Flashcards
Sx of gestational trophoblastic disease
Bleeding
Hyperemesis
Large for dates
Mid trimester - pe, hyperthyroidism, pul or neuro sx
What types of trophoblastic disease are there and what are their definitions
Complete mole - empty egg that is fertilised by one sperm thAt replicates or 2 sperm. Persistent in 15-25%
Partial mole - triploidy egg + 2 sperm. Persistent in 0.5-4%
Gestational choriocarcinoma - aggressive, arises from term del, top, mc etc. sx mass, bleeding, met sx. Crosses placenta.
Placental site trophoblastic tumour
Epithelioid trophoblastic tumour
Management gtd
D&c and send for histo
Baseline Fbc, u&e, g&h
TFT, cxr, lft, if needed
Inform of risk of invasive disease and risk of recurrence 1/70
Inform of need to avoid pregnancy until fu complete
Moles - wkly hcg until N then cease if partial. Complete monthly for 6/12
Fertility not affected
Gtd - met screen, refer to gynae onc
Assessment of pelvic pain
Cyclic - likely gynae component. Genital swabs, Pap smear, pelvic us. ? Refer to laparoscopy
Git sx - stool culture and stool blood. Fbc, crp, esr.
Sigmoidoscopy ? Colonoscopy
Urinary - urine mcs, urethral swab, renal tract imaging. ? Cystoscopy.
Msk sx - exclude rheumatoid etc diseases, spine and joint X-rays. Consider physio
What are the criteria for forcep delivery?
Cephalic No head above brim Fully Rom At spines or below Bladder empty Adequate analgesia No cephalopelvic disproportion
Initial mx for pph
- D - Call for help - midwives, senior doctors
Hx - GP, hx pph, antenatal hx - placentation, pet, med hx. Nature and duration of labour, tears etc, placenta, meds so far, bloods etc. baby ok? Est ebl so far - R - response
- A - airways. Head down, O2
- B - breathing
- C - circulation - 5 min obs, 2 x wide bore cannulas in cub fos. Send bloods urgently. Start resusc measures fast saline, send for blood products
- Assess for cause
- tone - rub fundus, uterotonics –> oxytocin + infusion, ergo, miso, pgf alpha myometrial
- tissue - placenta complete, feel in vagina for tissue, Mrop if needed, continue fundal rub
- trauma - epis, vaginal or cervical lac
- thrombin
If at any stage unresponsive or unstable obs code pink and prepare for theatre
Surgical mx pph
- Eua and repair lacs
- Compressive measures - bakri, haemostatic brace sutures - b lynch sutures and similar.
- Bilateral ligation of uterine arteries
- Bilateral ligation of internal iliac arteries
Selective emolisation, hysterectomy
Risk factors for pph
5-15% all deliveries Most in primips Grand multips Pix Large uterus Pet Abnormal placentation
Total blood vol = 1ml/kg
Follow up of PPH
Blood replacement as necessary Monitor coats and hb VTE prophylaxis Haematinics Debrief family Plans for future babies
Causes for secondary pph
1/3 unknown Subinvolution - placenta accreta or RPOC Endometritis Other infection eg of cs site Uterine fibroids Polyp or neoplasm AVM Missed lacs or haematomas
Hx for secondary pph
- Pregnancy - intrauterine infection, evidence of aberrant trophoblastic interaction (pet, mc, iugr)
- Delivery - prolonged, mode, difficult 3rd stage, placenta complete, epis, tears etc
- Bleeding characteristics, systemic symptoms, pain
Management secondary pph
- Stabilisation - drabc, NBM, lie flat, O2, obs, call for help as necessary, IV access and send bloods
- Quantification - weigh pads etc and replace as necessary
- Severe - massage uterus or bimanual compression, synt, elevate legs, examine for lacs etc
- Swabs
- Treat for endometritis - ABx
- US and/or hCG
- D&C once stabilised and settled - send for histo pathology
- Anaemia correction
Maternal risks for twin pregnancy
Morbidity and mortality 2.5x that of singletons Symptoms of pregnancy - gord and hyperemesis - wt gain - anaemia and other vitamin defs - take iron and incr folate Increased complications of pregnancy - PET - VTE - GDM - miscarriage, abruption PPROM and infection PTL Polyhydramnios Labour - operative delivery and attendant perineal trauma and surgical complications - need for epidural or similar - cord accident - PPH - Dysfunctional uterine contractions Pst partum - depression - sleep deprivation - financial and relationship strain
Foetal risks of twin delivery
Miscarriage IUGR/ unequal growth preterm del Cerebral palsy Congenital abnormalities TTTS TRAPS TAPS Language and speech impairment
Management of twins
Maternal health - iron sups, folate 5mg, +/- aspirin from 12/40 if other risk factors for PET
Early scan for placentation
Screening for aneuploidy
Foetal surveillance - 2-3/52 from NT and 2/52 from 18. Looking for growth, AFI and bladder as well as dopplers from 24/40
Gestation at birth - aim for 37/40
Incidence of infertility
Below 30yrs fecund ability is 20-25% ea cycle
15% all couples
1/7 30-35, then 1/5, 1/4
Broad classes of infertility
40% poor semen
30% tubal
30% ovulatory
Causes for male infertility
Impotence Retrograde ejaculation Anti-sperm antibodies Congenital factors Acquired urogenital factors - obstruction, torsion, tumour Endocrine Genetic Systemic Gonadal toxins Idiopathic Varicocoele
Nutritional advice for preconception counselling
Appropriate wt gain Screen for eating disorders Healthy balanced diet Refer to dietician / exercise program if needed Avoid uncooked food Toxo and salmonella Limit caffeine Avoid etoh and other drugs Supps - folate, iodine, vit d if needed.
