O&G Flashcards
Primary amenorrhoea?
Failure to start menstruating by age 16
- Needs Ix in 15y/o
OR 14 with no breast development
Secondary amenorrhoea?
Causes?
Periods stop for >6 months
Causes:
Physiological - Pregnancy/lactation
Drugs: Progestogens, GnRH analogues and antipsychotics
Premature menopause
PCOS (oligomenorrhoea)
Hyperprolactinaemia: Pituitary hyperplasia or benign adenoma (mx bromocriptine, cabergoline or surgery)
Sheehan’s
Hypothalamic hypogonadism:
- psychological, low weight/anorexia / excessive exercise
GnRH, FASH, LH and oestradiol are ALL reduced
Hypo/hyperthyroidism
CAH
Turner’s
Gonadal dysgenesis
Outflow tract obstruction (eg. imperforate hymen, Asherman’s syndrome, cervical stenosis)
Ovarian insufficiency
Primary: eg. genetic: turner’s syndrome
Secondary to chemo/radio
Most common cause of oligomenorrhoea during reproductive years
PCOS
Dysmenorrhoea?
Primary dysmenorrhoea - pain without organ pathology
- Excess PG causes painful uterine contractions
Rx: NSAIDs eg. mefenamic acid; paracetamol
Secondary dysmenorrhoea
- Associated with pathology eg. Adenomyosis, endometriosis, fibroids
- Appears later in life
Intermenstrual bleeding
Follows midcycle fall in oestrogen production
Other causes: Cervical polyps Ectropion Carcinoma Fibroids Hormonal contraception
Mx: IUS or COCP
Post-coital bleeding causes?
Cervical trauma/ectropions
Benign Polyps
Invasive cervical cancer
Cervicitis
Vaginitis
Atrophy of vaginal walls
Mx: Full H+E
Cryotherapy for ectropion
Refer to colposcopy to exclude malignancy
Post-menopausal bleeding causes?
Ix?
Bleeding >1yr after LMP
Causes:
Endometrial carcinoma
Endometrial hyperplasia/atypia/polyps
Cervical/vulval/ovarian carcinoma
Cervical polyps
Atrophic vaginitis
Foreign bodies
Ix: Cervical smear, TVUS +- endometrial biopsy & hysteroscopy (if thick endometrium or multiple bleeds
PCOS diagnostic criteria?
Rotterdam criteria: 2 out of 3 of:
1) Clinical or biochemical hyperandrogenism
2) Oligomenorrhea (10cm^3)
PCOS Sx?
Acne
Male pattern baldness
Hirsutism
Acanthosis nigricans on neck
and skin flexures
Raised LH + Test
Subfertility
Insulin resistance
Hyperinsulinaemia
What is Stein-Leventhal syndrome?
Obese hirsute women with PCO
PCOS Ix + Mx?
IX: US
Mx: Conservative Avoid smoking Treat any dibaetes, hypertension, dyslipidaemia, sleep apnoea Encourage weight loss + exercise
Medical
Metformin improves insulin sensitivity, menstrual disturbance and ovulatory function
Clomifene - induces ovulation BUT risk of multiple pregnancy/ ovarian cancer
COCP: controls bleeding
Cyproterone (anti-androgen) : for hirtsutism
Menorrhagia causes?
Dysfunctional uterine bleeding - heavy/irregular bleeding in absence of pathology. Associated with anovulatory cycles. Diagnosis of exclusion if PV normal & organ pathology ruled out
IUCD
Fibroids (O/E - Irregular enlargement of fibroids)
Endometriosis
Adenomyosis (O/E Uterine tenderness)
Pelvic infection
Polyps
Endometrial carcinoma
Menorrhagia Mx?
Medical:
1st: Progesterone containing IUS eg. Mirena, especially if wanting contraception
2nd: - Antifibrinolytics eg. tranexamic acid
- Anti-prostaglandins eg. mefanamic acid
- COCP
3rd: Progestogens IM or norethisterone 5mg TDS PO days 5-26 of menstrual cycle
- GnRH analogues
Surgical:
- Polyp removal, endometrial ablation, endometrial resection, myomectomy, hysterectomy, uterine artery embolisation
Menopause features?
- Caused by oestrogen levels
- Menstrual cycle irregularity - cycles become anovulatory
before stopping - Vasomotor disturbance (Sweats, palpitations, flushing)
- Atrophy of oestrogen dependent tissues and skin
- Cardio disease
- Urogenital problems:
Vaginal atrophy, frequency, urgency, nocturia, incontinence and recurrent infection
Osteoporsis
Menopause Mx?
Conservative:
- Counselling for psychosocial/physical sx
- Treat menorrhagia
- Use contraception until 1y> amenorrhoea if >50y or 2y> if
HRT?
Oestrogen
May help flushes and atrophic vaginitis
Postpones menopausal bone loss but no longer recommended for osteoporosis prevention
No cardiovascular benefits or protection against dementia
Increased stroke and thromboembolism risk
Increased BREAST cancer and ENDOMETRIAL cancer risk – greater risk when combined oestrogen/progesterone preparations are used compared to oestrogen alone
Progestogens
- Cyclical
- Reduce incidence of endometrial carcinoma
SE
- Increased weight
- Premenstrual syndrome
Mx:
Discuss risk of breast cancer with each pt considering HRT
Document this discussion in the Pts notes
Encourage breast awareness and to report breast change
warn that it is symptomatic Tx at the lowest dose needed to control sx for the shortest time possinle - sx often return on stopping
Be way with FH of breast cancer
HRT CI?
Oestrogen dependent cancer
Past PE
Undiagnosed PV bleedng
Raised LFTs
Pregnancy
Breastfeeding
Phlebitis
TOP: Law?
