Complications with Pregnancy and Labour Flashcards
What is pre-eclampsia
A pregnancy-specific multi-system disorder which usually occurs after 20 weeks
Pregnancy induced hypertension + proteinuria
Also get oedema
May also see maternal AKI, liver dysfunction, neuro features, fetal growth restriction
What are the risk factors for pre-eclampsia
Pre-existing hypertension, diabetes, autoimmune diseases (eg lupus), renal disease, a family history of pre-eclampsia, obesity, maternal age >40 and women with a multiple pregnancy
Most significant risk is previous pre-eclampsia
What happen to the kidneys in pre-eclampsia
Kidney function declines
Leads to salt and water retention - oedema formation (esp hands and face)
Renal blood flow and Glomerular filtration rate decreases
AKI is a comm
How do you treat eclampsia
Vasodilators and cesarean section
Only way to treat is to get the baby out
What is the risk with eclampsia
Lethal if not treated
What is eclampsia
Extreme pre-eclampsia - usually preceded by the normal symptoms
Causes vascular spasms, extreme hypertension, chronic seizures and coma
What is placenta praevia
When the placenta is low lying in the womb and covers all or part of the cervix - cut off is 2.5cm from the cervical os
It has an increased risk of haemorrhage
If found on US you need follow up scan to monitor its position
What genetic screen is offered to all pregnant women
A screening test for Down syndrome
Very accurate test - 90%
What is the link between down’s syndrome and maternal age
As maternal age increases so does the risk of Down’s syndrome
How do you test for Down’s syndrome in the 1st trimester
Measure of fluid thickness behind foetal neck using ultrasound (Nuchal thickness; NT)
As the thickeness/amount of fluid increases so does the risk of abnormality
Measured at 11-13+6 weeks
Combine this with maternal age and a measurement of HCG, AFP and PAPP-A (blood test)
This is 90% accurate
How do you test for Down’s syndrome in the 2nd trimester
Blood sample at 15-20 weeks
Assay of HCG and AFP
Also look at inhibin and oestriol
Combined with risk factors- age etc.
Describe the Harmony test
The test detects foetal DNA fragments in a sample of blood taken from the mother
Could be used to identify genetic conditions in the foetus
Non-invasive test
When is amniocentesis carried out
Usually performed after 15 weeks
When is chorionic villus sampling carried out
Usually performed after 12 weeks
11 and 13+6 weeks
What is the risk with amniocentesis and CVS
Miscarriage risk - both carry a risk of around 2%
CVS also comes with a risk of amniotic fluid embolism
What are the risk factors for gestational diabetes
BMI above 30kg/m2
Previous macrosomic baby weighing 4.5kg or above
Previous gestational diabetes
Family history of diabetes
Minority ethnic family origin with a high prevalence of diabetes
How do you diagnose gestational diabetes
a fasting plasma glucose level of 5.6mmol/litre or aboveor
a 2‑hour plasma glucose level of 7.8mmol/litre or above.
When would you need to regularly monitor foetal growth
Women with a single SFH which plots below the 10th centile or serial measurements which demonstrate slow or static growth
Women in whom measurement of SFH is inaccurate (for example: BMI > 35, large fibroids, hydramnios)
Which women are at high risk of pre-eclampsia
Those with:
hypertensive disease during a previous pregnancy
chronic kidney disease
autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension.
What treatment should women at high risk of pre-eclampsia be given
75mg of aspirin daily from 12weeks until the birth
Used for all women with previous case of pre-eclampsia and others with risk factors
What is the marker detected by pregnancy tests
BhCG
It has very high sensitivity
List abnormal pregnancy outcomes
Miscarriage
Ectopic pregnancy - abnormal location
Molar pregnancy - abnormal embryo
What cervical pathologies can lead to bleeding
Infection -e.g. STI
Malignancy
Polyps - benign but cna bleed if ulcerated
Cervical erosion - more common in pregnancy
What vaginal pathologies can cause bleeding
Infection
Malignancy (rare in reproductive age group)
Genital injury - consider domestic abuse/rape
What are the main symptoms of a miscarriage
Bleeding
Period type cramping
May have passed larger products/clots
Will have had a positive pregnancy test
How can you stage a miscarriage by speculum exam
Cervical os closed = threatened miscarriage
Products are seen at an open os = inevitable miscarriage
Products are seen in the vagina and the os is closing = complete
What are the symptoms of cervical shock
Cramps Severe abdominal pain Nausea and vomiting Sweating Fainting Bradycardia and hypotension
How do you use a scan to stage a miscarriage
US of uterus
If pregnancy in situ = threatened
May see pregnancy in process of expulsion = inevitable
Or an empty uterus = complete
How do you manage cervical shock
Resolves if products removed from cervix - definitive treatment Resuscitation with IV fluids, Uterotonics maybe required.
What can cause miscarriage
Embryonic abnormality : Chromosomal
Immunologic : APS
Infections : CMV, Rubella, Toxoplasmosis, Listeriosis
Severe emotional upsets, stress
Iatrogenic after CVS or amniocentesis
Associations: heavy smoking, cocaine, alcohol misuse
Uncontrolled diabetes, obesity, severe hypertension
PCOS
Uterus abnormalities
Sometimes unknown
What are the different types/stages of miscarriage
Threatened Miscarriage - risk to pregnancy
Inevitable Miscarriage - pregnancy can’t be saved
Incomplete Miscarriage - part of pregnancy lost already
Complete Miscarriage - all of pregnancy lost, uterus is empty
What is early foetal demise
Pregnancy is in situ but there is no heartbeat
Has a mean sac diameter
of over 25mm and/or a foetal pole of over 7mm
What is an anembryonic pregnancy
When there is no foetus but an empty sac
How do you manage a miscarriage
Assessing and ensuring haemodynamic stability.
- FBC, G and S, ẞhCG, test rhesus status
BHCG - will be declining in miscarriage
Examination
USS - determine if viable
Histology
Sensitive discussion and emotional support
Might discharge or admit - depends on outcome
Treatment: Conservative, Medical, MVA/Surgical
Anti-D administration if surgical intervention is needed
What is the definition of recurrent miscarriage
3 or more consecutive pregnancy losses
What are some of the risk factors for recurrent miscarriage
Antiphospholipid Syndrome Thrombophilia Balanced translocations Uterine abnormalities - particularly if late 1st trimester loss Obesity
How can you prevent recurrent miscarriage in women with high risk blood disorders
Use of low dose aspirin and daily Fragmin injections after confirmation of viable IUP in evidence of APS or Thrombophilia
Aspirin can be started before or when the patient takes a positive pregnancy
test and low molecular weight heparin should be started when intrauterine pregnancy is
confirmed
What is an ectopic pregnancy
Implantation is out with the uterine cavity
What are the common sites for an ectopic pregnancy
Fallopian tube most common
Other sites include, ovary, peritoneum, C-section scars or other abdominal organs
How does an ectopic pregnancy present
Pain - localized to one side, pevic or abdominal Bleeding - light PV Discharge Dizziness and collapse Shoulder tip pain SOB
Pallor
Haemodynamic instability - shock, hypotension, high HR
Signs of peritonism, guarding and tenderness
Acute abdomen is a sign of rupture
What are the red flags for ectopic pregnancy
Repeated presentation with abdo/pelvic pain
Pain requiring opiates in a woman known to be pregnant
How do you investigate an ectopic pregnancy
FBC, GandS, BhCG
Usually a sub-optimal rise in HCG
Transvaginal US - look for empty uterus, pseudo sac or mass elsewhere
Free fluid in Pouch of Douglas suggests rupture
How do you manage an ectopic pregnancy
Surgical management
- if patient is acutely unwell or have a large or ruptured ectopic (only safe option)
- remove the pregnancy laparoscopically if possible
- may lose affected tube
Medical management
- if woman is stable, low levels of ẞhCG (up to 5000) and ectopic is small and unruptured
- methotrexate is used (either one or 2 doses)
- continue HCG monitoring
Conservative management
- for “ the well patient” who is compliant with follow-up visits
- only if small, unruptured and HCG falling
- allow nature to take it’s course
- repeat pregnancy tests to ensure pregnancy has ended (HCG should fall)
What is a complete mole
Egg without DNA
1 or 2 sperms fertilise, result in diploid - fathers DNA only
Leads to 46 XX or 46 XY karyotype
No foetus but an overgrowth of placental tissue
What is the major risk associated with a complete mole
Risk of it becoming choriocarcinoma
Around 2.5% risk
What is a partial mole
Haploid egg
Fertilized by either 1 sperm which duplicates DNA material or 2 sperms result in triploidy
Has a karyotype of 69 XXX or 69 XXY
May have unviable or absent foetus and overgrowth of placental tissue
How does a complete molar pregnancy present on US
Snowstorm appearance in uterus due to multiple placental vesicles
These are grape like clusters swollen with fluid
How might a molar pregnancy present
Hyperemesis
Varied bleeding and passage of “grapelike tissue”
Fundus large for dates dates.
