Answers to EMQs

and Janesh Gupta2

(1)
Fetal Medicine, Rainbow Hospitals, Hyderabad, Telangana, India
(2)
University of Birmingham Birmingham Women’s Hospital, Birmingham, UK
 

Answers with Explanation

  • 1-C(CVS)—at 11 weeks gestation with a previous history of genetic syndrome, in this case beta-thalassemia, autosomal recessive with a 25 % chance of recurrence, a CVS would be ideal. CVS can be done at 11 weeks to obtain fetal DNA—allows for earlier diagnosis and, if results are unfavourable, gives the option of a first-trimester TOP.
  • 2-A(Amniocentesis)—Amniocentesis is a method of obtaining fetal cells from the amniotic fluid which can then be cultured to obtain a fetal karyotype. It can be done after 15 weeks of gestation and in this scenario is the ideal option to confirm fetal karyotype as per the patient’s wish.
  • 3-H(Cervical length by TVS)—Women with a history of spontaneous second-trimester loss or preterm delivery who have not undergone a history-indicated cerclage may be offered serial sonographic surveillance, as there is evidence to suggest that those who experience cervical shortening are at an increased risk of subsequent second-trimester loss/preterm birth and may benefit from ultrasound-indicated cerclage, while those whose cervix remains long have a low risk of second-trimester loss/premature delivery.
References
  • 4-I(Fetal ultrasound study)—Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman presenting with RFM after 28 + 0 weeks of gestation if the perception of RFM persists despite a normal CTG or if there are any additional risk factors for FGR/stillbirth.
References
Reduced fetal movements. RCOG Green-Top guideline No. 57. 2011. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​GTG57RFM25022011​.​pdf

Answers with Explanation

  • 5-G(Fetal blood transfusion)—Fetal parvovirus infection is known to cause fetal anaemia and hence hydrops. Intrauterine fetal blood transfusion will help correct the fetal anaemia and resolve the hydrops. As parvoviral infection is generally self-limiting, the overall results of fetal blood transfusion are very good.
References
To M, Kidd M, Maxwell D. Prenatal diagnosis and management of fetal infections. Obstet Gynaecol. 2009;11:108–16.
  • 6-D(Fetoscopic laser coagulation of placental anastomotic vessels)—This is a case of severe twin to twin transfusion in an MCDA twin pregnancy. The ideal treatment in this case is fetocopic LASER photocoagulation of the anastomotic vessels. Severe twin–twin transfusion syndrome presenting before 26 weeks of gestation should be treated by laser ablation rather than by amnioreduction or septostomy.
References
  • 7-C(Selective feticide)—Selective feticide is an invasive ultrasound-guided procedure. It is a reasonable alternative to expectant management or termination of the whole pregnancy in cases of twin pregnancy discordant for major fetal anomaly. Common indications are chromosomal anomalies, major structural anomalies and genetic disorders. The preferred route of fetal entry is transabdominal. Complications include pregnancy loss (6–12 %), preterm delivery (8 %), chorioamnionitis, placental abruption, bleeding, maternal coagulopathy, psychological stress and depression. The risk to the normal fetus is of extreme preterm delivery, neurodevelopment delay as a result of the death of its co-twin (much lower in dichorionic than monochorionic twins) and intrauterine death.
    Termination may be granted if ‘there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped’ (UK Abortion Act 1967, amended 1991, clause E). The risk of stillbirth after the procedure is 6–12 %, similar to the risk of stillbirth in multifetal gestation (12.3 %). The ongoing presence of the anomalous fetus potentially increases the complications in the antenatal period to those of a twin pregnancy, thereby putting the normal fetus at risk. Thus, selective feticide, by reducing the ongoing risks of the pregnancy, is beneficial to the mother in improving the chances of having at least one normal child.
References
(a) National Collaborating Centre for Women’s and Children’s Health. Multiple pregnancy-the management of twin and triplet pregnancies in the antenatal period (NICE clinical guideline 129). National Institute for Health and Clinical Excellence. London; 2011.
(b) Selective termination in dichorionic twins discordant for congenital defect., Fetal Medicine Unit, Madrid, Spain. Eur J Obstet Gynaecol. 2012;161(1):8–11.
  • 8-E-(Amniodrainage)—Therapeutic amniocentesis (amnioreduction/amniodrainage) has also been proposed in singleton pregnancies to reduce maternal symptoms, given by overdistension of the uterus in severe and acute hydramnios. The reduction in maternal distressing symptoms is significant.
References
(a) Elliott JP, et al. Large volume therapeutic amniocentesis in the treatment of hydramnios. Obstet Gynecol. 1994;84:1025–7.
(b) Piantelli G, et al. Amnioreduction for treatment of severe polyhydramnios. Acta Biomed. 2004;75(1):56–8.