General and Lifestyle advice preconception
Diet and exercise
Quit smoking
Assess soc supports
Oral health
Risks assoc w advanced maternal age
Decr fertility Incr mc Incr congenital abs Incr PTB Incr complications of pregnancy - PET, GDM, placental problems Incr medical conditions in pregnancy Incr stillbirth >40yo
Risks antenatally of smoking
APH Severe PET Mc Infertility IUGR PPROM PTL Stillbirth
Risks of smoking in/after pregnancy seen in childhood
DNA damage - childhood ca
SIDS
Asthma and other resp complications
Cognitive and beh problems and risk of becoming smokers
Risks of obesity in early pregnancy
Decr fecundability
Decr ovulatory cycles
Incr mc
Late antenatal complications associated w obesity
PET GDM VTE OSA Death Congenital abs (w DM)
Intrapartum complications of obesity
IOL Assisted or operative del FTP PPH Shoulder dystocia Difficulties w foetal monitoring Anaesthetic complications
Post op complications assoc w obesity
Cs scar healing and infection
VTE
Breast feeding difficulties
Symptoms of menopause
Transition usually lasts 4-5yrs
Onset usually 40s to 50s
Average last period 51 range 40-58.
Menstrual changes - cycles may shorten or lengthen. Bleeding usually increases. Abrupt cessation in 10%
Vasomotor symptoms - hot flushes. 80% women and severe in 10%. Up to 12yrs in 10%
Vaginal dryness, atrophy –> dyspareunia, incontinence, prolapse, recurrent UTI
Cognitive disturbance - irritability, anx/dep, difficulty concentrating, memory lapses
Sleep disturbance
Loss of libido
Ddx for menopause and possible Ix
DM
Thyroid disorders
Pregnancy or other causes for secondary amenorrhea
Ix for ddx Lipid profile if other RF Pelvic US if atypical DEXA if early or other RF Cervical screening or mammograms if due
Risks and benefits of HRT
Don't forget, diet, lifestyle, smoking, exercise, wt loss. - modifiable RF for CVD. Pap smears and mammography Preventative and holistic health BENEFITS Most effective Rx for vasomotor sx. May be cardio protective for younger women Osteoporosis Sexual fxn May improve mood, sleep etc
RISKS Thromboembolism Breast ca Endometrial ca w/out progesterone CVS w prolonged/ older use Stroke Gallbladder Migraine w aura Liver disease
Remember to Ix for abnormal bleeding
Causes for early menopause
Spontaneous in 90% Iatrogenic Turners syndrome, fragile x, galactosaemia Ai esp thyroid CT or RT Any pelvic surg
Symptoms of acute hyperbilirubinaemia
Lethargy Poor feeding Hypertonia High pitched cry Seizures Coma
Causes for jaundice <24 hrs
Always pathological
Rhesus, ABO or other blood grp incompatibility
Sepsis
Rare - red cell abnormalities
Causes for jaundice 1-10/7
Too high = 200-250
Cephalohaematoma or other bruising, cerebral haemorrhage
Polycythemia
Sepsis - UTI, hepatitis (conjugated >15%)
Haemolysis
Incr enterohepatic circulation - obstruction
Physiologic
breast milk jaundice / dehydration
Causes for late jaundice
Conjugated - TORCH - sepsis - idiopathic hepatitis - hbv Sepsis Resorption of bruising Gut obstruction Hypothyroidism Congenital malformations Haemolysis Breast milk jaundice
Management of neonatal jaundice
Take serum bili if early, widespread, otherwise unwell, Rh -ve and jaundiced, preterm and jaundiced
General - hydration
- FHx, feeding, irritability, skin changes, other obs, input/output, lethargy, hepatosplenomegaly, urine and stool changes
IX Assess for risk of sepsis FBC/film/retic count LFTs + conjugated DAT/Coombs tests Blood group + mothers
Conjugated Septic screen TFT Coags G6PD if likely TORCH screen
PHOTOTHERAPY
Temp 3-4hrly
Recheck bili 12-24hrly and cease when >50 below threshold
Demand feeding w input/output
Daily wts
Exchange if approaching threshold or Sx of acute encephalopathy
Incidence of breech at term
3-4% at 36-37/40
25% rate spontaneous version at term
6% reversion rate