Occasional shortness of breath
How do you manage a molar pregnancy
Surgical removal of the mole
Tissue is sent for histology to determine if partial or complete
Follow-up with Molar Pregnancy Services - centers in Dundee, Sheffield and London
What is implantation bleeding
Small amount of bleeding that occurs as the fertilised egg implants
Bleeding is light/brownish and limited
Soon signs of pregnancy emerge
Usually settles and pregnancy continues
What is a chorionic haematoma
Pooling of blood between endometrium and the embryo due to separation
How might a chorionic haematoma present
Bleeding, cramping, threatened miscarriage
May lead to infection and miscarriage if large
How do you manage a chorionic haematoma
Usually self limited and resolve - reassure
Closely monitor
How do you treat BV during pregnancy
Metronidazole 400mg b.d. 7 days
How do you treat chlamydia during pregnancy
Erythromycin, Amoxycillin
TOC 3 week later
What symptom is usually worse in miscarriage - pain or bleeding
Bleeding is usually predominant
Pain varies
When is anti-D used in miscarriage/molar ect
Given to rhesus negative women who go for surgical management
Higher risk of blood mix
What is hyperemesis gravidarum
Excessive and prolonged vomiting in pregnancy which alters quality of life
Is severe enough to cause dehydration and biochemical derangement
What are the complications of hyperemesis gravidarum
Dehydration, ketosis, electrolyte and nutritional disbalance
Weight loss, altered liver function
Malnutrition
Also puts a strain on mental health
How do you manage hyperemesis gravidarum
Rehydration IV, electrolyte replacement. Parenteral antiemetic Nutritional supplement Vitamin supplement : Thiamine/Pabrinex NG feeding or even TPN if severe May get PPI or H2 receptor blocker for reflux Steroid use in recurrent, severe cases Thromboprophyaxis - pregnancy and dehydration are hypercoaguable states
What are the first line anti-emetics for HG
Cyclizine
Prochlorperazine
What is the definition of being large for dates
Symphyseal-fundal height >2cm for Gestational age
What can be the underlying cause of being large for dates
Wrong dates - further along than thought
Foetal Macrosomia - big baby
Polydramnios - excess fluid
Diabetes - insulin resistance promotes fat storage
Multiple Pregnancy
What are the risks associated with foetal macrosomia
Clinician and maternal anxiety Labour dystocia - difficult birth Shoulder dystocia- more with diabetes Failure to progress Perineal trauma Post-partum haemorrhage
How do you diagnose foetal macrosomia
US scan - estimated foetal weight above 90th centile
Abdominal circumference above 97th centile
How do you manage foetal macrosomia
Exclude diabetes
Reassure
Usually have to induce labour before 40 weeks for a large baby
Some will need a C-section (if over 5kg)
What is the definition of polyhydramnios
Excess amniotic fluid
Amniotic Fluid Index >25cm
Deepest pool of fluid >8cm
What can cause polyhydramnios
Maternal diabetes - due to foetal polyuria
idiopathic
Anomaly- GI atresia, diaphragmatic hernia cardiac, tumours
Monochorionic twin pregnancy
Viral infection
Hydrops foetalis
What are the symptoms and signs of polyhydramnios
Abdominal discomfort Pre-labour rupture of membranes Preterm labour Cord prolapse Malpresentation Tense shiny abdomen inability to feel foetal parts
What investigations should you do for polyhydramnios
Oral Glucose Tolerance Test - check for diabetes
Serology - looks for viral cause
Antibody Screen
USS – foetal survey (looking for good swallow)
How do you manage polyhydramnios
Inform the patient of the complications and the birth plan
Serial US to monitor
Induction of labour by 40 weeks - risk of death of they go over
What are the risks during labour due to polyhydramnios
Risk malpresentation
Risk of cord prolapse
Risk of Preterm Labour
Risk of PPH
What factors increase your chance of having a multiple pregnancy
Assisted conception Race/Geography- African Family History Increased maternal age Increased Parity Tall women
Describe zygosity
How many eggs where involved
Monozygotic : splitting of a single fertilised egg
Dizygotic: fertilisation of 2 ova by 2 spermatozoa
More common
Describe chorionicity
Number of placentas
1 or 2?
1 has higher risk, especially if they are in the same amniotic sac
At what point will twins be conjoined
If they don’t separate fully by day 15
What type of twins have the highest risk
Monochorionic / monozygous twins
More likely to have complications
What are the symptoms and signs of a multiple pregnancy
Exaggerated pregnancy symptoms e.g. excessive sickness High AFP Large for dates uterus Multiple foetal poles US to confirm at 12 weeks
What are the complications of multiple pregnancy to the foetus
Congenital anomalies Intrauterine death Pre term birth Growth restriction- Cerebral palsy - higher risk Twin to twin transfusion
What are the complications of multiple pregnancy to the mother
Higher mortality Hyperemesis Gravidarum Anaemia Pre eclampsia Antepartum haemorrhage- abruption, placenta praevia Preterm Labour Caesarean section
How often do you need to see women with multiple pregnancy
MC: every 2 weeks
DC every 4 weeks
Get an US at each visit
What medication should women with multiple pregnancy take
Fe supplementation
Low Dose Aspirin
Folic Acid
What is twin to twin transfusion syndrome
When there is an artery/vein anastomosis between the twins
One will perfuse the other
Gives Oligohydramnios- polyhydramnios - one with excess one with to little
How do you treat twin to twin transfusion
Before 26/40 – foetoscopic laser ablation
>26/40- amnioreduction /septostomy
Deliver 34-36/40
When should you deliver twins
DCDA Twins deliver 37-38 weeks
MCDA Twins deliver after 36+0 weeks with steroids.
What is the max time you should allow between delivery of the first twin and second
Aim to deliver both in under 30 mins
Give Syntocinon after twin 1 to speed up
What is the definition of gestational diabetes
carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy
What are the complications of uncontrolled pre-existing diabetes in pregnancy
Congenital anomalies
Miscarriage
Intra uterine death
Worsening diabetic complications eg retinopathy, nephropathy
What are the complications common to both uncontrolled pre-existing diabetes and gestational diabetes s
Pre eclampsia Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia
Why does neonatal hypoglycaemia occur after delivery from a diabetic mother
Baby is used to her high glucose levels so it’s own insulin levels are raised to cope with them
After delivery they no longer get the high glucose so their high insulin is too much - hypo
What advice should you give to diabetic women before they conceive
Aim for HBA1C of 48
Avoid pregnancy if its too high
Stop any embryopathic medication eg ACE inhibitors, cholesterol lowering agents
Start high Dose Folic Acid 5mg
Which diabetic drugs can you use in pregnancy
Insulin- MDI /Insulin pump
Metformin (Type 2)
Which drugs should women with pre-existing diabetes be started on
Folic Acid 5mg
Low Dose Aspirin from 12 weeks
What are the risk factors for developing gestational diabetes
Previous GDM Obesity BMI 30 or more FH: 1st degree relative Ethnic variation: South Asia (India / Pakistan / Bangladesh), Middle Eastern, Black Caribbean Previous big baby Polyhydramnios Big baby
Is it normal to become insulin resistant in pregnancy
Yes
The pregnancy hormones Human placental lactogen, cortisol can cause this
Some women cannot compensate fully so get the diabetes
How do you diagnose gestational diabetes
Oral glucose tolerance test
Fasting >=5.1 mmol/l
2 hour >=8.5 mmol/l
What is the risk of the baby and mum going on to develop diabetes after a pregnancy with GD
Increased risk for the baby of obesity and diabetes in later life
Increased risk of type 2 diabetes for the mother
How do you manage diabetes in pregnancy
Diet, weight control and exercise Monitor for PET - BP and urine Growth scans Consider Hypoglycaemic agents - insulin Monitor babies BM after birth as risk of neonatal hypoglycaemia
What is the definition of a preterm delivery
Delivery before 37 weeks gestation
Extreme = 24-27+6 weeks
Very = 28-31+6 weeks
Moderate to late preterm = 32-36+6 weeks
What is considered a term pregnancy
Anything above 37 weeks
What can lead to a preterm birth
Infection Over distension = Multiple or polyhydramnios Placental abruption Intercurrent illness: UTI, appendicitis Cervical incompetence Idiopathic
What are the risk factors for preterm birth
Previous PTL Multiple Uterine anomalies Age (teenagers) Parity (=0 or >5) Ethnicity Poor socio-economic status Smoking Drugs (especially cocaine) Low BMI (<20)
What is the definition of small for gestational age
Estimated foetal weight or abdominal circumference below the 10th centile
What is intra-uterine growth restriction
Failure to achieve growth potential
What is the definition of low birth weight
Below 2.5kg
Regardless of gestation
How do you identify a small for gestational age foetus
Antenatal risk factors - mothers age over 40, smoker, cocaine etc
Screening during antenatal care - SFH at 24 weeks
Measure foetal abdominal circumference, head circumference +/- femur length
When are all women measured for symphysial-fundal height
24 week scan
What maternal factors can lead to a small foetus
Smoking Alcohol Drugs Height and weight -small Age Maternal disease e.g. hypertension
What placental factors can lead to a small foetus
Infarcts
Abruption
Often secondary to hypertension
What foetal factors can lead to a small foetus
Infection e.g. rubella, CMV, toxoplasma
Congenital anomalies e.g. absent kidneys
Chromosomal abnormalities e.g. Down’s syndrome
What are the consequences of intra-uterine growth restriction
Risk of hypoxia and death in labour Hypoglycaemia Effects of asphyxia Hypothermia Polycythaemia Hyperbilirubinaemia Abnormal neurodevelopment
What are the features of poor intrauterine growth
Predisposing factors
Fundal height less than expected
Reduced liquor
Reduced foetal movements
How do you monitor a small for dates baby
Growth scans combined with Doppler assessment - repeat regularly
Cardiotocography
Biophysical assessment - movement, liquor, breathing
How should blood flow through the umbilical artery
Should have a constant flow of blood to baby even in diastole.
