Antenatal Obstetrics 4 Flashcards
What is stillbirth? How common?
o Babies born dead after 24 weeks gestation
o 1 in 200 total births
Most common cause of stillbirth?
Idiopathic
Maternal causes of stillbirth?
Diabetes (pre-existing and gestational) Pre-eclampsia Sepsis Obstetirc cholestasis Acute fatty liver Thrombophilias (e.g. Protein C and protein S resistance, factor V leiden mutation, antithrombin II deficiency
Foetal causes of stillbirth?
Infection: Toxoplasma, Listeria, Syphilis, parvovirus Chromosomal abnormality Structural abnormality Rhesus disease leading to severe anaemia TTTS IUGR Alloimmune thombocytopaenia
Placental causes of stillbirth?
Postmaturity
Abruption
Placenta praevia: significant blled
Cord prolaspe
Other causes of stillbirth?
twins, social deprivation, increasing maternal age, smoking, previous CS, IVF, obesity
Diagnosis of stillbirth?
Absent foetal movements No foetal heart sounds Absent foetal heart beat on US (diagnostic) • Can repeat US if mother requests o Foetus looks macerated
Immediate management of stillbirth? When to advice delivery and how? Management of those not induced?
If Rh negative – give Anti-D
Kleihauer to diagnose foetomaternal haemorrhage
Ix – Temp, BP, urine, clotting screen
Advise delivery if pre-eclampsia, abruption, sepsis, coagulopathy, membrane rupture
• Induced using – mifepristone oral, prostaglandin vaginally and may need oxytocin
If not induced by 48h, check coagulopathy twice weekly
Some women choose to continue the pregnancy - >90% will spontaneously labour within 3 weeks
Management of stillbirth during labour?
Good analgesia
Wrap baby up and offer to present to mother
Photographs, lock of hair and palm print given
May need VTE prophylaxis
Practical steps following stillbirth?
Follow-up
Refer for genetic counselling if appropriate
Certificate of Stillbirth required
Bereavement counselling (SANDS)
Mother may be prescribed cabergoline to suppress lactation
Maternal tests performed to establish cause of stillbirth?
• Kleihauer, FBC, U&E, CRP, LFT, TFT, HbA1c, glucose, blood culture, viral screen (TORCH, etc), thrombophilia screen, antibodies, MSU, urine for cocaine, cervical swabs
Foetal tests performed to establish cause of stillbirth?
• Foetal and placental swabs, cord blood
• Post mortem
o If denied – MRI, cytogenetics, small volumes of tissue for metabolic studies
Define recurrent pregnancy loss? Risk factors?
• Three or more miscarriages occurring in succession before 24 weeks gestation (1% of couples).
• Risk Factors for future pregnancies
o Number of miscarriages
o Maternal age
Aetiology of recurrent misscarriages?
Antiphospholipid antibodies o Chromosomal defects (4% of couples) Uterine abnormalities are common with late miscarriage o Thrombophilia Bacterial vaginosis
What is antiphospholipid antibodies defined as?
Defined as presence of antibodies on 2 occasions plus 3 or more consecutive miscarriages <10 weeks, 1 foetal loss 10 weeks or older or 1 or more births of normal foetus >34/40 with severe pre-eclampsia or growth restriction
Common chromosomal defect causing recurrent miscarriages?
Usually balanced reciprocal or Robertsonian translocation
Common uterine defect causing recurrent miscarriages?
Cervical incompetence, polycystic ovary syndrome, adhesions etc.
Common thrombophilia causing recurrent miscarriages?
Factor V leiden, prothrombin gene and protein C and S deficiency
Investigations in recurrent miscarriages?
o Referral to specialist recurrent miscarriage clinic
o Tests for:
Antiphospholipid antibodies (positive if 2 tests +ve, 12 weeks apart)
Thrombophilia screening
Pelvic US to assess uterus
Karyotype foetal products
• If abnormal chromosome – karyotype parental blood
High cervical swab for bacterial vaginosis
Treatments in recurrent miscarriage - antiphospholipid syndrome?
Aspirin 75mg PO from day of positive pregnancy test
Enoxaparin 40mg SC as soon as foetal heart seen
Treatments in recurrent miscarriage - thrombophilia?
