7) For iron deficiency anemia 4) What is haematinic a) Iron supplement like ferrous 5) 1 pack cell blood can increase how sulphate and ferrous fumarate much hemoglobin level (increase approximately 1 Hb in 1 6) Complication of anemia week) # may consider double hematinic (doubling the dose) Answer b) Parenteral iron c) Packed cell transfusion. Anemia 8) Maternal transfusion should be Hemoglobin concentration <11.0 g/dL [WHO] considered for fetal indications in cases a) Mild (Hb 8-10 g/dL) of severe anemia. b) Moderate (Hb 5-8 g/dL) 9) Course of treatment should be based on c) Severe (Hb less than 5 g/dL clinical judgment and individualized; period of gestation, severity of anemia, Common cause of anemia in pregnancy type of anemia. 1) Microcytic anemia (Iron deficiency anemia. Needs to exclude Thalassemia Haematinic as both will give low MCV of <85 fL) a) Iron 2) Macrocytic anemia (folate deficiency) b) Folate 3) Trauma c) Vitamin C (increase absorption of iron) 4) Hemolytic anemia a) Sickle cell syndrome One packed cell b) Sickle cell disease - Is 450 ml of blood. Ideally it will c) Sickle cell traits increase 1 Hb level d) Sickle cell hemoglobin C disease. Complication of anemia Management for this lady 1) To mother 1) Admit to wards for observation a) Aggravate heart failure 2) Monitoring of vital sign. b) Risk of post partum hemorrhage 3) Full blood count (pay attention on c) Increase risk of infection hemoglobin level for grading and MCV for type of anemia), serum ferritin level, 2) To fetus total iron binding capacity. a) Fetal hypoxia 4) Full blood picture if iron deficiency b) IUGR anemia is unlikely c) Spontaneous abortion. 5) Establish the causes of anemia 44
    • Long Case Examination for Phase III Medical Students University Science Malaysia Clinical Management Guidelines for Obstetrician–Gynecologists Number 95, July 2008 Anemia: Hgb (g/dL) and Hct (percentage) The following recommendations are based levels below 11 g/dL and 33%, respectively, primarily on consensus and expert opinion in the first trimester; 10.5 g/dL and 32%, (Level C): respectively, in the second trimester; and 11 g/dL and 33%, respectively, in the third - All pregnant women should be trimester screened for anemia, and those with iron deficiency anemia should be Summary of Recommendations and treated with supplemental iron, in Conclusions addition to prenatal vitamins. The following conclusion is based on good - Patients with anemia other than iron and Consistent scientific evidence (Level A): deficiency anemia should be further evaluated. - Iron supplementation decreases the prevalence of maternal anemia at - Failure to respond to iron therapy delivery. should prompt further investigation and may suggest an incorrect The following recommendation and diagnosis, coexisting disease, conclusions are based on limited or malabsorption (sometimes caused by inconsistent scientific data (Level B): the use of enteric-coated tablets or concomitant use of antacids), - Iron deficiency anemia during noncompliance, or blood loss. pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality. Severe anemia with maternal Hgb levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in non reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Thus, maternal transfusion should be considered for fetal indications. 45
    • Long Case Examination for Phase III Medical Students University Science Malaysia 28 Years old Malay lady, housewife, G2P1 at Management of pregnant lady with fibroids 38W + 5/7 POA was admitted in view of 1) Management of fibroids during 1. One Previous scar a year ago due to pregnancy is just a monitoring of its fetal distress, uncomplicated CS growth. Drugs rarely being prescribed. 2. Uterine fibroid diagnosed during first 2) Fibroids can cause miscarriage. pregnancy Therefore, advise patient not to undergone vigorous activity. Questions 3) Corticosteroid injection if pre term labour is anticipated. 1) Why fibroid increase in size during 4) Monitoring of the fetus for fetal well pregnancy being, lie and presentation. 2) What fibroid changes can occur during 5) Observation of fetal lie and presentation pregnancy is crucial before allowing patient to go 3) Expected findings during PE for SVD. 4) How do you manage the pregnancy 6) Furthermore, obstructed labour should patient with fibroids? be excluded. 7) If patient is scheduled for caesarean Answer section, do not remove the fibroid during the surgery as it will cause heavy Why fibroid increase in size during pregnancy bleedings. 8) Fibroids will shrink after pregnancy. Fibroid is an estrogen-dependant for its growth. Management post pregnancy includes During pregnancy, the level of estrogen rise a) Ablation of the fibroids steadily until term. b) Surgery to remove the fibroids c) Hysterectomy Fibroid changes during pregnancy d) Medications to shrink the fibroids Red degeneration can occurs between 12th and 22nd week of pregnancy where the blood supply to the fibroid is cut off. As a result, the fibroid turn red and die. Red degeneration can cause intense abdominal pains and uterine contraction which could lead to early labour or miscarriage Expected findings during PE 1) More than 2 fetal pole palpated 2) Some fibroids may cause unstable lie or breech presentation. 46
    • Long Case Examination for Phase III Medical Students University Science Malaysia 16 years old Malay lady, single parent with e) Leading causes of death for girls aged G1P0 at 37 w + 6/7 POA with history of 15 to 19 in developing countries f) Predispose to un safe abortion 1) Bronchial asthma on MDI salbutamol g) High risk for HIV infection due to and MDI inflammide unprotected sex 2) Anemia on double hematinic. History of blood transfusion at 26/52 Dexamethasone 3) Ante partum hemorrhage secondary to PP type I at 34/52. Completed Pre term labor associated with complication of dexamethasone. respiratory distress syndrome, intraventricular 4) Currently admitted because of hemorrhage and necrotizing enterocolitis. contraction pain. Multiple randomized controlled trials has 5) Pre marital sex demonstrated that the admission of corticosteroid to the mother resulting significant reduction in these complication. Questions Both betamethasone and dexamethasone can cross the placenta. In USM, dexamethasone is 1) What is the effect of Salbutamol used instead of betamethasone. Betamethasone (ventolin) on uterine contraction may be a better choice because it can reduce the 2) Complication of teenage pregnancy risk of cystic periventricular leukomalacia. 3) Principles of Dexamethasone and dosage. It can be given in doses of 6 mg every 12 hours for four doses, and 12 mg every 12 hours for 2 doses during period of gestation of 24 W to 34 Answer through IM route. In term of lung maturity, no benefit has been Salbutamol action on uterus demonstrated in infants beyond 34 weeks Salbutamol stimulates beta 2 receptor in the gestation. However, it is still being given in uterus and causing muscles in the wall of uterus many centers because of no harm to the baby to relax. and mother. Furthermore, it still can improve the complication of intraventricular hemorrhage and Complication of teenage pregnancy necrotizing enterocolitis. Teenage pregnancy is defined as a teenage girl, Beware when used in mother with poorly usually within the ages of 13-19, becoming controlled diabetes in pregnancy, pregnant. [UNICEF] chorioamnionitis and immunosuppressed mothers a) Highest global incidence for premature birth and low birth weight Corticosteroid shows maximum effect after 24 b) High risk for anemia in pregnancy hour and lasted 7 days. Repeated use of c) Difficulties in labour due to corticosteroid should be avoided as it may underdeveloped pelvis impose complication to mother and fetus. d) High risk for obstructed labour, causing obstetric fistula if c-sec is not readily accessible 47
    • Long Case Examination for Phase III Medical Students University Science Malaysia 33 Years old Malay lady, housewife, G7P6 at 38 2) Counseling on mode of delivery and W POA was admitted for further management in reason why patient can not be allowed view of for SVD. 3) Plan for Caesarean section. Can be 1) Grand multi para performed at 38 week to 39 week of 2) Maternal obesity but MOGTT test is gestation. normal 4) Counseling for bi tubal ligation because 3) Placenta previa type III anterior but no patient is in high risk to develop uterine history of APH. rupture, hemorrhage and uterine atony 4) Biggest baby is 3.9 kg. after this c-sec delivery due to 5) Clinically, suspected macrosomic baby. a) Grand multi para On ultrasound, estimated fetal weight is b) 1 c-sec scar. 4.0 to 4.2 kg. 6) Not in labour yet. Intrapartum management Question 1) Preparation for c-sec (refer c-sec preparation) 1) What is the mode of delivery and justify 2) Blood GSH because anticipating in your answer blood loss because we will cut through 2) How do you manage this patient the placenta. Answer 3) Presence of senior obstetrician in case of complication to mother during operation Mode of delivery and pediatrician for management of baby. After thorough view on this patient presentation, caesarian section is the most appropriate mode Post partum of delivery because of 1) Baby should be check for capillary 1) Placenta previa type III in which blood sugar and early feeding is descending of fetal head into pelvic encouraged brim is impossible due to obstruction to 2) Baby should be managed by pediatrician cervical os. and kept in NICU for observation. 2) Maternal obesity and macrosomic baby 3) Mother should be offered with other will predispose to complication type of contraception if she refused bi especially shoulder dystocia. tubal ligation. 3) Induction of labour also impossible 4) Daily inspection on c-sec scars to look because of grand multi para with for any infection or ruptured scar. macrosomic baby. 5) Referral to the mother to dietitian and internal medicine team for further Management to this patient management on obesity. 6) Mother should be offered MOGTT Ante natal management screening on the next pregnancy. 1) Daily CTG for fetal surveillance. Ultrasound should also be done. 48
    • Long Case Examination for Phase III Medical Students University Science Malaysia 40 Years old Malay lady, housewife, G15P12+2 than in the multiparous group (P < .05). Similar (abortion) at 36W + 3/7 from low frequency of maternal diabetes, infection, socioeconomic status presented with this uterine wall scar rupture, variations in fetal heart problem list rate, fetal death, and neonatal mortality was found in the 3 groups. [Agota Babinszki et al] 1) Elderly pregnancy 2) Great grand Multipara (para >10) Principles of management in this patient 3) Unstable lie 1) Daily observation for fetal lie Questions 2) Exclude factors contributing to unstable lie such as fetal abnormality, placenta 1) Complication associated with great previa, uterine abnormality grand Multipara 3) Pelvic abnormality 2) Principles of management in this patient 4) Polyhydramnios 3) What is the contraindication for ECV? 5) Discuss on mode of delivery which is Answer expectant vs. active management (C-sec, ECV or stabilizing induction) Notes: The risk of cord prolapses leading to fetal 6) Advise on contraception. Tubal ligation hypoxia and fetal death is very high once the should be offered in view of membrane ruptures. Therefore, it is highly a) Advanced maternal age recommended that patient with unstable lie b) Great grand multi parity should be admitted to antenatal wards at 37 c) Two history of abortion. weeks onward for observation [The Practical d) Low socio economic status. Labour suite Management] As a Muslim, permanent method of contraception should only be performed Complication associated with great grand if specialist agrees that next pregnancy Multipara will be harmful to the patient’s life. The incidence of malpresentation at the time of Contra indication for ECV delivery, maternal obesity, anemia, preterm delivery, and meconium-stained amniotic fluid Absolute contraindication increased with higher parity, whereas the rate of 1) Multiple pregnancy excessive weight gain and cesarean delivery 2) APH decreased. Compared with grand multiparas, 3) PP great-grand multiparas had significantly elevated 4) PROM or PPROM risks for abnormal amounts of amniotic fluid, 5) Significant fetal abnormality abruptio placentae, neonatal tachypnea, and 6) Any indication for caesarean section. malformations but lower rates of placenta previa (P < .05). The incidence of postpartum Relative 1) Previous c-sec hemorrhage, preeclampsia, placenta previa, 2) IUGR macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand 3) Severe proteinuric hypertension multiparas than in multiparas, whereas the 4) Rhesus iso-immunization proportion of induction, forceps delivery, and 5) Evidence of macrosomia total labor complications was significantly lower 6) Any suspected fetal compromise. 49