Assoc with preterm, multips, polyhydramnios, IUGR, uterine and congenital abnormalities
Relative risk of vaginal breech and risks assoc w ECV
Vaginal breech assoc w 3x (5 - 1.6%) relative risk serious neonatal M&M at 6/12
No difference maternal
No difference at 2yrs
Foetal complication 6% Serious complication 0.24% - abruption 0.1%, foetal distress, cord prolapse PV bleeding 3% Mortality 1/5000
Contraindications to ECV
Macrosomia, IUGR Antepartum haemorrhage hx Hyperflexion/extension of head PET ROM Previous CS Foetal abnormalities severe Uterine anomalies Cord around neck Abnormal CTG
Success 40-60%
How to perform an ECV
US prior to confirm lie - exclude footling/kneeling breech, placental location, uterine and foetal morphology, head position, EFW CTG ok Blood group/antiD Empty bladder US to exclude cord and conf position Perform w IV access CTG and US after Tocolysis if needed
Physiological causes for amenorrhea
Pregnancy
Childhood
Lactation
Post menopausal
Iatrogenic causes for amenorrhoea
Hormonal therapy Hysterectomy/BSO CT/RT Pelvic irradiation Endometrial ablation Ashermans syndrome Other drugs - antipsychotics, metoclopramide, methyldopa
Causes for primary amenorrhoea
Remember to enquire about age of thelarche/adrenarche and maternal age of same
INFANTILE
Turners
Hypothyroidism
Gonadal dysgenesis - rarely Kallmanns syndrome
MASCULINE
Rare
True haemaphrodite
CAH
NORMAL
Androgen insensitivity
Mullerian abnormalities
Causes for secondary amenorrhea (pathological)
PCOS Obesity Prolactinomas Hypothalamic amenorrhoea Serious medical conditions Premature ovarian failure Ovarian causes - Ashermans
Hx for infertility
Thelarche/adrenarche and FHx of same Sx pregnancy Sx thyroid dysfxn Sx menopause Androgen related Sx Hx of periods if relevant and prev pregnancies MHx Meds - inc injections and devices SHx FHx
Exam for amenorrhoea Ix
Wt, ht, waist, hips General appearance, stigmata of disease etc Thyroid and breast exam Abdo exam External genitalia Int exam only if appropriate
Incidence and risk factors for miscarriage
50% all conceptions
15-20% all recognised pregnancies
70% threatened mc will go on
Age Number of previous pregnancies and miscarriages Smoking Drinking Other illicit drug use Uterine anomalies Genetics Connect tissue abs Uncontrolled DM
Miscarriage management - what to do at difference hCGs
Positive > 5
Becomes positive 9/7 post conception
Min doubling in first trimester every 48hrs
<2000 rpt in 48hrs and TVS at same time
>2000 and nil seen on TVS - risk of ectopic - beware multiple pregnancy, fibroids. Rpt in 48-72hrs TVS and hCG
Declining or plateauing - risk of no viable preg or ectopic. Follow to 0
Initial management of miscarriage
Resusc IV access, bloods and IVT Analgesia Spec and removal of POC as necessary Expectant, medical or surgical Mx Anti-d Send tissue for histo Consider referral to social work etc
Diagnosis of non viable miscarriage
Failure of hCG rise over 48hrs if <2000
CRL >7 and no HB
MSD >25mm and no embryo
Absence of embryo with HB 2/52 after YS and no embryo or 11/7 after YS and present embryo
Describe medical management of miscarriage
Most effective for incomplete - passage may take several weeks for intact sac
Less infection
Good if BF
More days of bleeding and volume overall
10% require d&c
Make f/u appt for 7-10 days
Rpt hCG in 3/52
Serial US
Consider surg if not passed in 7-10/7
Remind can change their mind and to return if bleeding, pain, infection
Describe medical management of miscarriage
No difference between medical and expectant in completeness/infection or need for d&c
Bleeding more and more prolonged that D&C
SE miso - flushes, dizziness, fatigue, thermoregulatory changes, N/V/D
May combine w mifepristone - May cause HTN - give 24-48hrs prior to miso and observe BP for 15min
Give miso 800mcg PV day 1 and 2.