LMWH (Enoxaparin)
Treatments in recurrent miscarriage - bacterial vaginosis?
Treat infection
Definition of miscarriage?
- Loss of a pregnancy before 24 weeks gestation
Define early miscarriage?
- Early miscarriage, if it occurs before 13 weeks of gestation
Define late miscarriage?
- Late miscarriage, if it occurs between 13 and 24 weeks of gestation
How common are miscarriages?
- 15-20% of pregnancies miscarry, mostly in 1st trimester
- Rate increases with maternal age
Definition of threatened miscarriage?
o There is bleeding but the foetus still alive, the uterus is the size expected from the dates and the OS is closed.
o Only 25% will go on to miscarry
Definition of inevitable miscarriage?
o Bleeding is usually heavier.
o Although the fetus may still be alive, the cervical OS is open.
o Miscarriage is about to occur
Definition of incomplete miscarriage?
Some fetal parts have been passed, but the os is usually open.
Definition of complete miscarriage?
o All fetal tissue has been passed.
o Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.
Definition of septic miscarriage?
o The contents of the uterus are infected causing endometritis.
o Vaginal loss is offensive and the uterus is tender.
o A fever can be absent.
o If pelvic infection occurs there is abdominal pain and peritonism
Definition of missed miscarriage?
o The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or USS is performed
o The uterus is smaller than expected for dates and the OS is closed
Aetiology of isolated miscarriages?
- Isolated non-recurring chromosomal abnormalities – 60% of one off miscarriages
- Exercise, intercourse and emotional trauma DO NOT cause miscarriage
Symptoms and signs of miscarriage?
- Bleeding PV in first 24 weeks
- Pain
- Enquire about: nausea, vomiting, dizziness, fainting, shoulder tip pain, urinary symptoms, passage of tissue
- Need to assess state of os and uterine size
Investigations in miscarriage?
- Urine pregnancy test
- Blood hCG
- USS
- Bloods: FBC, Rh group, antiphospholipid antibodies, thrombophilia screening
- Blood culture
Initial management of early pregnancy bleeding? What about is haemodynamically unstable?
o If >6 weeks and no pain, tenderness, cerical motion tenderness – refer for EPAU services
o If <6 weeks and no pain – repeat pregnancy test in 7 days, if positive then refer to EPAU
o If unacceptable pain or bleeding – surgical management of miscarriage
Evacuation of retained products of conception (ERPC)
o Immediate admission if haemodynamically unstable
IV fluids
If bleeding profuse – ergometrine 0.5mg IM
If there is a fever, swabs for bacterial culture are taken and IV abx are given
Management of uncertain viability of miscarriage?
o Arrange rescan in 10-14 days
Counselling in patient suffering a miscarriage?
o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o There is a likelihood of bleeding, but foetal tissue usually absorbed
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages
Expectant management of non-viable miscarriages?
o Expectant management (wait for miscarriage to pass naturally without intervention)
Offer for 7-14 days when confirmed miscarriage
Offer rescan in 2 weeks to ensure complete if no significant bleeding or increasing bleeding/pain
Repeat pregnancy test at 3 weeks later and return if positive
Medical management of miscarriage? When offered? Process?
Offered when failed expectant treatment
Give analgesia and anti-emetic
Misoprostol either orally/vaginally
Bleeding should start within 24 hours and may continue for 3 weeks
80-90% successful in <9 weeks gestation
Pregnancy test after 3 weeks and return if positive
Surgical management of miscarriage?
If heavy or persistent bleeding > 2 weeks, infected retained tissue or patient choice
Manual vacuum aspiration under LA in clinic OR Suction evacuation under GA in theatre
o Anti-D immunoglobulin given to all surgical patients
Complications of expectant miscarriage?
o Expectant leads to higher risk of incomplete miscarriage, need for surgical emptying or transfusion
Follow-up of patient with miscarriage?
- Cancel routine antenatal appointments
- Discuss questions patients have
- Avoid sex until symptoms of miscarriage settled completely
- Menstruation expected to resume within 4-8 weeks of miscarriage and ovulation will occur before that
- Provide leaflet
Complications of miscarriage?
- Heavy vaginal bleeding.
