Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Antenatal Care and Maternal Medicine Flashcards

24 sample cards from the Antenatal Care and Maternal Medicine deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. What is the approach to Group B Streptococcus (GBS) in the UK and the intrapartum prophylaxis used?

   UK uses a risk-based (not universal screening) strategy. Offer intrapartum IV antibiotic prophylaxis (benzylpenicillin) for: previous GBS-affected baby, GBS detected in current pregnancy, intrapartum pyrexia, prematurity or prolonged rupture of membranes.

2. Define maternal sepsis and name a commonly used early-warning/scoring approach in obstetrics.

   Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Recognition uses MEOWS (Modified Early Obstetric Warning Score) charts; the Sepsis Six bundle (cultures, lactate, urine output, oxygen, IV fluids, IV antibiotics) is delivered within 1 hour.

3. What is the most common causative organism of severe genital tract sepsis in pregnancy/puerperium?

   Group A Streptococcus (Streptococcus pyogenes), which can cause rapidly progressive, fulminant maternal sepsis; E. coli is also common.

4. Define fetal growth restriction (FGR) and distinguish it from small-for-gestational-age (SGA).

   SGA: estimated fetal weight or abdominal circumference $<10^{th}$ centile, which may be constitutionally small. FGR: a fetus failing to reach its genetic growth potential, usually due to placental insufficiency, with Doppler/growth-velocity abnormalities; severe SGA is $<3^{rd}$ centile.

5. In surveillance of the growth-restricted fetus, describe the typical sequence of Doppler deterioration.

   Increasing umbilical artery resistance $\to$ absent then reversed end-diastolic flow; middle cerebral artery shows reduced PI (brain-sparing, cerebroplacental ratio falls); finally ductus venosus a-wave abnormality/absent or reversed, and abnormal CTG/STV — indicating decompensation and need for delivery.

6. Which uterine artery Doppler finding at the second trimester is associated with increased risk of FGR and pre-eclampsia?

   Persistent high-resistance pattern with an early diastolic 'notch' and raised pulsatility index, reflecting failed trophoblastic invasion of spiral arteries.

7. How does routine antenatal anti-D prophylaxis (RAADP) reduce Rhesus sensitisation, and what is the single-dose regimen timing?

   Prophylactic anti-D immunoglobulin given to non-sensitised RhD-negative women neutralises fetal RhD cells. Single-dose RAADP: $1500\ IU$ at ~28 weeks (or two-dose at 28 and 34 weeks).

8. What test quantifies large fetomaternal haemorrhage to calculate additional anti-D dose, and the rule of thumb for dosing?

   Kleihauer test (acid-elution) detects/quantifies fetal cells in maternal blood. Approximately $500\ IU$ of anti-D covers ~$4\ mL$ of fetal red cells; additional anti-D and repeat Kleihauer guide large bleeds.

9. In a sensitised RhD-negative pregnancy, what non-invasive Doppler measurement detects fetal anaemia and what value triggers action?

   Middle cerebral artery peak systolic velocity (MCA-PSV). A value $>1.5$ multiples of the median (MoM) for gestation suggests moderate/severe fetal anaemia and warrants referral for possible intrauterine transfusion.

10. How is chorionicity in twins best determined and at what gestation, including the ultrasound signs?

    Best determined by ultrasound before 14 weeks. Dichorionic = 'lambda' (twin-peak) sign; monochorionic = 'T-sign' at the membrane-placenta junction. Chorionicity (not zygosity) drives risk and surveillance.

11. Describe twin-to-twin transfusion syndrome (TTTS), the pregnancies at risk, and its definitive treatment.

    TTTS occurs in monochorionic diamniotic twins due to unbalanced placental vascular anastomoses: donor (oligohydramnios, 'stuck twin') and recipient (polyhydramnios, possible hydrops). Staged by Quintero. Treatment of choice for severe (Stage II+) cases is fetoscopic laser ablation of anastomoses.

12. Compare the recommended timing of delivery for uncomplicated dichorionic, monochorionic diamniotic, and monochorionic monoamniotic twins.

    Dichorionic diamniotic: ~37 weeks. Monochorionic diamniotic: ~36 weeks (with steroids). Monochorionic monoamniotic: 32–34 weeks by caesarean (high cord-entanglement risk).