    • Long Case Examination for Phase III Medical Students University Science Malaysia 26 Years old Malay lady, G1P0 at 38 W POG a) Severe cognitive, neurological and currently presented with this problem developmental activity 1. Extended breech Management to this lady 2. Persistent proteinuria 3. Hypothyroidism on Tab Thyroxine 50 1) The management in view of breech is microgram OD and undergone total similar to normal pregnancy thyroidectomy in 2002 2) Excludes the causes of proteinuria. Take notes that primid with proteinuria and Questions hypothyroidism should increase 1) Hormones affecting level of thyroid suspiciousness to pre eclampsia even hormone during pregnancy. though it is already near term. 2) What is the effect of hypothyroidism in 3) For the management of hypothyroidism pregnancy a) WHO recommends intake of 200 3) Management to this lady micrograms/day of iodine during pregnancy to maintain adequate thyroid hormone production Answer b) Dosage of maintenance thyroxine could be increased during pregnancy Hormones interacting with thyroid hormones up to 50-200 microgram daily dose. (Doubling the dose by 25% to 50%) 1) High level of human chorionic c) Thyroid function tests every 6-8 gonadotropin will decrease the level of weeks during pregnancy to ensure TSH during first trimester normal thyroid function throughout 2) Estrogen will increases the amount of pregnancy. thyroid hormone binding proteins in the 4) Screening for congenital serum hence increases the total thyroid hypothyroidism to the baby using the hormone levels in the blood. However, umbilical cord blood during delivery. free hormone remains normal Effect of hypothyroidism on pregnancy 1) Mother a) No symptoms in mild hypothyroidism b) Maternal anemia c) Maternal myopathy d) Congestive heart failure e) Pre eclampsia f) Placental abnormalities g) Low birth weight infants h) post partum hemorrhage 2) Baby 50
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Asherman’s syndrome (intrauterine Fibroids, due to their mere presence, cause the adhesion) is associated with: entire uterus to enlarge, thereby stretching the blood vessels that supply the various parts of the A) Amenorrhea uterus. When the fibroids are removed, the B) Placenta previa remaining uterus collapses down to a smaller C) Subfertility volume and some of the blood vessels that D) Salphingitis supply the endometrium may become blocked. E) Menorrhagia Because of the lack of oxygen and nutrients, that area of tissue may die and a scar may form leading to Asherman’s syndrome. History: Named after Dr Asherman, an Israeli gynaecologist, who first described the condition Other cause: radiation cause ischemia to in the mid 20th century when he noted that some myometrium tissue women who had surgical treatments at the time of pregnancy stopped having periods Signs and symptoms after this treatment 1) Oligomenorrhea, amenorrhea 2) Pain (increase work by uterine muscle to get Def: A reduction or absence in menstruation rid blood through scar tissue) that may be due to scar tissue formation inside 3) Infertility the uterus and can occur as a result of 4) Haematometra (large bruise inside uterus that pregnancy and delivery, infection or diagnosed by pelvic US) gynaecological surgical procedure Complication **differ from endometrial ablation: induce 1) Placenta previa, accrete scar tissue in the uterus to prevent heavy periods 2) Infertility Classification according to 17th Congress of the 3) IUGR Federation of Frenchspeaking Societies of 4) Ectopic pregnancy Gynaecology and Obstetrics [1957] (1) Traumatic synechiae connected with surgical Investigation: or obstetrical evacuation of the uterus. 1) Hysteroscopy (2) Spontaneous synechiae of tuberculous origin. 2) Hysterosalpingogram (HSG) (3) Synechiae occurring after myomectomy. (4) Synechiae secondary to the attack of Management chemical or physical agents and, likewise, those resulting fromatrophic changes. 1) Admission to wards 2) Investigation to confirm the diagnosis Pathophysiology: Severely damaged decidua 3) Surgical excision of scar tissue by basalis are replaced with granulation tissue and hysteroscope under General anesthesia. opposing uterine wall adhere to form scar tissue. It is later infiltrated by myometrial cells and Answer: T, T, T, F, F covered by endometrium. 1
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Concerning heart disease in pregnancy a. Non pharmacological (mild) A. Mitral stenosis carries a better - limiting strenuous exercise prognosis than atrial defect - adequate rest B. Pregnancy should be induced at 38 - maintaining a low salt diet weeks in cases with grade IV - treating anemia and infections early dyspnoea - frequent antenatal examinations C. Rheumatic heart disease is more common than congenital heart disease Pharmacological D. Ergometrine should be avoided in - Sublingual GTN most cases - Digoxin E. Mitral volvotomy is contraindicated. - Diuretic(used with care as may impair uterine blood flow. No teratogenic effect) Introduction: About 0.5 – 4% of pregnant - Beta blocker (used with care;intrauterine women have cardiac disease. Common causes of growth retardation, apnea at birth,fatal HF in pregnancy are hypertension, eclampsia, bradycardia, hypoglycaemia and undetected valvular heart disease especially hyperbilirubinemia) mitral stenosis, congenital heart disease, and - ACEI and ARB are contraindicated in occasionally peripartum cardiomyopathy. pregnancy. Peripartum cardiomyopathy occurs in 1:3,000 -warfarin is teratogenic in early trimester. life births in Malaysia [Management of HF Heparin can be used LMW subcutaneous. Malaysia] Labour is spontaneous except in fetal NYHA classification did not show any marked compromise (consider pre mature delivery) differences in outcome. Epidural anaesthesia during labour is Eismenger’s syndrome and pulmonary recommended. hypertension carries 40-50% mortality rate (can be caused by mitral stenosis). TOF 5% if no Ergometrine causes 1. Vasoconstriction, HPT pulmonary HPT. and heart failure. So must be avoided. Used syntocinon only. Normal haemodynamic changes that occur in pregnancy are: Antibiotic prophylaxis in structural heart 1) Cardiac output increases by 30–50% during abnormality during labour (IV ampiillin 1.0g 6h normal pregnancy. X 3doses, IV gentamycin 80 mg 8 hourly X 3) 2) Cardiac output increases to 80% above - Surgical volvotomy ideally be performed baseline during labour and delivery. before pregnancy although it is safe to do it during pregnancy **Haemodynamic changes return to baseline 2 - Marfan syndrome is an autosomal dominant – 4 weeks after vaginal delivery and up to 6 connective tissue abnormality that may lead to weeks after caesarian delivery. mitral valve prolapsed and aortic regurgitation, aortic root dilatation and aortic rupture (50% in Management pregnancy) 1) Manage by multidisciplinary team consist of physician, obstetrician and pediatrician Answer: F, F, T, T, F 2
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Pyelonephritis in pregnancy Investigation A. Occur in 0.1% of pregnant woman 1) Full blood count B. If unilateral, is most often right sided 2) Urinalysis:Positive results for nitrites, C. Caused predominantly by staph. leukocyte esterase, WBCs, RBCs, and protein Aureus suggest UTI. D. Common in diabetic patient 3) Urine culture: A colony count of 100,000 colony-forming units (CFUs) per milliliter has Def: Pyelonephritis is the most common urinary historically been used to define a positive culture tract complication in pregnant women, occurring result in approximately 2% of all pregnancies. 4) Renal ultrasonography 5) Evaluation of fetal status Symptoms of pyelonephritis include the 6) Renal function test following: 1. Fever (Often, the temperature is very high.) Treatment 2. Chills -Ampicillin 2 g IV q6h for treatment of 3. Nausea and vomiting pyelonephritis; use in conjunction with an 4. Costovertebral angle (CVA) or flank pain aminoglycoside for treatment of pyelonephritis -Paracetamol Flank tenderness is right-sided in more than half of -Amoxicillin 7-Day regimen: 250 mg PO q8h or patients, bilateral in one fourth of patients, and left- 3-Day regimen: 500 mg PO qid sided in one fourth of patients. Pain may also be -Amoxicillin/clavulanate potassium found suprapubically with palpation. (Augmentin), 500 mg PO tid for 7-10 d -Ceftriaxone (Rocephin) Other symptoms may include nausea, vomiting, frequency, urgency, and dysuria. Complication - Bacteremia Women with additional risk factors - Respiratory insufficiency due to bacterial (immunosuppression, diabetes, sickle cell endotoxin damage to the alveoli, causing anemia, neurogenic bladder, recurrent or pulmonary edema; therefore, fluid overload persistent UTIs prior to pregnancy) are at an - Renal dysfunction increased risk of a complicated UTI - PPROM - Pre term birth Common organism 1. Escherichia coli (most common, in as Answer; F, T, F, T many as 70% of cases) 2. Group B Streptococcus (10%) 3. Klebsiella or Enterobacter species (3%) 4. Proteus species (2%) Physiological changes include urinary retention caused by the weight of the enlarging uterus and urinary stasis due to ureteral smooth muscle relaxation 3
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) STD include Answer: T, T, T, F, F A. Trichomonas vaginitis B. Condyloma accuminata C. Chlamydial infection D. Type 1 herpes hominis E. Toxoplasmosis Bacterial STDs include syphilis, gonorrhea, chancroid, lymphogranuloma venereum, granuloma inguinale, and chlamydial, mycoplasmal, and Ureaplasma infections. Viral STDs include genital and anorectal warts (Condylomata acuminata :HPV types 6 and 11), genital herpes, molluscum contagiosum, and HIV infection Parasitic infections that can be sexually transmitted include trichomoniasis (caused by protozoa), scabies (caused by mites), and pediculosis pubis (caused by lice). Type 1 herpes hominis causes classic “cold sores” or “fever blisters”, commonly known as herpes simplex, herpes genitals, herpes labialis Toxoplasmosis is caused by infection with Toxoplasma gondii, an obligate intracellular parasite. The infection produces a wide range of clinical syndromes in humans, land and sea mammals, and various bird species.Individuals at risk for toxoplasmosis include fetuses, newborns, and immunologically impaired patients. Congenital toxoplasmosis is usually a subclinical infection. Among immunodeficient individuals, toxoplasmosis most often occurs in those with defects of T-cell–mediated immunity, such as those with hematologic malignancies, bone marrow and solid organ transplants, or AIDS.T gondii oocysts are ingested in material contaminated by feces from infected cats. Oocysts may also be transported to food by flies and cockroaches 4
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Uterine rupture may be associated with Consequences of Uterine rupture in fetal A. Previous c-section 1) Fetal hypoxia or anoxia B. Myomectomy 2) Fetal acidosis C. Oxytoxin infusion 3) Admission to a NICU D. Prostaglandin administration 4) Fetal or neonatal death E. Breech extraction Consequences of Uterine rupture in mother Uterine rupture in pregnancy is a rare and often 1) Maternal bladder injury catastrophic complication with a high incidence 2) Severe maternal blood loss or anemia of fetal and maternal morbidity. Several factors 3) Hypovolemic shock are known to increase the risk of uterine rupture, 4) Need for hysterectomy but, even in high-risk subgroups, the overall 5) Maternal death incidence of uterine rupture is low. From 1976- 2005, 19 peer-reviewed publications that Risk Factor described the incidence of uterine rupture 1) Previous cesarean delivery reported 1654 cases of uterine rupture among 2) Previous myomectomy 2,504,456 pregnant women, yielding an overall 3) Congenital uterine anomaly rupture rate of 1 in 1514 pregnancies (0.07%). 4) Pregnancy considerations Grand multiparity, Maternal age, Uterine rupture is defined as a full-thickness Placentation (accreta, percreta, increta, separation of the uterine wall and the overlying previa, abruption) serosa. Cornual (or angular) pregnancy Differs from uterine scar dehiscence: Separation of a Overdistension (multiple gestation, preexisting scar that does not disrupt the overlying polyhydramnios) visceral peritoneum (uterine serosa) and that does Dystocia (fetal macrosomia, contracted not significantly bleed from its edges. In addition, the pelvis) fetus, placenta, and umbilical cord must be contained within the uterine cavity, without a need for cesarean Trophoblastic invasion of the myometrium delivery because of fetal distress. 5) Labor status Induced labor Uterine rupture results in: + With oxytocin • bleeding; + With prostaglandins • rupture of the amniotic sac (bag of waters); Augmentation of labor with oxytocin • partial or full delivery of the fetus into Duration of labor, Obstructed labor the abdominal cavity; and 6) Obstetric management considerations • loss of oxygen delivery to the fetus. Instrumentation (forceps use) Intrauterine manipulation (external Classic symptoms of rupture include: cephalic version, internal podalic version, breech • pain above and beyond normal labor extraction, shoulder dystocia, manual extraction pain; • discontinuation of uterine contractions; of placenta) • signs of fetal heart rate abnormalities; Fundal pressure • hemorrhage; and 7) Uterine trauma • Hypovolumic shock Direct uterine trauma and Violence Answer: All True 5