- Infection (can lead to endotoxic shock, hypotension, renal failure, ARDS, and DIC)
- Surgical → Asherman’s syndrome (adhesions in the uterus) or perforated uterus, infection, haemorrhage, cervical tears, intra-abdominal trauma
Counselling needed on grief for miscarriage?
o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages
Aetiology of mid-trimester miscarriage?
o May be due to mechanical causes (cervical weakness), uterine abnormalities, chronic maternal disease (DM, SLE), infection or no cause identified
Management of mid-trimester miscarriage?
o Cervical cerclage at 14 weeks of pregnancy – removed prior to labour
o Investigate to ensure any treatable cause is treated next time
Define VBAC?
o Woman gives birth vaginally, having had a C-section in the past
Success of VBAC?
o After 1 C-section, ¾ of women with straightforward pregnancy who go into labour give birth vaginally
o Successful vaginal birth more likely if:
Previous vaginal birth (8-9/10 will be success)
Labour starting naturally
BMI<30 at booking
Advantages of VBAC?
o If success vaginal birth: Greater chance of future vaginal births Recovery quicker, drive sooner Stay in hospital may be shorter Avoid operative risks Less respiratory problems in neonate
Disadvantages of VBAC?
o May need Emergency LSCS (25/100)
o Higher risk of:
Needing for blood transfusion compared to planned C-section
Uterine rupture (2-3x increase risk)
Emergency C-section higher risk of foetal death and brain injury
May need Ventouse or forceps delivery
More likely to tear muscle that controls anus (third- or fourth-degree tear)
Define FGM?
o Removal or partial removal of external female genitalia or injury to other internal female genital organs
o Illegal in UK under 2003 FGM Act and recognised form of child abuse
Most common areas for FGM?
o Traditionally practiced in Africa, but some parts of India and Indonesia
o In UK most affected women come from:
Somalia, Sudan, Kenya, Eritrea, Ethiopia, Yemen, Mali, Guinea, Egypt
How common is each type of FGM?
o 90% Types 1, 2 and 4
o 10% Type 3
What is type 1 FGM?
o Type 1 – Partial or total removal of clitoris and/or prepuce (clitoridectomy)
What is type 2 FGM?
o Type 2 – Partial or total removal of clitoris and labia minora, with or without excision of labia majora
What is type 3 FGM?
o Type 3 – Narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning of labia minora/labia majora, with or without excision of clitoris (infibulation)
What is type 4 FGM?
o Type 4 – Any other harmful procedures to female genitalia for non-medical purpose (pricking, piercing, cauterisation, incising and scraping)
Acute complications of FGM?
o Death, blood loss, sepsis, pain, urinary retention, tetanus, hepatitis and HIV
o Often unhygienic – by traditional circumciser, usually no anaesthesia and shared blades
Long-term sequelae of FGM?
o Aparenunia, superficial dyspareunia, anorgasmia, sexual dysfunction, chronic pain, keyloid scare, UTI, subfertility, HIV, emotional trauma
o Fear of childbirth, risk of CS, postpartum haemorrhage, episiotomy, vaginal lacerations
Management of FGM?
o Should report and safeguarding issue
o De-fibulation may be performed before marriage, electively at 20 weeks gestation or in 1st stage of labour
o If not correct antenatally – manage in unit with emergency obstetric care and get expert advice
o Offer epidural
o Repair – control bleeding (Re-infibulation is ILLEGAL)
Maternal conditions in pregnancy - cardiac disease - how common?
- Affects <1% of pregnancies
Maternal conditions in pregnancy - cardiac disease - how common is IHD?
More common now women are giving birth later and later
May have atypical symptoms
Maternal conditions in pregnancy - cardiac disease - Problems with pulmonary hypertension? Where do they need to managed?
Mortality rate of 25-40% in pregnancy
Due to lung disease, connective tissue disease, primary, veno-occlusive and Eisenmenger syndrome
Advise against pregnancy and offer ToP
Manage pregnancy in tertiary centre
Maternal conditions in pregnancy - cardiac disease - Congenital heart disease - most common and problems?
Most commonly PDA, ASD and VSD
If cyanotic and uncorrected, increased risk of IUGR
Refer for foetal echocardiography
Maternal conditions in pregnancy - cardiac disease - Marfans syndrome risks and management?
