Gynae Flashcards
What is needed following a medical termination of pregnancy?
Multiple level pregnancy test in 2 weeks
Management of vaginal thrush?
Oral fluconazole
Enlarged boggy uterus?
Adenomyosis
What is a C/I to injectable progesterone contraceptives?
Current breast cancer
Management of pregnant women who are<6 weeks gestation with painless bleeding?
Expectant management - repeat test in 7 days
Imaging of choice for adenomyosis?
Transvaginal US
How long should women wait before starting regular hormonal contraception after taking ulipristal?
5 days
Management of 2 missed pills in week 3?
Take an active pill and omit the pill-free interval
What is acceptable with nearly all anti epileptic drugs?
Breastfeeding
Risks of HRT?
- Increased risk of breast cancer
- Increased risk of endometrial cancer(if no progresterone)
- Increased risk of VTE
Unopposed oestrogen increases the risk of?
Endometrial cancer
If one pill missed, what is the next steps?
Take the next pill ASAP then continue as normal
If 2 pills are missed in week 2, what is the next steps?
No emergency contraception needed if previous 7 days have been taken correctly
What is the drug of choice for reversing respiratory depression caused by mag sulphate?
Calcium Gluconate
When should anti-D prophylaxis be given to women who are having an abortion?
If rhesus negative and after 10 weeks gestation
Management of switching from IUD to COCP
No additional contraception needed if removed on day 1-5
If later, barrier contraception needed for 7 days
When should oestrogen containing contraceptives be discontinued before surgery requiring immobilisation?
4 weeks before
COCP protects against which cancers?
Ovarian and endometrial
Presence of heartbeat on US of ectopic suggests what?
Surgical management needed
When do women require contraception post partum?
After 21 days
First line for menorrhagia?
Mirena IUS
2nd line= tranexamic acid or NSAIDs; if want hormonal then COCP or cyclical oral progestogen
Risk factors for premature ovarian failure?
positive family history, exposure to chemotherapy/radiation and autoimmune disease.
Which contraceptives are not affected by enzyme inducing drugs?
- Copper IUD
- Injection
- Mirena
When is anti-D given?
28 and 34 weeks
What are the normal blood test results for PCOS?
- Raised LH:FSH ratio
- Normal/Raised testosterone
- SHBG is normal/low
Most common ovarian cancer type?
Epithelial cell tumour
Most common type of fibroid?
Intramural fibroid
Vulval itching with white atrophic patches of skin?
Lichen sclerosis
What can be precipitated by antibiotic exposure?
Fungal infection
Current breast cancer is a C/I to what?
All hormonal contraceptives
Management of all postmenopausal women with atypical endometrial hyperplasia
Hysterectomy with bilateral salpingo-oophorectomy
Itching and vaginal burning with latex condoms?
Irritant contact dermatitis
blue and bulging membrane with a mass protruding from behind
Imperforate hymen
Failure of the corpus luteum to regress can lead to what?
Corpus luteal cyst
Why is a urine dip done when patients have hyperemesis gravidarum?
Assess for ketones as these would suggest ketosis/starvation
What vitamin can be given to patients with hyperemesis?
Thiamine to prevent Wernickes
What are causes of recurrent spontaneous miscarriages?
- Antiphospholipid
- Infection
- Uterine/Cervical abnormalities
What is CIN and how do you differ between CIN1/2/3?
CIN - premalignant condition where abnormally diving cells have now invaded below the basement membrane
1 - 1/3 of epithelium 2 - 2/3 of epithelium, 3 - 3/3 of epithelium
What are types of cervical cancer?
Squamous cell and adenocarcinoma
What is the investigation of choice to look for local and distant spread of invasive cervical carcinoma?
CT
What is an ectropion?
growth of endocervical columnar epithelium outside of the external os
Side effects of GnRH agonists?
Menopausal symptoms
Loss of bone mineral density
What causes ovarian torsion?
Small cyst ruptures on a free pedicle, restricting its blood supply causing potential ovarian necrosis
How do dermoid cysts arise?
Derived from primitive germ cells which can differentiate into any body tissue
What are signs of endometriosis on examination?
- Fixed, retroverted uterus
- Tender uterus
- Enlarged ovaries
- Uterosacral ligament nodules
- Visible lesions
Primary vs secondary infertility
Primary - couple have never been able to conceive
Secondary - couple have achieved conception in the past
Management of infertility in PCOS?
- Metformin
- Clomiphene
- Gonadotrophins
What is the classic PCOS triad?
- Hyperandrogenism
- Ovulatory dysfunction
- Polycystic ovaries
What bloods would you measure for ovulatory function?
- Day 21 progesterone
- FSH/LH
- Oestradiol
What are C/I to IUD insertion?
- STI/PID
- Ovarian/Endometrial/Cervical cancer
Why can women sometimes feel faint and become bradycardic during IUD insertion?
Cervical shock leads to vasovagal which causes reflex bradycardia
Where does endometrial cancer metastasize?
- Inguinal lymph nodes
- Lung
- Bone
- Liver
- Peritoneum
What are non contraceptive ways to manage menorrhagia?
- Tranexamic acid
- Aspirin
- Indomethacin
- Mefenamic acid
What are common places for endometrial tissue to grow?
- Ovaries
- Pouch of Douglas
- Uterosacral ligaments
What markers should be done in suspected ovarian cancer?
- CA125
- AFP
- BHCG
What are risk factors for uterovaginal prolapse?
- Multiparity
- Raised intrabdominal pressure
- Menopause
- Hysterectomy
What can be done to prevent prolapse?
- Pelvic floor excercises
- Support the vaginal vault during hysterectomy
What is management of prolapse?
- Pessaries
- Physio
- Surgical repair
What can cause oligohydramnios?
- PROM, renal agenesis, foetal abnormalities, IUGR
What complications can occur with oligohydramnios?
- Resp difficulties
- Skull deformities
- IUGR
- Pulmonary hypoplasia
- Cord compression
- Shoulder dystocia
- Foetal hypoxia
What is the management of oligohydramnios?
- Encourage maternal hydration
- Oligoinfusion
When should serum progesterone levels be taken to check ovulation?
7 days before next expected period
Missed pill rules
- If 1 missed (any time in cycle): take it and continue as normal
- If 2 or more missed: take it and use condoms for 7 days
- If 2 or more missed in week 1 and she has had sex this week or previous pill-free interval: + emergency contraception
- If 2 or more missed in week 3: start next pack as soon as she finishes current pack
Management of stage 1 cervical cancer to maintain fertility?
Cone biopsy
Which should be measured when thinking about premature ovarian insufficiency?
FSH - will be raised
What is the first line management for prolapse?