13. What defines reduced fetal movements and what is the initial assessment if RFM is reported after 28 weeks?

    There is no fixed threshold count; maternal perception of reduced movements is significant. Assessment: confirm fetal heart with handheld Doppler/CTG, then CTG; if further concern, ultrasound for growth, liquor and Doppler. RFM is associated with stillbirth and FGR.

14. Define stillbirth in the UK and name two leading associated/causative factors.

    Stillbirth: a baby born with no signs of life at or after 24 completed weeks of gestation. Common associations: placental insufficiency/FGR, placental abruption, congenital anomaly, infection, and pre-existing maternal disease (e.g. diabetes).

15. What investigations are recommended after a stillbirth to determine cause?

    Maternal: Kleihauer, infection screen, thrombophilia/antiphospholipid, glucose/HbA1c, TFTs, bile acids, autoimmune screen. Fetal/placental: postmortem examination (with consent), placental histology, fetal karyotype/microarray, and surface/skin swabs.

16. Define polyhydramnios using amniotic fluid index and deepest vertical pocket, and list common causes.

    Polyhydramnios: AFI $>25\ cm$ or deepest vertical pocket $>8\ cm$. Causes: maternal diabetes, fetal anomalies impairing swallowing (e.g. oesophageal/duodenal atresia, anencephaly), fetal anaemia/hydrops, TTTS (recipient), and infection; many are idiopathic.

17. Define oligohydramnios by deepest vertical pocket/AFI and list its principal causes.

    Oligohydramnios: AFI $<5\ cm$ or deepest vertical pocket $<2\ cm$. Causes: ruptured membranes, placental insufficiency/FGR (reduced fetal renal perfusion), fetal renal anomalies (e.g. renal agenesis, posterior urethral valves) and post-term pregnancy.

18. What is the Potter sequence and how does it relate to amniotic fluid?

    Potter sequence results from severe, prolonged oligohydramnios/anhydramnios (often bilateral renal agenesis or obstruction): pulmonary hypoplasia, limb contractures and characteristic flattened (Potter) facies — frequently lethal due to lung hypoplasia.

19. At booking, which factors place a woman in the higher-risk category requiring consultant-led (rather than midwifery-led) care?

    Examples: pre-existing medical disease (cardiac, renal, diabetes, epilepsy, hypertension), previous obstetric complications (pre-eclampsia, stillbirth, preterm birth, abruption), high or very low BMI, age extremes, multiple pregnancy, and previous caesarean/significant surgery.

20. What is the recommended weight-gain guidance and the management priority for a pregnant woman with BMI $\geq 30$?

    No formal UK weight-gain targets, but excess gain discouraged. Priorities: folic acid $5\ mg$, vitamin D, aspirin for pre-eclampsia prophylaxis, GDM screening (OGTT), VTE risk assessment, and consultant-led care with anaesthetic review.

21. In epilepsy, how does pregnancy affect seizure control and what monitoring is advised for lamotrigine?

    Seizure frequency may increase due to altered drug pharmacokinetics, nausea, sleep deprivation and reduced adherence. Lamotrigine levels fall in pregnancy (increased clearance) so levels are monitored and the dose often increased, then reduced postpartum.

22. What is obstetric cholestasis (intrahepatic cholestasis of pregnancy), its hallmark symptom/biochemistry, and main fetal concern?

    Pruritus (typically palms/soles) without rash, with raised serum bile acids (and often transaminases). Associated with increased risk of stillbirth, especially with bile acids $\geq 100\ \mu mol/L$; managed with monitoring and timed delivery.

23. What is the most common cause of jaundice/severe liver dysfunction unique to late pregnancy that presents with hypoglycaemia and coagulopathy?

    Acute fatty liver of pregnancy (AFLP) — a rare third-trimester emergency with nausea, vomiting, hypoglycaemia, deranged LFTs, coagulopathy and renal impairment; treatment is prompt delivery and supportive care.

24. How does maternal parvovirus B19 infection affect the fetus and what surveillance is required?

    Parvovirus B19 suppresses fetal erythropoiesis causing aplastic anaemia, which can lead to hydrops fetalis and loss. Surveillance: serial MCA-PSV Doppler for 8–12 weeks; intrauterine transfusion if severe anaemia/hydrops develops.

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