Abortion Act 1967 (amended 2002) and HFEA 1990 allow TOP IF:
A) Risk to mother’s life if pregnancy continues
B) TOP necessary to prevent permanent grave injury to physical/mental health of woman
C) Continuance of pregnancy risks injury to the physical/mental health of woman greater than if terminated (And foetus not >24wks)
D) Continuance risks injury to physical/mental health of existing children greater than if terminated (and fetus not >24wks)
E) Substantial risk that if child were born, he/she would suffer such physical or mental abnormalities as to be seriously handicapped.
97% for C
- 2 doctors must sign certificate HSA1
- If pts less than 16, try to get consent to involve parents
- TOPs after 23 weeks may only be carried out in NHS hospitals
What to do before TOP?
- 2 doctors must sign certificate HSA1
- If pts less than 16, try to get consent to involve parents
- TOPs after 23 weeks may only be carried out in NHS hospitals
Before TOP decision:
- Offer counselling
- Confirm pregnancy
- Give information on choice of methods
Before TOP:
- Screen for chlamydia and other STIs
- Abx prophylaxis: Metronidazole 1g PR/800 PO at TOP
- Discuss contraception
- If RhD -ve, give anti-D
- Assess VTE risk
TOP Methods?
less than 9 weeks: mifepristone (an anti-progestogen, often followed 48 hours later by prostaglandins to stimulate uterine contractions
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
Medical TOP
Antigestagen: eg. mifepristone used to disimplant feotus, followed by a prostaglandin eg. misoprostol
Highly effective after 6 weeks
For early TOPs, arrange follow up and scan 2/52 after procedure
5% will need surgical evacuation
NSAID pain relief
May need narcotic analgesia if gestation > 13 weeks
Surgical TOP
- Vacuum aspiration and dilatation
- May need cervical priming with misoprostol 400ug PV or sublingual 3h pre-op
- NSAID pain relief
- Less bleeding and pain than with medical TOP
Vacuum aspiration: Used from 7-16 weeks
LA safer than GA
Dilatation & Evacuation: surgical forceps may be used at 13-24 weeks after cervical priming
Complications:
- Failure to terminate
- Infection
- Haemorrhage
- Uterine perforation
- Uterine rupture
- Cervical trauma
Miscarriage? Mx?
Loss of pregnancy before 24wks gestation
20-40% pregnancies miscarry, mostly in first trimester
Most PC with PV bleeding
Pregnancy remains positive for several days after foetal death
Ix: TVUS
Mx:
- Remove blood/products from cervical canal
- Assess os & Uterine size
Where does bleeding come from?
- Need for anti-D?
- if profuse bleeding –> Ergometrine 0.5mg IM
- If severe bleeding/pain or retained tissue on ultrasound : ERPC (evacuation of retained products of conceptions)
- Medical mx with misoprostol when volume of retained products is 15-50mm across on TVUS
Miscarriage types
1) Threatened
- Mild symptoms/closed os
- 75% will settle, rest advice
- Associated with subsequent risk of PROM and preterm delivery
2) Inevitable
- Severe symptoms/ Os open
- Incomplete miscarriage, but most of products of conception have passed
3) Missed miscarriage:
- Foetus dies but is retained
- PC: Bleeding
- Uterus is small for dates
- Confirm with US
Mx: Medical if uterus small; surgical if uterine products >5cm in transverse plane
4) Mid-trimester MC:
- usually due to mechanical causes eg. cervical incompetence, uterine abnormalities or chronic maternal disease
- Incompetent cervix can be strengthened by a cervical cerclage suture at 14 weeks
5) Miscarriage with infection:
- Presents as acute salpingitis
Rx: Broad spectrum Abx eg. coamoxiclav + Metro
6) Septic miscarriage
- contents of uterus infected causing endometritis
Sx: Offensive vaginal D/C + Tender uterus
Recurrent spontaneous miscarriage?
3 or more consecutive miscarriages before 24wks
Affects 1% of women
Causes:
- APS
- Chromosomal defects
- Uterine abnormalities
- Infection
- Obesity
- Smoking
- PCOS
- Excess caffeine intake
- Higher maternal age
- Thrombophilia
- Alloimmune causes
Ix: APS antibodies screen
- karyotyping of both parents
- Pelvic US
- hysterosalpingogram
Ectopic pregnancy: Predisposing factors?
Sites?
Dmg to tubes (Salpingitis, previous surgery) Previous ectopic Endometriosis IUCD POP
Site: Tubal 97%
isthmus 25%
Ovary/cervix/peritoneum 3%
Ectopic: Sx, OE, MX?
Sx: D+N+V
Dark/fresh PV blood
Tubal colic causes abdo pain
Gradually increasing PV bleeding and bleeding into peritoneum producing shoulder tip pain due to diaphragmatic irritation and pain on defecation/urination
Rupture - sudden severe pain, peritonism and shock
OE: Faint, tender abdo, enlarged uterus, cervical excitation, adnexal mass
Mx: Anti-D prophylaxis
- Urinary/serum B-HCG
US
expectant management: option in those without acute symptoms/falling bHCG
Early ectopics - medical mx: Methotrexate
Surgical Mx: Salpingectomy/salpingotomy (Creating an opening in the tube to remove ectopic) via laparoscopy/laparotomy
Hydatidiform mole?
Complete hydatidiform mole
Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen - B-HCG resembles TSH. Thyrotoxic storm can occur at evacuation
Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
Around 2-3% go on to develop choriocarcinoma
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
Choriocarcinoma
2-3% of molar pregnancies go onto develop choriocarcinoma
Sx: May be yrs after pregnancy general malaise Uterine bleeding Sx from mets Nodules on CXR Pulmonary artery obstruction due to tumour emboli
Rx: Methotrexate based chemo
Ectropion?