Autosomal dominant with 80% cardiac involvement with mitral valve prolapse and/or aortic root dilatation
Risk of aortic rupture and dissection
Offer root replacement pre-pregnancy and LSCS if root >4.5cm
Maternal conditions in pregnancy - cardiac disease - Mitral stenosis monitoring/treatment?
Monitor with echo, aggressively treat AF (digoxin and BB safe), treat pulmonary oedema
Maternal conditions in pregnancy - cardiac disease - artificial heart valves treatment?
Warfarin throughout pregnancy, treatment-dose LMWH 6-12 weeks or LMWH throughout
Maternal conditions in pregnancy - cardiac disease - peripertum cardiomyopathy definition, referral?
Heart failure without known cause and no previous heart disease
Onset 1 month pre- and 5 months post-partum
Diagnosis by echo
Manage – elective delivery, anticoagulants, treatment for HF and may need LV assist devices
Antenatal management of cardiac disease in pregnancy?
o Regular cardiology/obstetric combined clinic visits
Prevent anaemia, obesity and smoking
Treat hypertension
Exclude pulmonary oedema and arrhythmias at each visit
Refer for Echo
o HF needs admission
Labour of cardiac disease in pregnancy?
o Have O2 and drugs to treat cardiac failure ready
o Aim for vaginal delivery at term, may need LSCS
o Use oxytocin
Risks of sickle cell in pregnancy??
- Increased risk of painful crises, perinatal mortality, premature labour and foetal growth restriction
Preconception review and management for sickle cell disease?
o Annual review, sickle specialist review
Screen for red cell antibodies& check partners carrier status
Echocardiogram
BP, urinalysis, U&E, LFT, Retinal screening
Daily penicillin/erythromycin
Vaccines up to date
o Stop ACE and hydroxycarbamide >3 months preconception
o 5mg Folic Acid daily throughout pregnancy
Antenatal management of sickle cell disease in pregnancy? Management of hospital admission and sickle cell crisis?
o Manage specialist MD team or high-risk protocols
growth scan 4-weekly from 24 weeks
o From 12 weeks – daily aspirin 75mg
o Admit with crises – IV opioids, nasal O2, fluids
Delivery management of sickle cell disease in pregnancy?
o Delivery 38-40 weeks at specialist hospital
o Continuous foetal monitoring and maternal O2 sats
o 7 days LMWH post-vaginal delivery, 6 weeks if CS
o Progestogenic contraception 1st choice
How common is transmission of HIV in pregnancy??
- Without intervention 15% babies acquire HIV
o 2/3 vertical transmission during vaginal delivery and breastfeeding & membrane rupture >4h doubles risk
Antenatal care of HIV mother in pregnancy?
o MDT care with HIV physician
HIV tests & genital infection screen at booking and 28 weeks (can do rapid labour tests)
Check Hep B&C, VZV, measles, toxoplasmosis antibodies
Offer vaccines to HepB, pneumococcal and influenza
o Continue HAART, if not on – give 24 weeks
o If on co-trimoxazole (P.jirovecii prophylaxis), offer folic acid 5mg daily
Management of premature labour in HIV mother?
o If >34 weeks – expedite delivery
o If <34 weeks – steroids, erythromycin and take HAART, seek specialist advice
When to perform vaginal and LSCS delivery in HIV?
o Vaginal Delivery
If viral load <50 (<400 if on HAART), continue HAART in labour
Avoid FBS, amniotomy
Low cavity forceps preferred
o Elective CS
38 weeks if on zidovudine monotherapy/HAART/high viral load/Hep C/not on HAART
If viral load <50 and CS needed – 39+ weeks
Postpartum care of HIV mother pregnancy:?
o Avoid breast-feeding
o Cabergoline 1mg PO within 24h (suppresses lactation)
o Neonates within 4h:
Zidovudine BD for 4 weeks and HAART if high risk (untreated mother/viral load >50)
Co-trimoxazole PCP prophylaxis
o Tested at day 1, 6 weeks, 12 weeks for HIV with confirmation at 18 months
o Contraception – IUD, condoms, depot suitable
Hyperthyroidism in pregnancy is usually what? Associated with what? Management?
