1 Maternal and perinatal mortality: the confidential enquiry
Perinatal mortality is used as a measure of antenatal care.
a) Define perinatal mortality.
b) List three of the main causes of perinatal mortality.
c) Name two drugs that may have contributed to the fall in the perinatal mortality rate.
d) List the classification systems used by the Confidential Enquiry into Maternal and Child Health (CEMACH).
2 Conception, implantation and embryology
c
d
a
b
20 mm
Pre-ovulatory follicle
Figure 4.1 Adapted from Baker PN (ed) Obstetrics By Ten Teachers, 18th edition.
London: Edward Arnold 2006.Objective structured clinical examination questions 45
a) Name the four structures labelled a, b, c and d.
b) Describe the process of meiosis.
c) Describe how pregnancy can be diagnosed and how it can be confirmed to be intrauterine.
3 Physiological changes in pregnancy
A 25-year-old woman in her first pregnancy attends a booking clinic at 12 weeks’ gestation.
a) Describe the cardiovascular changes that have occurred.
b) Outline the physiological function and changes that have occurred in human chorionic gonadotrophin (hCG).
c) This woman goes on to have a normal vaginal delivery at term. She opts to breast feed the baby. Outline the
physiological changes that occur within the mother with breast feeding.
4 Normal fetal development
A 22-year-old is admitted to the labour ward at 27 weeks pregnant. She is complaining of regular painful tightening. She describes having a mucus show the previous night, but denies any history of preterm rupture of
membranes. On examination, she is distressed and requiring analgesia. Vaginal examination reveals that she is
fully dilated with bulging forewaters. She delivers a live female infant that weighs 800 g.
a) Describe the physiological changes that occur in the cardiovascular circulation with birth.
b) Describe the physiological changes that occur in the respiratory system with birth.
c) What are the four main risks to the baby of premature delivery and how can these be minimized?
5 Antenatal care
A 30-year-old woman attends a routine booking clinic.
a) Take a booking history.
b) Explain the tests and scans that she will have during pregnancy assuming she has no risk factors.
6 Antenatal imaging and fetal assessment
a) What is this investigation?
b) What is this picture showing?
c) What is RI?
d) What waveforms are abnormal?
e) What does it predict?
Figure 4.246 Obstetrics
7 Prenatal diagnosis
A couple arrive in your antenatal clinic. They are both known to be carriers of the common mutation of the cystic fibrosis.
a) What are their chances of having a baby affected by cystic fibrosis?
b) What is the commonest mutation of the gene?
c) How can the diagnosis be made prenatally?
d) How early may the prenatal diagnostic test be made?
8 Second trimester miscarriage
Miss M is a 22-year-old single parent. She has had two previous miscarriages from two different partners. Her
last pregnancy ended in a miscarriage at 18 weeks after being admitted with backache. She is now 22 weeks pregnant by her dating scan. She has been admitted to the labour ward with low back pain and a mucus loss.
a) What is the likely diagnosis?
b) What are the key points in the examination and investigation?
c) Miss M then starts to have painful regular contractions. How would you manage her labour?
9 Antenatal obstetric complications
The community midwife refers a 25-year-old woman in her second pregnancy to an antenatal clinic: clinically
examination has shown the fetus to be in the breech position. An ultrasound scan confirms an extended breech
presentation.You are asked to counsel this woman as to the possible options that are available for her management.
10 Twins and higher-order multiple gestations
A 32-year-old woman attends your booking clinic. She has just had a dating scan that confirms the presence of
twins. The ultrasound report demonstrates that these are monochorionic diamniotic twins.
a) Define monozygotic twins.
b) Describe how chorionicity is determined by ultrasound scan.
c) Outline the risk of multiple pregnancy.
d) Outline the specific risks of monochorionic twins?