Consider surg if no passage after 48hrs but may leave for 8/7.
Bleeding May cont up to 3/52
May be in or outpt depending on gestation (9/40)
AntiD
Info on when to return
RV day 8 regardless
Oral analgesia and antiemetic
Eval progress w clinical, hCG and US
Describe surgical MC management
Must be used if persistent heavy bleeding, infection, unstable, GTD
Usually under GA
May give mife 24-36hrs prior
If >14/40 give miso 400mcg sl/po 4 hrs prior
For all give same 2hrs prior
RISKS
GA
Cervical trauma 1%
Perforation 0.1%
Mortality 0.6/1000 - lowest of all options
EPC or or GP FU
Counselling for early pregnancy loss
Try to have both parents present Discuss memory creation Risk of dep/anx, precip psychotic disorder Refer to gynae anyone with recurrent loss No evidence for deferring next pregnancy Preconception counselling Lifestyle, diet, health Contraception Support services
Causes for recurrent miscarriage
1% couples w 0.33 chance. After 3 risk for next preg is 40%
Idiopathic in 50%
Age and lifestyle - smoking, obesity
Chromosomal disorders - balanced translocations
Endocrine - PCOS, thyroid, DM
Thrombophilias - anti phospholipid disorders (15%) excess NK cells
Structural - uterine abnormalities (5% with 50% able to carry pregnancy to term), fibroids, cervical incompetence
Other - sperm fragmentation, incr maternal body temp
Define captured seccundum, cephalhaematoma and subgaleal haemorrhage
Caput seccundum - extra aponeurotic oedema caused by pressure on head during labour and del. benign, crosses suture lines
Cephalhaematoma - caused by friction between periosteum and skull so therefore does not cross suture lines. Unlikely to be dangerous but can be cause of sig blood loss as well as resorption jaundice
Subgaleal haemorrhage - separation of epicranial aponeurosis from periosteum. 0.6/1000 normal 4.6/1000 vacs. Insidious loss of significant amounts of blood. Crosses suture lines.
SSx of subgaleal haemorrhage
Suspect w APGARS < 7 at five minutes without sig asphyxia
Pitting, ballotable, fluctuant swelling crossing suture lines
Irritable to obtunded baby
Puffy eyes, elevated/displaced ears
Broad causes for neonatal respiratory distress
Sepsis - GBS Hyaline membrane disease Aspiration TTN Congenital abnormalities Pneumothorax OTHER Hypoglycaemia Hypothermia Anaemia Polycythemia Met acidosis
General measures for managing resp distress in a neonate
Maintain sats 92-96%
Hood or incubator
Monitor HR, resps and sats continuously
FBC CRP BC
CXR
Proph ABX until infectious process excluded - amp + gent
Monitor BSLs hourly until stable or 4hrs then four hrly
Small regular feeds - tachypnoea >60-80 precludes oral feeds. Consider NG/OG
Minimal handling
Maintain body temp
CPAP if persistent distress or req >30% oxygen
Fluids 60ml/kg/day
History taking for neonatal distress
Number pregnancy Prev preg probs Problems identified in preg - morph, RF for SGA etc, GDM Mode of del and indication for same Gestation Risk factors for sepsis - GBS positive without ABx - PROM - unwell mother - prev same Mec How is mother doing Mat Hx
Exam for neonatal distress
Obs Appearance - congenital abs - body temp, skin colour WOB Cry Pulses Urine output Resp and cardiac exam Abdo - masses, empty abdo BGL
APH hx
G/P Gestational age Complications to date Praevia? Blood group Prev bleeding MHx FM Pain/contractions Amount Consistency Clots? Triggers Colour Ongoing loss Weigh pads
Emergency management APH
Brief Hx inc gestational age and praevia, MHx, allergies, last ate Flat on side O2 support Two wide bore cannulas Urgent FBC, Coags, U&E, G&H, cross match at least 3 units IVT stat Cannula IDC 5min obs Foetal heart/CTG Prep for theatre
More sedate management for APH
Hx as prev
Foetal heart / CTG
Gentle abdo palp - tenderness, tone, lie
Spec/ bimanual if praevia excluded
Bedside US for placental location and foetal well being and position
Frequent obs
Differential diagnosis for adnexal mass
CYSTS
Functional - 24%. Follicular or corpus luteum. Most will resolve in couple of cycles. < 2.5cm considered N and may be up to 10cm
Benign masses - serous cystadenoma (20-25% malig and same bilat) or mucinous (5% bilateral and same malig), endometriomata, teratoma.