- If asymptomatic: nothing
- Conservative: weight loss and pelvic floor excercises
- Pessary
- Surgery: colporrhaphy
Which hormone surges just before ovulation?
LH
What is a fibroid?
Benign smooth muscle tumour originating from the myometrium
Most common tumour in young women?
Germ cell tumour
Lichen sclerosus needs what to be treated?
Potent topical steroid
Woman recently stopped breastfeeding with lump?
Galactocele
PCOS increases the risk of what?
Endometrial and ovarian cancer
What should be given to induce a withdrawal bleed when thinking about cancer in someone with PCOS?
Oral cyclical progestogen
When should a follow up smear after LLETZ be done?
6 months
Premenstrual syndrome management
COCP
SSRI
Before sterilisation, how long must women have been on effective contraception for?
1 month
Atrophic vaginitis often occurs in who?
post-menopausal women
How does atrophic vaginitis present?
vaginal dryness, dyspareunia and occasional spotting
exam= pale and dry
Mx of atrophic vaginitis?
vaginal lubricants and moisturisers
if don’t help then topical oestrogen creams
What is cervical ca screening?
HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Who is screened for cervical ca?
25-49yrs= every 3yrs
50-64yrs= every 5yrs
Scotland= 25-64yrs every 5yrs
Cervical screening if pt is pregnant?
delayed until 3m post-partum unless missed screening or previous abnormal smears
What women may opt out of cervical ca screening?
women who have never been sexually active so have very low risk
Best time to take a cervical smear?
around mid-cycle
Umbilical cord prolapse?
when umbilical cord descends ahead of the presenting part of the fetus
1/500 deliveries
What if umbilical cord prolapse is left untreated?
can lead to compression of cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death
RFs for cord prolapse?
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations eg. breech, transverse lie
50% of cord prolapses occur when?
at artificial rupture of the membranes
When is cord prolapse typically diagnosed?
when fetal heart rate becomes abnormal and the cord is palpable vaginally or if the cord is visible beyond the level of the introitus
Mx of umbilical cord prolapse?
obstetric emergency
- presenting part of fetus may be pushed back into uterus to avoid compression
- if cord is past level of introitus then minimal handling and it should be kept warm and moist to avoid vasopasm
- ask pt to go ‘on all fours’ until immediate c-section (left lateral position is alternative)
- tocolytics can be used to reduce uterine contractions
- retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
- c-section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
What is the introitus?
opening that leads to the vaginal canal
Umbilical cord prolapse= what if the cord is past the entrance to the vagina (introitus)?
minimal handling and it should be kept warm and moist to avoid vasospasm
Umbilical cord prolapse= ask pt to do what whilst awaiting c-section?
go on all fours
Umbilical cord prolapse= what can be used to reduce uterine contractions?
tocolytics
Umbilical cord prolapse= what may be helpful to gently elevate the presenting part?
retrofilling the bladder with 500-700ml saline
Umbilical cord prolapse: if treated early then…?
fetal mortality is low
incidence has been reduced due to increase in c-sections used in breech presentations
Ectopic pregnancy?
implantation of a fertilised ovum outside the uterus
Typical history for ectopic pregnancy?
female with history of 6-8w amenorrhoea who presents with lower abdo pain and later develops vaginal bleeding
Lower abdo pain in ectopic pregnancy?
due to tubal spasm
typically 1st symptom
pain is usually constant and may be unilateral
Vaginal bleeding in ectopic pregnancy?
less than normal period
may be dark brown
Amenorrhoea in ectopic pregnancy?
typically 6-8w from start of last period
if longer eg. 10w this suggests another cause eg. inevitable abortion
Other than abdo pain what other type of pain may be present in ectopic pregnancy?
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
CP of ectopic pregnancy?
- lower abdo pain
- vaginal bleeding
- amenorrhoea 6-8w
- shoulder tip pain +/- pain on defecation/urination
- dizziness, fainting or syncope
- symptoms of pregnancy eg. breast tenderness
Ectopic pregnancy= examination findings?
- abdo tenderness
- cervical excitation (aka cervical motion tenderness)
- adnexal mass= DO NOT EXAMINE for adnexal mass due to increase risk of rupture of pregnancy BUT pelvic exam to check for cervical excitation is recommended
Pregnancy of unknown location, a serum b-hCG level of what points towards diagnosis of ectopic pregnancy?
> 1500
Ix for ectopic pregnany?
- stable= Ix and Mx in early preg assessment unit
- unstable= refer to A&E
Ix= pregnancy test positive;
GOLD= transvaginal USS
3 ways to manage ectopic pregnancy?
1) expectant Mx
2) medical Mx
3) surgical Mx
Expectant Mx for ectopic pregnancy criteria?
- <35mm
- unruptured
- asymptomatic
- no fetal heartbeat
- hCG <1000
- compatible if another intrauterine pregnancy
Medical Mx for ectopic pregnancy criteria?
- <35mm
- unruptured
- no signif pain
- no fetal heartbeat
- HCG <1500
- not suitable if intrauterine pregnancy
Surgical Mx for ectopic pregnancy criteria?
- > 35mm
- can be ruptured
- pain
- visible heartbeat
- HCG >5000
- compatible with another intrauterine pregnancy
Expectant Mx for ectopic pregnancy involves what?
monitor closely over 48hrs and if B-hCG levels rise again or pt develops symptoms the intervention needed
Medical Mx for ectopic pregnancy?
methotrexate but only if pt is willing to attend follow up
Surgical Mx for ectopic pregnancy?
Salpingectomy or salpingotomy
Salpingectomy or salpingotomy for ectopic pregnancy?
- Salpingectomy 1st line if not other RFs for infertility
- Salpingotomy if RFs for infertile eg. contralateral tube damage
- 1 in 5 who have salpingotomy also need further Tx eg. methotrexate and/or salpingectomy
Pathophysiology for ectopic pregnancy?
97% are tubal, with most in ampulla
more dangerous if in isthmus
3% in ovary, cervix or peritoneum
trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
Natural history of ectopic pregnancy?
Natural history - most common are absorption and tubal abortion:
- tubal abortion
- tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
- tubal rupture
fertilised ovum implanting and maturing outside the uterine cavity.
ectopic pregnancy
Where do most ectopic pregnancies (97%) impant?
fallopian tube
others= ovary, abdomen, cervix, caesarean section scar, interstitial part of the fallopian tube, or the cornua of a unicornuate or bicornuate uterus.
RFs for ectopic pregnancy?
tubal damage, maternal age over 35 years, and smoking. However, there are no identifiable risk factors in about a third of cases.
Cx of ectopic pregnancy?