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Labour may be obstructed by A) Ovarian tumor B) Cystocoele C) Ectopic kidney D) Distended bladder E) Vaginal septum Obstructed labour means that, in spite of strong contractions of the uterus, the fetus cannot descend through the pelvis because there is an insurmountable barrier preventing its descent. Obstruction usually occurs at the pelvic brim, but occasionally it may occur in the cavity or at the outlet of the pelvis. [WHO] Causes of obstructed labour: 1) cephalopelvic disproportion (small pelvis or large fetus) 2) abnormal presentations, e.g. - brow - shoulder - face with chin posterior - aftercoming head in breech presentation 3) Fetal abnormalities, e.g. - hydrocephalus* - locked twins* 4) abnormalities of the reproductive tract, e.g. - pelvic tumour* - stenosis of cervix or vagina** - tight perineum.** * Rarer causes. ** This may be associated with scarring caused by female genital mutilation, or previous “gishiri” cut. Answer: All true 6
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) During pregnancy and puerperium, fibroid However, without pathologic examination of the A) increase in size uterus, this determination is not possible. B) Undergo red degeneration Uterine leiomyosarcomas are found in C) Become infected approximately 0.1% of women with leiomyomas D) May undergo sarcomatous changes and are reported to be more frequently E) Cause post partum hemorrhage associated with large or rapidly growing fibroids. Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, non-cancerous The two most common symptoms of fibroids tumors arising from the myometrium (smooth (also called leiomyomas) are abnormal uterine muscle layer) of the uterus. In addition to bleeding and pelvic pressure. smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, Leiomyomas are also associated with a range of proteoglycan, fibronectin). Other names for reproductive dysfunction including recurrent these tumors include fibromyomas, fibromas, miscarriage, infertility, premature labor, fetal myofibromas, and myomas. malpresentations, and complications of labor. Leiomyomas are usually detected in women in Diagnosis their 30's and 40's and will shrink after 1. bimanual pelvic examination menopause in the absence of post-menopausal 2. ultrasonography, MRI (magnetic estrogen replacement therapy. (Dependent on resonance imagery), and CT estrogen for growth) 3. Hysterosalpingography, sonohysterography, and hysteroscopy Two to five times more prevalent in black women than white women Red degeneration: obsolete term for necrosis, with staining by hemoglobin, which may occur Leiomyomas are classified by their location in in uterine myomas, especially during pregnancy; the uterus. Subserosal leiomyomas are located marked by softening and a red color resembling just under the uterine serosa and may be partly cooked meat. [stedman] pedunculated (attached to the corpus by a narrow stalk) or sessile (broad-based). Medical treatment Intramural leiomyomas are found 1) NSAIDS for dysmenorrhea predominantly within the thick myometrium but 2) antifibrotic drug, pirfenidone may distort the uterine cavity or cause an 3) GnRH agonist (Specifically, uterine irregular external uterine contour. Submucous volume has been shown to decrease leiomyomas are located just under the uterine approximately 50% after three months mucosa (endometrium) and, like subserosal of GnRH agonist therapy.) leiomyomas, may be either pedunculated or - Use to reduce fibroid size few sessile. Tumors in subserosal and intramural months before surgery or locations comprise the majority (95%) of all - When menopause is within few leiomyomas; submucous leiomyomas make up months the remaining 5%. Others; Cervical, Intraligamentary (within broad ligament, cause Surgical treatment uteric compression) and Parasitic(attached Myomectomy (pt wish to reproduce) outside the uterus, i.e. the bladder) Hysterectomy Transformation of uterine leiomyomas (benign) Answer: T, T, F, F, T to uterine leiomyosarcomas (malignant smooth muscle tumors of the uterus) is extremely rare, and, in fact, many researchers and clinicians believe this type of transformation never occurs. 7
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Placenta previa is associated with * Multiple gestation (larger surface area of the A) Painless vagina bleeding placenta) B) Abnormal fetal heart rate * Erythroblastosis C) Twin pregnancy * Prior uterine surgery D) Android pelvis * Recurrent abortions E) Diabetes Melitus * Nonwhite ethnicity * Low socioeconomic status Placenta previa involves implantation of the * Short interpregnancy interval placenta over the internal cervical os. Variants * Smoking include complete implantation over the os * Cocaine use (complete placenta previa), a placental edge * Other causes include digital exam, abruption partially covering the os (partial placenta previa) (pre-eclampsia, chronic hypertension, cocaine or the placenta approaching the border of the os use, etc) and other causes of trauma (eg, (marginal placenta previa). A low-lying placenta postcoital trauma). implants in the caudad one half to one third of the uterus or within 2-3 cm from the os. Grade. A leading cause of third trimester hemorrhage, placenta previa presents classically as painless I Placenta Lateral Minor bleeding. Bleeding is thought to occur in encroaches on association with the development of the lower the lower uterine segment in the third trimester. Placental uterine segment attachment is disrupted as this area gradually but does not thins in preparation for the onset of labor. When reach the this occurs, bleeding occurs at the implantation cervical os. site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding II Placenta marginal major if sites promotes uterine contractions and a vicious reaches the posterior cycle of bleeding-contractions-placental margin of the located separation-bleeding. cervical os but does not cover Placental migration occurs during the second it. and third trimesters, owing to the development of the lower uterine segment, but it is less likely if the placenta is posterior or if there has been a III Placenta previous caesarean section. partially cover the os. Causes IV Placenta is Complete Major * Hemorrhaging, if associated with labor, would be secondary to cervical dilatation and symmetrically disruption of the placental implantation from the implanted in the cervix and lower uterine segment. The lower lower uterine uterine segment is inefficient in contracting and segment thus cannot constrict vessels as in the uterine corpus, resulting in continued bleeding. * Advancing age (>35) * Multiparity * Infertility treatment Answer: T, F, T, F, F 8
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Complication of abruptio placenta corrected to ensure adequate hemostasis in the A) Eclampsia case of a cesarean B) Acute renal failure C) DIVC Prematurity: Delivery is required in cases of D) Fetal death severe abruption or when significant fetal or E) Post partum hemorrhage maternal distress occurs, even in the setting of profound prematurity. In some cases, immediate Abruptio placentae is defined as the premature delivery is the only option, even before the separation of the placenta from the uterus. administration of corticosteroid therapy in these Patients with abruptio placentae typically premature infants. All other problems and present with bleeding, uterine contractions, and complications associated with a premature infant fetal distress. A significant cause of third- are also possible. trimester bleeding associated with both fetal and maternal morbidity and mortality, abruptio Signs and symptoms placentae must be considered whenever bleeding is encountered in the second half of pregnancy. 1) Vaginal bleeding - Vaginal bleeding is present in 80% Hemorrhage into the decidua basalis occurs as of patients diagnosed with placental the placenta separates from the uterus. Vaginal abruptions. bleeding usually follows, although the presence - Bleeding may be significant enough of a concealed hemorrhage in which the blood to jeopardize both fetal and maternal pools behind the placenta is possible. health in a relatively short period. - Remember that 20% of abruptions If the bleeding continues, fetal and maternal are associated with a concealed distress may develop. Fetal and maternal death hemorrhage and the absence of may occur if appropriate interventions are not vaginal bleeding does not exclude a undertaken. The primary cause of placental diagnosis of abruptio placentae. abruption is usually unknown, but multiple risk 2) Contractions/uterine tenderness factors have been identified. - Contractions and uterine hypertonus are part of the classic triad observed Complication with placental abruption. - Uterine activity is a sensitive marker Cesarean delivery: Cesarean delivery is often of abruption and, in the absence of necessary if the patient is far from her delivery vaginal bleeding, should suggest the date or if significant fetal compromise develops. possibility of an abruption, If significant placental separation is present, the especially after some form of fetal heart rate tracing typically shows evidence trauma or in a patient with multiple of fetal decelerations and even persistent fetal risk factors. bradycardia. A cesarean delivery may be 3) Decreased fetal movement complicated by infection, additional - This may be the presenting hemorrhage, the need for transfusion of blood complaint. products, injury of the maternal bowel or - Decreased fetal movement may be bladder, and/or hysterectomy for uncontrollable due to fetal jeopardy or death. hemorrhage. In rare cases, death occurs. Hemorrhage/coagulopathy: Disseminated intravascular coagulation (DIC) may occur as a Answer: F(risk factor), T, T, T, T(uterine atony) sequela of placental abruption. Patients with a placental abruption are at higher risk of developing a coagulopathic state than those with placental previa. The coagulopathy must be 9