11 Disorders of placentation
An 18-year-old in her first pregnancy is admitted to the antenatal ward for observation. She is 26 weeks pregnant. Consider the following blood results:
Blood test 24 weeks 26 weeks
Serum urate (μmol/L) 150 230
24-hour urinary protein (g/save) 0.6 3.5
Platelet count 230 120
a) What is the most likely diagnosis?
b) List three maternal signs that would help guide our management.
c) What are three possible maternal complications of this disease if its remains untreated?
d) What investigations would you perform on the fetus?
e) How should this woman by managed?Objective structured clinical examination questions 47
12 Preterm labour
A 26-year-old Caucasian woman presented at 25 weeks’ gestation in her first pregnancy. She gives a good history
of ruptured membranes 3 hours prior to admission. On clinical examination, no uterine activity was noted. The
maternal blood pressure was 140/75 mmHg, the temperature was 37°C and the pulse rate was 80 beats per minute.
An aseptic speculum examination revealed clear fluid in the vagina.
a) Outline four investigations that would be useful in the further management of this patient with confirmed
ruptured fetal membranes.
b) At what gestational age can a fetus survive outside the womb?
c) With regard to women delivering after preterm rupture of the fetal membranes, what postnatal complications
are important?
d) How would you advise this woman in her next pregnancy?
13 Medical diseases of pregnancy
Mrs MV is known to have pre-existing cardiac disease.
a) What is the most common acquired cardiac lesion?
b) What are the effects of cardiac disease on pregnancy?
c) How should her labour be managed?
14 Perinatal infections
A 35-year-old woman comes to a booking clinic. She has had a routine human immunodeficiency virus (HIV) test
at her booking visit; this has shown her to be HIV positive. She has been counselled regarding the diagnosis of HIV.
a) What type of virus is HIV?
b) Name two types of cell that have CD4 receptors.
c) Outline two strategies of treatment that are available.
d) What interventions have been shown to reduce the transmission of HIV to the baby?48 Obstetrics
15 Labour
You are asked to examine the following chart.
a) What is the chart called?
b) Describe the chart in front of you.
c) Describe the stages of labour.
d) What does abnormal labour pattern does the diagram illustrate?
e) How would you manage this obstetric problem?
16 Operative interventions in obstetrics
The following illustration shows an instrument that will be seen on any labour ward.
Figure 4.4
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
CERVIX
DESCENT
X (Red)
Liquor
Moulding
Affix Identity Label
Name:
30-08-2002 O
01-09-2002 Rh+Ve
D.O.B: 07-01-79
Membranes Ruptured Spontaneous
Show First
Noted
Date ......................................
E D D .................................... Blood Group ..............................
Parity .........................................
Date: 29-08-02 Onset of Labour Contractions
Date: 30-08-02
Time: 00.30 Time: 06.00
Special Instructions
Amniotomy Date
Spontaneous Time
10
98765432
Syntocinon
Prostaglandin
Contractions
in 10 minutes
Weak
Moderate
Strong
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
Time
(24 hr Clock)
(mu/min)
(μg/min)
10
0 (Blue)
Figure 4.3Objective structured clinical examination questions 49
a) Name the instrument in the picture.
b) Give three indications for its use.
c) Give three situations were this instrument is contraindicated.
d) Give two maternal complications of this instrument.
e) What are the possible fetal complications of this instrument?
17 Obstetric emergencies
Mrs Smith has delivered a 3500 g baby on the delivery suite, where she was given intramuscular syntometrine.
However, she has continued to lose blood and the estimate is 1000 mL. She is not clinically shocked and you are
to see her because of her blood loss.
a) Define postpartum haemorrhage.
b) List the action you would take once you arrived to see this woman.
c) List the four most common causes of postpartum haemorrhage.
18 The puerperium
You are asked to see a 37-year-old woman in labour ward. She had an emergency Caesarean section for breech
presentation 8 days ago. Over the last few hours, she has become breathless and has developed chest pain.
a) What is the most likely diagnosis?
b) What in the history would you ask to aid your diagnosis?
c) What would you look for on examination?
d) What investigations would you carry out to confirm the diagnosis?
e) What are the treatment options that are available?
19 Psychiatric disorders in pregnancy and the puerperium
A 27-year-old mother is seen by the community midwife 5 weeks after having a Caesarean section for failure to
progress in the first stage of labour. She describes being miserable and starts to cry.
a) What is the mostly likely diagnosis?
b) What other symptoms might she have?
c) How is this condition treated?
d) Name a psychiatric disorder specific to pregnancy.
e) Outline the treatments that are available.