Tubal rupture (which may lead to maternal death, if treatment is delayed).
Recurrent ectopic pregnancy.
Adverse effects of treatment.
Grief, anxiety, or depression.
Signs and symptoms of ectopic pregnancy?
Common symptoms include abdominal or pelvic pain, amenorrhoea or missed period, and vaginal bleeding. Less common symptoms include gastrointestinal symptoms, dizziness, shoulder tip pain, and urinary symptoms.
Common signs include pelvic, adnexal, and abdominal tenderness. Less common signs include cervical motion tenderness, pallor, abdominal distension, shock, and hypotension.
If women presents with symptoms of ectopic pregnancy then…
Pregnancy should be confirmed (if not already done).
The woman should be examined for signs of an ectopic pregnancy.
Immediate hospital admission for ectopic preg when?
if there are signs of haemodynamic instability or significant concerns about the degree of pain or bleeding.
Ectopic pregnancy: Immediate referral to an early pregnancy assessment service or out-of-hours gynaecology service should be arranged for women…..
with a positive pregnancy test, and the following on examination:
- Abdominal pain and tenderness.
- Pelvic tenderness.
- Cervical motion tenderness.
Ectopic pregnancy: Referral to an early pregnancy assessment service (with urgency depending on clinical judgement) should be arranged for women if they have….
bleeding or have other symptoms and signs of early pregnancy complications if they also have any of the following:
- Pain.
- A pregnancy of 6 weeks’ gestation or more.
- A pregnancy of uncertain gestation.
When should expectant Mx be used for women in ectopic pregnany?
less than 6 weeks’ gestation who are bleeding but not in pain, and who have no risk factors, such as a previous ectopic pregnancy. Advise these women:
- To return if bleeding continues or pain develops.
- To repeat a urine pregnancy test after 7 to 10 days and to return if it is positive.
- That a negative pregnancy test means that the pregnancy has miscarried.
Diagnostic tool of choice for ectopic pregnancy?
transvaginal ultrasound
Secondary care Tx options for ectopic pregnancy?
expectant management (watchful waiting), medical management (commonly with methotrexate), or surgery.
After Tx for ectopic pregnancy, what should be done?
woman should be followed up in primary care and offered appropriate support, information, and advice.
Endometriosis?
condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of reproductive age have a degree of endometriosis.
Clinical features for endometriosis?
- chronic pelvic pain
- secondary dysmenorrhoea= pain typically starts days before bleeding
- deep dyspareunia
- subfertility
- non-gynae= urinary symptoms eg. dysuria, urgency, haematuria; dyschezia (painful bowel movements)
- pelvic exam= reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Endometriosis= findings on pelvic exam?
reduced organ mobility, tender nodularity in posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Dyschezia?
painful bowel movements
Ix for endometriosis?
- no role for Ix in primary care eg. USS= if symptoms signif then refer pt for definitive diagnosis
- GOLD= laparoscopy
GOLD standard Ix for endometriosis?
laparoscopy
Mx of endometriosis depends on what?
clinical features
Is there correlation between laparoscopic findings and severity of symptoms in endometriosis?
no there is poor correlation
Mx for endometriosis?
NSAIDs +/or paracetamol 1st line for symptomatic relief
if analgesia doesn’t help= COCP or progestogens eg. e.g. medroxyprogesterone acetate should be tried
doesn’t help/fertility priority= refer to secondary care eg. GnRH analogues or surgery
Secondary care Mx options for endometriosis if analgesia/hormonal Tx doesn’t improve symptoms or if fertility is a priority?
- GnRH analogues
drug therapy doesn’t seem to have impact on fertility
- Surgery= laparoscopic excision or ablation of endometriosis + adhesiolysis to try and improve chance of conception; ovarian cystectomy (for endometriomas) also recommended
Role of GnRH analogues in endometriosis if analgesia/hormonal Tx ineffective?
induces a ‘pseudomenopause’ due to low oestrogen levels
growth of endometrium-like tissue outside the uterus.
endometriosis
Endometriosis= Endometriotic deposits are most commonly distributed where?
pelvis; on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas. Extra-pelvic deposits, such as in the bowel and pleural cavity, are rare
Endometriosis is associated with what?
menstruation. The hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation
Cause of endometriosis?
The exact cause of endometriosis is unknown. It is thought that endometriosis develops as a result of a combination of several factors, including retrograde menstruation, personal genetics, metaplasia, and environmental factors.
Summary of endometriosis?
can be a chronic disease affecting women throughout their reproductive lives (and sometimes beyond). For most women, symptoms can be controlled with hormonal treatment, however, some women may have complex needs and require long-term support.
When to suspect endometriosis?
in women (including young women aged 17 years and younger) presenting with one or more of the following symptoms or signs:
- Chronic pelvic pain (defined as a minimum of 6 months of cyclical or continuous pain).
- Period-related pain (dysmenorrhoea) affecting daily activities and quality of life.
- Deep pain during or after sexual intercourse.
- Period-related or cyclical gastrointestinal symptoms, in particular painful bowel movements.
- Period-related or cyclical urinary symptoms, particularly blood in the urine or pain passing urine.
- Infertility in association with one or more of the above.
What to do if suspect endometriosis?
thorough history and examination should be undertaken to:
- Identify RFs (such as early menarche, nulliparity, or family history of endometriosis).
- Exclude differential diagnoses (such as other gynaecological conditions, irritable bowel syndrome, or pelvic inflammatory disease).
- Identify complications (such as fertility problems or depression).
Ix if suspect endometriosis?
if suspected then transvaginal ultrasound scan should be arranged to exclude other pathology, identify endometriomas and deep endometriosis, and to guide referral and management.
The possibility of endometriosis should not be excluded if the abdominal or pelvic examination or ultrasound is normal. If clinical suspicion remains or symptoms persist, referral for further assessment and investigation should be considered.
Diagnosis of endometriosis can only be made definitively by laparoscopic visualization of the pelvis.
Diagnosis of endometriosis can only be made definitively by what?
laparoscopic visualisation of the pelvis
Summarise Mx for suspected/confirmed endometriosis?
Review to manage endometriosis-related pain with simple analgesics and/or hormonal treatment, as appropriate.
Assessing the woman’s individual information and support needs, taking into account her circumstances, symptoms, priorities, desire for fertility, aspects of daily living, and her physical, psychosexual, and emotional needs.
Assessing for, and managing, complications of endometriosis, such as fertility problems or depression.
Endometriosis: when to refer to secondary care?
Where the diagnosis is unclear.
For women with severe, persistent, or recurrent symptoms.
For women with pelvic signs of endometriosis.