If there are breaks in flow to the baby or even backflow then it is worrying
What should be given to a premature baby before planned delivery
Steroids - lung maturity
Magnesium sulphate - cerebral palsy
What is the commonest cause of maternal death
Cardiac problems
What are obese women at high risk of during pregnancy
Blood clots
including in early pregnancy
What are the red flags for CV disease in pregnancy
Chest pain - they need an ECG
SOB when lying flat
Struggling to climb stairs - need echo and 24hr ECG
Are murmurs and palpitations common in pregnancy
YES - very common
Most of the time they are benign
Why might a woman with a heart condition not cope with pregnancy
Heart needs to work 40% harder in pregnancy so if they have an existing heart problem it might not cope
Can have aortic dissection as the pressure splits the vessel
Is tachycardia normal in pregnancy
Yes
Should still investigate for potential pathology
Why is it risky to put a pregnant women under anaesthetic
Less residual capacity in pregnancy as the lungs are working harder
Desaturate quickly if under anaesthetic
What is a red flag for breathlessness in pregnancy
Only if it impacts daily activity
Otherwise it is quite common and usually improves on exertion
What is the most common chronic medical disorder to complicate pregnancy
Asthma
Its a very common condition itself
Acute exacerbations can be dangerous in pregnancy
May improve, deteriorate or remain unchanged - 1/3 do each
Why do pregnant women need the flu jab
Women are slightly immunocompromised in pregnancy so higher risk
How do you test asthma in pregnancy
Treat asthma the same as if not pregnant
Increase dose and or frequency of inhaled steroids is first step if its gotten worse
What is the risk of poorly controlled asthma in pregnancy
Severe exacerbations during pregnancy or poorly controlled asthma are risk factors for low birth weight babies, premature rupture of membranes, premature delivery and hypertensive disorders
What happens to risk of VTE in pregnancy
It increases by 4-6x
Vast majority occurs in the left leg
How can you investigate a VTE in pregnancy
Compression duplex ultrasound - if normal but still suspect then repeat in a week
How do you treat VTE risk in pregnancy
LMWHs are the agents of choice for antenatal thromboprophylaxis
Dose is weight adjusted
They are effective, safe and don’t cross the placenta
Given antenatally and for 6 weeks postnatal
How do you investigate PE in pregnancy
CXR and V/Q scans are safe to do in pregnancy
Also do an ECG
Can you give warfarin to a pregnant woman
No
Teratogenic in 1st trimester
In 2nd and 3rd it crosses the placenta - which increases bleeding risk for baby
Don’t give rivaroxaban either
It is safe to take while breastfeeding though wait several days due to PPH risk
What happens to connective tissue diseases in pregnancy
Significant risks of aggravation of disease by pregnancy
Many of the drugs used are not safe in pregnancy
What are the clinical features of anti-phospholipid syndrome in pregnancy
Recurrent early pregnancy loss
Late pregnancy loss - usually preceded by FGR
Placental abruption
Severe early onset pre-eclampsia
Severe early onset Fetal Growth Restriction
How do you manage anti-phospholipid syndrome in pregnancy
Aspirin +/- fragmin
Stop warfarin if they’re on it
A lot more foetal observation
May suggest as early delivery
What is the risk of uncontrolled epilepsy in pregnancy
10x risk of maternal death Risk of abdominal trauma during seizure Preterm births Hypoxia and acidosis Many of the drugs are teratogenic and related to congenital malformations
What happens to seizure frequency in pregnancy
For most women seizure frequency is improved or unchanged
Good seizure control is important
Should you stop anti-epileptics in pregnancy
No - the seizures are too high a risk
Can trial lower doses or monotherapy before pregnancy/conception to see if it will work
Which anti-epileptic is associated with neural tube defects
Sodium valproate
It must be avoided if possible in all women of reproductive age
What increases the risk of seizures during labour
Stress, pain, sleep deprivation, over-breathing and dehydration
If a woman has a seizure during labour what can happen
If generalised tonic-clonic seizures occur, maternal hypoxia, foetal hypoxia and acidosis may result
If a woman collapses during pregnancy how should you position her
Left lateral tilt
to take pressure off the IVC and aorta (uterus will press on them if flat on back)
How do you treat an intra-partum seizure
Left lateral tilt IV lorazepam / diazepam PR diazepam / buccal midazolam IV Phenytoin May need to expedite delivery by CS
What can lead to an abnormal labour
Malpresenation - breech
Malposition - facing wrong way and more likely to get stuck
More common if baby is early or late
Obstruction or foetal distress
What are the risks with a vaginal breech delivery
Risk of head entrapment or foetal injury
Can cause foetal hypoxia or distress
Prolapse of the cord
Risk of cord compression Increased risk of over extension of the neck when delivering the head last
Harder to get the head out
Compression of the head can be too quick in breech (hasn’t had time to slowly remould) so you have to deliver the head slowly
What is considered a late/post term birth
Over 42 weeks is considered late and will be offered an induction
If labour is too fast, what effect does it have on the baby
Fast labour can lead to foetal hypoxia as lack of a break between contractions means the placental vasculature doesn’t have time to refill and baby can be under perfused
What are the risks of an obstructed labour
Sepsis - ascending infection uterine rupture obstructed AKI postpartum haemorrhage fistula formation - lots of pressure on vaginal wall foetal asphyxia neonatal sepsis
What may cause a failure to progress in labour
Power = Inadequate contractions: frequency and/or strength Passages = Short stature / Trauma / Shape of pelvis Passenger = big baby or malposition
What is a partogram
A chart that monitors the progress of labour It records: Foetal Heart Amniotic Fluid Cervical Dilatation Descent Contractions Obstruction - Moulding Maternal Observations
What is meconium staining a sign of
Foetal distress
How often should you check the baby’s heart
Stage 1 labour = during and after a contraction
Stage 2 = At least every 5 minutes during & after a contraction for 1 whole minute
What are some risk factors for foetal hypoxia
Small fetus Preterm / Post Dates Antepartum haemorrhage Hypertension / Pre-eclampsia Diabetes Meconium Epidural analgesia Induced labour
What are the acute causes of foetal distress
Abruption Vasa Praevia - bleeding from the foetal circulation Cord Prolapse Uterine Rupture Feto-maternal Haemorrhage Uterine Hyperstimulation Regional Anaesthesia
What is the normal heart rate for a term baby
110-150
Should you get accelerations in the foetal HR
YES
Want to see accelerations in the HR as it shows baby is moving about normally
Should you get decelerations in the foetal HR
Normal to decelerate slightly during a contraction – should recover quickly
They are also normal before 26 weeks
Be concerned if at end of contraction or if they last longer
Abnormal from 26 weeks onwards if not in labour
How does hypoxia present in a CTG
Loss of accelerations
Repetitive deeper and wider decelerations
Rising foetal baseline heart rate
Loss of variability
How can you get a sample of foetal blood
Pin prick of blood is taken from the foetal scalp – can look for pH
Acidaemia is a sign of hypoxia
At what point is foetal blood pH considered abnormal
Less than 7.2
The baby needs delivered at this point as it is at risk
What are the 2 methods of operative vaginal delivery
Forceps or vonteuse
For instrumental delivery the babies head must be below the spine and the cervix fully dilated
What are the indications for operative/instrumental vaginal delivery
Delay (failure to progress stage 2) Foetal distress Maternal cardiac disease Severe PET / Eclampsia Intra-partum haemorrhage Umbilical cord prolapse
What are the main indications for a caesarean section
Previous CS Foetal distress Failure to progress in labour Breech presentation Maternal request
What are the risks with a C-section
Sepsis Haemorrhage VTE Trauma Complications in future pregnancy
What is the difference in outcome between pre-existing hypertension and pre-eclampsia
If pre-existing it won’t return to normal after delivery (eclampsia will recover after delivery)
Will also have a raised BP at booking and may already be on treatment if it was pre-existing
What are the risks of pre-existing hypertension in pregnancy
PE
IUGR
Abruption
What is pregnancy induced hypertension
Hypertension which develops in the second half of pregnancy - usually after 20 weeks
No proteinuria or other features of pre-eclampsia
Likely to develop it in all subsequent pregnancy
Usually resolves around 6 weeks post-partum
What is the cause of pre-eclampsia
There is abnormal placental perfusion and ischaemia
The mothers response is to try and force more blood through which leads to endothelial damage
What is HELLP Syndrome
Haemolysis, Elevated Liver Enzymes, Low Platelets
Associated with pre-eclampsia
Presents with epi/RUQ pain
What are the symptoms of pre-eclampsia
Headache
Visual disturbance - may be transient
Epigastric / RUQ pain - liver issues
Nausea / vomiting
Rapidly progressive oedema - particularly hands
Hyper-reflexia / involuntary movements / clonus
What are the signs of pre-eclampsia
Hypertension Proteinuria Oedema Abdominal tenderness Disorientation Small for Gestational Age Intra uterine fetal death Hyper-reflexia / involuntary movements / clonus
What investigations would you do for pre-eclampsia
Urea and Electrolytes
Liver Function Tests
Full Blood Count
Used to exclude HELLP
Serum Urate Coagulation Screen Urine - Protein Creatinine Ratio (PCR) Cardiotocography Ultrasound - foetal assessment Foetal CTG Abdominal exam Fundoscopy
When would you need to admit someone with pre-eclampsia
BP >160/110 OR >140/90 with (++) proteinuria or other clinical concerns
Significant symptoms - headache / visual disturbance / abdominal pain
Abnormal biochemistry
Significant proteinuria - >300mg / 24h
Need for antihypertensive therapy
Signs of foetal compromise
At what point would you treat hypertension in pregnancy
Most treat if BP ≥150/100 mmHg
Aim for 140-150/90-100 mmHg
Don’t want to drop the BP too much as could cause harm
When do foetal movements usually start
20 weeks
How can you cure pre-eclampsia
Delivery of the baby and placenta
Need to get mum stable before birth - BP etc.
