Even more essay questions

We have started a re-write of all old-type essay questions. Here are a few we have re-written. Answer plans are already on-line but we will post them here mid-week.

Women having a vaginal delivery after one previous caesarean section are at increased risk of uterine rupture. (a) How can this risk be reduced? [6 marks](b) How would you identify and manage this complication in a woman in spontaneous labour after one previous caesarean section? [14 marks]

A 25 year old woman presents in labour at 5cm dilatation in the 39th week of her first pregnancy. Four hours later, she is 6cm dilated on vaginal examination with intact membranes. (a) Justify your clinical assessment and initial management plan [10 marks]. (b) Justify your subsequent intra-partum care given that progress remains inadequate [10 marks]

Venous thrombo-embolism is a major cause of maternal death. (a) Which women are at high risk of venous thrombo-embolism during pregnancy? [6 marks] (b) How can morbidity and mortality from venous thrombo-embolism be reduced in high risk pregnant women? [14 marks] 

please post some EMQs on osteoporosis, T score, Z score, as such Q were asked in March 2012 exam.

Dear Paul,

KIndly give your valuable suggestions, if my approach is right for this answer 

a)    Women with previous history  of recurrent VTE, inherited thrombophilia of antithrombin deficiency,Factor V leiden mutation, and acquired thrombophilia of antiphospholipid syndrome are at very high risk of VTE. Women with previous unprovoked VTE, family history of VTE in first degree relative, estrogen (contraception or pregnancy ) provoked veno-thromboembolism categorised into high risk group of VTE. Obesity, BMI>30,age>35 years, smoking, previous medical co- morbidities of cancer, heart, renal disease are other pre-existing risk factor of veno-thromboembolism. Obstetric related high risk factors of veno-thromboembolism are multiple pregnancy, pre-eclampsia,OHSS, assisted reproduction. Further surgical intervention during pregnancy, immobilisation also predisposes women to veno-thromboembolism.

b)    Women who are at high risk of  veno-thromboembolism should receive pre-prenancy counselling and a prospective management plan should be formulated for thromboprophylaxis during pregnancy. If they become pregnant before such counselling, they should be referred to expert in thrombosis in pregnancy or consultant obstetrician. Risk is highest in pregnancy and this further increase per day in puerperium. They are stratified into categories, according to the risk factors present and previous episodes of veno-thromboembolism. High risk category include previous unprovoked VTE, estrogen provoked VTE, family history of VTE in first degree relative.

To ensure decrease in morbidity and mortality from VTE , adequate antenatal and postnatal thromboprophylaxis is required. They should be started on LMWH as soon as possible in early pregnancy. LMWH is safe during pregnancy and breastfeeding. Continue LMWH as thrombo-prophylaxis during entire antenatal period – Enoxaparin 40 mg( for weight till 90 kg)subcutaneous daily or  Dalteaparin 5000IU subcutaneous daily or Tanzaparin can be used. Higher doses will be required for obese females. Renal function should be normal for LMWH continuation. Dehydration should be avoided, if hyperemesis occur, treat it promptly.If  women has to be admitted in hospital or develop some other intercurrent problem, risk assessment for VTE should be made again and LMWH should be prescribed by medical staff.

Ask her to avoid dose of LMWH when labour pain starts, or develop bleeding. She should deliver in consultant- led unit.Care should be taken to maintain adequate hydration intrapartum. She should be kept mobilised in intrapartum period as well.  Ensure adequate labour analgesia. Active management of third stage of labour should be done so as to prevent PPH which is a risk factor of VTE. Assess progress of labour properly as emergency caesarean section is associated with four fold increased risk of VTE as compared to vaginal birth. Intrapartum and postpartum risk assessment of VTE should be done.  After delivery if there is no bleeding LMWH should be administered after 4 hours and 12 hours before removal of epidural catheter. Continue postpartum thromboprophylaxis of LMWH for 6 weeks or till the risk factors persist.

Dear Paul,

please give your valuable suggestion on the essay of VBAC.

a)    Proper selection of case after review of surgical notes of previous CS helps in reducing the risk of uterine rupture during VBAC. Previous uncomplicated lower segment CS with no extension of incision is the most suitable caesarean in which planned VBAC can be carried out. Inter-delivery interval should be > 2 years as shorter interval of 12-24 months increase risk of uterine rupture to 2-3 folds. Present uncomplicated term pregnancy with spontaneous onset of labour increase the success of VBAC.Continuous electronic foetal monitoring should be carried out intra-partum as abnormal cardiotocograph is the most consistent feature of uterine rupture. Decision of induction of labour and with what agent, should be consultant led as induction increases the chances of uterine rupture. Augmentation of labour should also be carried out after consultant’s decision and oxytocin should be such titrated that there are 3-4 contraction in 10 min. Consultant led decision of serial vaginal examination to assess cervico-metric progress and minimum standard set at which labour should be discontinued and proceed to emergency CS helps in reducing the risk of uterine rupture during VBAC.

b)    Thorough clinical examination will help us in identifying the complication of uterine rupture during VBAC. Pulse, BP should be assessed as maternal hypotension, tachycardia, shock  and loss of consciousness may be there. If conscious, patient may give history of something give way sensation and pain persist in between contractions. On palpation of abdomen there is no adequate relaxation in between the contractions, acute onset scar tenderness, CTG may show deceleration, absent foetal heart. On vaginal examination there may be increase bleeding, loss of station of fetal head , all such features point towards uterine rupture.

Prompt management is required of uterine rupture .Two wide bore intravenous cannulae should be set and blood should be taken for cross match for at-least four units of blood. Inform blood bank to manage adequate blood products and haematologist as suggestion may be required. Send baseline FBC, RFT and U&E. Crystalloid should be started at rate of 125-150 ml/hr. Consent should be taken for immediate exploratory laparotomy and possible hysterectomy. Shift patient to OT for exploratory laparotomy. Consultant anaesthetist and 2 consultant obstetrician preferably should operate the case. Consultant haematologist should be there in OT for required suggestions. Delivery should be attended by consultant neonatologist, as resuscitation of newborn may be required. Depending upon the site of rupture and tone of uterus further management is carried out. If it is at the lower segment at site of previous scar and no atony , repair done with double layer closure. But if rupture extends into upper segment or atonic uterus is there, subtotal hysterectomy is an appropriate option. Post-partum effective contraception should be given if uterus preserved. Thromboprophylaxis is indicated with LMWH for 6 weeks.

Regarding part (a), shouldn't a VE be part of the assessment for suspected delayed progress, even with intact membranes? I noticed it wasn't part of the answer given. Please clarify. Thank you.

Dear Paul,

RCOG has divided risk of VTE into very high risk group, high risk and intermediate risk. So i had mentioned very high risk and high risk in the part a of answer.And for postpartum risk, rcog has mentioned 2 or more risk factors. Your answer also contains same points as mine but i couldnot get then how to write the answer.Please help me.

1

Dear Paul,

I came across with some queries while solving above mentioned mcqs.

1)NiCE mentioned that HeFA recommends or restrict 2 embryos 

to be transferred

2) NICE guideline on HTN in pregnancy, state that  for recurrent seizure  mgso4, 2-4 gmi.v bolus has to be given

3) If factor V heterozygosity is a risk factor for preeclampsia then why not homozygosity.

Dear Paul,

I shall be highly obliged if you can please sort out my queries..befor exam

looking forward

Shradha