Answers

  • (9) A. Lichen sclerosus
    Lichen sclerosus can occur in any age group. Skin in the whole genital region may be affected, including the perianal area and genitocrural folds. The skin has well-demarcated whitening that does not extend to the vaginal mucosa. Pruritus is a common associated symptom.
  • (10) A. Lichen sclerosus
    The classical histological features are an atrophic epidermis with overlying hyperkeratosis, an effaced dermoepidermal junction, superficial dermal hyalinisation and lymphocytic infiltration.
  • (11) E. Psoriasis
    Vulval psoriatic lesions are well defined, uniform and symmetrical. The appearance is that of a beefy-red area that may affect any part of the vulva, but not the vaginal mucosa. Characteristic lesions may be present in other locations. Histologically, there is papillomatosis, parakeratosis with neutrophil exocytosis and spongiform pustules.
  • (12) F. Herpes simplex
    The lesions described are likely to represent herpes simplex. The differential diagnosis of genital ulcers also includes chancroid and syphilis.

Answers

  • (13) F–Power calculation
    The power of a study is determined by the sample size and the difference between the magnitudes of difference between the outcomes. This needs to be determined so that sample size can be estimated.
  • (14) J—Systematic review
    A comprehensive review of all the evidence, conducted with scientific methods, is likely to give the most reliable evidence.
  • (15). C—Intention to treat analysis
    A study that includes all the patients initially recruited in the final analysis is called an intention to treat analysis.

Answers

  • (16) E—Nexplanon implant
    Many of the options listed may be appropriate in such a scenario. However, one must balance the risks with the failure rate. High-dose progesterone and oestrogens are absolute contraindications, but adequate contraception is essential as pregnancy has a high risk of maternal mortality. In a 16 year old, Nexplanon is more desirable than a levonorgestrel intrauterine system as the uterus may not have fully developed. The patient must be counselled with regard to abnormal vaginal bleeding that occurs with the use of Nexplanon.
  • (17) B—Copper IUCD
    A previous failure, in consideration of her age and marital status and in the absence of menorrhagia, the IUCD is the best choice.
  • (18) D—GyneFix IUD
    The GyneFix IUCD is designed for the nulliparous patient. The use of condoms should also be advised to avoid sexually transmitted infection.

Answers

  • (19) E—Endometrial outpatient biopsy
    Endometrial biopsy is the most useful next step investigation as this is likely to give a histological diagnosis. Hysteroscopy may also be useful but will not give a histological diagnosis.
  • (20) F—Fsh, Lh and oestradiol
    The only part missing in the history is ‘hot flushes’. The single most useful diagnosis would be a hormonal profile. A hysteroscopy may be a useful investigation, but alone may not give a diagnosis.
  • (21) B—Cervical smear
    Women with HIV infection are more likely to develop cervical cancer, as the history suggests here. A cervical smear should give a diagnosis. Any immunocompromised woman should have annual smears.