20 Neonatology
a) List three different deliveries where a trained neonatal resuscitator should be present.
b) Describe the Apgar score and how it is used.
c) Describe how you would manage a neonate that has been delivered without respiratory effort, but with a
heart rate of 100 beats per minute and is centrally cyanosed.
d) Describe level 2 neonatal intensive care.50 Obstetrics
OSCE answers
1 Maternal and perinatal mortality: the confidential enquiry
a) Perinatal mortality rate is defined as the number of stillbirths and early neonatal deaths per 1000 live births
and stillbirths.
b) Any three of the following: congenital anomaly; severe immaturity; infection; intracranial haemorrhage;
isoimmunization; and unknown.
c) Maternal steroids and surfactant.
d) The extended Wriggleworth, the obstetric (Aberdeen) classification, and the fetal and neonatal factor
classification.
See Chapter 3, Obstetrics by Ten Teachers, 18th edition.
2 Conception, implantation and embryology
a) 1, Oocyte; 2, zona pellucida; 3, granulosa cells; 4, follicular fluid.
b) Meiosis begins with diploid cells. The cell then undergoes an initial cell division that leads to two haploid
daughter cells. During the second division, no DNA replication occurs. Thus, 23 double-stranded chromosomes will separate into single-stranded chromosomes to form the nucleus of each daughter cell.
c) The first sign of pregnancy is a missed period and can be confirmed by several methods. The pregnancy test
measures the hormone human chorionic gonadotrophin (hCG) and commercial available kits are sensitive
to 25 IU/L in urine. Quantitative serum hCG assay levels greater than 15 IU /L will usually denote a pregnancy.
Ultrasound is commonly used to detect pregnancy. Transvaginal ultrasound will demonstrate a gestation sac
4–5 weeks after the last menstrual period and a fetal heart between 5 and 6 weeks. Abdominal ultrasound will
demonstrate a gestation sac between 5 and 6 weeks, and a fetal heart a week later.
See Chapter 4, Obstetrics by Ten Teachers, 18th edition.
3 Physiological changes in pregnancy
a) Pregnancy is associated with dramatic cardiovascular changes, which occur from an early gestation. Overall
there is a 10–20 per cent increase in the maternal heart rate and a 10 per cent increase in the stroke volume. These
increases the cardiac output by 30–50 per cent. Associated with these changes are decreases in the maternal
mean arterial pressure and in the peripheral vascular resistance.
b) Human chorionic gonadotrophin is composed of α and β subunits. hCG levels increase dramatically over the
first 10 weeks.After 10 weeks, hCG reduces in concentration until 12 weeks, when it plateaus for the remainder
of pregnancy. During early pregnancy, hCG has a major role in maintaining the function of the corpus
luteum and the production of progesterone.
c) The serum prolactin concentrations increases throughout pregnancy. However, it does not promote lactation during this time, as its function is antagonized by oestrogen. The rapid fall in oestrogen within the first
48 hours after birth allow lactation to occur. Early sucking promotes lactation by increasing the posterior pituitary release of oxytocin and prolactin. Oxytocin causes the myoepithelial cells to contract and express milk,
and prolactin to increase milk synthesis.
See Chapter 5, Obstetrics by Ten Teachers, 18th edition.OSCE answers 51
4 Normal fetal development
a) At birth, the cardiovascular system undergoes extensive remodelling under the changed haemodynamics of
the now activated pulmonary system. In addition, the cessation of the umbilical blood flow in the ductus venosus causes a fall in the right atrial pressure and closure of the foramen ovale. Ventilation of the lungs opens
the pulmonary circulation, with a rapid fall in the pulmonary vasculature resistance. The ductus arteriosus
closes functionally within a few days of birth.
b) The fluid within the lung is reabsorbed. Compression of the chest at delivery forces out approximately onethird of the fluid and the release of adrenalin promotes reasorption of the rest. Surfactant is released, triggered
by adrenalin and steroids. There is a fall in the capillary pressure of the lungs that occurs with the expansion
of the alveoli, and the vasodilatory effect of oxygen. Respiratory movements of the chest commence.