Red ring around the os as endocervical epithelium has extended over the ectocervical epithelium
Due to eversion
Occurs temporarily under hormonal influence during puberty, with the COCP and during preggers
Prone to bleeding, excess mucus production and infection
Normal finding in young women, particularly if pregnant or on COCP
Rx: No Tx usually, cryocautery can be used after taking a smear
Nabothian cyst?
Mucus retention cysts found on cervix
Harmless
Rx: cryotherapy if discharging
CIN?
CIN - preinvasive cervical cancer
–> Atypical cells present within the squamous epithelium
CIN I - mild dysplasia - lower basal 1/3 of cervical epithelium. Commonly regress. Assoc. with HPV 6,11
CIN II (Moderate dysplasia) - 2/3 of thickness of epithelium. Associated with HPV 16/18 --> Less likely to regress, and significant number develop into invasive SCC of cervix.
Cervical screening?
1st smear taken aged 25
3 yearly from 25 yr, 5 yearly from 50 – 64 yr
Only screen after 65 if one of last 3 was abnormal
HIV +ve should have annual smears
Borderline/mild dyskaryosis - original sample tested for HPV
- -ve - routine recall
+ve - refer to colposcopy
Moderate dysk - consistent with CIN II. refer to colposcopy
Severe dysk - Consistent with CIN III - refer to colposcopy
Suspected invasive cancer - refer for urgent colposcopy (within 2 weeks)
Inadequate - repeat smear. If 3 inadequete samples, colposcopy
Cervical cancer vaccine?
1 Gardasil targets HPV 6, 11, 16 & 18
3 IM does, 0.5mL (deltoid/lateral thigh). Age range: 9–18yrs (9–26 ). Dose 2 is ≥1 month after dose 1, and dose 3 ≥4 months after dose 1. CI: pregnancy, bleeding disorders
Cervarix (bivalent; HPV16 & 18).
Cervical carcinoma risk factors?
Prolonged COCP use High parity > 4 sexual partners Early first coitus HIV other STDs smoking
Cervical carcinoma: Sx
Sx: post-coital bleeding, offensive DC, intermenstrual/PMB. Later features: involvement of ureters, bladder, rectum and nerves cause uraemia, haematuria, rectal bleeding and pain
O/E: Ulcer/mass may be visible/palpable on cervix
CIN Mx
Mx of pre-invasive cancer:
- Colposcopy
- Abnormal epithelium has characteristic blood vessel patterns and stains white with acetic acid
- take punch biopsies for histology
CIN I - observe
CIN II & III - destroyed by cryotherapy, laser, cold coagulation or large loop excision of transformation zone (LLETZ)
- Annual smears for atleast 10 years
- If the squamo-columnar junction cannot be seen or if small-volume invasive carcinoma is found on histology, the abnormal tissue is removed by cone biopsy which may be curative
nb. Colposcopy does not detect adenocarcinoma
Cervical carcinoma Staging & Mx?
Staging: most are SCC, 15-30% are Adenocarcinoma
Stage I - confined to cervix
Stage IIaextended locally to upper 2/3 of vagina
Stage IIb Extended locally to parametria
Stage III - IIIa - lower 1/3 of vag, IIIb to pelvic wall
Stage IV - IVa: Bladder or rectum IVb: spread to distant organs
MX
Stage Ia: cervical cone biopsy/cold knife excision
Stage Ia2/Ib1 - radical hysterectomy with pelvic lymphadenectomy or radiotherapy
Stage II/III/IV: Chemoradiation
Endometritis?
Uterine infection possibly involving fallopian tubes and ovaries
Uncommon
Usually seen after miscarriage, TOP, childbirth, IUCD insertion or surgery
Often secondary to STIs
Sx: lower abdominal pain, fever, uterine tenderness on bimanual palpation
Ix: cervical swabs and blood cultures
Rx: Abx doxycycline & metronidazole
Endometrial US thickness?
TVUS gives better resolution than transabdominal
If thickness >5mm, consider endometrial Ca
Vaginal carcinoma?
Usually squamous
Commonest in the upper third of the vagina
Sx: bleeding Spread: local by lymphatics Rx: radiotherapy
Lichen sclerosus?
5% associated with VIN, 4% have cancer in 12.5 yrs, 1/3 assoc with sq cell hyperplasia
Most- post-menopasual but can affect children and young women
Classical lesion- fig of 8 crinkled parchment like appearance (around vulva and anal region)
Pruritis, irritation, ulceration
Bx may be needed to confirm diagnosis and rule out VIN/ invasion
Rx- testosterone propionate/ cypropionate
2%/ colbetasol propionate
VIN?
Demographic?
Ix?
Associations?
Mx?
Average age 40 years, increasing incidence in last 20 years (particularly in under 35s)
VIN1 mild, VIN2 mod, VIN3 severe
30% associated with invasion
Ix: Colposcopy, 5% acetic acid or 1% toluidene blue, biopsy
Associated with HPV DNA- 16, 18, 31, 33, 35, 51
Mx
May be multifocal
Surgical excision/ laser Rx
Vulval cancer?
Demographic
Sx
Ix
Uncommon cancer - mostly postmenopausal women (mean = 65)
SCC accounts for 90% of cases
Dual aetiology; HPV vs chronic irritation (lichen sclerosus)
Sx: vulval lump/mass
Long history pruritis, vulval bleeding, Discharge , dysuria
Fibroids
- What are they
- Associations
- Pregnancy?
Benign smooth muscle tumours of the uterus
Often multiple
Start as lumps in the wall of the uterus but may grow to bulge out of the wall so that they lie under the peritoneum or under the endometrium
Fibroids are common fq increases with age and in non-Caucasians
Associated with mutation in gene for fumarate hydratase
Oestrogen dependence – enlarge in pregnancy, on the COCP and on HRT; atrophy after the menopause
May enlarge or degenerate gradually or suddenly
Red degeneration: pain and uterine tenderness;
haemorrhage and necrosis occur
May calcify – womb stones
May undergo sarcomatous change rarely – causes pain, malaise, bleeding and increase in size
Cause heavy periods due to increased endometrial surface, dysfunctional endometrium, impaired uterine contractility.