Answers

  • (22) B—0.5 %
    Bowel adhesions to the anterior abdominal wall are found in 0.5 % of patients without prior surgery, 20 % with a previous Pfannenstiel incision and 50 % with a previous midline incision.
  • (23) J—Reduces incidence of vascular trauma only
    Open laparoscopy will reduce the incidence of vascular trauma and is advocated in patients with an anticipated complicated entry due to previous surgery. Current evidence suggests that bowel injury is not reduced, but is more readily identified.
References
Preventing entry-related gynaecological laparoscopic injuries. RCOG Green-Top guideline No. 49. 2008. http://​www.​rcog.​org.​uk/​files/​rcog-corp/​uploaded-files/​GT49PreventingLa​paroscopicInjury​2008.​pdf
  • (24) I
Explanation
For women having continuous EFM, a documented systematic assessment based on these definitions and classifications should be undertaken every hour. During episodes of abnormal FHR patterns when the woman is lying supine, she should be advised to adopt the left-lateral position. Prolonged use of maternal facial oxygen therapy may be harmful to the baby and should be avoided. There is no research evidence evaluating the benefits or risks associated with the short-term use of maternal facial oxygen therapy in cases of suspected fetal compromise. In the presence of abnormal FHR patterns and uterine hypercontractility not secondary to oxytocin infusion, tocolysis should be considered. A suggested regimen is subcutaneous terbutaline 0.25 mg. In the event of abnormal CTG following epidural top up, it may be reasonable to infuse intravenous fluids to prevent hypotension.
  • (25) L
Explanation
A diagnosis of delay in the established first stage of labour needs to take into consideration all aspects of progress in labour and should include:
  • Cervical dilatation of less than 2 cm in 4 h for first labours.
  • Cervical dilatation of less than 2 cm in 4 h or a slowing in the progress of labour for second or subsequent labours.
  • Descent and rotation of the fetal head.
  • Changes in the strength, duration and frequency of uterine contractions.
  • If slow progress is due to ineffective contractions, then oxytocin infusion should be started. Effective uterine contractions are defined as 3–5 contractions in ten minutes each lasting 45–55 s.
  • (26) J
Explanation
In view of the abnormal CTG and the vaginal exam findings fulfilling criteria for safe instrumental delivery, it would be acceptable to resort to an instrumental delivery. The choice of instrument depends on the operator’s experience.
Classification for operative vaginal delivery:
  • Outlet.
    • Fetal scalp visible without separating the labia.
    • Fetal skull has reached the pelvic floor.
    • Sagittal suture is in the anteroposterior diameter or right or left occiput anterior or posterior position (rotation does not exceed 45°).
    • Fetal head is at or on the perineum.
    • Low leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor.
  • Two subdivisions:
    • Rotation of 45° or less from the occipitoanterior position
    • Rotation of more than 45° including the occipitoposterior position
  • Mid:
    • Fetal head is no more than 1/5th palpable per abdomen.
    • Leading point of the skull is above station plus 2 cm but not above the ischial spines.
  • Two subdivisions:
    • Rotation of 45° or less from the occipitoanterior position
    • Rotation of more than 45° including the occipitoposterior position
  • High:
  • Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines.
References
Operative vaginal delivery. RCOG Green-Top guideline No. 26.
  • (27) D
Explanation
Changing from intermittent auscultation to continuous EFM in low-risk women should be advised for the following reasons:
  • Significant meconium-stained liquor, and this change should also be considered for light meconium-stained liquor.
  • Abnormal FHR detected by intermittent auscultation (less than 110 beats per minute [bpm], greater than 160 bpm, any decelerations after a contraction).
  • Maternal pyrexia (defined as 38.0C once or 37.5C on two occasions 2 h apart).
    Fresh bleeding developing in labour.
  • Oxytocin use for augmentation.
  • The woman’s request.
  • (28) M
Explanation
Observations during the first stage of labour include:
  • 4-hourly temperature and blood pressure
  • Hourly pulse
  • Half-hourly documentation of frequency of contractions
  • Frequency of emptying the bladder
Vaginal examination offered 4-hourly, or where there is concern about progress or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss)
In addition:
Intermittent auscultation of the fetal heart after a contraction should occur for at least 1 min, at least every 15 min, and the rate should be recorded as an average. The maternal pulse should be palpated if a FHR abnormality is detected to differentiate the two heart rates. Ongoing consideration should be given to the woman’s emotional and psychological needs, including her desire for pain relief.
  • (29) B
Explanation
Category 1 CS is when there is immediate threat to the life of the woman or fetus, and category 2 CS is when there is maternal or fetal compromise which is not immediately life threatening.
This patient requires a category 1 CS in the presence of fetal bradycardia.
  • (30) G
Explanation
Women with prelabour rupture of membranes at term (at or over 37 weeks) should be offered a choice of induction of labour with vaginal PGE2 or expectant management.
Induction of labour is appropriate approximately 24 h after prelabour rupture of the membranes at term. Vaginal PGE2 is the preferred method of induction unless there are contraindications. It should be used as a gel or tablets or a controlled release pessary. The recommended regimens are:
  • One cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 h if labour is not established (up to a maximum of two doses)
  • One cycle of vaginal PGE2 controlled release pessary: one dose over 24 h
  • (31) N
Explanation
For women having continuous EFM, a documented systematic assessment based on these definitions and classifications should be undertaken every hour. During episodes of abnormal FHR patterns when the woman is lying supine, she should be advised to adopt the left-lateral position. Prolonged use of maternal facial oxygen therapy may be harmful to the baby and should be avoided. In the presence of abnormal FHR patterns and uterine hypercontractility not secondary to oxytocin infusion, tocolysis should be considered. A suggested regimen is subcutaneous terbutaline 0.25 mg.
  • (32) D
Explanation
Changing from intermittent auscultation to continuous EFM in low-risk women should be advised for the following reasons:
  • Significant meconium-stained liquor, and this change should also be considered for light meconium-stained liquor
  • Abnormal FHR detected by intermittent auscultation (less than 110 beats per minute [bpm]; greater than 160 bpm; any decelerations after a contraction)
  • Maternal pyrexia (defined as 38.0C once or 37.5C on two occasions 2 h apart)
  • Fresh bleeding developing in labour
  • Oxytocin use for augmentation
  • The woman’s request
  • (33) M
Explanation
Observations during the first stage of labour include:
  • 4-hourly temperature and blood pressure
  • Hourly pulse
  • Half-hourly documentation of frequency of contractions
  • Frequency of emptying the bladder
Vaginal examination offered 4-hourly, or where there is concern about progress or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss).
In addition:
Intermittent auscultation of the fetal heart after a contraction should occur for at least 1 min, at least every 15 min, and the rate should be recorded as an average. The maternal pulse should be palpated if a FHR abnormality is detected to differentiate the two heart rates. Ongoing consideration should be given to the woman’s emotional and psychological needs, including her desire for pain relief.
  • (34) D
Explanation
After delivery, the placental bed, caesarean section and episiotomy wounds, cervical and vaginal lacerations are all susceptible to bacterial infection. Prolonged rupture of membranes, prolonged labour, operative vaginal delivery, caesarean section, pre-existing vaginal infection or history of Group B streptococcal (GBS) infection, postpartum haemorrhage, wound haematoma, retained pieces of placenta, membranes or intrauterine clot, or retained swabs all increase the risk of postpartum infection. The condition presents with lower abdominal pain, fever and offensive vaginal discharge or secondary postpartum haemorrhage. Management consists of broad spectrum antibiotics with coverage for anaerobic organisms as well.
References
Glackin K, Harper M. Postpartum pyrexia. Obstet Gynaecol Reprod Med. 22(11):327–31.
  • (35) H
Explanation
Pregnancy itself affects the immune system, and conditions such as anaemia, impaired glucose tolerance or diabetes mellitus reduce resistance to infection. Obesity, an increasing problem in the developed world, is a risk factor for sepsis, as is multiparity. Antibiotic prophylaxis plays an important role in preventing surgical-site infection. Therapy should be directed towards likely offending organisms endogenous in the lower genital tract including: Escherichia coli, other Gram-negative rods, Streptococcus species, Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, Gardnerella vaginalis and anaerobes including Bacteroides species and Peptostreptococcus species. To optimise intraoperative tissue concentration, prophylactic antibiotics should be given at the time of induction. Repeated doses confer no further benefit and increase the risk of adverse effects and antibiotic resistance. The antibiotic of choice should be well tolerated, safe to use and will be determined by local microbial population and their known sensitivities.
References
Glackin K, Harper M. Postpartum pyrexia. Obstet Gynaecol Reprod Med. 22(11):327–31.
  • (36) J
Explanation
Caesarean section has become the most common obstetric surgery, with one in three of pregnant women having a caesarean delivery. The use of urinary catheters during and after CS is routinely used with caesarean delivery. Alleged benefits of using catheters include the following: it maintains bladder drainage that may improve visualisation during surgery and minimise bladder injury, and there is less retention of urine after operation, but it could be associated with an increased incidence of urinary tract infection, urethral pain, voiding difficulties after removal of the catheter, delayed ambulation and increased hospital stay. Prophylactic antibiotics reduce the rate of bacteriuria and other signs of infection, such as pyuria, febrile morbidity and Gram-negative isolates in patients’ urine, in surgical patients who undergo bladder drainage for at least 24 h postoperatively.
References
Abdel-Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section. Cochrane Database Syst Rev. 2014, Issue 4. Art. No.: CD010322.
Lusardi G, Lipp A, Shaw C. Antibiotic prophylaxis for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev. 2013;7:CD005428.
  • (37) B
Explanation