c) Respiratory distress syndrome may lead to hypoxia. The administration of antenatal steroids to the mother
reduces the risk and severity. In this case, antenatal steroids were not administered; however, the severity of
respiratory distress syndrome can be reduced by the administration of surfactant. Hypothermia is a common problem related to the large surface area, lack of subcutaneous fat and keratinized skin. This large surface area also predisposes to dehydration. This can be reduced by nursing the infant in an incubator. Jaundice
secondary to liver immaturity is common in the preterm infant; this can be treated with phototherapy.
Periventricular haemorrhage and intraventricular haemorrhage commonly lead to cerebral palsy.
See Chapter 6, Obstetrics by Ten Teachers, 18th edition.
5 Antenatal care
a) The booking history should include the following: name; age; occupation; past obstetric history; past medical
history; treatment history; and social history.
b) This question is best approached by dividing it into tests that are performed during the various trimesters of
pregnancy.
First trimester
All pregnant women are encouraged to undergo screening for a number of health issues, which may have an
impact on the pregnancy or the fetus. The following tests are performed routinely during the first trimesters:
• A full blood count is used to screen for anaemia and thrombocytopenia, both of which may require further
investigation.
• Maternal blood group is determined, which will help with cross-matching at a later date. Rhesus status will
be determined and prophylaxis will be offered at 28 and 34 weeks, if the mother is rhesus negative.
• Rubella status will be determined as vertical transmission carries serious risk of congenital abnormalities,
especially in the first trimester. Women who are found to be non-immune should be advised to avoid infectious contacts.
• Hepatitis B status should be determined, so that passive and active immunization can be offered to the baby
postdelivery.
• All women should be offered human immunodeficiency virus (HIV) testing as the use of antiretroviral
agents, elective Caesarean section and avoidance of breast-feeding reduces the vertical transmission to less
than 5 per cent.
• A dating ultrasound would be offered to all women. This has the benefits of accurate dating.
Second trimester
During the second trimester, at around 15 weeks, the triple test would be offered to all pregnant women. This is
used to indicate the risk of the mother having a baby with Down’s syndrome.52 Obstetrics
Third trimester
Measurement of blood pressure occurs at all antenatal visits; however, its main role is during the late second and
early third trimester as a screening test for pre-eclampsia. Urine will also be analysed at all antenatal visits for
protein, blood and glucose. This is used to detect infection, pre-eclampsia and gestational diabetes.
See Chapter 7, Obstetrics by Ten Teachers, 18th edition.
6 Antenatal imaging and fetal assessment
a) This is an umbilical artery Doppler.
b) The picture shows a normal umbilical artery Doppler waveform.
c) Resistive index; this is calculated from the maximum umbilical artery systolic velocity the minimum
umbilical end-diastolic velocity/the maximum umbilical artery systolic velocity. When this value rises above
the 95th centile of the range, this implies that the fetal placental perfusion is faulty.
d) Absent or reversed end-diastolic flow.
e) Absent or reversed end-diastolic flow have been shown to correlate strongly with fetal distress and intrauterine death.
See Chapter 8, Obstetrics by Ten Teachers, 18th edition.
7 Prenatal diagnosis
a) This is an autosomal recessive disorder. Therefore, if both parents are carriers, then the chances of having an
effected child are 1:4 in each pregnancy.
b) The commonest mutation is the delta 508 mutation and this is present is 68 per cent of cases.
c) This could be diagnosed parentally from a chorionic villus biopsy.
d) The chorionic villus biopsy can be performed at any time after 10 weeks’ gestation.
See Chapter 9, Obstetrics by Ten Teachers, 18th edition.
8 Second trimester miscarriage
a) The combination of two previous losses that presented with backache would suggest mid-trimester loss.
b) A general examination should be performed to check that the woman is well. This should include the
patient’s vital signs: pulse, temperature and blood pressure. A temperature may suggest infection, as would a
tachycardia. Abdominal examination should be performed to palpate for contractions. Fetal heart auscultation should be performed to confirm fetal viability. Initially, a sterile speculum examination should be performed and a vaginal swab taken. Visualization of the cervix will determine whether it is dilating.