If the initial management is not effective, not tolerated, or contraindicated (for consideration of other management options, including diagnostic laparoscopy).
When to review pt with endometriosis?
after 3–6 months, or earlier if symptoms are troublesome.
If initial hormonal treatment for endometriosis is ineffective, not tolerated, or contraindicated, refer the woman to a gynaecology service, specialist endometriosis service, or paediatric and adolescent gynaecology service
For women with confirmed endometriosis, particularly women who choose not to have surgery, ensure that they are followed up in secondary care if they have:
Deep endometriosis involving the bowel, bladder or ureter or
One or more endometrioma that is larger than 3 cm.
What happens to BP in normal pregnancy?
BP normally falls in 1st trimester (esp diastolic), and continues to fall until 20-24w
after this time the BP usually increases to pre-pregnancy levels by term
Women who are at high risk of developing pre-eclampsia should take what?
aspirin 75mg od from 12 weeks until the birth of the baby
Hypertension in pregnancy in usually defined as what?
- systolic > 140 mmHg or diastolic > 90 mmHg
or
- an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing a pregnant pt is hypertensive what should be done?
categorise into either pre-existing HTN; pregnancy induced HTN (PIH aka gestational HTN) or pre-eclampsia
3 categories of HTN in pregnant pt?
1) pre-existing HTN
2) pregnancy induced HTN
(PIH) aka gestational HTN
3) pre-eclampsia
Pre-existing hypertension in pregnancy?
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women
Pre-existing hypertension in pregnancy Mx?
If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review
If pt has pre-existing HTN in pregnancy, what meds should be stopped?
ACE inhibitor or ARB for pre-existing should be stopped and start alternative eg. labetalol or nifedipine
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)?
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension) Mx?
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
Pre-eclampsia?
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)?
pre-eclampsia
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Pre-existing hypertension
Mx of HTN in pregnancy?
1st line= oral labetalol
2nd= nifedipine eg. is asthmatic or methyldopa
Definition of hypertension in pregnancy?
diastolic blood pressure of 90–109 mmHg and/or systolic blood pressure of 140–159 mmHg.
Definition of severe hypertension in pregnancy?
diastolic blood pressure of 110 mmHg or greater and/or systolic blood pressure of 160 mmHg or greater.
Definition of chronic HTN in pregnancy?
Hypertension that is present at, or prior to the booking visit, or before 20 weeks’ gestation — blood pressure tends to fall during the first and second trimesters and a woman with high blood pressure before week 20 of pregnancy can therefore be assumed to have pre-existing hypertension.
Definition of gestational HTN?
New hypertension presenting after 20 weeks’ gestation without significant proteinuria.
Definition of pre-eclampsia?
New hypertension presenting after 20 weeks’ gestation with significant proteinuria. Pre-eclampsia is a multi-system disorder which can affect the placenta, kidney, liver, brain, and other organs of the mother.
HELLP syndrome?
(Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome) is a severe form of pre-eclampsia.
Severe form of pre-eclampsia?
HELLP syndrome
HELLP syndrome stands for what?
Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome
Eclampsia?
occurrence of one or more seizures in a woman with pre-eclampsia.
What is defined as significant proteinuria in pregnancy?
a urinary protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol. Proteinuria of at least [1+] on dipstick testing should prompt one of these additional tests.
Pregnant Women at high risk of pre-eclampsia should take?
aspirin 75—150 mg daily from 12 weeks’ gestation until the birth of the baby.
What should be taken at presentation and at each antenatal visit to check for HTN in pregnancy?
Blood pressure should be taken and a dipstick urine test done for proteinuria
An explanation of the symptoms of pre-eclampsia should be given and the woman advised to seek immediate medical review if she develops any of the following (including during the first four weeks postpartum):
Severe headaches (increasing frequency unrelieved by regular analgesics).
Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
Persistent new epigastric pain or pain in the right upper quadrant.
Vomiting.
Breathlessness.
Sudden swelling of the face, hands, or feet.
Women with suspected pre-eclampsia require…
urgent secondary care assessment
What is essential in HTN in pregnancy?
postpartum monitoring and follow up
Official definition of pre-eclampsia?
new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
1) Proteinuria, or
2) Other maternal organ dysfunction:
- Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more).
- Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain).
- Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata.
- Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis.
- Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.
women are considered to be at high risk of pre-eclampsia if they have?
One of the following high risk factors:
- A history of hypertensive disease during a previous pregnancy.
- CKD
- Autoimmune disease, such as SLE or antiphospholipid syndrome.
- DMT1/2
- Chronic HTN
Two or more of the following moderate risk factors:
- First pregnancy.
- Aged 40 years or older.
- Pregnancy interval of more than 10 years.
- BMI of 35 kg/m2 or greater at the first visit.
- Family history of pre-eclampsia.
Multiple pregnancy.
For women assessed to be at high risk of pre-eclampsia?
1) Refer for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
2) Ensure that aspirin 75—150 mg daily is prescribed from 12 weeks’ gestation until birth. This is usually arranged in secondary care, but should be initiated in primary care if the woman will not be seen by a specialist until after 12 weeks.
Seek specialist advice before prescribing aspirin to girls younger than 16 years of age, and in those with thrombophilia or uncontrolled blood pressure. There is no evidence that use of low-dose aspirin in pregnancy is associated with an increased risk of congenital abnormalities or other fetal complications.
3) Offer advice about healthy lifestyle (including rest, work, exercise, and weight
For all pregnant women, dipstick the urine for protein and measure blood pressure at each antenatal visit.
If dipstick screening is positive [1+ or more], use…
albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
- If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria.
- If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold.
- Do not use first morning urine void to quantify proteinuria in pregnant women.
Arrange emergency secondary care assessment for any woman in whom pre-eclampsia is suspected. Advise women with severe hypertension (blood pressure of 160/110 mmHg or more) then
they will be offered hospital admission for ongoing monitoring of their condition and of their baby’s wellbeing.
Women with less severe hypertension may be offered admission depending upon whether there are clinical concerns for the wellbeing of the woman or baby or if they are considered to be at high risk of adverse events. If there are no such concerns, the woman will be offered ongoing specialist management on an outpatient basis.
Pre-existing HTN in pregnancy: women with chronic hypertension are at high risk of what?
pre-eclampsia and should be referred for consultant-led care at booking for specialist input to assess and manage the obstetric risk.
Pre-existing HTN in pregnancy: advice?
Healthy lifestyle (including work, rest, exercise, healthy diet, and weight) as recommended for all pregnant women.
Restriction of dietary salt.
Pre-existing HTN in pregnancy: stop what drugs?