Fibroids in pregnancy?
Premature labour
Malpresentations
Transverse lie
Obstructed lie
PPH
Red degeneration common
Fibroids types?
Intramural
Subserosal
Submucosal
Pedunculated submucosal
5% are submucous, hysteroscopic resection is tx of choice
Type 0 – pedunculated without intramural extension
Type 1 – sessile fibroid w intramural extension 50%
Fibroids Sx, Ix and Mx?
Sx: Asymptomatic, menorrhagia, dysmenorrhoea, fertility problems, pain, mass, frequency, urinary retention
Ix: US, MRI, hysteroscopy/hysterosalpingogram
Mx:
Menorrhagia: Tranexamic acid, mefanamic acid or progestogens
Surgical resection:
- pretreatment with GnRH analogues can shrink fibroids and make resection easier
Myomectomy
Hysterectomy
Adenomyosis?
Presence of endometrial tissue within the myometrium
Age: 40
Cause: endometrium grows into the myometrium; pockets of menstrual blood can be seen in the myometrium
Sx: asymptomatic; painful, regular, heavy menstruation
OE: uterus is mildly enlarged and tender
Ix: MRI
Mx: IUS or COCP with or without NSAIDs for menorrhagia Mefanamic acid Tranexamic acid COCP Mirena IUS Endometrial ablation Uterine artery embolisation Hysterectomy
Endometrial carcinoma? Risk factors?
Usual PC = Postmenopausal bleeding - initially scanty and occasional, and then heavy and frequent. May also PC as intermenstrual bleeding or menorrhagia.
- Most are adenocarcinomas of columnar endometrial gland cells
- Others are adenosquamous carcinomas (poorer prognosis)
- Related to excessive exposure to oestrogen unopposed by progesterone
Risk factors:
- Obesity
- Unopposed oestrogen (PCOS)
- FH of breast, ovary or colon Ca
- Nulliparity
- LAte menopause
- DM
- Tamoxifen, tibolone
- Pelvic irradiation
- Lynch syndrome type II (HNPCC)
Endometrial Ca Ix, Staging and Rx?
Ix: Cervical smear, uterine ultrasound, uterine sampling/curettage, hysteroscopy
Staging: I = body of uterus only II = body + Cervix III = advancing beyond uterus but not beyond pelvis IV = extending outside pelvis
Mx:
stage I/II - total hysterectomy + bilateral salpingo-oopherectomy +- radiotherapy
Stage III and IV: radiotherapy and/or high dose progestogens
Recurrent disease: Medroxyprogesterone, surgical exoneration & radiotherapy
Benign Ovarian tumours types?
Physiological cysts (functional cysts)
1) Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
2)Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
Benign germ cell tumours
1) Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
Benign epithelial tumours
Arise from the ovarian surface epithelium
1) Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
2) Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
Commonest ovarian cyst?
Follicular cyst
Commonest benign ovarian tumour in women
Dermoid cyst
Most common benign epithelial tumour?
Serous cystadenoma
Ovarian tumour types?
1) Surface derived tumours (65%)
- Serous cystadenoma (B)
- Serous cystadenocarcinoma (M)
- Mucinous cystadenoma (B)
- Mucinous cystadenocarcinoma (M)
- Brenner tumour (B)
2) Germ cell tumours (15-20%)
- Teratoma (Mature - B, immature M)
- Dysgerminoma (M)
- yolk sac tumour (M)
- Choriocarcinoma (M)
3) Sex cord-stromal tumours
- Granulosa cell tumour (M)
- Sertoi-leydig cell tumour (B)
- Fibroma (B) - Meig’s
4) Mets
- Krukenberg tumour (M) - Mets from a GI tumour result in a mucin-secreting signet ring cell adenocarcinoma, most commonly from pylorus. 80% bilateral
What is Meig’s syndrome?
Ascites , pleural effusion + ovarian fibroma
Ovarian Ca?
Rare
In ~80% it causes few symptoms until it has metastasized
5 year survival
Ovarian Ca Sx , Ix & pattern of spread
Sx: Initially vague or asymptomatic persistent abdo distention Early satiety/loss of appetite Pelvic or abdo pain Increased urinary urgency/frequency Similar to Sx of IBS
Ix: Histology, ascites, ultrasound/CT, CA-125
Risk of malignancy index (US score, menopausal status & CA125 levels) - if RMA>250 refer to MDT
Pattern of spread:
- Transcoelomic
- Lymphatic spread to pelvic and paraaortic nodes
Ovarian Ca Staging and Rx?
Staging:
I - disease limited to 1 or both ovaries
II - Beyond ovaries but in pelvis
III - ovary and peritoneal implants outside pelvis/ +ve retroperitoneal or inguinal nodes
IV - distant mets
Rx: Adenocarcinomas (89%) - Curative surgery - total hysterectomy + bilateral salpingo-oppherectomy + partial omentetomy
+ Chemo
–> unless very early disease with low grade histology
Follow up levels of Ca125 and CT
Pelvic infection?
90% sexually acquired - mostly chlamydia
10% follow childbirth/instrumentation
Acute Salpingitis - Pain, fever, spasm of lower abdo muscles, cervicitis, purulent/bloody vag DC
MX: endocervical & urethral swabs
IV ABx : Ceft + Doxy followed by doxy + Metro
Complications:
- Abscess
- chronic infection
- Long term tubal blockage
- Increased rate of ectopic pregnancy
Chronic salpingitis?
Unresolved acute salpingitis
- Inflammation leads to fibrosis leading to adhesions
- Tubes may be distended with pus/fluid
Sx: Pelvis pain, menorrhagia, sexondary dysmenorrhoea, discharge, deep dyspareunia
Ix: Laparascopy
Endometriosis?