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) A patient with severe placental abruption will 2. Early Rupture of Membranes (AROM) need 3. Internal Fetal Monitoring (fetal scalp A) CVP line electrode) B) Artificial Rupture Of Membrane 4. Tocometry C) Sedation with morphine 5. Intrauterine Pressure Catheter D) Beta adrenergic drug 6. Cautious use of Pitocin E) Arterial Blood Gas analysis E. Risks 1. Preterm birth Sher Severity Grading system 2. Intrauterine Growth Retardation 1. Grade 1: (Herald bleed) Management: Emergent 1. Less than 100cc of uterine bleeding 2. Uterus non-tender Rapid management is critical as fetal death 3. No Fetal Distress occur in up to 30% within 2h. Do not wait for 2. Grade 2 US as it is clinically diagnosed 1. Uterus tender 2. Fetal Distress 1. Brisk bleeding 3. Concealed hemorrhage 2. Unstable vital signs 4. Progresses to Grade 3 without delivery 3. Fetal Distress 3. Grade 3 4. Grade II or III placental abruption 1. Fetal death 2. Maternal shock Immediate interventions 3. Extensive concealed hemorrhage 1. Oxygen 4. Coagulopathy 2. Trendelenburg position 1. Absent: 3A (66% of patients) 3. Obtain immediate Intravenous Access 2. Present: 3B (33% of patients) 1. Two large bore IV (16-18 gauge) 2. Initiate Isotonic crystalloid bolus Management: Stable patient (Grade I) 1. Normal saline or Ringers 4. Call for immediate Obstetric and A. General neonatal support 1. Obstetrics Consultation 5. Delivery within 20 minutes if Fetal 2. RhoGAM if Maternal blood Rh -ve Distress** Cesarean Section unless imminent B. Criteria Vaginal Delivery 1. Reassuring Fetal Heart Tracing 6. RhoGAM if Maternal blood Rh -ve 2. No coagulopathy 3. Normotensive without Preeclampsia Monitoring 4. Nontender uterus 1. Orthostatic Blood Pressure and pulse 5. Negative ultrasound with normal AFI 2. Monitor Intake and output C. Preterm gestation *Keep Urine Output over 30cc per hour 1. Consider Tocolysis with Magnesium 3. Monitor Hemoglobin or Hematocrit q1- Sulfate. Contraindicated in all but mild 2 hours prn abruption <34 weeks**Controversial and risky 1. Keep Hemoglobin >10 g/dl or 2. Steroids to promote lung maturity Hematocrit >30% 3. Consider Amniocentesis for lung 2. Packed Red Blood Cell transfusion maturity studies as needed 4. External Fetal Monitoring 4. Monitor coagulation studies 5. Observe during short term 1. Fresh Frozen plasma transfusion as hospitalization needed D. Term gestation or mature lung studies 2. Platelet transfusion as needed 1. Active management labor towards rapid fetal delivery Answer: T, F(once pt stable), T, F, T 10
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) The following are associated with placental Twin-to-twin transfusion syndrome (TTTS) is insufficiency the result of an intrauterine blood transfusion A) Diabetes Mellitus from one twin (donor) to another twin B) Post maturity (recipient). TTTS only occurs in monozygotic C) Twin pregnancy D) Cigarette smoking (identical) twins with a monochorionic placenta. E) Dieting during pregnancy The donor twin is often smaller with a birth weight 20% less than the recipient's birth Definition: weight. The donor twin is often anemic and the Placental insufficiency is the failure of the recipient twin is often plethoric with hemoglobin placenta to supply nutrients to the fetus and differences greater than 5 g/dL. [EMedicine remove toxic wastes. article 271752] In post maturity of the baby [before term, growth of placenta is proportional to growth of fetus. However after term, placenta start to Answer: T, T, T, T, T regress while the baby continue to grow] Causes [from Ten Teachers] Reduced uteroplacental perfusion: Inadequate trophoblast invasion, anti phospholipid syndrome, diabetes mellitus, Sickle cell disease, multiple gestation, collagen vascular disease. This will result in small placenta with gross morphological changes. Usually infarct and basal hematoma. Reduce feto placental perfusion: Single umbilical artery, twin-twin transfusion syndrome. Antiphospholipid syndrome (APS) is a disorder that manifests clinically as recurrent venous or arterial thrombosis and/or fetal loss. Characteristic laboratory abnormalities in APS include persistently elevated levels of antibodies directed against membrane anionic phospholipids (ie, anticardiolipin [aCL] antibody, antiphosphatidylserine) or their associated plasma proteins, predominantly beta- 2 glycoprotein I (apolipoprotein H); or evidence of a circulating anticoagulant. [EMedicine article 333221] 11
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Hydatidiform mole is associated with Failure of the placental-site trophoblastic tumor increased urinary output of to produce large amounts of estrogen, in contrast to normal pregnancy and Hydatidiform mole, a) estrogen resulted in marked androgen/estrogen b) human chorionic gonadotrophin imbalance, high circulating concentrations of c) prostaglandin free testosterone, and Virilization. [Nagelberrg d) pregnanediol SB& Rosen SW, 1985] A decrease of E3 in e) human placental lactogen these abnormal pregnancies would result mainly in a lower level of tissue P450arom Gestational trophoblastic disease encompasses concentration [Takara Yamamoto et al, 1997] of several disease processes that Originate from placenta HPL Value increased in multiple pregnancies a) Complete mole (no fetal tissue, 90% 46 (twins or more), Placental site trophoblastic XX and 10% 46 XY) tumor, intact molar pregnancy, Diabetes, Rh b) Partial mole (69, XXX or 69, XXY with incompatibility and deccreased in Toxemia, fetal tissue present) Aborting hydatidiform mole, Choriocarcinoma c) Placental site trophoblastic tumors and Placental insufficiency [Medline Plus] d) Choriocarcinomas e) Invasive moles PGDH activity in neoplastic tissues was found to be one tenth or less of that in normal term Neutral steroids in urine were determined human placentae. PGDH may be important in quantitatively with gaschromatography on the accumulation of PGs in neoplastic tissues. If capillary columns in a case of benign choriocarcinoma cells were able to synthesise hydatidiform mole associated with bilateral prostaglandin E2 or PGF2α then the very limited theca-lutein cysts. A remarkable finding was the amounts of PGDH in these cells would allow very high levels of 17-hydroxypregnanolone considerable quantities of these prostaglandins and pregnanetriol, which continued to rise until to be produced. The lack of PGDH in these cells the 15th day after molar evacuation.[Vanluchene suggests that very little or no PGE2 is E et, al, 1977] synthesised in choriocarcinoma cells. Rapid urine qualitative hCG assays may not be Answer: T, T, F, F, T reliable in the presence of markedly elevated hCG levels found in molar pregnancy. [Davison CM et al, 2004] Urinary pregnanediol levels, on the other hand are frequently decreased. [Clinical Laboratory Medicine by Richard Ravel] Decreased urinary pregnandeniol level but increased in serum progesterone and estradiol- 17 beta suggest molar pregnancy 12
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Prolactin the nipples and mammary gland, as occurs a) is secreted by the posterior pituitary during nursing, leads to prolactin release. This b) is necessary for mammary ductal effect appears to be due to a spinal reflex arc growth that causes release of prolactin-stimulating c) level in plasma is unaffected by hormones from the hypothalamus. smoking d) is necessary for the establishment of lactation Estrogens provide a well-studied positive control e) secretion is controlled by an inhibiting over prolactin synthesis and secretion. Increase factor blood concentrations of estrogen during late pregnancy appear responsible for the elevated Prolactin is a single-chain protein hormone levels of prolactin that are necessary to prepare closely related to growth hormone secreted by the mammary gland for lactation at the end of lactotrophs in the anterior pituitary. It is synthesized as a prohormone. gestation. Prolactin induces lobuloalveolar growth of the Excessive secretion of prolactin - mammary gland. Alveoli are the clusters of cells hyperprolactinemia - is a relatively common in the mammary gland that actually secrete milk. disorder in humans. This condition has numerous causes, including prolactin-secreting Prolactin stimulates lactogenesis or milk tumors and therapy with certain drugs. production after giving birth. Prolactin, along with cortisol and insulin, act together to Common manifestations of hyperprolactinemia stimulate transcription of the genes that encode in women include amenorrhea (lack of milk proteins. menstrural cycles) and galactorrhea (excessive or spontaneous secretion of milk). Men with hyperprolactinemia typically show hypogonadism, with decreased sex drive, decreased sperm production and impotence. Such men also often show breast enlargement (gynecomastia), but very rarely produce milk. http://www.vivo.colostate.edu/hbooks/pathphys/endo crine/hypopit/prolactin.html Dopamine serves as the major prolactin- inhibiting factor or brake on prolactin secretion. A minimum of 5 cigarettes significantly It is secreted into portal blood by hypothalamic decreases prolactin concentration in smokers. A neurons, binds to receptors on lactotrophs, and matched pair’s comparison confirmed that inhibits both the synthesis and secretion of smoking reduces the level of prolactin [Gabriela prolactin. Agents and drugs that interfere with et al, 1995] dopamine secretion or receptor binding lead to enhanced secretion of prolactin. Answer: F, T, F, T, T Prolactin secretion is positively regulated by several hormones, including thyroid-releasing hormone, gonadotropin-releasing hormone and vasoactive intestinal polypeptide. Stimulation of 13
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) With regards of the blood volume and its [Wikipedia] In pregnancy, liver produces more composition during pregnancy transferrin. Serum Ferroxidase I and II are progressively a) the total RBC falls by about 20% increased with serum Total Iron Binding from the normal non-pregnant Capacity (TIBC) and unsaturated iron binding volume capacity (UIBC) as pregnancy advances b) the packed cell volume falls [Agroyannis B et al] c) there is rise in the iron binding capacity The total iron-binding capacity exceeded normal d) the blood cholesterol rises starting in the sixth lunar month in the e) the protein bound iodine level falls nontreated group and in the seventh lunar month in the treated group, and it decreased slightly in the latter toward term and had returned to Physiology of anemia in pregnancy normal in both groups by the fourth postpartum A disproportionate increase occurs in plasma week [George D. Malkasian] volume (25% to 50%) compared to red blood cell mass (10% to 25%) during pregnancy, with Serum protein bound iodine levels increased resultant hemodilution and reduction in significantly with age in both sexes and in hematocrit of 3% to 5%. These changes begin at pregnant women, while it decreased approximately 6 weeks gestation and normalize significantly in alcoholics, cigarette smokers and by 6 weeks postpartum. [The John Hopkins marijuana addicts [O M Ebuehi et al] Manual of Gynecology and Obstetrics 3rd Ed.] It is well known that with the effect of hormonal Packed cell volume (PCV) is determined by changes during pregnancy, plasma lipid levels measuring the height of the red cell volume in a increase. Expected elevations for triglyceride micro-hematocrit capillary filled with whole and cholesterol levels during a normal blood, after centrifugation. It is a directly gestational period usually do not exceed 332 measured value, Meanwhile hematocrit (Hct) is mg/dL and 337 mg/dL, respectively the corresponding calculated value (RBC X (corresponding 95th percentile values). MCV), PCV and Hct are interchangeable even However, elevations over the 95th percentile though PCV is slightly higher than the more values can be observed during pregnancy, and accurate Hct due to plasma trapping (between patients with levels over these expected the packed cells in a centrifuged capillary). adaptation levels can be divided into 2 groups: (1) supraphysiologic hyperlipoproteinemia In present study hemoglobin percent and packed during pregnancy and (2) extreme cell volume was significantly decreased in 2nd hyperlipoproteinemia limited to gestational and 3rd trimester of pregnancy when compared period (triglyceride level >1000 mg/dL) with the control group and same category of [Basaran A.] women who were not supplemented with iron. It is evident that the significantly low hemoglobin percent and packed cell volume (PCV) in Answer: F, T, T, T, F pregnant women is due in part to dietary iron deficiency. Therefore, iron therapy in pregnancy is helpful to maintain the hemoglobin percent and packed cell volume nearer to that of non pregnant normal women. [Wahed F et al] Total iron-binding capacity (TIBC) is a medical laboratory test which measures the blood's capacity to bind iron with transferrin. 14
