UKOM SpOG cheat sheet

UK schedule: booking visit by 10 weeks; dating scan 11+2 to 14+1 weeks; anomaly scan 18+0 to 20+6 weeks; nulliparous women have 10 appointments, parous women 7.

Naegele rule: estimated due date = first day of last menstrual period + 280 days (adjust by cycle length); ultrasound crown-rump length at 7-13 weeks is the most accurate dating method.

Folic acid 400 micrograms daily from preconception to 12 weeks; 5 mg daily if BMI 30 or more, diabetes, epilepsy on antiepileptics, or previous neural tube defect.

Physiological changes: plasma volume rises 40-50% causing dilutional anaemia; cardiac output increases 30-50%; systemic vascular resistance falls, so blood pressure is lowest in mid-pregnancy.

Rhesus D negative women: offer anti-D prophylaxis at 28 weeks (and after sensitising events); check antibody status at booking and 28 weeks.

Screening: combined test at 11+2 to 14+1 weeks (nuchal translucency, free beta-hCG, PAPP-A); quadruple test at 14+2 to 20 weeks if too late for combined.

Gestational diabetes risk factors triggering OGTT at 24-28 weeks: BMI over 30, previous macrosomia over 4.5 kg, previous GDM, family history, South Asian/Black/African-Caribbean origin.

Iron requirement rises to about 27 mg/day; haemoglobin below 110 g/L in first trimester or below 105 g/L later suggests anaemia needing investigation.

Pre-eclampsia: new hypertension after 20 weeks plus proteinuria (protein:creatinine ratio over 30 mg/mmol) or maternal organ dysfunction; aspirin 75-150 mg from 12 weeks reduces risk in high-risk women.

Severe features at 140/90 or above plus symptoms (headache, visual disturbance, epigastric pain), platelets below 100, ALT over 70, creatinine over 90 micromol/L, or pulmonary oedema.

Placenta praevia: painless vaginal bleeding, soft uterus; avoid digital vaginal examination; deliver by caesarean at 36-37 weeks if major praevia.

Placental abruption: painful bleeding with a tense uterus, fetal distress, and disseminated intravascular coagulation risk; ultrasound sensitivity is low, so diagnosis is clinical.

Preterm labour before 30 weeks: magnesium sulphate for neuroprotection, antenatal corticosteroids (betamethasone) from 24 to 34+6 weeks, and tocolysis only to buy time for steroids or transfer.

Twin pregnancy: monochorionic twins need scans every 2 weeks from 16 weeks to detect twin-twin transfusion syndrome; dichorionic twins scanned every 4 weeks.

Hyperemesis gravidarum: persistent vomiting with weight loss over 5%, ketonuria, and electrolyte disturbance; give thiamine before glucose to prevent Wernicke encephalopathy.

Rhesus isoimmunisation: rising anti-D titres or middle cerebral artery peak systolic velocity over 1.5 multiples of the median suggests fetal anaemia requiring intrauterine transfusion.

First stage: latent phase to 4 cm with regular contractions; active phase from 4 cm, expect cervical dilatation of at least 0.5-1 cm/hour in a first labour.

Partogram action line: 4 hours to the right of the alert line; crossing it warrants obstetric review, amniotomy, or oxytocin augmentation.

Fetal heart monitoring: intermittent auscultation every 15 minutes in first stage and every 5 minutes in second stage for low-risk labour; continuous cardiotocography if risk factors.

Cardiotocography categories: baseline 110-160 bpm, variability 5-25 bpm, accelerations, no decelerations = normal; prolonged deceleration over 3 minutes needs urgent review and left lateral position.

Second stage: passive until the head is visible or maternal urge to push; active pushing for up to 1 hour in nulliparous and 30 minutes in parous women before review.

Shoulder dystocia: McRoberts manoeuvre plus suprapubic pressure first; then internal rotational manoeuvres, all-fours position, and finally cleidotomy or Zavanelli manoeuvre.

Third stage: active management with 10 IU intramuscular oxytocin, controlled cord traction, and uterine palpation reduces postpartum haemorrhage compared with expectant management.

Instrumental delivery prerequisites: fully dilated cervix, engaged head at or below station 0, ruptured membranes, empty bladder, adequate analgesia, and consent.

Primary postpartum haemorrhage: blood loss over 500 mL after vaginal or 1000 mL after caesarean birth within 24 hours; causes are tone, trauma, tissue, and thrombin.