Consider some extra management such as steroids if baby is going to be premature
What are the indications for delivery in pre-eclampsia
Term gestation
Inability to control BP
Rapidly deteriorating biochemistry / hematology
Eclampsia
Foetal Compromise - abnormal Ultrasound or CTG
How do you manage eclampsia
Control BP if above 140/90 - Labetalol first line or nifedipine if labetalol not suitable (e.g. asthmatics)
Switch to IV if not repsonding
Monitor BP every 48 hours at least (more often if admitted)
Measure FBC, LFT and renal function twice a week
Foetal CTG
Stop / Prevent Seizures- Mg sulphate
Fluid Balance
Delivery
How do you treat an eclamptic seizure
4g IV Magnesium sulphate as loading dose
IV infusion of 1g/hr
A further 2mg if another seizure
If seizures are persistent consider diazepam
Which drug must be avoided in delivery with pre-eclampsia
Ergometrine
This is often used to prevent post-partum haemorrhage
What is the leading cause of maternal death in the UK
Mental illness and suicide
1/2 of suicides occur 12 weeks after birth
What are the red flags for maternal mental health
Recent significant change in mental state or emergence of new symptoms
New thoughts or acts of violent self harm
New and persistent expressions of incompetency as a mother or estrangement from their baby
Evidence of psychosis
How should you screen for mental health issues in pregnancy
Check mental history (PC, PMH, FH) in booking appointment
Identify risk factors
Screen for mood and mental state at each appointment - dont be afraid to ASK
What are the risks of eating disorders in pregnancy
Risks of IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis and miscarriage,
How can you manage pre-existing depression in pregnancy
68% relapse if stop meds in pregnancy
If mild you could consider stopping meds and referring for psychological therapy
Follow up with GP for milder cases
Refer to psychiatry if severe and high risk
Describe the baby blues
Brief period of emotional instability after birth which affects up to 80% of women
Less severe than PP depression
May feel tearful, irritable, anxious, have poor sleep and confusion
Usually from day 3-10 and is self limiting
Lasts no longer than 2 weeks post delivery
How do you manage the baby blues
Support and reassurance
Usually self-limiting
When does puerperal psychosis present
Usually presents in the first 2 weeks after delivery
How does puerperal psychosis present
Early symptoms are sleep disturbance and confusion, irrational ideas
Then mania, delusions, hallucinations, confusion
What are the risk factors for puerperal psychosis
Bipolar disorder
Previous puerperal psychosis
1st degree relative with a history
How do you manage puerperal psychosis
Emergency admission to a specialised mother-baby unit
Treat with antidepressants, antipsychotics, mood stabilizers and ECT
How many women are affected by post-natal depression
10% women
1/3 lasts a year or more
How does post-natal depression present
Onset 2-6 weeks postnatally
Tearfulness, irritable, anxiety, lack of enjoyment and poor sleep, weight loss, can present as concerns re baby (often irrational)
Can last weeks to months
May have a suicide risk
How do you manage post-natal depression
Mild- moderate: self help, counselling
Moderate-severe: psychotherapy and antidepressants, admission
What are the risks to the baby of untreated depression
Low birth weight
Pre-term delivery
Adverse childhood outcomes - ADHD, emotional issues
Poor engagement / bonding - reduces infant learning and cognitive development
The use of lithium in pregnancy is associated with what
Cardiac defects
The altered pharmacokinetics caused by pregnancy also massively affects lithium
What are the risks of psychiatric treatments at various stages of pregnancy
1st trimester the risk is of teratogenicity
3rd trimester there is a risk of neonatal withdrawal
When breast feeding there is a risk of medication passing into the milk (much less than in utero)
What antidepressants are the first line for use in pregnancy
SSRIs
Lower risk and effective
Sertraline is best
What are the risks of taking antidepressants in pregnancy
Paroxetine can increase risk of heart defects in first trimester
Risk of neonatal withdrawal in the 3rd
Also increased risk of persistent pulmonary hypertension and low birth weight
Can you use benzodiazepines in pregnancy
Nope
Risk of foetal malformation in 1st trimester
Risk of floppy baby syndrome (hypothermia/tonia and resp depression) in 3rd
Need to avoid regular use when breastfeeding
Which antipsychotics should be avoided in pregnancy
Clozapine at all time points due to risk of agranulocytosis
Olanzapine - ↑ risk of gestational diabetes & weight gain
Can you use anti-psychotics in pregnancy
Yes
Most appear to be safe but need to work with psychiatry
Safer to give rather than destabilise mental illness
Can you use lithium in pregnancy
Yes and no
Avoid using in pregnancy of possible as there is a risk of cardiac abnormality
However it is higher risk to suddenly stop it - high chance of relapse
Cannot use when breastfeeding
Can you use sodium valproate in pregnancy
No
Should be avoided in women of childbearing age and stopped before a planned pregnancy
Increases risk of neural tube defects and longer term risk of neurological development issues
What are the risks of using carbamazepine in pregnancy
↑ risk of neural tube defects
Facial dysmorphism and fingernail hypoplasia
May be linked to GI and cardiac abnormalities
What are the risks of using lamotrigine in pregnancy
↑ risk of oral cleft - avoid in 1st trimester if possible
Risk of Stevens-Johnson Syndrome during breastfeeding
What are the risks of consuming alcohol when pregnant
Risks of miscarriage Foetal Alcohol Syndrome - learning difficulty Withdrawal Risk of Wernicke's encephalopathy Korsakoff syndrome Microcephaly
What are the features of foetal alcohol syndrome
Facial deformities - smooth philtrum, thin vermillion, small palpebral fissures Lower IQ Neurodevelopmental delay Epilepsy Hearing, heart and kidney defects
What are the risks of opioid use in pregnancy
Maternal death Neonatal withdrawal IUGR SIDS Stillbirth
What are the risks of smoking in pregnancy
Miscarriages Intra-uterine death Stillbirth Abruption IUGR SIDS Admission to NICU at birth Pre-term birth Hypothermia Bronchitis Asthma Pneumonia
What is the definition of an antepartum haemorrhage
Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
What can cause antepartum haemorrhage
Placental abruption
Placenta praevia
These are most common
Uterine rupture Carcinoma Polyp Infection Vasa praevia
How do you quantify antepartum haemorrhage
Spotting
Minor = <50ml
Major = 50-1000ml and no shock
Massive = >1000ml and/or shock
What is placental abruption
Separation of a normally implanted placenta – partially or totally before birth of the foetus
Leads to a painful haemorrhage
What are the risk factors for a placental abruption
Pre-eclampsia/ Hypertension Trauma (to abdo) Smoking Thrombophilias, renal disease or diabetes Polyhydramnios, Multiple pregnancy Preterm-PROM Abnormal placenta Previous Abruption
How does placental abruption present
Severe Abdominal Pain- continuous Hard or tender uterus Bleeding Preterm labour Maternal collapse Haemodynamic instability Foetal distress Potential history of trauma - e.g. car crash
How does placental abruption present on a CTG
Irritable uterus
1 contraction per minute
Foetal HR may be slow or absent
Loss of variability and decelerations
How do you manage a placental abruption
Resuscitate mother - IV fluids
Monitor bloods and urine output
Assess CTG & Deliver the baby - urgent delivery by C-section or induction
What are the maternal complications of placental abruption
Hypovolaemic shock Anaemia Post-partum haemorrhage Renal tubular necrosis leading to renal failure Coagulopathy Infection Thromboembolism
What are the foetal complications of placental abruption
Risk of foetal death
Hypoxia