Pregnancy related - theca lutein, corpus luteum
Other - ectopic, PID, PCOS
Malignant 6%
Management of ovarian cysts
Ca 125 not required for all simple cysts
LDH, AFP and hCG in all complex masses < 40yo - possible dermoid
No malig features and < 3cm repro age or 1cm - no follow up
Repro age and < 7cm follow up
Haemorrhagic, endometrioma 6-12wks then yearly
Mid size and dermoid yearly
Surgical eval
OCP not recommended. Remember to mention possibility of rupture/bleed and torsion
Outline management of SGA/IUGR
Hx - obtesteric Hx, MHx, FHx, Hx of infections in pregnancy, progress to date, ?first trimester screening
- test for CMV and toxo +/- syphilus and malaria
- screen for PET
Confirm dates
Confirm IUGR serially and tertiary morph if not completed
Refer to tertiary centre if appropriate
Foetal wellbeing - biophys + dopplers + AFI and CTG serially
Mode of delivery
Timing of delivery - explain will go to SCN/NICU if appropriate
Communicate prognosis
Introduce to neonatal care
Prevention in next pregnancy
Primary survey of abdominal trauma in pregnancy
Must be focused at mother A consider C spine if obtunded B 10L C observe signs of peripheral perfusion, control obvious bleeding, flat, manually displace or tilt, cannula, IVT D neuro, GCS and pupils E keep warm CXR, pelvis and CT head/spine
Secondary survey abdominal trauma
Quick Hx - gestational age, problems, blood group, MHx, allergies, last ate
Complete physical with catheter or breathing support if needed
Obstetric - FH or CTG
- abdo palp position, tenderness, contractions, fundal ht, visible bruising
- spec cervix situation, membranes, bleeding
- VE only when placental location known
- urine for haematuria
Bloods including Kleihauer
US abdo/pelvis
CT if indicated
Consider antiD
If >20/40 admit for observation
- 4hr CTG
- if concerning features more than basic CTG/FH every 4hrs
- May discharge if no concerning features
Think about shock, abruption, PTL
APH raises the risk of what following conditions?
SGA/IUGR - start serial scans Oligohydramnios PPROM PTL PPH Anaemia LSCS
Causes for APH
2-5% pregnancies and 50% no cause found PLACENTAL Placenta praevia Marginal sinus rupture Vasa praevia
LOCAL/GENITAL Ectropion Cervical dysplasia Cervicitis Vaginitis/trauma Cervical polyp Show Vulvovaginal varicosities PR/urinary source
Risk factors for neonatal sepsis
Prolonged ROM FD Maternal pyrexia or unwell ness Obstetric procedures Preterm Hx GBS - early onset >80% GBS and important outside NICU setting w late onset (48hrs)
SSx neonatal sepsis
General - pallor, lethargy, jaundice, irritability, quiet, temperature days regulation, poor tolerance to handling
Resp
CVS tachycardia, episodic brady, hypotensive, poor perfusion - decr urine output
GIT feeding, vomiting, diarrhoea, abdo distension
Cutaneous petechiae, bruising, rash
Neuro high pitched cry irritability, lethargy, seizures
Management of neonatal sepsis
Full Hx and exam looking for sources SCN w freq monitoring Resp and cardiac support if needed Incubator w light therapy if needed Fluid boluses for hypotension Unlikely to tolerate feeds so give fluid only or TPN if needed Minimal handling Neutral heating Bloods - glucose, FBC, U&E CRP, LFTs inc bili differential, cultures Urine unlikely in early CXR LP where suspicion high