Management sequence for postpartum haemorrhage: uterine massage, oxytocin, ergometrine, carboprost, misoprostol, tranexamic acid 1 g, then balloon tamponade, uterine artery embolisation, or hysterectomy.

Endometritis after caesarean: fever, uterine tenderness, and foul lochia; treat with intravenous broad-spectrum antibiotics such as clindamycin plus gentamicin.

Mastitis: breast tenderness, fever, and flu-like symptoms; continue breastfeeding and give flucloxacillin; an abscess needs ultrasound-guided drainage.

Secondary postpartum haemorrhage (24 hours to 12 weeks) most often reflects retained placental tissue or endometritis; manage with antibiotics and ultrasound-guided evacuation if needed.

Venous thromboembolism risk persists for 6 weeks postpartum; low molecular weight heparin prophylaxis is risk-stratified, and breastfeeding does not preclude warfarin.

Postpartum thyroiditis: occurs in 5-10% of women, with thyrotoxicosis at 1-4 months followed by hypothyroidism; most recover, but some need levothyroxine.

Puerperal psychosis: onset usually within 2 weeks, with confusion, delusions, and risk of infanticide; requires urgent psychiatric admission and is distinct from postpartum depression.

Cervical cancer screening: liquid-based cytology with HPV testing; HPV-positive with abnormal cytology goes to colposcopy; HPV-negative low-grade changes return to routine recall.

Cervical cancer staging is clinical (FIGO 2018); stage IB1 is a tumour 2 cm or less, treated by radical hysterectomy or radical trachelectomy if fertility-sparing.

Endometrial cancer: postmenopausal bleeding is the classic presentation; transvaginal ultrasound endometrial thickness over 4 mm warrants biopsy.

Ovarian cancer: CA-125 is raised in about 80% of epithelial tumours; risk of malignancy index uses CA-125, menopausal status, and ultrasound score; surgery plus platinum-based chemotherapy is standard.

Risk-reducing bilateral salpingo-oophorectomy is offered to BRCA1 carriers at 35-40 years and BRCA2 carriers at 40-45 years after childbearing is complete.

Vulvar cancer: most are squamous cell carcinomas; sentinel node biopsy is used for unifocal tumours under 4 cm with no clinically suspicious nodes.

Gestational trophoblastic disease: complete mole has a snowstorm appearance and markedly raised beta-hCG; follow-up with serial beta-hCG and contraception (avoid pregnancy) until normal.

Chemotherapy agents: cisplatin is nephrotoxic and ototoxic (hydrate and monitor); paclitaxel causes neuropathy and needs premedication for hypersensitivity.

Polycystic ovary syndrome Rotterdam criteria: two of three of oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasound.

WHO group II anovulation (including PCOS): first-line ovulation induction is letrozole or clomiphene citrate; metformin is an adjunct in insulin-resistant women.

Infertility workup: semen analysis, ovulation assessment (mid-luteal progesterone), and tubal patency (hysterosalpingography or laparoscopy and dye).

Ovarian reserve: antral follicle count and anti-Mullerian hormone are the best predictors of response to stimulation; day-3 FSH is less reliable.

Ovarian hyperstimulation syndrome: enlarged ovaries, ascites, haemoconcentration; mild cases with oral fluids, severe cases need hospital admission and thromboprophylaxis.

Hypogonadotropic hypogonadism (WHO group I): low FSH and low oestradiol; treat with pulsatile GnRH or gonadotropins, not clomiphene.

Premature ovarian insufficiency: loss of ovarian function before age 40; give hormone replacement to at least the normal age of menopause to protect bone and cardiovascular health.

Hyperprolactinaemia: dopamine agonists (cabergoline) are first-line; check prolactin after excluding pregnancy, hypothyroidism, and drug causes.

Stress urinary incontinence: leakage on effort or sneezing; first-line is pelvic floor muscle training for at least 3 months; surgery is mid-urethral sling or colposuspension.

Urgency urinary incontinence: overactive bladder with urgency; bladder training plus antimuscarinic or beta-3 agonist (mirabegron); check post-void residual before starting antimuscarinics.

Pelvic organ prolapse staging uses the POP-Q system; stage 1 is more than 1 cm above the hymen, stage 2 is within 1 cm of the hymen, stage 3 is more than 1 cm beyond.

Anterior compartment prolapse (cystocele) is the most common; posterior (rectocele) often presents with difficulty defecating or needing digital splinting.