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Ovulation in human become vigorous and the mesosalpinx contracts to bring the tube in more contact with the ovary a) is associated with surge of LH while the fimbria contracts rhythmically to b) is characteristically followed by the sweep over the ovarian surface. As progesterone development of secretory level rises 4-6 days after ovulation, it inhibits endometrium tubal motility. This may lead to relaxation of the c) is associated with an increased in tubal musculature to allow passage of the ovum motility of the Fallopian tube into the uterus by the action of the tubal cilia. d) is associated with a sustained fall in The effects of estrogen and progesterone on the basal body temperature oviductal motility and morphology is mediated e) followed by a rise in urinary through these steroids' receptors. The changes in pregnanetriol receptors levels are critical in determining the functional state of the oviduct.[Diaa M. EI- Mowafi, MD;Zagagig University, Egypt] The midcycle LH surge is responsible for a dramatic increase in local concentrations of In women, ovulation causes an increase of one- prostaglandins and proteolytic enzymes in the half to one degree Fahrenheit (one-quarter to follicular wall. These substances progressively one-half degree Celsius) in basal body weaken the follicular wall and ultimately allow a temperature (BBT); monitoring of BBTs is one perforation to form. Ovulation most likely way of estimating the day of ovulation. The represents a slow extrusion of the oocyte tendency of a woman to have lower through this opening in the follicle rather than a temperatures before ovulation, and higher rupture of the follicular structure [Novak temperatures afterwards, is known as a biphasic Gynecology 14 ed] pattern. Charting of this pattern may be used as a component of fertility awareness.[Wikipedia] During the normal menstrual cycle the excretion of pregnanetriol increased on the day that the excretion of oestrone and oestradiol reached a maximum during the follicular phase. Pregnanediol excretion did not begin to increase until 2 days later. The excretion of pregnanetriol reached a peak and began to decrease before that of pregnanediol. Thus the pattern of pregnanetriol excretion was different from that of the excretion of oestrogens or pregnanediol. [K. Fotherby] It is found that the cyclic change in urinary pregnanetriol excretion is variable in extent but there is a correlation between the urinary excretion of oestrogens, pregnanediol and pregnanetriol during the ovulatory cycle [Mary TP & Ian FS] Peristaltic movement of fallopian tube is primarily regulated by three intrinsic systems: the estrogen-progesterone hormonal milieu, the Answer: T, T, T, F, T adrenergic-nonadrenergic system, and prostaglandins. Before ovulation, contractions are gentle, with some individual variations in rate and pattern. At ovulation, contractions 15
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Pre eclampsia is associated with booking (1.55, 1.28 to 1.88), or maternal age ≥ A) Diabetes Mellitus 40 (1.96, 1.34 to 2.87, for multiparous women). B) Rhesus iso immunization Individual studies show that risk is also C) Urinary tract infection increased with an interval of 10 years or more D) Polyhydramnios since a previous pregnancy, autoimmune E) Twin pregnancy disease, renal disease, and chronic hypertension. [Duckitt & Harrington] Severe pre-eclampsia and eclampsia are relatively rare but serious complications of The most significant risk factors for developing pregnancy, with around 5/1000 maternities in pre-eclampsia are a history of pre-eclampsia and the UK suffering severe pre-eclampsia and 5/10 the presence of Antiphospholipid antibodies. 000 maternities suffering eclampsia. In [Duckitt & Harrington] eclampsia, the case fatality rate has been reported as 1.8% and a further 35% of women Pre-existing diabetes and a pre-pregnancy BMI experience a major complication [RCOG of ≥ 35 almost quadruple the risk; nulliparity, a Guideline No. 10(A)] family history of pre-eclampsia, and twin pregnancy almost triple the risk; and maternal Who is at risk of getting pre-eclampsia? age ≥ 40, a booking BMI of ≥ 35, and a systolic 1) First pregnancy blood pressure ≥ 130 at booking double the risk. 2) First pregnancy with a new partner [Duckitt & Harrington] 3) Aged 40 or over 4) Mother or sister had pre-eclampsia Pre-existing hypertension, renal disease, chronic during pregnancy autoimmune disease, and ≥ 10 years between 5) Pre-eclampsia in a previous pregnancy pregnancies increase the risk but it is not clear 6) Body mass index (BMI) of 35 or more by how much. [Duckitt & Harrington] (you weigh 90 kg or more) 7) Multiple pregnancy These data demonstrates a significant positive 8) Medical problem such as high blood relation with maternal age, diabetes in pressure, kidney problems and/or pregnancy, and fetal macrosomia with diabetes. polyhydramnios. Anemia during pregnancy, 9) Pregnant from egg (oocyte) donation. cesarean delivery rate, and congenital anomalies were significantly higher in the study Controlled cohort studies showed that the risk of group.[Mathew Mariam et al] pre-eclampsia is increased in women with a previous history of pre-eclampsia (relative risk Answer: T, F, F, F, T 7.19, 95% confidence interval 5.85 to 8.83) and in those with antiphospholipids antibodies (9.72, 4.34 to 21.75), pre-existing diabetes (3.56, 2.54 to 4.99), multiple (twin) pregnancy (2.93, 2.04 to 4.21), nulliparity (2.91, 1.28 to 6.61), family history (2.90, 1.70 to 4.93), raised blood pressure (diastolic ≥ 80 mm Hg) at booking (1.38, 1.01 to 1.87), raised body mass index before pregnancy (2.47, 1.66 to 3.67) or at 16
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) In normal labour It is widely accepted that prostaglandins play a central role in parturition through their actions a) endogenous oxytocin is responsible on uterine contractility and on cervical ripening. for the initiation of uterine In both human and nonhuman primates, the contraction major intrauterine sources of prostaglandins are b) there is progressive increase in the fetal membranes and the deciduas [George J. normal cortisol Haluska et al]. PGs have also been shown to c) the uterine contractions is increased play an important role in up-regulation of the by release of endogenous fetal hypothalamic-pituitary-adrenal axis, prostaglandin membrane rupture and the maintenance of d) during the first stage of labour, the uterine and placental blood flow [McKeon & maternal arterial pressure rises Challis] during each uterine contraction 13, 14-dihydro-15-keto-prostaglandin F (PGFM) levels increased a labor progressed, and reached They are four major hormonal systems involve maximal levels before placental separation had during labor which are oxytocin, endorphins, occurred. Peripheral plasma concentrations of epinephrine& Norepinephrine and prolactin. oxytocin did not change significantly at any stage of labor or 2 hours post partum. These Oxytocin causes the rhythmic uterine results suggest that prostaglandins have a role in contractions of labor, and levels peak at birth the third stage of labor, and this finding may through stimulation of stretch receptors in a have important clinical implications. [SM woman’s lower vagina as the baby descends. Sellers et al] The high levels continue after birth, culminating with the birth of the placenta, and then gradually With active labor there are clear identifiable subside. The baby also has been producing changes in arterial compliance and cardiac load oxytocin during labor, perhaps even initiating as reflected in rapid ejection times (RETs) and labor; [Dr Sarah J Buckley MD] pulse wave arrival times (PWATs), respectively. These findings are absent in Prelabour. [Edward These results give further support to the H. Hon et al] hypothesis that maternal stress leads to a reduced concentration of prolactin and increased Serial measurements of cardiac output and mean concentration of cortisol whereas relief of pain arterial pressure were performed in 15 women and maternal anxiety with meperidine lessens during the first stage of labour and at one and 24 both effects.[E. Onur et al] hours after delivery.....Over the same period basal mean arterial pressure also Maternal plasma Cortisol levels in 62 increased......There were also further increases in primiparous women rose during labour and mean blood pressure during contractions.[S C remained high for 20 minutes after delivery. Robson et al] Umbilical cord Cortisol levels were substantially lower than maternal levels. The maternal Answer: T, T, T, T, T Cortisol level was slightly lower in those who required oxytocin. This relationship between maternal Cortisol levels and the use of oxytocin was not affected by the use of epidural analgesia. The mean maternal Cortisol level rose to a lesser extent in the women who had epidural analgesia than in those who did not.[Haddad & Morris] 17
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Regarding ectopic pregnancy a) the common site is the cornu of uterus b) anaemia is due to thrombocytopenia c) hemoperitoneum results from tubal rupture d) ovary is another common site e) shock may follow tubal rupture Ectopic pregnancy refers to the implantation of a fertilized egg in a location outside of the uterine Pictures from cavity, including the fallopian tubes, cervix, http://emedicine.medscape.com/article/258768-overview ovary, cornual region of the uterus, and the abdominal cavity. This abnormally implanted The classic clinical triad of ectopic pregnancy is gestation grows and draws its blood supply from pain, amenorrhea, and vaginal bleeding (50%). the site of abnormal implantation. As the Patients may present with other symptoms gestation enlarges, it creates the potential for common to early pregnancy, including nausea, organ rupture because only the uterine cavity is breast fullness, fatigue, low abdominal pain, designed to expand and accommodate fetal heavy cramping, shoulder pain, and recent development. Ectopic pregnancy can lead to dyspareunia. massive hemorrhage, infertility, or death. 38 year-old woman presented with gynaecologic [Vicken P Sepilian] It is occur in 2% of all haemorrhage, pelvic pain and hypovolemic pregnancy shock. Without any ambiguity, the diagnosis Anything that impairs migration of embryo to was directly made during contrast enhanced the andometrial cavity will predispose a woman Multidetector Computed Tomography (MDCT). to ectopic pregnancy. this includes pelvic Massive hemoperitoneum with fresh blood clots inflammatory disease, history of prior ectopic in the hypogastric area, active free peritoneal pregnancy, History of tubal surgery and extravasation of intravascular contrast material conception after tubal ligation, Use of fertility and dramatic peripheral enhancement, - "ring of drugs or assisted reproductive technology, Use fire" sign - of an adnexal cystic structure were of an intrauterine device, Increasing age, the key signs. [Coulier B et al] smoking, Salpingitis isthmica nodosum, Finding of hemoperitoneum on ultrasound diethylstilbestrol (DES) exposure, a T-shaped examination may not be an absolute uterus, prior abdominal surgery, failure with contraindication to conservative management of progestin-only contraception, and ruptured tubal ectopic pregnancy [Bignardi & Condous] appendix. Rupture may be heralded by sudden, severe Sites and frequencies of ectopic pregnancy. By pain, followed by syncope or by symptoms and Donna M. Peretin, RN. (A) Ampullary, 80%; signs of hemorrhagic shock or peritonitis. Rapid (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) hemorrhage is more likely in ruptured cornual Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; pregnancies [The Merck Manuals] (F) Ovarian, 0.2%; (G) Cervical, 0.2%. Answer: F, F, T, F, T 18