A cervico-vaginal swab should be obtained to exclude infection. A urine sample should be obtained to
exclude urinary tract infection, which may precipitate uterine activity. A full blood count should be taken to
look for signs of infection. An ultrasound scan should be performed to confirm viability and gestation.
c) Adequate analgesia is essential so the patient suffers as little distress as possible. Vaginal delivery will almost
always occur due to the small size of the fetus. Some of these babies will show signs of life and the parents
need to be warned of this to avoid unnecessary distress. The parents should be offered contact details of support groups.
See Chapter 10, Obstetrics by Ten Teachers, 18th edition.OSCE answers 53
9 Antenatal obstetric complications
There are three available management options that need to be discussed with the patient. These are: elective
Caesarean section; external cephalic version (ECV); and vaginal breech delivery. The candidate would be
expected to take a brief obstetric history. This would be to determine if there were any factors in the history that
would be a contraindication to vaginal breech delivery or ECV.
The term breech trial demonstrated that there was a reduction in the perinatal mortality and morbidity with
elective Caesarean section over vaginal breech delivery. However, there are some factors that would increase the
strength of recommendation for a Caesarean section, these being a large or small baby, a small pelvis on pelvimetry, previous Caesarean section and an extended fetal neck.
External cephalic version is carried out between 36 and 37 weeks’ gestation. The procedure has been shown to
reduce the number of Caesarean sections due to breech presentation. Contraindications to ECV are placenta praevia, oligohydramnios, previous Caesarean section, multiple gestation and pre-eclampsia. The risks of the procedure,
which need to be outlined, are placental abruption, premature rupture of the fetal membranes, cord accident,
transplacental haemorrhage and fetal bradycardia.
Vaginal breech delivery is still an acceptable option, if the mother understands the increased risks to the fetus.
There are a number of factors that increase the likelihood of a successful breech delivery: normal size baby, flexed
neck, multiparous, breech deeply engaged, and positive mental attitude of the woman.
See Chapter 11, Obstetrics by Ten Teachers, 18th edition.
10 Twins and higher-order multiple gestations
a) Monozygotic twins arise from a single fertilized ovum that splits into two identical structures. The type of
monozygotic twins depends on how long after conception this splitting occurs.
b) The most reliable time to determine chorionicity is at the end of the first trimester. In dichorionic twins, there
is a extension of the placental tissue into the base of the intertwin membrane, this is known as the ‘lambda’
sign. In monochorionic twins, this sign is absent and the membrane joins the uterine wall in a ‘T’-shape.
c) There is an increased risk of intrauterine growth restriction compared to singleton pregnancies. The risk of
fetal anomaly is greater in all twin pregnancies; however the risk is highest in monochorionic twin pregnancies. There is an increased risk of preterm labour in all twin pregnancies. The overall perinatal mortality rate
for twins is six times higher than for singleton pregnancies.
d) Monochorionic twins carry a risk of twin-to-twin transfusion syndrome. This occurs due to vascular anastomoses between the two fetoplacental circulations. This is a potential dangerous complication, which, without treatment, will lead to miscarriage or severe preterm delivery in 90 per cent of cases.
See Chapter 12, Obstetrics by Ten Teachers, 18th edition.
11 Disorders of placentation
a) The most likely diagnosis based on the blood picture is pre-eclampsia.
b) Any three of the following: blood pressure 140/90mmHg; hypereflexia; clonus; papilloedema; visual disturbances; small for gestational age.
c) Three of the following: eclampsia; cerebrovascular accidents; renal failure; adult respiratory distress syndrome.
d) An ultrasound scan for fetal growth and liquor volume. Umbilical artery Doppler scans should be performed.
e) Treat blood pressure with antihypertensives.Administer steroids to accelerate lung maturity. Monitor fetus and
indices, and consider delivery with worsening indices. Inform the neonatal unit about impeding delivery.