ACE inhibitor, ARB. thiazide or thiazide-like diuretic
Be aware that pregnant women previously diagnosed with chronic hypertension may exhibit blood pressure within the normal range due to the physiological drop in blood pressure that occurs in early pregnancy. Continued antihypertensive treatment is not necessary if:
Sustained systolic blood pressure is less than 110 mmHg, or
Sustained diastolic blood pressure is less than 70 mmHg, or
The woman has symptomatic hypotension.
If a woman with chronic hypertension is not already taking antihypentensive treatment, while she is waiting to see a specialist, offer drug treatment if there is:
Sustained systolic blood pressure of 140 mmHg or higher, or
Sustained diastolic blood pressure of 90 mmHg or higher.
Target blood pressure following antihypertensive treatment in pregnancy is
135/85 mmHg.
How should I manage a woman with new hypertension after 20 weeks’ gestation?
Arrange secondary care assessment by a healthcare professional trained in the management of hypertensive disorders of pregnancy for all women with new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy.
Be aware of the signs and symptoms of, and risk factors for pre-eclampsia.
Advise women with new onset severe hypertension (blood pressure of 160/110 mmHg or more) that they are likely to be admitted to hospital for ongoing monitoring of their condition and of their baby’s wellbeing.
Women with less severe hypertension may not be routinely admitted and will instead be offered additional maternal and fetal monitoring on an outpatient basis.
Women with existing HTN in preg need to take what?
aspirin from 12w
If the woman is over 20 weeks’ gestation and has new proteinuria on dipstick testing but no hypertension:
this can be a symptom of impending pre-eclampsia —if there are other symptoms of pre-eclampsia, arrange same-day obstetric assessment.
If there are no other symptoms of pre-eclampsia, consider possible urinary tract infection (UTI):
- If there is [1+] protein on dipstick testing and either the woman has symptoms of a UTI, or the dipstick test is positive for nitrite or for both leucocyte esterase and blood, make a working diagnosis of UTI.
- Send a midstream specimen of urine (MSU) for culture and sensitivity
Proteinuria in pregnancy after 20w gestation: If there is [2+] protein or more on dipstick testing…
arrange urgent secondary care assessment, even if there is evidence of a possible UTI.
Proteinuria in pregnancy after 20w gestation: For women exhibiting [1+] protein on dipstick testing and no other symptoms of pre-eclampsia?
follow-up and reassess in 1 week:
Advise the woman to seek immediate medical attention if she develops symptoms of pre-eclampsia in the intervening period.
Dipstick the urine and measure the blood pressure. Use albumin:creatinine ratio or protein:creatinine ratio to quantify persistent ([1+] on dipstick) proteinuria.
Seek specialist obstetric advice if proteinuria is significant (protein:creatinine ratio of at least 30 mg/mmol, or albumin:creatinine ratio of at least 8 mg/mmol), or if there are any other concerns or uncertainty.
All women with pre-eclampsia who are discharged to primary care with abnormal blood results should have what?
repeat blood tests to measure platelet count, transaminases, and serum creatinine as clinically indicated, until results return to normal
Follow up= Women with pre-eclampsia who did not take antihypertensive treatment:
Should have their blood pressure measured at least once between days 3–5 after birth. If blood pressure is abnormal, it should then be measured on alternate days until it normalizes.
Target blood pressure is lower than 140/90 mmHg.
Antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
Follow up= Women with pre-eclampsia who took antihypertensive treatment:
Should continue receiving antihypertensive treatment.
Should have their blood pressure measured every 1–2 days for up to 2 weeks after transfer to community, care until treatment is no longer required and there is no hypertension.
If blood pressure falls below 140/90 mmHg — a reduction in treatment can be considered.
If blood pressure falls below 130/80 mmHg — treatment can be reduced.
HTN in pregnancy: If antihypertensive treatment is required in the postnatal period:
Be aware that methyldopa taken during pregnancy should ideally be stopped within 2 days of birth as it may increase the risk of depression.
For women who are not breastfeeding or planning to breastfeed, hypertension should be managed as for a member of the general population.
HTN in pregnancy: what it pt wants to breastfeed?
start enalapril post-partum or If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this sucessfully)
if not controlled then nifedipine (or amlodipine) + enalapril
ineffective then + atenolol or labetalol
What HTN drugs should be avoided in women who are breastfeeding?
diuretics and ARB
As antihypertensives can pass (in small quantities) into breastmilk, women who are breastfeeding should be advised to monitor their babies for symptoms of hypotension, such as
drowsiness, lethargy, pallor, cold peripheries, or poor feeding
HTN in pregnancy= A postnatal review 6–8 weeks after birth should be carried out in primary care or by a specialist:
All women who have had pre-eclampsia should undergo medical review of their hypertension.
A urinary reagent-strip test should be carried out. Women with [1+] proteinuria should be offered a further review in primary care or by a specialist three months after delivery to assess kidney function.
How should I follow up a woman with chronic hypertension postpartum?
Measure blood pressure (this will usually be done by the community midwife after hospital discharge):
- Daily for the first 2 days postnatally.
- At least once between days 3–5 postnatally.
- As clinically indicated if the woman’s antihypertensive treatment is changed postnatally.
Continue antihypertensive treatment if required:
Aim to keep blood pressure lower than 140/90 mmHg.
Review antihypertensive treatment 2 weeks postnatally.
Ensure that women with chronic hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.
How should I follow up a woman with gestational hypertension postpartum?
Most women with gestational hypertension will be followed up by the maternity unit after delivery until their blood pressure has returned to normal, or will be referred to a specialist if blood pressure remains elevated.
How should I follow up a woman with gestational hypertension postpartum= what should be done?
The woman’s blood pressure should be measured:
- Daily for the first 2 days postnatally.
- At least once between days 3–5 postnatally.
- As clinically indicated if the woman’s antihypertensive treatment is changed postnatally.
If continued antihypertensive treatment is required:
Target blood pressure is lower than 140/90 mmHg.
Gestational HTN follow up?
For women with gestational hypertension who did not take antihypertensive treatment and have given birth, antihypertensive treatment should be started if blood pressure is 150/100 mmHg or higher.
Women who remain on antihypertensive treatment postnatally should be offered a medical review in primary care, or with their specialist 2 weeks after transfer to community care.
Ensure that women with gestational hypertension are offered a medical review 6–8 weeks after the birth either in primary care, or with a specialist as appropriate.
Consider the possibility of imminent pre-eclampsia or eclampsia in a woman up to 4 weeks postpartum (even if she has not had previous hypertension or pre-eclampsia) if she develops any of the following:
Severe headaches (increasing frequency unrelieved by regular analgesics).
Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
Persistent new epigastric pain or pain in the right upper quadrant.
Vomiting.
Hypertension.
Proteinuria.
Breathlessness due to pulmonary oedema.
Sudden swelling of the face, hands, or feet.
Consider the possibility of eclampsia in any woman who has…
a seizure within 4 weeks of delivery.
Pre-eclampsia?
emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications.
Pre-eclampsia classic triad?
new-onset hypertension
proteinuria
oedema
Current definition of pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Potential consequences of pre-eclampsia?
eclampsia
fetal complications
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
Cx of pre-eclampsia= eclamsia?
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
Cx of pre-eclampsia= fetal Cx?
intrauterine growth retardation
prematurity
Features of severe pre-eclampsia?
hypertension: typically > 160/110 mmHg and proteinuria
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
High RFs for pre-eclampsia?
Moderate risk factors
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
Moderate RFs for pre-eclampsia?
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
Reducing the risk of hypertensive disorders in pregnancy?
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth:
≥ 1 high risk factors
≥ 2 moderate factors
Initial assessment for pre-eclampsia?
arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
Further Mx for pre-eclampsia?
oral labetalol 1st line
Nifedipine (e.g. if asthmatic) and methyldopa may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Average age of menopause?
51yrs
Menopause= climacteric?
the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail
Menopause= recommended to use effective contraception until when?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Definition of menopause?
permanent cessation of menstruation
when women has not had a period for 12m
Cause of menopause?
loss of follicular activity
Diagnosis of menopause?
clinical: not had period for 12m
Symptoms of menopause typically last for how long?
7yrs but may resolve quicker or last longer
duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.
Summarise menopause Mx into categories?
- Lifestyle modifications
- Hormone replacement therapy (HRT)
- Non-hormone replacement therapy
Menopause= Mx with lifestyle?
Hot flushes= regular exercise, weight loss, reduce stress
Sleep disturbance= avoid late evening exercise and good sleep hygiene
Mood= sleep, regular exercise and relaxation
Cognitive symptoms= regular exercise and sleep hygiene
Contraindications for HRT?
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
HRT= If the woman has a uterus then it is important not to give what?
unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.
HRT= If the woman does not have a uterus then what can be given?
oestrogen alone can be given either orally or in a transdermal patch.
HRT: Women should be advised that the symptoms of menopause typically last for how long?
2-5yrs
Risks of HRT?
VTE= a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke= slightly increased risk with oral oestrogen HRT.
Coronary heart disease= combined HRT may be associated with a slight increase in risk.
Breast cancer= there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer= increased risk with all HRT.
Mx of menopause without HRT= vasomotor symptoms?
fluoxetine, citalopram or venlafaxine
Mx of menopause without HRT= vaginal dryness?
vaginal lubricant or moisturiser
Mx of menopause without HRT= Psychological symptoms?
self-help groups, cognitive behaviour therapy or antidepressants
Mx of menopause without HRT=
Urogenital symptoms?
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
Menopause= For vasomotor symptoms, how long of HRT may be required with regular attempts made to discontinue treatment?
2-5yrs
Menopause= how long may vaginal oestrogen be used?
may need long term
Stopping HRT?
When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.
When should women be referred to secondary care for menopause?
if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.
Obesity in pregnancy definition?
BMI >30 at 1st antenatal visit
Obesity in pregnancy: maternal risks?
miscarriage
venous thromboembolism
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
postpartum haemorrhage
wound infections
higher c-section rate
Obesity in pregnancy: fetal risks?
congenital anomaly
prematurity
macrosomia
stillbirth
increased risk of developing obesity and metabolic disorders in childhood
neonatal death
Obesity in pregnancy: Explain to women with a BMI of 30 or more at the booking appointment what?
how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy
Folic acid dose if pregnant women is obese (BMI >30)?
5mg not 400mcg
Mx for obesity in pregnancy?
- 5mg folic acid
- screen for gestational diabetes with OGTT at 24-28w
- if BMI >=35 then give birth in consultant led obstetric unit
- if BMI >=40 then antenatal consultation with obstetric anaesthetist and a plan made
Placenta praevia?
placenta lying wholly or partly in the lower uterine segment
what % will have low-lying placenta when scanned at 16-20 weeks gestation?
5%
but incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix
Placenta praevia= associated factors?
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
Clinical features of placenta praevia?
shock in proportion to visible loss
NO PAIN
uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large
Diagnosis of placenta praevia?
digital vaginal examination should NOT be performed before an ultrasound as it may provoke a severe haemorrhage
often picked up on the routine 20 week abdominal USS
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
Grading of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
Placenta praevia= If low-lying placenta at the 20-week scan?
rescan at 32 weeks
no need to limit activity or intercourse unless they bleed
if still present at 32 weeks and grade I/II then scan every 2 weeks
Placenta praevia= when determines the method of delivery?
final ultrasound at 36-37 weeks to determine the method of delivery
Method of delivery for placenta praevia?
elective caesarean section for grades III/IV between 37-38 weeks
if grade I then a trial of vaginal delivery may be offered
if a woman with known placenta praevia goes into labour prior to the elective caesarean section what should be done?
an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
Placenta praevia with bleeding?
admit
ABC approach to stabilise the woman
if not able to stabilise → emergency caesarean section
if in labour or term reached → emergency caesarean section
Placenta praevia prognosis?
death is now extremely rare
major cause of death in women with placenta praevia is now PPH
Placental abruption?
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
occurs in approximately 1/200 pregnancies
Placental abruption cause?
not known but associated factors:
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
Placental abruption clinical features?
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
Placental abruption Mx= Fetus alive and < 36 weeks?
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Placental abruption Mx= Fetus alive and > 36 weeks?
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Placental abruption Mx= fetus dead?
induce vaginal delivery
Cx of placental abruption?
Maternal:
- shock
- DIC
- renal failure
- PPH
Fetal:
- IUGR
- hypoxia
- death
Placental abruption prognosis?
associated with high perinatal mortality rate
responsible for 15% of perinatal deaths
Postpartum haemorrhage (PPH) is defined as?
blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
Primary PPH?
occurs within 24 hours. It affects around 5-7% of deliveries.
The causes of PPH (postpartum haemorrhage)?
4 Ts:
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Risk factors for primary PPH include?
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
Mx of PPH?
life-threatening emergency - senior members of staff should be involved immediately
ABC approach=
- two peripheral cannulae, 14 gauge
- lie the woman flat
- bloods including group and save
- commence warmed crystalloid infusion
mechanical=
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output
medical=
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
surgical= if medical options fail to control the bleeding then surgical options will need to be urgently considered
PPH Mx= ABC approach?
two peripheral cannulae, 14 gauge
lie the woman flat
bloods including group and save
commence warmed crystalloid infusion
PPH Mx= mechanical?
palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
catheterisation to prevent bladder distension and monitor urine output
PPH Mx= medical?