Prematurity - iatrogenic and spontaneous
Small for age or growth restriction
How can you prevent a placental abruption
If mum has APS then start on LMWH or aspirin
Stop any illicit drugs
Stop smoking
Largely cannot be prevented
Define placenta praevia
It is a low lying placenta
The placenta lies directly over the internal os
When is the term low-lying placenta used in place of placenta praevia
When the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning
What is the link between C-sections and placenta praevia
They are associated with an increased risk of placenta praevia in subsequent pregnancies
The risk rises as the number of previous sections increases
What are the risk factors for placenta praevia
Previous C-section Previous TOP Advanced maternal age Multiparity Multiple pregnancy Assisted conception Smoking Deficient endometrium - endometritis, scars, fibroids etc
How do you screen for placenta praevia
Midtrimester foetal anomaly scan should include placental localisation
Rescan at 32 and 36 weeks if persistent PP or LLP
What are the signs and symptoms of placenta praevia
Painless bleeding >24 weeks;
Usually unprovoked but sex can trigger bleeding
Bleeding can be minor eg spotting/ severe
Foetal movements usually present and CTG normal
Soft uterus
Presenting part high
How do you manage placenta praevia
Resuscitation Mother : ABC Assess Baby’s condition Steroids 24-35+6 weeks Anti D if Rhesus Negative Conservative management if stable Good delivery plan - will need C-section of placenta covers os or is less than 2cm away
When should a pregnancy with placenta praevia be delivered
Consider at 34+0to 36+6weeks if history of PVB or other risk factors for preterm
Uncomplicated placenta praevia consider delivery between 36 and 37weeks
Will need C-section of placenta covers os or is less than 2cm away
Otherwise can consider vaginal delivery
What is placenta accreta
A morbidly adherent placenta: abnormally adherent to the uterine wall
What are the potential complications of placenta accreta
Associated with severe bleeding and post-partum haemorrhage
May end up needing a hysterectomy
What are the risk factors for placenta accreta
Placenta praevia
Prior caesarean delivery - higher with multiple
How do you manage placenta accreta
Prophylactic internal iliac artery balloon
Caesarean hysterectomy
Expect a blood loss >3L and plan for this
What is the definition of a uterine rupture
Full thickness opening of uterus, including serosa
What are the risk factors for a uterine rupture
Previous C-section or uterine surgery
Multiparity
Use of prostaglandins or syntocinon
Obstructed labour
What are the signs and symptoms of uterine rupture
Severe abdominal pain Shoulder-tip pain Maternal collapse PV bleeding Acute abdomen and peritonism May have a loss of contraction Foetal distress on the CTG
How do you manage an uterine rupture
Urgent Resuscitation & Surgical management
IV fluids or transfusion
Anti-D if Rh -ve
What is vasa praevia
When unprotected foetal vessels traverse the membranes below the presenting part over the internal os
Will rupture during labour
How do you diagnose vasa praevia
Ultrasound TA & TV with doppler
Clinical diagnosis if there is sudden dark red bleeding and foetal bradycardia/death
What are the risk factors for vasa praevia
Placental abnormalities
History of low lying placenta
Multiple pregnancy
IVF
How do you manage vasa praevia
Antenatal diagnosis-
Steroids from 32 weeks
Consider inpatient management if risks of preterm birth
Deliver by elective c/section before labour
Emergency C-section if they bleed before this
What is the definition of a post-partum haemorrhage
Blood loss equal to or exceeding 500ml after the birth of the baby (vaginally)
Primary within 24h of delivery
Secondary >24h - 6/52 post delivery
Severity dependent on the amount of blood lost
What are the classifications of PPH
Minor: 500ml- 1000ml ( without clinical shock)
Major: >1000ml or signs of cardiovascular collapse or on-going bleeding
What can cause a PPH
Tone - uterine atony
Trauma - vaginal tear, cervical laceration, rupture
Tissue - retained products
Thrombin - coagulopathy
What are the antenatal risk factors for PPH
Anaemia Previous caesarean section Placenta praevia, percreta, accreta Previous PPH Previous retained placenta Multiple pregnancy Polyhydramnios Obesity Fetal macrosomia
What are the intrapartum risk factors for PPH
Prolonged labour Operative vaginal delivery Used of syntocinon in labour Caesarean section Retained placenta Perineal tear or episiotomy
How do you initially manage PPH
ABCDE IV access - IV warmed crystalloid infusion Give O2 - 15L/min Monitor bloods and obs Cross match 6 packs of cells Determine the cause of the haemorrhage Early blood transfusion Administer Tranexamic acid
How do you stop a PPH without surgery
Uterine massage- bimanual compression
Expel clots
5 units IV Syntocinon stat (synthetic oxytocin which stimulates uterine contractions)
Foleys Catheter - minimise pressure on uterus
Confirm placenta and membranes complete
Repair any vaginal/perineal trauma
Tranexamic acid may also be given
If PPH still not controlled give a synthetic prostaglandin
What are the leading causes of maternal death after birth
Thromboembolism and cardiac disease - up to 6 weeks after
Cancer and suicide are the leading causes from 6 weeks to 1year
What are the 5Hs that can lead to maternal collapses
Head - eclampsia, CV accident, epilepsy
Heart - MI, arrhythmia
Hypoxia - PE, asthma
Haemorrhage - abruption, trauma, rupture
wHole body and Hazards - hypoglycaemia, sepsis etc
In a case of maternal collapse - who is the priority, mother or baby
Mother - need to stabilise her first
Why is resuscitation harder in a pregnant woman
Uterus puts pressure on vessels and diaphragm
Foetus takes oxygen and circulation from mother
Higher risk of hypoxia as O2 requirement is increased
More likely to aspirate
Harder to intubate
Describe aortocaval compression in pregnancy
From 20 weeks gestation the uterus can compress the IVC and aorta when lying supine
Often leads to supine hypotension which can lead to maternal collapse
To treat - turn woman to left lateral position or manually move uterus
At what point of cardiac arrest should the baby be delivered
If there is no response to correctly performed CPR within 4 minutes of maternal collapse delivery should be undertaken by emergency C-section
This will help with resus as pressure is taken off vessels
What are the major reversible causes of cardiac arrest (4Hs and 4Ts)
Hypoxia Hypovolaemia Hypo/hyper metabolic Hypothermia Thrombosis Tamponade Toxins Tension pneumothorax
How would you manage an eclamptic seizure
Note time and length of seizure Give high flow oxygen Get iv access Move patient into left lateral and open airway Monitor baby
What is cord prolapse
When the umbilical cord exist the womb before the baby
This leads to Direct compression and cord spasm = decreased flow- hypoxia- death
Requires immediate delivery
What is shoulder dystocia
Any cephalic delivery where manoeuvres other than gentle traction are required to deliver the baby after the head has delivered
Due to a foetal anterior shoulder getting stuck on the maternal pelvic symphysis
What are the risk factors for shoulder dystocia
Obesity Diabetes Foetal macrosomia Prolonged 1st and 2nd stage, Instrumental delivery
What are the signs of shoulder dystocia
Slow delivery of the head
Head bobbing - head consistently retracts back between contractions
Turtling - head becomes tightly pulled back against the perineum
Not progressing
What are the complications of shoulder dystocia
Risks of stillbirth Hypoxic brain injury Brachial plexus injury Fractures PPH 3rd & 4th degree distress
If the Down’s screening is positive what further tests are offered
Amniocentesis – diagnostic (after 15 weeks)
Chorionic villus sampling – diagnostic (11-14 weeks)
What are the possible underlying reasons for an increased nuchal translucency?