Endometrial glandular tissue occuring outside uterine cavity eg. on ovary
- If foci found in uterine wall muscle - adenomyosis
10% of all women, 35-50% of women with subfertilitiy
Foci are under hormonal influence with waning in pregnancy and menopause and bleeding during menstruation.
Endometriosis Sx?
OE
Asymptomatic, pelvic pain (particular at the time of periods. Constant if adhesions), secondary dysmenorrhea, deep dyspareunia, thigh pain, pain on defecation, menorrhagia (especially with adenomyosis), subfertility
OE: VE - tenderness or thickening behind uterus/adnexa, fixed retroverted uterus or uterosacrl ligament nodules and general tenderness.
Retroverted uterus
Everything stuck together
Endometriosis Ix and Rx?
Complications?
Ix: Laparoscopy
Rx: Medical - analgesia NSAIDs hormonal therapy: COCP/progestogens GnRH analogues IUS
Surgical:
- surgical excision or laser ablation
- Total hysterectomy & bilateral salpingo-oopherectomy
- -> Important to do medical first as endometriosis can recur after excision
Complications:
- Obstruction
- Ovarian endometroid and clear cell cancers
- Hodgkin’s lymphoma
- Melanoma
Subfertility?
Defined as failure to get pregnant after 2 years of regular (2-3wk) UPSI)
Offer investigation after 1 year of trying to conceive In subfertile couples consider: Production of ova Production of sperm Meeting of ova and sperm Implantation of embryo
Ix: Blood tests for anovulation Serum mid-luteal progesterone Day 5 FSH & LH TFT Prolactin Semen analysis Volume Sperm count/morphology Infection Hysterosalpingogram Rx: intrauterine insemination,
bromocriptine for hyperprolactinaemia,
Pulsed GnRH/clomifene/IVF for anovulation,
surgery for tubal problems,
IUI/IVF with or without ICSI for male infertility
NB. NO FERTILITY TX ON NHS IF STILL SMOKING
Uterine prolapse - Types
Descent of uterus and/or vaginal walls beyond normal anatomical confines
Occurs as a result of weakness in supporting structures
Types:
Urethrocoele – prolapse of lower anterior vaginal wall involving urethra only
Cystocoele – prolapse of upper anterior vaginal wall involving the bladder
Apical prolapse – prolapse of uterus, cervix and upper vagina
Enterocoele – prolapse of the upper posterior wall of the vagina; resulting pouch usually contains loops of small bowel
Rectocoele – prolapse of the lower posterior wall of the vagina involving the anterior wall of the rectum
Uterine prolapse risk factors?
Delivery (large infants, prolonged second stage & instrumental delivery)
Ehlers danlos
Menopause
Chronically raised intra-abdominal pressure eg. obesity, chronic cough, constipation, heavy lifting or pelvic mass, pelvic surgery eg. hysterectomy or continence procedures
Uterine prolapse Sx, IX and Mx?
Sx: asymptomatic, heavy dragging sensation/sensation of a lump
Worse at the end of day or when standing up
May interfere with intercourse, urinary frequency or incomplete bladder emptying
Sims speculum
Ix: Pelvic ultrasound, urodynamic testing
Mx:
Conservative: lose weight, treat chest problems eg. quit smoking
Pessaries - ring/shelf pessary if pt unfit for surgery
Surgery: Hysteropexy; hysterectomy ; sacrocolpopexy
Pregnant abdo palpation - what do you feel?
Uterus not felt until 12 wks
16 weeks - Fundus halfway between symphysis pubis and umbilicus
20-24wks: fundus reaches umbilicus
36 wks: Fundus under ribs
From 16wks SFH increases 1cm/wk
nb. Foetal HS heart from doppler from 12 weeks & Pinard from 24
Reasons for discrepency between fundal height & dates?
Inaccurate menstrual history
Multiple gestation
Fibroids
Polyhydramnios
Adnexal mass
Maternal Size
Hydatidiform mole
Foetal movements?
1st noted by mothers at 18-20 weeks
Increase until 32 weeks and then plateau
Average 31/h
Foetuses sleep for 20-40min cycles day and night
Reduced foetal movements: advise lying semi-recumbent for 2h; if
Mechanisms of labour?
1) Descent, with head in left/right lateral position. Flexion
2) Further descent and internal rotation of head
3) Complete internal rotation of head, beginning extension due to sacral curve
4) Complete extension as head delivered
5) Restitution (external rotation of head)
6) internal rotation + delivery of anterior shoulder
7) Delivery of posterior shoulder
Mechanisms of labour?
1) Flexed fetus descends - head very flexed on spine, descends and engages
2) Internal rotation: Whole fetus internally rotates its facing towards maternal back - head at level of ischial spines
3) Extension of head - head extends around pubis symphysis due to sacral angle until delivered
4) Restitution (external rotation) - after head delivered, fetus rotates back to its original position (Shoulders AP)
5) Delivery of shoulders - Anterior shoulder comes out first, then rest in pelvic axis (ie. anteriorly)
What is CTG?
Normal trace?
CTG - US detects fetal heart beats + tocodynamometer over uterine fundus recording any contractions
Normal trace:
- Baseline: 110-160
- Variability: >5bpm
- Accelerations: >2 of 15bpm over 15 minutes
How to interpret a CTG?