See Chapter 13, Obstetrics by Ten Teachers, 18th edition.54 Obstetrics
12 Preterm labour
a) The first investigation that should be initiated is genital tract swabs. This may guide antibiotic therapy, if
required. An ultrasound can give valuable information on the amniotic fluid volume. There is a direct correlation between the amount of amniotic fluid and the time to labour. Maternal well-being should be regularly assessed; this should include pulse and blood pressure, and some advocate serial C-reactive protein and
white cell count. Fetal well-being should also be regularly monitored with cardiotocography.
b) Neonatal survival can rarely occur at 23 weeks, is possible between 24 and 25 weeks, and is likely after 26 weeks.
c) Any woman delivering after preterm rupture of the fetal membranes is at increased risk of endometritis and
postpartum haemorrhage. Therefore, prophylactic antibiotics should be considered.
d) This woman should be advised that there are non-modifiable and modifiable risk factors, and that she is at
20 per cent risk of preterm birth in this pregnancy in view of her previous history. Smoking is an independent
risk factor and cessation of smoking will reduce her risk of preterm labour. Drug abuse is also linked to preterm
labour and can be stopped. An interpregnancy interval of less than 1 year is associated with an increased risk
and, therefore, delaying subsequent pregnancies may reduce the risk. An early dating scan should be arranged
to ensure precise assessment of fetal gestational age.Vaginal swabs should be taken and tested for bacterial vaginosis (BV) and Group B streptococcus. Treatment of women with BV in high-risk populations has been shown
to reduce the preterm birth rate by 60 per cent.
See Chapter 14, Obstetrics by Ten Teachers, 18th edition.
13 Medical diseases of pregnancy
a) Mitral stenosis.
b) Prematurity is a common effect of cardiac disease. This can be either iatrogenic or because the fetus is small for
gestational age. There is also an increase in the maternal mortality; however, this varies depending on the cardiac
lesion. There is also a 5 per cent risk that the fetus will have a congenital heart defect.
c) Induction of labour should be avoided unless for obstetric indications. Prophylactic antibiotics should be
given to prevent bacterial endocarditis. A close monitoring of fluid balance should be initiated. Anaesthesia
should be discussed with a senior anaesthetist. The second stage of labour should be kept short.
See Chapter 15, Obstetrics by Ten Teachers, 18th edition.
14 Perinatal infections
a) HIV is an single-stranded retrovirus that binds to CD4 receptors.
b) T-helper lymphocyctes, macrophages, dendritic cells and microglia cells present CD4 receptors.
c) There are two main strategies used in the treatment of HIV. If there is no evidence of immunodeficiency,
then antiretoviral drug therapy is commenced as highly active retroviral therapy. This is a combination of
several drugs that include nucleoside reverse transcriptase inhibitors, a non-nucleoside reverse transcriptase
inhibitor and a protease inhibitor. If there is evidence of immunodeficiency, then treatment is aimed at prevention of opportunistic infection.
d) Vertical transmission occurs in 25–40 per cent of pregnancies, if there are no interventions to reduce the risk.
The three intervention that have been shown to reduce the vertical transmission of HIV are: avoiding breast
feeding, elective Caesarean section, and the use of antiviral drugs in the later half of pregnancy and neonatal
period.
See Chapter 16, Obstetrics by Ten Teachers, 18th edition.OSCE answers 55
15 Labour
a) The chart is a partogram of X.
b) This is a partogram. It is a pictorial presentation of the process of labour.
c) The first stage of labour is defined as the time from the diagnosis of labour to full dilatation of the cervix. The
second stage of labour is defined as the time from full dilation of the cervix to the delivery of the fetus or fetuses.
The third stage of labour is defined as the time from the delivery of the fetus to delivery of the placenta.
d) Secondary arrest of labour due to irregular uterine contractions.
e) From the partogram, the membranes are still intact, as there is no liquor draining. Therefore, an artificial
rupture of the membranes should be performed, then the patient should be examined 2 hours after this. If
there is still no progress, then syntocinon should be commenced.
See Chapter 17, Obstetrics by Ten Teachers, 18th edition.