Down’s Syndrome Trisomy 13 & 18 Turner’s syndrome Intrauterine demise Cardiac abnormalities
What does an elevated Maternal Serum Alpha Feta Protein suggest
It can suggest multiple pregnancy or developmental conditions such as spina bifida or gastroschisis
When can Anti D be given to prevent Rhesus isoimmunisation
28 weeks give Anti-D to negative mothers (blanket prophylaxis)
Baby’s cord blood is tested if mother is negative and if they are found to be positive then the mother is given another dose (up to 72hrs after)
Give to anyone experiencing heavy bleeding or requiring surgical intervention for a miscarriage
How do administer anti-D
IM in the deltoid
A single dose of anti-D lasts approximately 6 weeks so may need repeat doses if repeated sensitising events
If a baby is becoming more acidotic what is this a sign of
Hypoxia
What are the 4 main abnormal outcomes of a pregnancy
Miscarriage
Ectopic pregnancy
Molar pregnancy
Pregnancy of Unknown Location
List risk factors for ectopic pregnancy
Previous abdominal surgery PID Tubal damage - surgery or infection Smoking Previous ectopic IVF
What is considered heavy bleeding in early pregnancy
Having to change a pad every hour
Passing clots
How do you conservatively manage a miscarriage
Done if low risk - light bleeding
Basically let nature take its course
Inform the patient that she is miscarrying and ask her to monitor bleeding at home and contact you if it get worse or develops pain
They should contact the early pregnancy unit
NICE guidelines suggest telling her to take a pregnancy test in 10 days time and get back to you - should be negative if miscarriage complete
A woman presents early in pregnancy with one sided abdominal pain - what must be considered/excluded
Ectopic pregnancy
Typical gestation for presentation is 5-6 weeks
What is the the ultrasound criteria for making a diagnosis of miscarriage on ultrasound scan
Gestational sac of more than 25mm with no obvious contents
Foetal pole with crown-rump length over 7mm with no evidence of cardiac activity
Most sonographers will require a second opinion
What are the management options for a miscarriage
Conservative/watch and wait – let nature take its course
Medical - misoprostol given
Surgical - either manual vacuum aspiration or more complex surgery done under GA
Describe the surgical management of a miscarriage
Most common is manual vacuum aspiration (MVA)
As it sounds
Done under local anaesthetic with gas and air
Patient may feel some touching and crampy pain – not a completely pain free procedure, she may be a little uncomfortable
Bleeding for a little while after is normal
Other surgical options are more complex and done under GA
Describe the medical management of a miscarriage
Give misoprostol to try and get the uterus to expel the gestational sac
As long is there is no medical risk (bleeding disorder, anaemia etc.) they can be done as an outpatient
Outpatient they are given the medicine in hospital but then they go home to complete the miscarriage
Those over 10 weeks will usually be inpatient (with covid this has been extended to 12 weeks)
Which features on abdominal exam suggest ectopic pregnancy
Guarding or peritonism = particularly on one side
What examinations / investigations would you do for a suspected ectopic
Abdominal exam - look for guarding/peritonism
Potentially a bimanual and speculum
Retake the HCG levels
Would also do FBC, LFTs and U&E
USS
What test must be done before methotrexate can be used to manage an ectopic pregnancy
US needs to exclude a intrauterine pregnancy as methotrexate is teratogenic so you don’t want to give it to a pregnant woman
Free fluid around the ectopic pregnancy indicates what
That it is at high risk of rupture
What are the potential outcomes for a pregnancy of unknown origin
Can be intrauterine - normal
Ectopic
How do you manage a pregnancy of unknown origin
If clinically well they can go home
Repeat her HCG test in 48hrs – in a healthy pregnancy it should double in this time
If it only has a 50-60% rise it is likely to be an ectopic
If it starts falling then it’s likely a non-continuing pregnancy
Give worsening advice egarding
seeking urgent re assessment if increased pain/ faint/
unwell
An elevated ALP is normal in pregnancy - true or false
True
It is produced by the placenta
Not concerned if only one raised on LFT
Which examinations would you perform on a woman with pre-eclampsia
Fundoscopy
Abdominal exam
Foetal CTG
Check for hyperreflexia and clonus
List some of the potential sources of infection post C-section
Uterus (exposed to outside)
UTI (will be catheterised)
Retained placenta
Wound infection
How would you confirm the source of infection post-C-section
Confirmed with swabs (high vaginal, wound etc.) and urine samples
Can you use d-dimer to diagnose DVT in pregnant women
No
It can be raised anyway in pregnancy so may give false result
Use doppler ultrasound instead
The more pregnancies you have the higher your DVT risk - true or false
True
What is HELLP Syndrome
A rare liver and blood clotting disorder that can affect pregnant women
Complication/severe form of pre-eclampsia
H- haemolysis (red cells break down)
EL - elevated liver enzymes
LP - low platelets
What are the symptoms of HELLP syndrome
May present like pre-eclampsia: abdo pain (epi or RUQ), nausea and vomiting, headache, changes in vision, swelling, SOB, shoulder pain when breathing, bleeding, jaundice
The HELLP signs on blood tests, high BP and proteinuria
What are the main causes of death in HELLP syndrome
Liver capsule rupture
Stroke - cerebral edema or cerebral hemorrhage
How do you treat HELLP syndrome
Only definitive treatment is to deliver the baby
May give steroids if it’s going to be preterm
Some women may require blood products
Control their BP and give MgS to prevent seizure
List risk factors for HELLP syndrome
White ethnicity maternal age >35 Obesity Chronic hypertension Diabetes Autoimmune conditions Previous pregnancy with pre-eclampsia +/- HELLP Multiple gestation
What is the first line management for shoulder dystocia
First line is McRobert’s manoeuvre - flex and abduct mum’s hips as much as possible (more space)
Women in which age group are at highest risk of molar pregnancy’s
Those under 20 and those over 35
Are ACE inhibitors safe in pregnancy’s
NO
Associated with an increased risk of adverse foetal outcomes
Teratogenic and toxic to baby
As are ARBS
What is the first line treatment for hypertension in pregnancy
Labetalol
Unless contraindicated
How does an amitotic embolism present
PE features - acute SOB, tachycardia, tachypnoea, and hypoxia
Wedge-shaped infarction on chest x-ray
Also seen are chills, sweating, anxiety and coughing
Will occur in a woman during or just after labour
There will be foetal cells in the maternal blood vessels - found at autopsy
List risk factors for thromboembolic events in pregnancy
Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
How do you prevent thromboembolic events in high risk pregnancies
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy
If woman has 3 risk factors it is started at 28 weeks and continued until six weeks postnatal.
If she has 4 or more risk factors you immediately start LMWH and continue until 6 weeks post-natal
If a woman presents with symptoms of miscarriage and has an open cervical os what type is it
Inevitable
How do manage a threatened miscarriage
Discharge home with safety netting and advice
Bleeding is not uncommon but as os is closed you cannot predict what will happen
Have a realistic discussion and offer support
Ask her to contact the early pregnancy unit again
How do you manage a ruptured ectopic pregnancy
ABCDE and call for immediate help
Get IV access x2 and provide fluid resus and urgent blood transfusion (o-ve?)
Patient need immediate theatre admission for emergency laparotomy/
diagnostic laparoscopy
What is the most common cause of iatrogenic premature delivery of the fetus
Hypertensive disorders of pregnancy such as pre-eclampsia, eclampsia and HELLP
What is the main cause of maternal death in those with pre-eclampsia
Cerebral haemorrhage
How does pre-eclampsia affect the baby
Can lead to IUGR or even intrauterine death
Placental abruption is also more common
How can you manage pre-eclampsia before delivery
BP management - abetalol, nifedipine and methyldopa are the most frequently used
IV magnesium sulphate
Regular foetal monitoring - cardiotocography and US
How would you manage diabetes prior to conception
Need good glycaemic control
Lifestyle advice
5mg folic acid for 3 months prior to conception
Hba1c target should be < 48 mmol/mol prior to conceiving
Alter treatment to ensure safe drugs for pregnancy
Which diabetes medications are safe in pregnancy
Metformin
Sulphonylureas
Rapid-acting insulin analogues, e.g. Lispro and Aspart
Long-acting insulins
How does poor maternal glycaemic control affect the foetus in the first trimester
Associated with an increased rate of congenital abnormalities (particularly neural tube defects and congenital heart disease) and miscarriage.
How should women with pre-existing diabetes be monitored in pregnancy
Retinal screening is advised in every trimester
Should be given aspirin from 12 weeks due to pre-eclampsia risk
Fetal cardiac ultrasound and monthly fetal growth scans
Uterine artery doppler at 20 weeks
Hypoglycaemia unawareness can occur in pregnancy - true or false
True
Nausea and vomiting of pregnancy contribute
There is an increase in insulin sensitivity
Ketoacidosis is also more common
How does poor maternal glycaemic control affect the foetus in the second trimester
Main risk at this stage is macrosomia
Caused by foetal hyperinsulinemia
Which women should be offered an oral glucose tolerance test at 24-28 weeks of gestation
Family history of diabetes in first degree relative
Previous macrosomic baby
Obesity (BMI >30 kg/m2)
Family origin with high prevalence of diabetes mellitus
How do you manage gestational diabetes
Diet and exercise advice for mum
Metformin, short-acting or long-acting insulin can be used if lifestyle not enough
Regular growth scans
Monitoring for pre-eclampsia
Delivery up to 40+6 weeks of gestation if uncomplicated
Pyelonephritis is more common in pregnancy - true or false
True
Due to physiological dilatation of the upper renal tract
UTIs are also common and can preceed it
List differentials for headache in pregnancy
Migraine Cerebral venous thrombosis Idiopathic intracranial hypertension Drug related Post-dural puncture headache
How does migraine present
Throbbing and unilateral headache
Scotomata - partial visual loss
Fortification spectra - aura
Transient neurological symptoms like hemianopia or aphasia can also occur but resolve after the episode.
What is a post-dural puncture headache and how does it present
Headaches that can occur after epidural or spinal analgesia
They usually develop in the 5 days after the procedure
Worse on standing - positional
Most frequently occur in the frontal and occipital regions.