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Endometriosis or inadequacy of ovulation. Some studies say that up to 50 percent of patients with a) commonly affects the ovaries endometriosis have some degree of ovulatory b) is usually not associated with dysfunction and this should certainly be taken infertility into account in the treatment of patients with c) intestinal obstruction is a possible endometriosis and infertility. [Endometriosis - complication if bowels are involved d) often present with dysmenorrhea The '90s Outlook] e) is primarily an acute inflammatory Usually, the pain associated with endometriosis process is right before or during the menstrual period in the initial stages; however, as the disease Endometriosis is the presence of endometrial- progresses, it may occur throughout the cycle. like tissue outside the uterine cavity, which The pain may be acute or chronic. In about half induces a chronic inflammatory reaction. It can of the patients with severe or extensive occur in various pelvic sites such as on the endometriosis, the pain is chronic all through the ovaries, fallopian tubes, vagina, cervix, or cycle which gets worse right before and during uterosacral ligaments or in the rectovaginal menstruation, and during or shortly after septum. It can also occur in distant sites intercourse. [Endometriosis - The '90s Outlook] including laparotomy scars, pleura, lung, diaphragm, kidney, spleen, gallbladder, nasal Endometriosis may invade the rectovaginal mucosa, spinal canal, stomach, and breast. [Ami septum and the anterior rectal wall. It may also K Davé, MD] involve the upper rectum and sigmoid colon, infiltrating the muscularis. Cyclical rectal Ovaries is the most common site for bleeding (hematochezia) is pathognomonic of implantation of the endometrial cell (up to 75%) endometriosis. However, transmural bowel because 1) through the theory of retrograde involvement by endometriosis remains a rarity. menstruation, ovaries are adjacent to the opening The ileum, appendix, and cecum may also be of the tube in the pelvic area and that location involved, leading to intestinal obstruction. alone will make the ovaries more prone to be Cicatrization as a consequence of endometriosis contaminated with the regurgitated menstrual may lead to symptoms of obstruction even in flow.2) ovaries have the highest level of steroid postmenopausal women. [Ami K Davé, MD] hormone compared to any other organ and hence they represent an ideal environment for implantation and growth of the endometrial Answer: T, F, T, T, F tissue. Infertility in endometriosis are due to 1) increase level of prostaglandin production which is interfering with sperm-ovum interaction, embryo growth, interfering with sperm motility, and interfering with the function of some central nervous system areas that are responsible for control of reproduction and 2) The presence of endometrial tissue in the pelvic and peritoneal cavities will cause some degree of abnormality 19
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question1: Which of the following statements alone have been described. The Cochrane are true regarding the pharmacological induction Database indicates that with the available of fetal respiratory maturity? evidence, antenatal TRH cannot be recommended for clinical practice at the present a) Maternally administered thyroid releasing time. Adverse maternal side-effects were hormone (TRH) alone may cause lung significant for women receiving antenatal TRH maturation. and these included hypertensive episodes. b) Antenatal TRH has no maternal side-effects. c) Treatment with antenatal corticosteriods Q11: Beta sympathomimetic drugs: between 28 and 32 weeks reduces the incidence a) Increase maternal stroke volume. of fetal intraventricular haemorrhage. b) Decrease fetal heart rate. d) The use of antenatal cortiosteriods between c) Increase maternal bowel motility. 28 and 32 weeks with pre-labour ruptured d) Decrease intracellular potassium in maternal membranes is associated with a significant cells. increase in neonatal infection. e) Decrease maternal urinary output. e) Antenatal corticosteriods may cause long- term cognitive disabilities in infants treated Answer: T, F,F,F,T prenatally. Beta adrenergic agonists, currently the most a) False widely used tocolytic drugs in the UK, include b) False ritodrine, salbutamol and terbutaline. These c) True pharmacological agents act via Beta-1 and Beta- d) False 2 adrenergic receptors. Beta-I receptor responses e) False include an increase in maternal heart rate and stroke volume, a decrease in bowel motility and The meta-analysis of 36 prospective studies an increase in metabolic lipolysis. The Beta-2 indicate that treatment between 28 and 32 weeks adrenergic response includes an increase in renal with antenatal corticosteriods prior to the onset renin production and a decrease in urinary of premature labour resulted in a substantial output. reduction in the incidence of respiratory distress syndrome. The reduction in respiratory Question, answer and discussion are taken from morbidity was associated with overall reductions Self-assessment questions: Premature labour, by in the incidence of neonatal intraventricular M.Kilby, Current Obstetrics & Gynaecology haemorrhage, necrotizing enterocolitis and early (1996) volume 6 issue 3 neonatal death. There was no strong evidence of any adverseeffects of corticosteroids in these trials. Long-term follow-up of children in several of these studies indicated no adverse effect on growth, physical development or cognitive skills. Trials investigating the improved efficacy of antenatal TRH given with antenatal corticosteriods, as compared to corticosteriods 20
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 2: The following are contraindications significantly reduces intraventricular to tocolytic inhibition of preterm labour: haemorrhage. d) Antibiotic administration significantly a) Abruptio-placenta. reduces maternal infective morbidity in b) Chorioamnionitis. prelabour ruptured membranes. c) Pre-labour ruptured membranes. e) Intrapartum antibiotic therapy significantly d) Severe pregnancy induced hypertension. reduces fetal infective morbidity in prelabour e) Mild intrauterine growth restriction. ruptured membranes. a) True a) True b) False b) True c) False c) False d) True d) True e) True e) False Analgesia and anaesthesia of choice for preterm Antepartum haemorrhage of whatever cause is a labour and delivery are not well established. contraindication to the suppression of preterm Epidural anaesthesia may well have benefits labour as is intrauterine infection and severe especially in the management of the first and pregnancy induced hypertension which may be second stage of a preterm vaginal breech life threatening to the mother. In prelabour delivery. However, such a choice of analgesia is rupture of membranes, although there is no contraindicated in chorioamnionitis. Although absolute contraindication to tocolysis as long as both an elective episiotomy and low forceps there is no overt evidence of delivery have been historically discussed as chorioamnionitis,there is little evidence to useful in reducing the length of second stage and suggest that tocolysis significantly improves protecting the premature fetus at delivery, there perinatal mortality. In selected cases of mild are no data to support this as a potential benefit intrauterine growth restriction in which the fetus to the fetus. is not compromised, it may be beneficial to suppress labour to allow antenatal Administration of antibiotics prophylactically to corticosteriods to be administered. women with prelabour ruptured membranes preterm delays delivery and reduces both However, any evidence of fetal compromise maternal and neonatal infection. No effect has should lead to prompt delivery of the fetus. yet been shown demonstrating an improvement in perinatal mortality. In particular, in women known to be carrying Group B Streptococci, Question3: During a preterm delivery: intrapartum antibiotics should be adopted as standard care. a) Epidural anaesthesia is contraindicated if chorioamnionitis is present. Question, answer and discussion are taken from b) Elective episiotomy is advised for all vaginal Self-assessment questions: Premature labour, by deliveries. M.Kilby, Current Obstetrics & Gynaecology c) The elective use of low outlet forceps delivery (1996) volume 6 issue 3 21
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Q4: The following drugs significantly reduce There is no evidence that corticosteriod preterm labour when administered: administration suppresses preterm labour and there is anecdotal evidence indicating that intra- a) Ritodrine. amniotic injection of betamethasone may b) Indomethacin. actually be used to induce labour. c) Nifedipine. d) Pethidine. Q5: The following are useful predictors of e) Dexamethasone. preterm labour: a) A previous history of preterm labour. ANSWER 4 b) Maternal plasma oestradiol concentration 14 a) True days prior to onset of labour. b) False c) Fetal fibronectin. c) False d) Multiple pregnancy. d) False e) Uterine anomaly. e) False Answer: T, F, T, T, T Although beta-sympatho-mimetics themselves may not have beneficial effects for the fetus they The background rate of preterm labour in the are effective at postponing delivery, especially UK is approximately 7%. If a patient has had a for short intervals of up to 24 h. This suggests previous preterm labour this rises to between 14 that they may have a place if, for instance, and 18%. A uterine anomaly is proven in corticosteriods could be administered to promote between 5 and 16% of all preterm deliveries. pulmonary maturity. However, injudicious use Multiple pregnancy is associated with preterm of corticosteriods and beta-sympathomimetics delivery and this is paticularly true with have been reported to precipitate acute monochorionic placentation. The majority of pulmonary oedema. The only statistically biochemical prediction indices, including serum significant differences in prospective trials oestradiol concentrations, have a poor predictive comparing the use of calcium antagonists with index at detecting preterm delivery. Fetal beta-sympatho-mimetics have indicated that fibronectin, a component of the extra cellular there were fewer neonates of less than 2.5 kg matrix in the cervix, has been shown both in and there were more admissions to neonatal' cross sectional studies, and more recently in intensive care after the treatment with calcium longitudinal studies, to have a positive predictive antagonists. At the present time, only a small value of preterm delivery in high risk patients of number of prospective studies are reported. 46%. Meta-analysis from the Cochrane Database does not support the use of calcium antagonists or Question, answer and discussion are taken from magnesium sulphate in preference to beta- Self-assessment questions: Premature labour, by sympatho-mimetics in the suppression of M.Kilby, Current Obstetrics & Gynaecology preterm labour. (1996) volume 6 issue 3 Pethidine may suppress both fetal and maternal respiration and has no proven benefit in the management of preterm labour. 22
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Q6: Regarding the lecithin-sphingomyelin ratio: c) True a) This test is carried out on amniotic fluid. d) True b) Sphingomyelin is a general membrane lipid. e) False c) The ratio for normal pregnancies is greater than 0.5 at 20 weeks. Cervical incompetence is a dysfunction in the d) If the ratio is less than 2 there is less than a integrity ofthe internal cervical os. It is 10% chance of the baby developing respiratory characterised by painless cervical dilatation in distress syndrome. the mid second trimester. With regard to e) Lecithin is produced by type II pneumocytes. aetiology, several factors are important. In-utero exposure of Diethylstilboestrol carries a 45% Answer: T, T, F, F, T risk of pregnancy loss due to cervical incompetence. Acquired factors include cervical The L/S ratio was introduced by Gluck in 1971. trauma. This includes over zealous mechanical Amniocentesis allows the collection of fluid and dilatation of the cervix prior to diagnostic the results are expressed as the ratio of lecithin curettage. Loop excision of the transformation (phosphatylcholine) fraction enriched by cold zone is rarely associated with cervical acetone precipitation. The sphingomyelin is used incompetence. With contemporary cervical as a control because amniotic fluid volume cerclage, the majority of patients have their changes during gestation cannot be accurately operation during pregnancy. The classical measured clinically. In normal pregnancies the Shirodkar's suture and McDonald's suture have L/S ratio is less than 0.5 at 20 weeks. The value approximately the same success rate in of 2.0 indicates a low risk of respiratory distress prevention of premature labour. Ritodrine alone syndrome at any point in gestation. The L/S ratio will not stop the contractions due to cervical is not reliable if amniotic fluid is heavily incompetence and there is little prospective contaminated with blood or meconium. Lecithin evidence to confirm that ritodrine therapy has a and other phosphatyl-lipids are produced by the role to play perioperatively in cervical cerclage. type II pneumocytes within the lungs. Question, answer and discussion are taken from Q7: With cervical incompetence: Self-assessment questions: Premature labour, by a) In-utero exposure to Diethylstilboestrol (DES) M.Kilby, Current Obstetrics & Gynaecology is a causative factor. (1996) volume 6 issue 3 b) A history of loop diathermy excision of the transformation zone of the cervix for treatment of CIN is a common association. c) Shirodkar and McDonald cerclage techniques carry the same success rates. d) When the amniotic membranes are ruptured then cervical cerclage is contraindicated. e) This may be treated by oral Ritodrine. ANSWER 7 a) True b) False 23