DR C BRaVADO
DR - Define risk
C - Contractions per 10 min - hyperstimulation = >5 contractions in 10 mins
BRa - Baseline rate (should be 110-160bpm)
V - Variability > 5BPM
A - Accelerations of the foetal heart with contractions/movement is reassuring
D - Decels:
- Early - synchronous with contractions - normal response to head compression
- Late - persist after contraction - suggestive of fetal hypoxia
- Variable: reflect cord compression
O - overall assessment
Intrapartum fetal HR monitoring
- Aims to detect patterns known to be associated with fetal distress - diagnosis supported by fetal hypoxia on blood sampling
- Intermittent auscultation at the end of contractions with doppler/Pinard used for low risk labours
- 1st stage - every 15 mins
- 2nd stage - every 5 mins
Continuous FHR monitoring only if abnormality noted or intrapartum problems occur
- -> poor predictive value
- -> over diagnosis of fetal distress
Indications for continuous FHR monitoring
High risk pregnancy
Use of oxytocin
Decelerations noted after a contraction (Late)
Rate 160
Fresh meconium passed
Maternal pyrexia
Fresh bleeding in labour
Maternal requests
Mx of a poor trace?
Management of a poor trace
Lie mother on left side and give O2
Stop oxytocin
If there is uterine hypercontractility -> terbutaline 0.25mg SC
Take foetal blood sample
Foetal blood sampling
Used to check for hypoxia in presence of pathological CTG trace
Not used in acute compromise
Take with mother lying in left lateral position
Foetal acidosis reflects hypoxia
pH >7.25 – normal; repeat in 1 hour if CTG remains pathological
pH 7.21 7.2 – call consultant obstetrician and deliver immediately
CTG: Loss of baseline variability?
Baseline variability of >5 beats/min shows response to vagal tone, sympathetic stimuli, and catecholamines in a well-oxygenated fetal brainstem
Loss of baseline variability may reflect a preterm fetus who is asleep, drug effects (e.g. diazepam, morphine, phenothiazine), or hypoxia.
CTG: Baseline tachycardia?
Heart rate >170 beats/min is associated with maternal fever, or β- sympathomimetic drug use, chorioamnionitis (loss of variation too), and acute/subacute hypoxia
Persistent rates >200 are associated with fetal cardiac arrhythmia
CTG: Baseline bradycardia?
Rarely associated with fetal hypoxia (except in placental abruption)
It may reflect ↑ fetal vagal tone, fetal heart block, or, if spasmodic, cord compression
CTG: Decelerations
Early decelerations
Coinciding with uterine contractions reflect increased vagal tone as fetal intracranial pressure rises with the contraction
Late decelerations
When the nadir of the deceleration develops some 30sec after the peak of the uterine contraction, reflect fetal hypoxia, the degree and duration reflecting its severity
Variable decelerations,
Both in degree and relation to uterine contractions, may represent umbilical cord compression around the limbs or presenting part
Pathological CTG pattern?
2 or more non-reassuring features:
- Baseline rate 100–109 or 161–180 beats/minute
- Variability 50% contractions, occurring over 90 minutes
- Prolonged deceleration of 180 beats/minute
Variability 50% contractions, or late decelerations, both over 90 minutes
Single prolonged deceleration of >3 minutes
US in pregnancy?
Early in pregnancy:
Confirm ectopic or viable intrauterine pregnancy (4 weeks +3 days for regular 28 day cycle) with transvaginal scan
Estimate gestation, ascertain viable foetus or diagnose twins
Exclude hydatidiform mole
Estimating gestation:
Crown-rump length measured at 6-12 weeks
From 12 weeks biparietal diameter can be measured
From 14 weeks femur length can be measured
Foetal abnormality
Routine scans to find abnormality at 18-20 weeks
Indications:
Family history of neural tube defect
Maternal diabetes
Maternal epilepsy
Oligohydramnios
Multiple pregnancy
Foetal echocardiography:
Offered to high risk groups at 22-24 weeks
Physiological changes in pregnancy?
Hormonal:
- Progesterone - decreased smooth muscle excitability (Uterus, gut, ureters) and raises body temp
- Oestrogens (90% oestriol) - increased breast and nipple growth, water retention and protein synthesis
Haemodynamic:
- Blood volume - rises from week 10-32 - dilutional anaemia
- WCC, platelets, ESR, cholesterol, B-globulin and fibrinogen raised
- Albumin/ Y-globulin fall
- Urea + creatinine fall
Cardiovascular:
- CO rises from 5 –> 6.5-7L/min in first 10 weeks (increased SV + HR)
- BP falls during 2nd trimester, rises to non-pregnancy levels by term
Aorto-caval compression
- from 20wks, gravid uterus compresses IVC in supine women reducing VR. This reduces CO by 30-40% (supine hypotension) –> relieved by lying in left lateral position
Other changes:
- Ventilation increased by 40% - Gut motility reduced –> Constipation
- GFR increases by 60^
- Skin pigmentation
Prenatal diagnosis?
High risk pregnancies:
Maternal age >35 (chromosomal defects)
Previous abnormal baby or family history of inherited condition
Ultrasound:
11-13 - weeks screens for nuchal translucency (foetal heart failure) and chorionicity
18 weeks – anomaly scan
AFP
Amniocentesis
CVS
Foetoscopy
Down’s screening?
Combined test standard (11-13+6wks):
1) Nuchal tranlucency
2) Serum B-HCG
3) Pregnancy associated plasma protein A
High risk - 1 in 150 or more
If women book later, either triple or quadruple test should be offered between 15-20 weeks
Triple test at 16: AFP + unconjugated oestriol + B-HCG
Quadruple also has inhibin A
Confirm diagnosis with amniocentesis or CVS
Prenatal diagnosis: Amniocentesis & CVS?