Aspiration pneumonitis is a syndrome resulting from the inhalation of gastric contents. The incidence in obstetric anaesthesia has fallen, largely due to improved anaesthetic techniques and the increased use of regional anaesthesia at caesarean section. However, aspiration pneumonitis is still a cause of maternal morbidity and mortality, and it is important to use effective prophylaxis. Antacids (like sodium citrate), H2 receptor antagonists (like ranitidine) and proton pump antagonists (like omeprazole), all reduce the acidity of the stomach contents. An antacid plus an H2 receptor antagonist also reduce acidity. In theory, a combination like this, where the antacid acts quickly and the H2 receptor antagonists takes a little longer, should protect at periods of greatest risk, i.e. the beginning and end of the procedure (i.e. intubation and extubation).
References
Paranjothy S, Griffiths JD, Broughton HK, Gyte GML, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database Syst Rev. 2014, Issue 2. Art. No: CD004943.
  • (38) A
Explanation
The symptoms and signs of VTE include leg pain and swelling (usually unilateral), lower abdominal pain, low-grade pyrexia, dyspnoea, chest pain, haemoptysis and collapse. It is up to ten times more common in pregnant women than in nonpregnant women of the same age and can occur at any stage of pregnancy, but the puerperium is the time of highest risk. When suspected, objective testing should be performed expeditiously, and treatment with low molecular weight heparin (LMWH) started until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated. Where there is clinical suspicion of acute PTE, a chest X-ray should be performed. Compression duplex Doppler should be performed where this is normal. If both tests are negative with persistent clinical suspicion of acute PTE, a ventilation–perfusion (V/Q) lung scan or a computed tomography pulmonary angiogram (CTPA) should be performed.
References
RCOG Green-Top guideline No. 37b. The acute management of thrombosis and embolism during pregnancy and the puerperium.
  • (39) J
Explanation
Uterine rupture is a well-recognised complication of labour when a uterine scar exists. The risk is undoubtedly related to the site of the uterine scar and probably to the number of previous uterine surgeries. Rarely, rupture is recognised only after delivery of the baby and should be a differential diagnosis for postpartum collapse. If the rupture extends into the broad ligament, the woman can present with gradually increasing abdominal pain and a very tender abdominal mass. Diagnosis of uterine rupture warrants resuscitation and exploratory laparotomy. The importance of immediate senior involvement and teamwork cannot be overemphasised. Repair of the uterus is possible in the majority of women. In others, haemorrhage from extension of the rupture into the broad ligament or extensive damage to the uterus requires hysterectomy. Hysterectomy rates following uterine rupture have been quoted as 3.4/10 000 women choosing trial of labour following caesarean section.
References
Manoharan M, Wuntakal R, Erskine K. Uterine rupture: A revisit. Obstet Gynaecol. 2010;12:223–30.
  • (40) E
Explanation
After delivery, the placental bed, caesarean section and episiotomy wounds, cervical and vaginal lacerations are all susceptible to bacterial infection. Prolonged rupture of membranes, prolonged labour, operative vaginal delivery, caesarean section, pre-existing vaginal infection or history of Group B streptococcal (GBS) infection, postpartum haemorrhage, wound haematoma, retained pieces of placenta, membranes or intrauterine clot, or retained swabs all increase the risk of postpartum infection. The condition presents with lower abdominal pain, fever and offensive vaginal discharge or secondary postpartum haemorrhage. Management consists of broad spectrum antibiotics with coverage for anaerobic organisms as well.
References
Glackin K, Harper M. Postpartum pyrexia. Obstet Gynaecol Reprod Med. 22(11):327–31.
  • (41) D
Explanation
Disseminated intravascular coagulation (DIC) is a type of coagulopathy characterised by widespread intravascular activation of the coagulation system leading to vascular deposition of fibrin and a consumption of clotting factors. It is associated with certain obstetric complications including amniotic fluid embolisation, placental abruption and severe chorioamnionitis. It may also be triggered by massive blood loss. The management of a coagulopathy requires effective communication with the haematologist who will advise on the use of clotting factors. Ideally, coagulopathy should be prevented by anticipating depletion in clotting factors and transfusing appropriately. It is not necessary to wait for laboratory clotting results if a developing coagulopathy is suspected. A prothrombin time (PT) and APTT ratios of >1.5 are associated with an increased risk of a clinical coagulopathy; in the presence of ongoing bleeding, this requires correction with FFP.
References
Moore J, Chandraharan E. Management of massive postpartum haemorrhage and coagulopathy. Obstet Gynaecol Reprod Med. 20(6):174–80.
  • (42) I
Explanation
Uterine inversion, either partial or complete, is a rare but serious obstetric complication. It may present:
  • Acutely—within 24 h of delivery
  • Subacutely—over 24 h and up to the 30th postpartum day
  • Chronic—more than 30 days after delivery
It presents most often with symptoms of a postpartum haemorrhage. The classic presentation is of:
  • Postpartum haemorrhage
  • Sudden appearance of a vaginal mass
  • Cardiovascular collapse (varying degrees)
Treatment should follow a logical progression.
Hypotension and hypovolaemia require aggressive fluid and blood replacement.
Immediate uterine repositioning is essential for acute puerperal inversion. Measures may include:
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May 5, 2017 | Posted by in GYNECOLOGY | Comments Off on Answers to EMQs

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