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) QUESTION 8: In preterm labour complicated syncytio-trophoblast of patients with preterm by a low-grade infection: labour. a) Bacterial phospholipases cause a direct release of arachidonic acid from the amnion and Q9: Relaxin: decidual cells. a) Has a stimulatory effect on the myometrium. b) Bacterial lipopolysaccharides stimulate b) Has an inhibitory effect that is more rapid increased production of interleukin-I (1L-I) from than progesterone. amnion and decidual cells. c) Affects frequency modulation of uterine c) IL-1 stimulates the decidual production of IL8 contractions. d) Corticotrophin releasing hormone (CRH) d) Elevates uterine cyclic AMP concentrations. does not stimulate prostaglandin production e) Stimulates prostocyclin production by the from decidual cells. myometrium. e) Annexin production by the trophoblast and decidua decrease with the onset of labour. Answer: F, T, T, T, T ANSWER: T, T, T, F, T Experimental animal models have suggested that Relaxin has an inhibitory effect on myometrial Approximately 30% of all preterm labours are activity. This is separate from that induced by associated with some mild chorioamnionitis. progesterone. The inhibitory effect of Relaxin is Bacterial phospholipases directly release more rapid in onset than that of progesterone. arachidonic acid which are precusors of many Although spontaneous myometrial contractility eieosanoids from decidual cells. Also is suppressed, sensitivity to oxytocin is lipopolysaccharides stimulate decidual cells to maintained and its primary effects are one of increase cytokines such as IL-I and tumour frequency modulation of contractions. Relaxin necrosis factor from amnion and decidual cells. also elevates uterine cyclic AMP production in The cytokines are elevated in the amniotic fluid common with other uterine relaxants. It is from patients with preterm labour and infection unknown whether Relaxin has its effect directly and may secondarily release other cytokines on the myometrium, but experimental evidence such as IL-8 which are chemotaxtic peptides for indicates that cultured myometriai cells, when neutrophils and T-cells. Cortieotrophin releasing stimulated with Relaxin, produce prostacyclin. hormone is produced by the syncytio-trophoblast and stimulates prostaglandin production from cultured decidual cells. The prostaglandins Question, answer and discussion are taken from produced may have a direct effect upon the Self-assessment questions: Premature labour, by myometrium which is adjacent to the chorion, M.Kilby, Current Obstetrics & Gynaecology amnion and decidual cells.The annexins are (1996) volume 6 issue 3 substrates for tyrosine kinases and influence phospholipase A2 production and, therefore, may increase myometrial intracellular free calcium concentration. It is believed that they bind to phospholipids preventing phospholipase A2 from gaining access to its substrate. Both annexin protein and mRNA are decreased in the 24
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Q7: which of the following statements Q5: Concerning placenta praevia, which of the concerning placental abruption is/are true: following statements is/are true: a) The incidence of placenta praevia is 1 in a) In western society placental abruption is 5000. commonly associated with poor nutrition. b) Placenta praevia is more common in b) Placental abruption can occur in association Caucasian women. with external cephalic version. c) Owing to the position of the placenta in c) Placental abruption is more common with placenta praevia, prolapsed cord is much less multiple pregnancy. likely. d) Placental abruption is more common with a d) Previous lower segment Caesarean section is history of previous abruption. a risk factor for placenta praevia. e) Postpartum haemorrhage is a common e) There is no association between the incidence complication of placental abruption, which often of placenta praevia and maternal age. requires hysterectomy to control the bleeding. a) False. The true incidence is 0.3-1.0%. a) False. Poor nutrition has previously been b) False. Placenta praevia is more common in reported as being associated with placental black women. abruption, but within the western world this is c) False. Prolapsed cord is up to three times now a rare finding. more likely with placenta praevia. b) True. External cephalic version is associated d) True. with placental abruption, especially if the e) False. More common in older women and manoeuvre is carried out under general multiparous women. anaesthetic. Presumably, if the manoeuvre is carried out under general anaesthetic, the Question, answer and discussion are taken from operator exerts more 'energy' into the procedure Self-assessment questions: The Placenta, by as she/he does not have the benefit of S.Smith, Current Obstetrics & Gynaecology appreciating the maternal perception of (1998) volume 8 issue 1 discomfort. c) True. d) True. e) False. Postpartum haemorrhage is a common sequel of placental abruption, but only rarely is hysterectomy required for its control. Senior obstetric input is mandatory in the management of postpartum haemorrhage under these circumstances, as it is of the utmost importance that a hysterectomy is performed neither too early nor too late. 25
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 4: Anti phospholipid syndrome: Question, answer and discussion are taken from a) The mechanism of action of antiphospholipid Self-assessment questions: Recurrent Abortion antibodies is unknown. by H.J.A. Carp, Current Obstetrics & b) In the presence of antiphospholipid Gynaecology (1999) volume 9 issue 1 antibodies, pregnancy losses occur with equal frequency in all three trimesters. c) The treatment of choice is with steroids and aspirin. d) Anticardiolipin antibody is a very specific marker of pregnancy loss. Answer: T, F, F, F, T Various pathways have been suggested to explain the action of antiphospholipid antibodies: coagulation in small vessels leading to the placenta, vasoconstriction owing to inhibition of prostacycline, and disruption of the phospholipid intracellular bridges between elements of trophoblast. In the presence of antiphospholipid antibodies, approximately 60% of pregnancy losses will be in the first trimester, but there is a heavy preponderance (40%) of second- and third- trimester losses. Various treatment regimens have been used. At present heparin (or low- molecular-weight heparin) and low-dose aspirin seems to be the most effective regimen. Steroids are no longer widely used owing to the possible side effects. However, the issue is far from settled. Anticardiolipin antibody is a very non-specific marker of pregnancy loss. It can be raised after viral infections etc. It is only of real significance if a high level is present, or if thromboses and/or other autoantibodies are present. Treatment of thrombophilias, has mainly been found to be effective in cases of late pregnancy loss rather in first trimester miscarriage. 26
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 1: Regarding the diagnosis and Question 2: Concerning the epidemiology of classification of hypertension in pregnancy: preeclampsia: a) The phase 5 Korotkoff sound is more reliably a) The incidence of preeclampsia in primigravid detected in pregnancy than the phase 4 sound. mothers in the UK is 1%. b) ‘Significant proteinuria’ is denoted by the b) Preeclampsia is more common in the black presence of 500 mg of protein in a 24 h population. collection. c) The incidence of preeclampsia is higher in c) The combination of hypertension and triploid pregnancy. proteinuria always signifies the presence of d) The incidence of preeclampsia is higher in preeclampsia. lower socio-economic groups. d) The presence of oedema is a useful diagnostic e) The risk of developing preeclampsia is sign. decreased in a pregnancy complicated by e) Preeclampsia never presents before 20 weeks’ placenta praevia. gestation. Answer: F, T, T, T, T Answer: T, F, F, F, F The incidence of pre-eclampsia in privigravid women in the UK is between 7 and 10%. Some Pre-eclampsia is generally defined as ethnic groups appear to be at increased risk and hypertension of at least 140/90 mmHg measured in particular the black population is said to have on at least two separate occasions and arising de an increased risk. It is, however, difficult to novo after the 20 weeks’ gestation, in the separate this risk from other predisposing factors presence of 300 mg of protein in a 24 h such as parity, obesity and an inherited tendency collection of urine.While the rapid appearance of to essential hypertension. There is a well- oedema (particularly when it involves the face) documented relationship between may herald the advent of pre-eclampsia, this hyperplacentosis and the development of pre- sign is not part of the diagnostic pattern and, eclampsia; thus, multiple, molar and triploid indeed, is present in two-thirds of normal pregnancy are all associated with an increased pregnant women. The combination of incidence of pre-eclampsia. Placenta praevia is hypertension and proteinuria does not always traditionally said to confer a decreased risk of signify preeclampsia. Renal disease often developing pre-eclampsia and certainly the presents with proteinuria and may or may not be incidence of one is lower in the presence of the accompanied by hypertension. This is the more other. However, the protective effect of placenta likely diagnosis if the presentation is before 20 praevia may merely reflect the increased weeks’ gestation. However, a hydatidiform mole incidence of earlier delivery associated with this can rarely present in the first trimester with condition. A higher incidence of pre-eclampsia preeclampsia. The measurement of blood has been reported in lower socio-economic pressure in pregnancy has long been the subject groups. This difference most likely reflects of much controversy. The evidence at present differences in age, parity, levels of antenatal suggests that Korotkoff phase V sound is the care and smoking. most reproducible endpoint in pregnancy. Question, answer and discussion are taken from Self-assessment questions: The pathogenesis of pre- eclampsia, by L.C. Kenny, Current Obstetrics & Gynaecology (1999) volume 9 issue 4 27
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 3: Pre-eclampsia is associated with: d) Decreased maternal levels of vitamin E. a) An increase in the maternal platelet count. e) An increase in the maternal ratio of b) An increase in the maternal mean platelet prostacyclin to lipid peroxides. volume. c) A decrease in maternal thromboxane Answer: F, F, T, T, F production. d) An increase in circulating maternal levels of There are many emerging similarities between b- the condition of atherosclerosis and pre- thromboglobulin. eclampsia. The two conditions share a similar e) An increase in platelet adhesion. lipid profile; low maternal maternal serum concentrations of HDL cholesterol, raised Answer: F, T, T, T, T concentrations of serum triglycerides, and increased formation of small, dense LDL Longitudinal analysis of the peripheral platelet particles. Furthermore, many of the risk factors count in pregnancy has revealed that pre- for the two disorders are similar; obesity, black eclampsia is associated with thrombocytopaenia. race, lipid abnormalities, insulin resistance and As a result the mean platelet volume has been raised homocysteine concentrations all reported to increase in preeclampsia. The predispose to atherosclerosis and pre-eclampsia. population of larger platelets in this condition These similarities and the generally accepted may be explained by increased consumption, role of oxidative stress in atherosclerosis, leading to an increase in the proportion of support the emerging concept that reduced immature, larger platelets in the peripheral placental perfusion interacts with maternal circulation. There is substantial evidence of factors to generate oxidative stress in pre- platelet activation in pre-eclampsia. Circulating eclampsia. The most important lipid-soluble levels of factors stored within platelets reflect anti-oxidant in human plasma is vitamin E. In platelet activation Several studies have reported normal pregnancy plasma levels of prostacyclin increased levels of the platelet granule protein b- and vitamin E increase, whereas thromboxane thromboglobulin in women with pre-eclampsia levels are decreased and serum levels of lipid as compared with normal pregnant controls and peroxide remain relatively constant. In pre- this elevation precedes the development of eclampsia, there is an imbalance in the clinical signs by at least 4 weeks. Thromboxane thromboxane to prostacyclin ratio with elevated production, as measured by urinary metabolites, maternal levels of lipid peroxides and decreased is increased in women with pre-eclampsia. This levels of vitamin E. increase in thromboxane production leads to an increase in platelet adhesion and aggregation Question, answer and discussion are taken from . Self-assessment questions: The pathogenesis of Question 4: Pre-eclampsia is associated with: pre-eclampsia, by L.C. Kenny, Current a) Increased maternal serum concentrations of Obstetrics & Gynaecology (1999) volume 9 highdensity issue 4 lipoprotein cholesterol. b) Decreased maternal concentrations of serum triglycerides. c) Increased maternal serum homocysteine concentrations. 28