Amniocentesis
Foetal loss rate is 1% at 16 weeks gestation but 5% for early amniocentesis at 10-13 weeks
Amniotic fluid AFP is measured and cells in the fluid are cultured for karyotyping
Chorionic villus sampling
At 10 weeks the placenta is sampled by transcervical or transabdominal approach under continuous ultrasound control
Use up to 20 weeks
Does not detect neural tube defects, may cause foetal malformation and is not recommended in dichorionic multiple pregnancy
Prenatal diagnosis: AFP
Glycoprotein synthesised by the foetal liver and GI tract
Foetal levels fall after 12 weeks; maternal levels continue to rise to 30 weeks
Maternal AFP measured at 17 weeks
In 10% with high AFP there is a foetal malformation e.g. neural tube defect
In 30% with no malformation there is an adverse outcome e.g. placental abruption or 3rd trimester death
Non-specific test on its own
Foetoscopy?
Carried out at 18 weeks with ultrasound guidance to find external malformations, do foetal blood samples or biopsy
Foetal loss rate is 4%
Placenta previa?
Placenta lies in the lower uterine segment
Risk of significant haemorrhage by mother and foetus
Avoid PV examinations and advise against penetrative intercourse
Placenta previa mx?
Major placenta previa (placenta covers internal os) requires C-section
Minor placenta previa (placenta in lower segment but does not cross the internal os) – aim for normal delivery unless the placenta encroaches within 2cm of the internal os
Presentation may be as APH or as failure of the head to engage
Problems are with bleeding and with mode of delivery as the placenta obstructs the os and may shear off during labour
Poor lower segment contractility predisposes to postpartum haemorrhage
After delivery:
Examine placenta for abnormalities such as clots, infarcts, amnion nodosum, vasa praevia, single umbilical artery
Weigh the placenta
Blood taken from cord – cord gases, Hb, Coombs’ test (AIHA), LFTs and blood group
Placenta Previa associations?
C-section Sharp curette TOP MULTIPARITY MULTIPLE PREGNANCY MOTHERs AGE >40 assisted conception Deficient endometrium Manual removal of placenta D&C Fibroids Endometritis
Thrombopropholaxis in pregnancy
women with 3 or more persisting risk factors, consider antenatal and postnatal LMWH prophylaxis, starting as early in pregnancy as possible
Consider normal dose prophylaxis when admitted in labour
Treat for 6wks postpartum and supply compression stockings post partum
Women with Past VTE +- thrombophilia:
very high risk: High dose prophylactic LMWH eg. enoxaparin 40mg/12h SC if 50-90Kg
Booking visit bloods & Ix?
FBC
Serum antibodies e.g. anti-D
Glucose tolerance test
Syphilis serology
Rubella immunity
HIV and hepatitis B offered
Haemoglobin electrophoresis – sickle cell anaemia and thalassaemia
Screening for infections involved in preterm labour (e.g. chlamydia, BV) offered to women at increased risk
Urine microscopy & culture
Urinalysis – glucose, protein and nitrites
Booking visit health promotion?
Folic acid 0.4mg PO until 12 weeks
- Women at higher risk of NTD 5mg until 12th week: (either partner has NTD, previous pregnancy NTD, FH, antiepileptic drugs, coeliac, DM or thalassemia trait, or BMI > 30)
Vit D for women with BMI >30 or south asian/afro–carribean
Avoidance of infection: listeriosis avoided by drinking pasteruised /UHT milk, avoiding soft/blue cheese, pate, partially cooked ready meals
Sleep in lateral position
Antenatal schedule
BP and urine checked at every visit
16 weeks: review of chromosomal abnormalities screening test and blood tests at booking
18-21 weeks: anomaly scan for structural abnormalities
25 weeks: appointment for nulliparous women to exclude early onset pre-eclampsia
28 weeks: fundal height measured, FBC & antibodies are check; glucose tolerance test (if indicated); anti-D given to rhesus D women
31 weeks: fundal height measured in nulliparous women and blood tests from week 28 are reviewed
32 weeks: repeat anomaly scan if placenta was low at 20 weeks
34 weeks: fundal height measured, FBC rechecked if Hb was previously low
36, 38 & 40 weeks: fundal height measured, foetal lie and presentation checked (refer for ECV if indicated)
41 weeks: fundal height measured, foetal lie and presentation is checked, membrane sweeping offered and induction of labour offered by 42 weeks
Constipation in pregnancy?
Occurs as gut motility decreases due to progesterone
Treat with oral fluids and high-fibre diet
Avoid stimulant laxatives - they increase uterine activity in some women
IX and Rx in hyperemesis gravidarum?
Ix:
PCV and U&Es – to help guide fluid regimen
LFTs – 50% have abnormal LFTs
TFTs – abnormal in 60%; severity of hyperemesis correlates with degree of biochemical hyperthyroidism
Rx:
Admit
VTE prophylaxis
Thiamine supplements – to prevent Wernicke’s encephalopathy
Mild – ginger, pyridoxine, dry bland food and carbonated drinks
IV normal saline with potassium added (guided by U&Es) – rapid reversal of hyponatraemia can cause fatal central pontine myelinosis
Anti-emetics may be needed if rehydration does not improve condition – cyclizine 50mg PO/IM/IV TDS
Sickle Cell disease in Pregnancy?
Pregnancy worsens anaemia so increased risk of crises and acute chest syndrome
Increased risk of infection and foetal growth restriction
Prenatal testing for foetus at 8-10 weeks
Give 75mg aspirin daily from 12 weeks – reduces risk of developing pre-eclampsia
Crises affect 27-50%; admit if fever, severe or atypical pain
Treat pain with morphine/diamorphine not pethidine as it risks fits
Give O2 if oxygen saturation is less than 95%
Give heparin thromboprophylaxis 7d post vaginal delivery and 6 weeks post caesarean
Anaemia in pregnancy?
Hb
HIV pregnancy?
Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)
Antiretroviral therapy
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation
Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy
zidovudine is usually administered orally to the neonate if maternal viral load is
Pre-existing diabetes in pregnancy?