Risk factors for prolapse: vaginal parity, advancing age, obesity, chronic cough, constipation, and connective tissue disorders; caesarean birth reduces but does not eliminate risk.

Pessaries are a good option for women who wish to avoid surgery; ring pessaries need regular review for erosion and discharge.

Urodynamic stress incontinence is demonstrated on filling cystometry; detrusor overactivity shows involuntary contractions during filling.

Obstetric anal sphincter injury: third-degree tears involve the anal sphincter, fourth-degree involves the anal epithelium; repair by an experienced clinician and follow-up are essential.

Bacterial vaginosis: clue cells, thin grey discharge, fishy odour with potassium hydroxide; treat with metronidazole; not sexually transmitted.

Vulvovaginal candidiasis: thick white discharge and itching; treat with topical imidazole or a single oral fluconazole dose; recurrent cases need longer therapy.

Chlamydia: most are asymptomatic; test with nucleic acid amplification; treat with doxycycline 100 mg twice daily for 7 days (azithromycin is an alternative in pregnancy).

Pelvic inflammatory disease: treat empirically with ceftriaxone plus doxycycline plus metronidazole; remove an intrauterine device only if no improvement after 48-72 hours.

Combined oral contraceptive pill: failure rate under 1% with perfect use; efficacy is reduced by enzyme-inducing drugs (rifampicin, carbamazepine, phenytoin, St John's wort).

Emergency contraception: levonorgestrel 1.5 mg up to 72 hours or ulipristal acetate up to 120 hours; a copper intrauterine device is the most effective option up to 5 days.

Copper intrauterine device: works by spermicidal effect; can be used as emergency contraception and lasts 5-10 years; heavier periods are a common side effect.

Syphilis: screen with treponemal or non-treponemal tests; treat with benzathine penicillin; in pregnancy, penicillin is the only recommended treatment to prevent congenital syphilis.

Fetal growth restriction: estimated fetal weight below the 10th centile plus abnormal Doppler findings; umbilical artery absent or reversed end-diastolic flow indicates severe compromise.

Doppler interpretation: umbilical artery pulsatility index falls with advancing gestation normally; middle cerebral artery pulsatility index falls in fetal hypoxia (brain-sparing).

Cardiotocography: sinusoidal pattern (fixed 3-5 bpm oscillation) suggests severe fetal anaemia or hypoxia and needs urgent delivery.

Biophysical profile: combines cardiotocography with fetal breathing, movement, tone, and amniotic fluid volume; a score of 8 or more is generally reassuring.

Amniotic fluid index: oligohydramnios is an index below 5 cm or deepest vertical pocket below 2 cm; polyhydramnios is a deepest vertical pocket over 8 cm.

Rhesus disease: assess with middle cerebral artery peak systolic velocity; a value over 1.5 multiples of the median suggests anaemia requiring cordocentesis and transfusion.

Preterm prelabour rupture of membranes: confirm with speculum examination; avoid digital examination; give erythromycin and corticosteroids, and deliver by 37 weeks if no labour.

Fetal monitoring in labour: categorise as normal, suspicious, or pathological; pathological traces need conservative measures (left lateral, fluids, stop oxytocin) or expedited delivery.

Eclampsia: give magnesium sulphate 4 g intravenous loading then 1 g/hour; monitor reflexes, respiratory rate, and urine output; calcium gluconate is the antidote for toxicity.

Maternal collapse: left lateral tilt or manual uterine displacement after 20 weeks relieves aortocaval compression; start cardiopulmonary resuscitation with chest compressions.

Perimortem caesarean: perform within 4-5 minutes of maternal cardiac arrest if no return of circulation, to improve maternal and fetal survival.

Amniotic fluid embolism: sudden hypoxia, hypotension, and coagulopathy during labour or immediately postpartum; supportive care with blood products and intensive care.

Uterine rupture: sudden fetal bradycardia, loss of station, and abdominal pain in a woman with previous caesarean; requires immediate laparotomy and delivery.

Sepsis in pregnancy: give broad-spectrum antibiotics within 1 hour, fluids, and early obstetric review; group A streptococcus is a common cause of severe puerperal sepsis.

Shoulder dystocia drills: document time of head delivery and manoeuvres used; brachial plexus injury and hypoxic injury are the main fetal risks.

Massive obstetric haemorrhage: activate major haemorrhage protocol, give tranexamic acid 1 g within 3 hours, and use a 1:1:1 ratio of red cells, plasma, and platelets.