o Usually Graves’ disease
o Associated with infertility, foetal loss and malformations
o Transient exacerbations may occur in 1st trimester and postpartum
o Carbimazole and propylthiouracil (PTU mostly)
Monitor levels and TFTs
o Partial thyroidectomy can be done in 2nd trimester if dysphagia/malignancy/large goitre
Hypothyroidism in pregnancy associated with? Management?
o Untreated associated with infertility, oligomenorrhoea or menorrhagia, stillbirth, miscarriage, anaemia, pre-eclampsia and IUGR
o Reduced IQ and neurodevelopmental delay
o Optimise T4 preconception and each trimester
o Replace with levothyroxine
Post-partum thyroiditis features and management?
%, hyperthyroidism followed by hypothyroidism
o Hyperthyroidism – usually self-limiting but may need BB
o Monitor hypothyroid for 6 months and treat if symptomatic – withdraw at 12 months to see if long-term treatment needed
o Associated with postpartum depression
Management of asymptomatic bacteriuria in pregnancy?
o If present on MSU – cefalexin 500mg PO TDS given
Avoid trimethoprim in 1st trimester and nitrofurantoin in 3rd trimester
o Check MSU on each visit
o Treat cystitis as per asymptomatic bacteriuria
Management of pyelonephritis in pregnancy?
o More common due to dilatation of upper renal tract in pregnancy
o Blood and urine cultures needed
o IV Cefuroxime, if sepsis consider stat dose of gentamicin
o If for at least 24 hours and oral 2-3 weeks
o Check MSU and renal function regularly
Management of chronic renal disease in pregnancy?
o Risks of miscarriage, pre-eclampsia, IUGR, preterm delivery
o Avoid pregnancy if severe renal disease as expect further deterioration
o Outcome poor if on dialysis
Management of AKI in pregnancy?
o Causes – Sepsis, HELLP, hypovolaemia, volume contraction, NSAIDs
o Monitor urine output and fluid balance carefully, U&E
o Aim>30ml/hr
o Specialist advice needed about diuretics and dialysis
Management of rheumatoid arthritis in pregnancy?
o Usually alleviated by pregnancy
o DO NOT USE METHOTREXATE
o Sulfasalazine can be used
o NSAIDs used in 1st and 2nd trimesters
Management of SLE in pregnancy?
o Exacerbations common, most moderate and involve skin
o Planned pregnancy needs 6 months stable disease with azathioprine and hydroxychloroquine
o Aspirin 75mg given throughout pregnancy
o Prone to pre-eclampsia
Hydralazine and methyldopa can be used for pre-eclampsia
o If needing prednisolone >7.5mg daily 2 weeks before delivery, IV hydrocortisone used in labour
Features, investigations of antiphospholipid in pregnancy?
o Antiphospholipid antibodies (lupus anticoagulant +/- anticardiolipin antibodies on 2 tests taken 8 weeks apart) present
o Often baby dies due to 1st trimester loss or placental thrombosis
o Need regular foetal Doppler and US for growth from 20 weeks
MAnagement of antiphospholipid in pregnancy?
o Aspirin 75mg OD and Enoxaparin 40mg SC/24h from when foetal heart identified (6 weeks)
o Postpartum – use heparin or warfarin as thrombosis risk high
Management of epilepsy in pregnancy?
- MDT management
- Folic acid 5mg
- Foetal risks – NTD, orofacial cleft, CHD, foetal anticonvulsant syndrome
- Anticonvulsants 1st line - Lamotrigine, leviteracetam
- AVOID SODIUM VALPROATE
- AED dose may need increasing
- Oral Vit K in last 4 weeks of pregnancy
When would you not perform a VE?
Pregnant women not in established labour
Monitoring in VBAC?
EFM
Deliver in a unit where there is immediate access to CS and on-site blood transfusion.
With induction of labour, increased risk of uterine rupture if oxytocin infusion or prostaglandin infusion used
CI of VBAC?
Previous uterine rupture
Classical C-Section incision
Other CI for vaginal delivery
Indications of VBAC?
Singleton cephalic of 37 weeks with one VBAC
Need consultant review of 2 or more VBAC