Symptoms such as neck stiffness, tinnitus, photophobia and nausea can be associated
What is peripartum cardiomyopathy
Heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery
Presents with heart failure and sometimes ventricular arrhythmia or CA
What are the risk factors for peripartum cardiomyopathy
African ethnicity Multiple pregnancy Pregnancy complicated by pre-eclampsia Advanced maternal age Teenage pregnancy Diabetes mellitus Malnutrition Smoking
Which trisomy’s are tested for in pregnancy
Trisomy 13 - Patau’s syndrome
Trisomy 18 - Edward’s syndrome
Trisomy 21 - Down’s syndrome
Screened for at the 12 week scan
What happens at the 20 week scan
This is the anomaly scan
Check from top to bottom to look for developmental abnormalities - e.g. Diaphragmatic hernia, dextrocardia, kidneys, missing limbs etc
Also do placental location - certain location (over cervix) have a high haemorrhage risk
Can trimethoprim be used in pregnancy
Yes and No
Cannot be used in 1st trimester but is safe in 2 and 3
Pregnancy itself is a risk factor for DVT and PE - true or false
True
Also obesity, smokers, previous clots
Can nitrofurantoin be used in pregnancy
Yes and no
It is safe in the 1st trimester but is not safe in the 3rd
How do you treat chlamydia in pregnancy
Doxycycline should be avoided in pregnancy
Use azithromycin instead
Why is methyldopa no longer used in pregnancy
It has a high risk of post-natal depression (used to be the most used)
Now use labetalol or nifedipine
When should a woman be given anti-D
If she is known to be rhesus negative
Given prophylactically at 28 weeks to cover any sensitising events
Which systems should be checked in a primary obstetric survey (acutely unwell pregnant woman)
Head - AVPU Heart - cap refill, pulse, BP, sounds Chest - air entry, RR, O2 Abdo - is there guarding, rebound or tenderness, is baby alive, requirement for laparotomy or delivery? Vagina - bleeding, stage of labour Legs - DVT?
What are the contraindications to fluid resuscitation in an acutely unwell pregnant woman
Pulmonary oedema
secondary to severe pre-
eclampsia or renal failure.
List potential cardiac causes of maternal collapse
MI Arrhythmias Peripartum cardiomyopathy Congenital heart disease Dissection of thoracic aorta
Which monitoring should be used for an acutely unwell pregnant woman
Continuous ECG, resp, pulse, BP and pulse oximetry
Consider arterial and CVP lines to aid monitoring
List some pulmonary causes of maternal collapse
Asthma
PE
Pulmonary oedema
Anaphylaxis - hypoxia
List some ‘head’ (CNS) causes of maternal collapse
Eclampsia Epilepsy CVA Intracranial haemorrhage Vasovagal response
List types of haemorrhage that could lead to maternal collapse
Abruption Uterine atony Genital tract trauma Uterine rupture Uterine inversion Ruptured aneurysm
How do you manage uterine atony
O2
Expel clots and massage uterus (bimanual compression)
IV access for fluids and bloods (FBC, coag, Cross match 4 units)
Uterotonics: Syntocinon/Ergometrine/Carboprost
Tranexamic acid
Urinary catheter
If these don’t work they may need surgery - uterine balloon or laparotomy
What effect does CMV have in pregnancy
For baby it is a cause of potentially severe congenital infection,
miscarriage and stillbirth
May cause microcephaly, chorioretinitis, IUGR and
severe mental disability
In mum it can be a mild or non-specific illness
How do you prevent foetal varicella syndrome
Give VZV immunoglobulin to those pregnant
women who are susceptible and have been in contact
with the infection
Vaccine is also available
What effect can chicken pox have in pregnancy
Can cause foetal varicella syndrome contracted
before 20 weeks
Causes skin carring in dermatomal distribution, neurological abnormalities, hypoplastic limbs and eye defects
Pregnant women are at risk of pneumonia and hepatitis in this infection
What effect does parvovirus have in pregancy
Causes a maculopapular rash which in clinically
indistinguishable from rubella without serological
testing
Usually mild and self-limiting but an cause polyarthropathy syndrome
and anaemia
For baby it can cause foetal anaemia
What effect does zika virus have in pregancy
Is a cause of congenital microcephaly
Asymptomatic in mum
What effect does influenza have in pregancy
Is a cause of mortality, IUGR and PTL in pregnant
women if contracted
IOL < 42 weeks actually reduces the chance of
needing a C section - true or false
True
Mothers with a history of puerperal psychosis can have elective admission to a mother and baby unit for monitoring - true or false
True
Allows them to get any support they need before they are at risk
Elective C-section can be carried out from what date
Not done until > 39 weeks
Unless fetal or maternal health at risk
This is due to association with leaning needs in infants born electively
before 39 weeks and increased risk of respiratory distress in
neonates at less than 39 weeks delivered via cs
There is a risk that seizures can increase in pregnant women with epilepsy - true or false
True
Important to manage seizures with help of neuro team
important to stay medicated and report increasing symptoms
Women with epilepsy should be given high dose folic acid in pregancy - true or false
True
Should be in 5mg
What are the risks of obesity in pregnancy
Foetal anomalies: increased NTD and cardiac and increased rate of missed anomalies Stillbirth Hypertension/PET Gestational diabetes- GTT FTP in labour C section/ forceps Fetal distress- difficult c section Macrosomia- Shoulder dystocia IUGR- growth scans Maternal anaemia, vit d deficiency and folate deficiency from poor diet and pregnancy demands- Thrombus risk V Anaesthetic complications
What causes the hypercoagulable state in pregnancy
There is an increase in factors VII, VIII, IX, X, XII, fibrinogen and plasminogen
Increases the risk of VTE
How is urine PCR used in the diagnosis of pre-eclampsia
It helps you quantify the amount of protein in the urine.
The use of prophylactic oxytocin at delivery reduces the risk of PPH by 50% - true or false
true
What are the risks to the mother if she fails to progress in labour
Sepsis
Uterine rupture
Increased risk of post-partum haemorrhage
Increased risk of perineal tear and trauma
Incontinence
Pelvic floor dysfunction
Maternal exhaustion
What is the risk of premature and prolonged rupture of membranes
Chorioamnionitis - uterus is exposed to the outside leading to infection
Can affect baby and lead to sepsis in mum
The majority of deaths in pregnancy are due to the complications of pregancy itself - true or false
False
2/3 of maternal deaths are due to a medical or mental health condition not complications of pregnancy itself
What is a direct maternal death
A death that occurs as a result of a pregnancy specific disorder
I.e. couldn’t have occurred without them being pregnant such as PPH or pre-eclampsia
What is an indirect maternal death
When a pregnant or recently pregnant woman dies from a medical complication such as epilepsy
Can be pre-existing disease or something that developed during the pregnancy
Not directly caused by pregnancy itself but aggravated by it
List red flags for post-partum depression
New persistent expressions of incompetency
Estrangement from the baby
Recent significant change in mental state or emergence of new treatment
New thoughts or acts of violence and self harm
Women with cardiac risk factors should have a cardiac assessment prior to pregnancy or in early pregnancy - true or false
True
What is the biggest cause of maternal death
During pregancy the majority of death are caused by chest ailments
The biggest cause is heart disease
Then VTE
Psychiatric would also be extremely common if it included those up to 1 year post-partum (big suicide risk)
When should a perimortem C-section be carried out
If mum collapses and requires CPR
Perform a perimortem C-section within 4 or 5 minutes of CPR starting
This increases the mum’s chance of survival as it reduces pressure on her body/circulation
Should carry it out immediately - worry about closing the wound later as bleeding won’t be as big a risk as the cardiac arrest
May also increase baby’s chances
What position should you put a pregnant woman in to perform CPR
You should try and push the belly to the left hand side (uterine displacement)
If you cant you should wedge something under one side
How can you stimulate breathing in a newborn
Use a towel or blanket to rub them to stimulate breathing
Talk to them and blow on their face
If not breathing within a minute, give rescue breaths
Most respond within 30 secs
If that doesnt work then CPR (3 chest compressions to 1 breath)
Are ACEi safe in breastfeeding
Yes
What type of drug is nifedipine
Calcium channel blocker
Which anti-hypertensives are be used IV for severe hypertension in pregancy
Labetalol
Hydralazine
List potential causes of breathlessness in pregnancy
Physiological - common Anaemia Asthma Pulmonary embolism COVID-19 pneumonitis Pneumothorax Pulmonary oedema
List potential causes of pulmonary oedema in pregnancy
Pre-eclampsia
Peripartum cardiomyopathy
Undiagnosed heart disease
What are the features of acute fatty liver of pregnancy
Characteristic histological pattern (microvesicular steatosis)
Causes synthetic liver dysfunction - raised bilirubin, transaminases
More common in twin pregnancies, male fetuses, women with a low body mass index (BMI)
Presents with vomiting, abdo pain, polydipsia/polyuria and encephalopathy
Is LMWH safe in breastfeeding
Yes
Which maternal factors increase the risk of sepsis in pregnancy
Anaemia
Obesity
Black or minority ethnic group origin
Which medical factors increase the risk of sepsis in pregnancy
Impaired glucose tolerance/diabetes
Impaired immunity/immunosuppressant medication
Which obstetric factors increase the risk of sepsis in pregnancy
History of pelvic infection
History of group B streptococcal infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
Cerebral palsy can be caused by intrapartum hypoxia - true or false
True
The commonest features of hypoxic injury are spasticity affecting all four limbs and hypotonia.