16 Operative interventions in obstetrics
a) Ventouse.
b) Delay in the second stage, fetal distress in the second stage and maternal conditions requiring a short second
stage.
c) Face presentation, gestation less than 34 weeks and marked active bleeding from the fetal blood sample site.
d) Vaginal lacerations and cervical injury.
e) Chignon, cephalohaematoma, neonatal jaundice and lacerations of the fetal scalp.
See Chapter 18, Obstetrics by Ten Teachers, 18th edition.
17 Obstetric emergencies
a) Postpartum haemorrhage is defined as excess blood loss (1000 mL) in the first 24 hours after delivery.
b) Call for help, massage the uterus, gain intravenous access, administer high-dose syntocinon, and determine
the cause of the bleeding and deal with it.
c) This can be remembered with the simple ‘four Ts’: tonic uterus; trauma; tissue – check placenta complete;
thrombin – clotting.
See Chapter 19, Obstetrics by Ten Teachers, 18th edition.
18 The puerperium
a) The mostly likely diagnosis in a woman presenting with this history is a pulmonary embolism.
b) The patient may complain of a cough and haemoptysis. She may also complain of a swollen, painful calf secondary to a deep venous thrombosis (DVT) of the leg. There may be a family history of DVT or pulmonary
embolism (PE).
c) Examination may reveal tachypnoea, raised jugular venous pressure and right ventricular heave. The patient’s
calf may also be swollen and painful, suggesting a DVT.
d) A chest X-ray should be performed. This is usually normal; however, it excludes other causes of breathlessness. An electrocardiogram should be performed, but this may also be normal except for a sinus tachycardia.
Arterial blood gases would show hypoxaemia and hypercapnia. The definitive test for a PE is a V/Q scan. This
will demonstrate a ventilation/perfusion mismatch.
e) The initial treatment is with intravenous heparin or subcuticular low-molecular-weight heparin.
See Chapter 20, Obstetrics by Ten Teachers, 18th edition.56 Obstetrics
19 Psychiatric disorders in pregnancy and the puerperium
a) The mostly likely diagnosis is postpartum depression.
b) She may complain of early morning waking, a loss of appetite, low energy, lack of enjoyment, anxiety, thoughts
of self-harm.
c) There are three main treatment options. These include remedy of social factors. However, several randomized trials have demonstrated the benefits of non-directive counselling from specially trained midwives and
health visitors. If pharmacotherapy is deemed necessary, tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) are widely used. There is evidence to support their safety in the postnatal breast feeding women.
d) Puerperal psychosis.
e) The treatment is aimed at treating the acute psychotic event. This can be achieved with the use of neuroleptics, such a haloperidol or chlorpromazine. If there is a significant manic component to the presentation, then
lithium carbonate should be initiated. Electroconvulsive therapy is an option in women with severe depressive psychosis. Antidepressants are used as a second-line therapy.
See Chapter 21, Obstetrics by Ten Teachers, 18th edition.
20 Neonatology
a) There are many circumstances were a trained resuscitator should be present. These include: preterm deliveries; vaginal breech delivery; significant fetal distress; serious fetal abnormality; rotational forceps; and Caesarean
section.
b) The Apgar score is a tool that was developed to assist the recognition of an infant who is failing to make a
successful transition to extrauterine life. It has five separate categories that are scored 0, 1 or 2, depending on the
observation of the neonate to give a maximum of score of ten. The categories are appearance (central trunk
colour), pulse rate, response to stimulus, muscle tone and respiratory effort. It should be recorded at 1 minute
and 5 minutes unless there is a problem, when further observation should be recorded.
c) The baby should be dried and placed under a radiant heat source wrapped in a warm dry towel. The process
of drying often provides enough stimuli to induce breathing. If there no response, then commence active resuscitation using five inflation breaths via a bag and mask, and summon help.
d) Level 2 intensive care is provided by specially trained nursing staff that care for two babies at a time. Examples
would include babies requiring parenteral nutrition, having apnoeic attacks or requiring oxygen treatment,
and weighing less than 1500 g.
See Chapter 22, Obstetrics by Ten Teachers, 18th edition.
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