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
there is also interest in the role tranexamic acid may play in PPH
PPH Mx= Surgical options?
intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
PPH Mx= what medical Mx is first line? What can not be used in asthma? What can not be used in HTN?
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
Secondary PPH?
occurs between 24 hours - 12 weeks.
Secondary PPH typically due to what?
It is typically due to retained placental tissue or endometritis.
DM in pregnancy?
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes.
87.5% have gestational diabetes
7.5% have type 1 diabetes
5% have type 2 diabetes
Most common medical disorder complicating pregnancy?
HTN
then gestational diabetes
RFs for gestational diabetes?
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Test of choice to screen for gestational diabetes?
oral glucose tolerance test (OGTT)
When is the oral glucose tolerance test (OGTT) done to screen for gestational diabetes?
pt with previous gestational diabetes= OGTT asap after booking and at 24-28w if 1st test is normal
any other RFs= OFTT at 24-28w
What is also recommended as an alternative of OGTTs to test for gestational diabetes?
early self-monitoring of blood glucose
Diagnostic thresholds for gestational diabetes?
either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Mx of gestational diabetes= newly diagnosed women should be seen where?
in a joint diabetes and antenatal clinic within a week
Mx of gestational diabetes?
- diabetes and antenatal clinic within 1w
- self-monitoring of blood glucose
- advice about diet (foods with low glycaemic index) and exercise
- fasting glucose <7 at diagnosis= trial diet and exercise
- if not met within 1-2w then start metformin
- still not met= + short acting insulin
- fasting glucose >=7 at diagnosis= start insulin
- glucose 6-6.9 and evidence of Cx eg. macrosomia or hydramnios= insulin
- glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Mx of gestational diabetes= fasting glucose <7 at diagnosis?
- trial diet and exercise
- if not met within 1-2w then start metformin
- still not met= + short acting insulin
Mx of gestational diabetes= fasting glucose >=7 at diagnosis?
start insulin
Mx of gestational diabetes= glucose 6-6.9 and evidence of Cx eg. macrosomia or hydramnios?
insulin
Mx of gestational diabetes= glibenclamide should only be offered for women who?
cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Gestational diabetes= Mx of pre-existing diabetes?
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)?
Time Target
Fasting= 5.3 mmol/l
1 hour after meals= 7.8 mmol/l
or
2 hour after meals= 6.4 mmol/l
Gestation limit for abortion?
24w
When may women get termination of pregnancy after 24w?
in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is risk of serious physical or mental injury to the woman.
How is termination of pregnancy approved/who can perform?
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
When should anti-D prophylaxis be given in termination of pregnancy?
to women who is rhesus D negative and are having an abortion after 10+0 weeks gestation
Where is medical termination of pregnancy done?
can be done at home depending on gestation
How long does medical termination of pregnancy occur?
hrs to days to complete
can be unpredictable
Medical Mx for termination of pregnancy?
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions
After medical Mx for termination of pregnancy, what must be done?
pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG (rather than just be positive or negative) and is termed a multi-level pregnancy test
Surgical options for termination of pregnancy?
use of transcervical procedures to end a pregnancy, including manual
vacuum aspiration (MVA), electric vacuum aspiration (EVA) and dilatation and evacuation (D&E)
cervical priming with misoprostol +/- mifepristone is used before procedures
women are generally offered local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia
following a surgical abortion, an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity
Termination of pregnancy= women are offered a choice between medical or surgical abortion up to and including what age of gestation?
23+6w
Choice between medical and surgical termination of pregnancy?
after 9 weeks medical abortions become less common. Factors include increased likelihood of women seeing products of conception pass and decreased success rate
before 10 weeks medical abortions are usually done at home
1967 Abortion Act?
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
2 methods of abortion?
medical and surgical
Medical abortion summary?
the use of medications (mifepristone followed by misoprostol) to end a pregnancy.
Surgical abortion summary?
the use of transcervical procedures (manual vacuum aspiration, electric vacuum aspiration, or dilatation and evacuation) to end a pregnancy.
In England, Scotland, and Wales, a pregnancy can be lawfully terminated by a registered medical practitioner in an NHS hospital or premises approved for this purpose if two medical practitioners are of the opinion, formed in good faith, that either:
The pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant person or any existing children of their family.
The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant person.
Continuing the pregnancy would involve risk to the life of the pregnant person, greater than if the pregnancy were terminated.
There is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Are abortions free on NHS?
yes
How to access abortion services?
people can self-refer directly to an abortion care provider or be referred by a GP, sexual health clinic, or specialist clinic (such as Brook service)
Fibroids?
benign smooth muscle tumours of the uterus.
They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years.
Who are uterine fibroids more common in?
more common in Afro-Caribbean women
rare before puberty, develop in response to oestrogen
Features of uterine fibroids?
may be asymptomatic
menorrhagia= may result in iron-deficiency anaemia
bulk-related symptoms=
lower abdominal pain (cramping pains, often during menstruation); bloating; urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility
rare features:
polycythaemia secondary to autonomous production of erythropoietin
Subfertility
Menorrhagia
lower abdo pain, often during menstruation
bloating
urinary frequency
fibroids
Diagnosis of uterine fibroids?
transvaginal USS
Mx of asymptomatic fibroids?
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids?
- IUS= useful if the woman also requires contraception; cannot be used if there is distortion of the uterine cavity
- NSAIDs e.g. mefenamic acid
- tranexamic acid
- combined oral contraceptive pill
- oral progestogen
- injectable progestogen
Treatment to shrink/remove fibroids= medical?
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term - why?
treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Treatment to shrink/remove fibroids= surgical?
myomectomy: this may be performed abdominally, laparoscopically or
hysteroscopically
hysteroscopic endometrial ablation
hysterectomy
Treatment to shrink/remove fibroids- options?
- medical
- surgical= myomectomy
- uterine artery embolization= if there are symptomatic fibroids and a woman wishes to avoid surgery
Prognosis of uterine fibroids?
generally regress after menopause
Cx of uterine fibroids?
subfertility and iron-deficiency anaemia
red degeneration - haemorrhage into tumour - commonly occurs during pregnancy
What are uterine fibroids?
(leiomyomas) are benign tumours which are caused by proliferation of a mixture of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium.
Fibroids size?
They can be single, multiple, of variable size, and may develop anywhere within the myometrium (subserosal, intramural, or submucosal).