How can the risk of cerebral palsy be decreased
Induced hypothermia
Baby is cooled in an effort to prevent further neuronal loss
What maternal factors can cause an increase in foetal heart rate
Pain, dehydration, use of epidural analgesia or maternal pyrexia (e.g. sepsis)
Can even lead to tachycardia
What factors can cause an decrease in foetal heart rate variability
Use of opioids
Foetal hypoxia
Can be due to foetal sleep - only non-reassuring after 30 mins
What is considered a pre-terminal CTG
Prolonged bradycardia as well as total loss of variability (often with shallow decelerations)
Seen after hypoxia
Baby needs delivered immediately
What is a foetal HR overshoot on a CTG
Increase in foetal HR following a variable deceleration
The decel causes a drop in foetal BP which triggers attempts at fetal compensation, which in turn result in such transient tachycardia or overshoots
Considered a pre-pathological feature
What are the main features of a CTG
Foetal HR which includes:
Baseline HR
Baseline variability
Presence or absence of accelerations or decelerations
Uterine contraction - shows frequency not strength
What are the ranges for non-reassuring foetal HR and abnormal FHR
Non-reassuring 100-109 and 161-180
Abnormal <100 or >180
What is the normal range for variability on a CTG
5 and 25 bpm is considered ‘reassuring’
Below 5 bpm for 30-50 mins is non-reassuring
If more than 50 mins it’s abnormal
What is the definition of an acceleration on a CTG
Sudden increase from the baseline FHR of at least 15 bpm for at least 15 seconds
It is a reassuring feature
A deceleration has the same parameters but opposite (e.g. decrease HR)
What causes an early deceleration
These are associated with head compression which stimulates baroreceptors
Should be synchronous with the contraction.
What causes a late deceleration
Chemoreceptors stimulation
They are either synchronous with the contraction but with recovery lasting beyond the contraction or occur after the contraction
What causes a variable deceleration
Commonly seen with cord compression
How does adrenaline release affect the action of oxytocin
Adrenaline is a oxytocin agonist
This aims to prevent labour in a stressful environment - inhibits it to allow mum to find a safe spot (biological)
At which point is the second stage of labour considered delayed
In a nulliparous patient,: when the active second stage has reached 2 hours
In a multiparous patient: when the active second stage has lasted 1 hour
At this point the patient should be referred to the obstetric registrar unless the birth is imminent.
What is the definition of failure to progress in labour
Defined as less than 2cm dilatation in 4hours
What are the requirements for a forceps delivery (FORCEPS)
Fully dilated cervix (10cm)
Occipitoanterior position (Occipitoposterior position is possible with Kielland forceps and ventouse)
Ruptured membranes
Cephalic presentation
Engaged presenting part – the fetal head must not be palpable abdominally and must be below the ischial spines
Pain relief
Sphincter (bladder) empty – will need catheterisation.
What are the advantages of C section
Avoid tears to perineum and therefore problems with long-term urinary and faecal incontinence
No injury to the cervix or high vaginal areas.
Less chance of neonatal trauma
What are the advantages of operative/instrumental vaginal delivery
Approx. 80% of patients will have a spontaneous vertex delivery subsequently
Reduced analgesic requirements
Shorter hospital stay and quicker recovery
Less physical restrictions on bonding with the baby
What are the disadvantages of operative/instrumental vaginal delivery
Can cause neonatal trauma such as intracranial haemorrhage, facial nerve palsy, marks to face, brachial plexus injury
Maternal trauma - perineal tears, bowel symptoms (if anus damaged), psychological trauma, urinary symptoms
High risk of PPH
What are the disadvantages of C section
Comes with all the risks of surgery such as haemorrhage, VTE, longer hospital stay
Risk of uterine rupture in future labours and placenta accreta in future pregnancy.
4 times greater maternal mortality
List some contraindications to ventouse delivery
Prematurity (<34weeks)
Face presentation
Suspected fetal bleeding disorder such as Haemophilia
Fetal predisposition to fracture e.g. osteogenesis imperfecta
Maternal HIV or Hepatitis C.
What is the risk of taking stimulants such as cocaine or ecstasy in pregnancy
Maternal – hypertensive disorders including pre-eclampsia, placental abruption, death via stroke and arrhythmias.
Fetal – prematurity, neonatal abstinence syndrome , teratogenicity, IUGR, pre-term labour, miscarriage, developmental delay, Sudden Infant Death Syndrome (SIDS), withdrawal
What is the risk of taking opiates in pregnancy
Risk of neonatal abstinence syndrome, IUGR, SIDS, stillbirth and maternal deaths.
What is the risk of taking cannabis in pregnancy
Cognitive deficits, miscarriage, fetal growth restriction
What is the safe level of alcohol consumption for pregnant women
There is no safe limit
Advised to avoid it completely
List potential maternal sensitization events (rhesus)
Placental abruption
Any abdominal trauma (from road traffic accidents for example)
Amniocentesis or chorionic villus sampling
External cephalic version
Intra-uterine surgery/transfusion
Fetal death
Vaginal bleeding from 12weeks
Surgical management of miscarriage at <12 weeks
Evacuation of retained products of conception and molar pregnancy
Termination of pregnancy
Ectopic pregnancy
Delivery (if baby is rhesus-D positive)
Describe the process of rhesus isoimmunisation
If the mother is rhesus negative and exposed to her foetus’ rhesus positive blood i t causes her to produce IgM antibodies against rhesus - sensitizing event
IgM is too big to cross placenta so baby is fine
However, in future pregnancies when the mother is exposed to the same antigen from the fetus’ red blood cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus leading to haemolytic disease of the newborn
Suicide is a leading cause of death in the perinatal period; - true or false
True
Between 6 weeks and 1 year post natal it is the biggest killer
What is a coincidental maternal death
Incidental or accidental death during pregnancy but not due to or aggravated by pregnancy
e.g. RTA
What is defined as a late maternal death
Deaths occurring more than 42 days after the end of pregnancy but before 1 year
What are the surgical management options for PPH
Examine under anaesthetic in theatre to look for trauma, RPOC, rupture etc
Balloon insertion to put pressure on bleeding blood vessels
Arterial Embolisation via Interventional Radiology
“B-Lynch” sutures
Uterine artery ligation
Internal Iliac ligation
Hysterectomy as a last resort!
How do you prevent secondary PPH
Give thromboprophylaxis
- Debrief couple
- Manage anaemia with iron supplementation
List the degrees of vaginal tears
1st degree: involving the skin only
2nd degree: involving the skin and levator ani; usually requires stitches
3rd degree and 4th degree: extend to the external anal sphincter muscle; these may need operated on as mothers can experience faecal incontinence due to overstretching of the
pudental nerve branches
Which women are at risk of post-partum depression
- Young, single
- Domestic issues
- Lack of support
- Substance abuse
- Unplanned/unwanted pregnancy
- Pre-existing mental health problem
Which pregnant women should be referred to psychiatry
Patients with severe anxiety/depression
- Patients with a history of BPSD or schizophrenia
- Patients with a history of puerperal psychosis
- Patients with current psychosis
- Patients who have developed mental illness in later stages of pregnancy/puerperium
- Patients with a significant family history of BPSD/puerperal psychosis
Which other diagnoses must be excluded before settling on hyperemesis gravidarum
Must exclude other causes of excessive,
prolonged vomiting, such as a urinary tract infection, gastritis, peptic ulcer, viral hepatitis
and pancreatitis
In early pregnancy, all rhesus negative women that are undergoing a surgical procedure
require a dose of anti-D - true or false
True
What is the definition of a miscarriage
Loss of pregnancy after a positive test between conception and 23+6 weeks
How would you diagnose a threatened miscarriage
There is bleeding with or without cramping. The cervical os is closed. Ultrasound will show evidence of an intrauterine pregnancy and if the foetal pole is present and measuring more than 7mm a foetal heart should be present
How would you diagnose an inevitable miscarriage
Symptoms consistent with miscarriage
US scan may reveal a viable pregnancy or products that are in the
process of expulsion
Speculum examination will reveal an open cervical os, possibly with products of conception sitting at the cervical os
What is a septic miscarriage
Where there is an infection alongside an incomplete or a complete miscarriage.
How would you diagnose a septic miscarriage
Present with symptoms of miscarriage
Also fevers, rigors, uterine tenderness, bleeding,
offensive discharge and pain
Inflammatory markers will be raised
What is a missed miscarriage
Where there are no symptoms of miscarriage or a history of threatened miscarriage, but on ultrasound scanning there is no viable pregnancy
How does age affect miscarriage risk
Increasing maternal age increases risk of miscarriage
Paternal age also contributes
Greatest risk is when the mother is over 35 and the father is over 40
The risk of miscarriage increases after each
subsequent miscarriage - true or false
True
Cervical shock occurs during which type of miscarriage
Incomplete
Caused by the presence of products at the cervix
What will the trend in HCG levels be in miscarriage
Would be expected
to halve every 48 hours.
A 50% fall is highly suggestive of a miscarriage or failing pregnancy
How do you manage a septic miscarriage
ABCDE assessment and possibly resuscitation
Start on sepsis 6 - appropriate antibiotics
Requires active miscarriage management - either medical or surgical