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 5: Maternal cardiovascular changes Question 8: Liver function: associated with preeclampsia include: a) Normal pregnancy is associated with a a) An increase in maternal plasma volume. decrease in maternal alkaline phosphatase. b) A decrease in the maternal haematocrit. b) During normal pregnancy maternal levels of c) A rise in the maternal plasma oncotic alanine transaminase (ALT) and aspartate pressure. transaminase (AST) fall. d) An exaggerated maternal arterial response to c) The principal pathological finding in the liver angiotensin II. in pre-eclampsia comprises of periportal fibrin e) An exaggerated maternal arterial response to deposition, haemorrhage and hepatocellular bradykinin. necrosis. d) An increase in maternal levels of Answer: F, F, F, T, F transaminases in pre-eclampsia reflects hepatocellular damage. In normal pregnancy, plasma volume increases e) Lactate dehydrogenase levels are a reliable by about 40% and leads to a fall in the marker of haemolysis. haematocrit. The traditional and most widely accepted model of the haemodynamic Answer: F, T, T, T, T characteristics of pre-eclampsia is one of a relatively reduced plasma volume, The relative haemodilution of normal pregnancy vasoconstriction and resulting hypoperfusion of leads to an approximate 20% reduction in the organs such as the placenta and kidneys. Thus, level of circulating liver enzymes in pregnancy, the haematocrit in pre-eclampsia is typically with the exception of alkaline phosphatase, increased. The reduced plasma volume which normally increases with increasing associated with pre-eclampsia reflects the shift gestation. Abnormal liver function in pre- of fluid into the extravascular space across leaky eclampsia reflects liver dysfunction occurring as capillary membranes. Increasing proteinuria in a result of vasoconstriction of the hepatic bed. pre-eclampsia leads to marked Elevated levels of transaminases reflect hypoalbuminaemia and a fall in plasma oncotic heptocellular necrosis. Haemolysis may increase pressure. In normal pregnancy, a relative arterial asparate transaminase, but will refractoriness to angiotensin II develops. This disproportionately increase lactate can be detected as early as 8 weeks and is dehydrogenase levels with serial measurements maximal at term. In women who develop pre- providing a reliable indicator of the degree of eclampsia, the pressor response to angiotensin II haemolysis present. The histopathology of the remains relatively greater than in normal liver in pre-eclampsia comprises peri-portal women. Ex vivo studies have demonstrated that fibrin deposition, haemorrhage and heptocellular endothelium- dependent relaxation to numerous necrosis. It is thought that segmental hepatic substances, including bradykinin, is impaired in vasospasm leads to localized coagulopathy arteries isolated from women with pre- allowing fibrin deposition while endothelial and eclampsia. The combination of these two liver-cell necrosis produce haemorrhage. findings may contribute to the relative vasoconstriction associated with pre-eclampsia. Question, answer and discussion are taken from Self-assessment questions: The pathogenesis of pre- eclampsia, by L.C. Kenny, Current Obstetrics & Gynaecology (1999) volume 9 issue 4 29
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 7: Changes in the coagulation system levels of fibrinopeptides in women with pre- in pre-eclampsia include: eclampsia as compared with normal pregnant a) An increase in maternal levels of antithrombin women. Anti-thrombin III is produced by the III. liver and is an important inhibitor of b) An increase in maternal levels of factor VIII coagulation. Levels are unchanged in normal related antigen. pregnancy but are decreased in the majority of c) A decrease in maternal levels of women with pre-eclampsia. The decline in anti- fibrinopeptide A. thrombin III activity is thought to result from d) A decrease in maternal levels of protein C. increased consumption and has been reported to e) An increase in maternal levels of protein S. precede the development of clinical signs by as much as 13 weeks. Protein C is a potent Answer: F, T, T, T, F inhibitor of activated factor V and VIII, and is an activator of fibrinolysis. Levels are In normal pregnancy, the overall state of the substantially reduced in pre-eclampsia. coagulation system is one of activation. Activated protein C resistance resulting from a Evidence for this comes from studies which mutation in coagulation factor V has now report increased concentrations of clotting emerged as a leading cause of thrombosis in factors and raised levels of highmolecular- pregnancy and a recent report links the HELLP weight fibrinogen complexes. Sensitive studies syndrome with factor V mutation. Protein S of coagulation factors provide evidence that serves as a cofactor for activated protein C. pre-eclampsia accentuates a state of Levels of protein S in pregnancy may decrease hypercoagulability already created in normal to levels similar to those with congenital protein pregnancy. During normal pregnancy, the levels S deficiency. Furthermore, levels of protein S of factor VIII coagulation activity and factor- decrease further in women with pre-eclampsia, VIII-related antigen show a proportional rise as compared with normal pregnant controls. and, thus, their ratio remains constant. In pre- eclampsia, there is an early rise in the factor- Question, answer and discussion are taken from VIII-related antigen:coagulation activity ratio Self-assessment questions: The pathogenesis of which correlates with the severity of the disease. pre-eclampsia, by L.C. Kenny, Current This increased ratio is a result of increased Obstetrics & Gynaecology (1999) volume 9 levels of factor- VIII-related antigen. This issue 4 substance is synthesized by endothelial cells and megakaryocytes and is released by aggregating platelets. It, therefore, seems probable that the increase in circulating levels is a result of endothelial damage and platelet aggregation. The action of thrombin on fibrinogen is a crucial step in the coagulation cascade. Thrombin cleaves two pairs of peptides, fibrinopeptides A and B from fibrinogen to produce fibrin. Fibrinopeptide concentrations are considered to be the best markers of accelerated thrombosis. The majority of studies have reported increased 30
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 6: Concerning renal function in pre- Question 10: Eclampsia: eclampsia: a) Is an absolute indication for delivery. a) The proteinuria of pre-eclampsia results b) Complicates 15 in 10 000 maternities in the mainly from a loss of intermediate weight UK. proteins. c) Can occur in the absence of significant b) The rate of increase in the amount of hypertension. proteinuria is both a sensitive and specific d) Leads to death most commonly by cerebral predictor of maternal outcome. haemorrhage. c) Glomerular filtration deteriorates first and is e) Can result in cortical blindness. followed by a deterioration in tubular function. d) Hyperuricaemia generally develops before Answer: T, F, T, T, T proteinuria. e) Glomerular endotheliosis is present in all The principal and clinically most disturbing cases of established pre-eclampsia. cerebral sequelae of pre-eclampsia are eclamptic convulsions. Eclampsia is defined as the Answer: T, F, F, T, F occurrence of one or more convulsions, not attributable to other cerebral conditions in a Renal function deteriorates in pre-eclampsia in patient with pre-eclampsia. It should be noted, two stages. The first stage involves impairment however, that eclampsia can rarely present in the of tubular function and this is reflected by a absence of significant hypertension. The reduction in uricacid clearance and the reported incidence varies geographically; figures development of hyperuricaemia. Later, from the UK suggest the incidence to be 4.9/10 glomerular filtration becomes impaired and 000 maternities. Eclampsia is thought to result proteinuria of intermediate selectivity develops. from focal cerebral vasospasm and An increasing plasma urate is thus an early sign hypoperfusion leading to abnormal electrical in the evolution of pre-eclampsia and proteinuria activity and seizures. The lack of any is conventionally recognized as a late sign. The neurological deficit following uncomplicated presence of proteinuria heralds a poorer eclampsia supports the concept that vasospasm prognosis for the fetus, but the actual amount of precipitates the convulsions. This is in contrast proteinuria and the rate of increase have been to convulsions caused by thrombosis and found to be poor predictors of maternal or haemorrhage, as is often the case in postpartum perinatal outcome. Renal biopsy in established eclampsia, when significant cortical damage cases of pre-eclampsia demonstrates a may occur, including the development of characteristic non-inflammatory lesion cortical blindness. The commonest cause of commonly referred to as glomerular death in women dying with eclampsia is cerebral endotheliosis. This primarily involves a haemorrhage. combination of swelling of the glomerular endothelial cells and sub-endothelial ‘fibrinoid’ Question, answer and discussion are taken from deposits, which encroach on and occlude the Self-assessment questions: The pathogenesis of pre- capillary lumen. This lesion is characteristic, but eclampsia, by L.C. Kenny, Current Obstetrics & not pathognomonic of pre-eclampsia, as normal Gynaecology (1999) volume 9 issue 4 renal pathology has been described in some cases. 31
    • In Pursuit to Excel MCQ Exam for Professional III Examination (MCQ) Question 9: Regarding drug treatment in pre- intrauterine growth retardation, oliguria, renal eclampsia: failure and neonatal anuria in late pregnancy, and are thus contraindicated in pregnancy. a) Angiotensin-converting enzyme inhibitors are not associated with serious side effects in the Question, answer and discussion are taken from antenatal period. Self-assessment questions: The pathogenesis of pre- b) Peak plasma levels of methyldopa are reached eclampsia, by L.C. Kenny, Current Obstetrics & 24 h after an oral dose. Gynaecology (1999) volume 9 issue 4 c) Labetolol is a combined a- and b- adrenoceptor blocker. d) Nifedipine can be safely used concomitantly with magnesium sulphate. e) Hydrallazine has no effect on uteroplacental blood flow. Answer: F, F, T, F, F The hypertension of pre-eclampsia is caused by increased peripheral resistance and drug treatment is directed towards relieving this without compromising cardiac output. Methyldopa has been extensively studied in pregnancy and is the agent of choice for chronic blood-pressure control. It reduces systemic vascular resistance without significantly altering heart rate or cardiac output. Peak plasma concentrations are reached after 2 h, although the maximum fall in arterial pressure occurs 4–8 h after an oral dose. Labetolol is a combined a- and b-adrenoreceptor blocker. The a1 blockade induces vasodilatation with little change in the cardiac output. Nifedipine can be used for acute or chronic treatment and appears to be safe in pregnancy. It lowers systemic vascular resistance and improves cardiac output without adversely comprising uteroplacental blood flow. It is, however, best avoided in combination with magnesium sulphate as profound hypotension may result. Hydrallazine is used for the acute management of hypertensive crises. It too lowers systemic vascular resistance, but it has a variable effect on uteroplacental blood flow and can occasionally lead to fetal distress. Angiotensin- converting enzyme inhibitors are associated with 32