Who do fibroids typically develop in?
women of reproductive age and regress after the menopause.
Uterine fibroids are commonly….
asymptomatic and may be found incidentally on pelvic examination or ultrasound scan.
RFs for fibroids?
increasing age (until the menopause); early menarche; older age at first pregnancy; comorbidities such as obesity and hypertension; black and Asian ethnicity; family history
Cx of fibroids?
iron deficiency anaemia from heavy menstrual bleeding; bladder and bowel compressive symptoms (especially with large fibroids); subfertility or infertility; obstetric complications; tortion (of a pedunculated fibroid)
Fibroids= Typical clinical features on history-taking include?
Heavy menstrual bleeding and/or dysmenorrhoea.
Pelvic pain, pressure, or discomfort; dyspareunia.
Abdominal discomfort or bloating; back pain.
Urinary symptoms, such as frequency, urgency, urinary incontinence, or retention; urinary tract infections (UTIs).
Bowel symptoms, such as bloating, constipation, and/or painful defecation.
Subfertility or infertility (particularly if there are submucosal fibroids).
Fibroids= typical clinical features on examination?
A firm, enlarged, and irregularly shaped non-tender uterus on pelvic examination.
A central irregular abdominal mass (if a large fibroid).
Assessment of a women with suspected or confirmed fibroid(s) includes?
Asking about symptoms including severity, duration, and impact on daily functioning and quality of life; previous fertility issues and hopes for future fertility; risk factors; and any previous treatments.
Performing an abdominal and bimanual pelvic examination to assess for pelvic tenderness and any mass(es).
Arranging a routine pelvic ultrasound scan to determine the number, size, and location of fibroid(s).
Checking a FBC to assess for iron deficiency anaemia if there is a history of heavy menstrual bleeding and/or symptoms of anaemia.
Fibroids: arrange an urgent referral to an appropriate specialist using a two-week cancer pathway when?
if there are any clinical or radiological features suggesting a gynaecological or other malignancy
Fibroids: arrange a referral to an appropriate specialist when?
if she has an uncertain diagnosis; severe or refractory symptoms; confirmed fibroids measuring 3 cm or more in diameter or suspected submucosal fibroids; suspected fertility or obstetric issues; rapid or unexpected growth of fibroids after the menopause.
Asymptomatic fibroids Mx?
Reassurance that no treatment is routinely needed
Ix for fibroids?
clinical
routine pelvic ultrasound scan (transabdominal and transvaginal, if needed) to determine the number, size, and location of fibroid(s), particularly if there are any of the following:
- The uterus is palpable abdominally.
- History or examination suggests a pelvic mass.
- Examination is inconclusive or difficult, for example, if a woman is obese.
Differential diagnosis for fibroids?
Malignant= ovarian ca; endometrial ca; GI malignancy
Benign= endometrial polyp or hyperplasia; adenomyosis or endometriosis; urinary retention; pregnancy; ectopic pregnancy
Chickenpox in pregnancy= risk to who?
both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Chickenpox in pregnancy= risks to the mother?
5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)?
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Features of fetal varicella syndrome?
skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Chickenpox in pregnancy= risks to fetus?
- fetal varicella syndrome
- shingles in infancy= 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Severe neonatal varicella?
chickenpox= if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= any doubt about the mother previously having chickenpox?
maternal blood should be urgently checked for varicella antibodies
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= 1st line PEP for pregnant women at any stage of pregnancy?
oral aciclovir (or valaciclovir) given at day 7 to day 14 after exposure, not immediately
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= when should oral aciclovir be given for PEP?
at day 7 to day 14 after exposure, not immediately
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)= why give oral aciclovir for PEP at day 7 to day 14 after exposure, not immediately?
in a study the incidence and severity of varicella infection was significantly higher in those given aciclovir immediately (10/13 (77%) who received aciclovir immediately developed clinical varicella compared with 3/14 (21%) who started aciclovir at day 7)’
Mx of chickenpox in pregnancy= when should oral aciclovir be given if she presents with chickenpox (not exposure)?
if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
If pregnant women develops chickenpox in pregnancy, what should be sought?
specialist advice
there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of…
aciclovir in pregnancy
Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) if a pregnant woman has suspected chickenpox and any of:
Respiratory symptoms.
Neurological symptoms.
Haemorrhagic rash or bleeding.
Severe disease (for example dense rash with or without numerous mucosal lesions).
Significant immunosuppression (including recent use of systemic corticosteroids).
Chickenpox in pregnancy= Consider/discuss the need for admission with a specialist if other risk factors for severe illness and complications are present such as:
Pregnancy approaching term.
Previous obstetric complications or risk factors.
Smoking.
Chronic lung disease.
Social risk factors.
Close monitoring in the community is not possible.
Chickenpox in pregnancy- after giving oral aciclovir, what else needs to be done?
Close monitoring is needed — review daily, or earlier if her condition deteriorates and have a low threshold for considering admission. Where close monitoring in the community is not possible, admission should be considered.
If there is deterioration, fever persists, or cropping of the rash continues after 6 days, refer for urgent hospital assessment.
If a high temperature develops (particularly after initial improvement) with redness and pain surrounding the chickenpox lesions, consider bacterial superinfection and manage accordingly.
Chickenpox in pregnancy= most infectious period?
from 24 hours before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5 days after the onset of the rash)
During this time, advise a pregnant woman with chickenpox to avoid contact with:
- People who are immunocompromised (for example those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
- Other pregnant women.
- Infants aged 4 weeks or less.
Chickenpox in pregnancy= what can be given to alleviate the itch?
Topical calamine lotion.
Chlorphenamine is NOT recommended for the management of the itch of chickenpox in pregnancy.
Chickenpox in pregnancy= what can be used for fever or pain?
paracetamol NOT NSAIDs
If the woman has no history of chickenpox or shingles (or is uncertain) and has a history of significant contact, establish the stage of gestation and seek urgent specialist advice. Test for what?
varicella-zoster immunoglobulin G (IgG) antibodies
Chickenpox in pregnancy= results of varicella-zoster immunoglobulin G (IgG) antibodies if immunity unknown?
If the test shows varicella-zoster immunoglobulin G antibodies (evidence of immunity from past infection or immunization), the woman can be reassured that she is immune.
If the woman’s antibody status is negative, urgently discuss with a specialist the need for prophylaxis (antiviral treatment)
Pregnancy is a RF for developing what?
VTE
A woman with a previous VTE history is automatically considered high risk and requires what in pregnancy?
low molecular weight heparin throughout the antenatal period and also input from experts.
A pregnant woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for what?
antenatal prophylactic low molecular weight heparin.
VTE in pregnancy: The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
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