Aim for HbA1c 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
Insulin needs increase 50-1055% as pregnancy progresses
Aim for fasting level 3.5-5.3mmol/L
Give glucogel and glucagon kit
During labour give 1L of 5-10% glucose/8h IVI with 1-2u insulin via a pump (sliding scale)
GDM screening?
women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Gestational diabetes is diagnosed if either:
Fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/
GDM Mx?
1) Newly diagnosed should be seen in joint diabetes & antenatal clinic within a week
2) teach women about selfmonitoring of blood glucose
3) Diet advice (low GI) + exercise
4) if fasting glucose 7, insulin should be started
4c) If at diagnosis, fasting glucose between 6-6.9 + evidence of complications eg macrosomia/hydramnios - start insulin
- Glibenclamide only for women who cannot tolerate metformin/ fail to meet glucose targets and decline insulin
GDM complications?
Maternal complications
polyhydramnios - 25%, possibly due to fetal polyuria
preterm labour - 15%, associated with polyhydramnios
Neonatal complications
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia (secondary to beta cell hyperplasia)
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
Thyroid problems in pregnancy?
Hyperthyroid
- Usually Grave’s
- Increased risk of prematuriy, foetal loss and malformation
- Propylthiouracil low does best trx
- If not controlled by drugs: partial thyroidectomy in 2nd trimester
- Increased levels can cause foetal hyperthyroidism after 24 weeks causing premature delivery, craniosynostosis, goitre, polyhydramnios and extended neck in labour
Labour, delivery, surgery and anaesthesia can precipitate thyroid storm
Hypothyroidism in pregnancy
Untreated hypothyroidism risks increased rates of miscarriage, stillbirth, premature labour and abnormality
Increase levothyroixine by 30% as soon as the patient is pregnant
Neonatal thyrotoxicosis
Seen in 1% of babies in women with past Graves’ disease as thyroid receptor antibodies cross the placenta
Test thyroid function in affected babies frequently
Signs: foetal tachycardia >160bpm and intrauterine growth restriction
Jaundice in pregnancy?
Viral hepatitis and gallstones may cause jaundice in pregnancy
Ix: urine bile, serology, LFTs, USS
Intrahepatic cholestasis of pregnancy:
Pruritus of palms and soles in the second half of pregnancy Mild elevation of liver transaminases Elevated bilirubin Risk of preterm labour, foetal distress and stillbirth
Give vitamin K 10mg PO OD to the mother and 1mg IM to the baby at birth
Ursodeoxycholic acid reduces pruritus and abnormal LFTs Symptoms resolve within days of delivery
Acute fatty liver of pregnancy?
Acute fatty liver of pregnancy:
Mother develops abdominal pain, jaundice headache, vomiting and thrombocytopaenia and pancreatitis
Hepatic steatosis with micro-droplets of fat in liver cells
Deep jaundice, uraemia, severe hypoglycaemia and clotting disorder may develop causing coma and death
Rx:
Supportive treatment for liver and renal failure
Treat hypoglycaemia with a CVP line
Expedite delivery
Foetal valproate syndrome?
major organ system anomalies, autism, small ears, small broad nose, long upper lip, shallow philtrum & micro/retrognathia
Cleft lip
Neural tube defects: commoner with valproate and carbamazepine
Connective tissue disorders in pregnancy?
RA - usually alleviated but may be exacerbated in the puerperium
- Methotrexate CI , Sulphasalazine may be used
AZT - may cause IUGR
- NSAIDs can be used in1 st/2nd trimester, but not recommended in 3rd as they can cause premature closure of PDA
SLA - exacerbatins common
- pre-eclampsia, olgohydramnios and IUGR
- -> Anti-Ro/Anti- La antibodies can irreversibly dmg foetal heart condution system causing congenital heart block
Connective tissue disorders - which Abds are dangerous for neonate?
Anti-Ro
Anti-La
===> both can irreversibly dmg foetal heart conduction system causing congenital heart block
Pre-existing hypertension Mx?
Preconception: ACE inhibitors, A2A blockers and chlorothiazide risk congenital abnormality so change these to Labetalol (first line) or nifedipine (second line), methyldopa , hydralazine
Antenatal: Ensure suitable antihypertensive is being used Aim for BP 80 Give aspirin 75mg PO OD from 12 weeks until baby is born USS to assess foetal growth, amniotic fluid and volume and umbilical artery velocity at 28-30 weeks and 32-34 weeks CTG if foetal activity is abnormal Monitor BP during labour If severe hypertension does not respond to treatment advise operative delivery Do not give methyldopa post-delivery as there is a risk of postnatal depression Avoid diuretics if breastfeeding
Gestational hypertension Mx?
Needs assessment in secondary care
Urine testing for proteinuria
Check urine and BP weekly if mild
If BP >150/90 start antihypertensive treatment e.g. labetalol
If BP >160/110 admit to hospital, measure BP 4 times daily and check urine daily
Aim for delivery after 37 weeks unless pre-eclampsia supervenes
If BP outside target range (>160/110) advise operative delivery
Continue antenatal antihypertensives postnatally
Antenatal infections screen for?
TORCHHH Toxo Other: Syphilis, Listeria, VZV, Chlamydia, gonorrhoea, TB Rubella CMV HSV HBV HIV
Rubella and pregnancy?
Childhood vaccination prevents susceptibility
Asymptomatic reinfection can occur
Foetus is most at risk in the 1st 16 weeks gestation
CMV in pregnancy?
Causes more congenital retardation than rubella in the UK
Maternal infection is mild
Vertical transmission to foetus occurs in 40%
5% develop early multiple handicaps and have cytomegalic inclusion disease Sx: IUGR, pneumonia, thrombocytopaenia; neurological sequeulae: hearing, visual and mental impairment or death Amniocentesis at >20 weeks and shell viral culture can detect foetal transmission Reactivation of old CMV can occur in pregnancy – rarely affects the baby
Toxoplasmosis in pregnancy?
40% of foetuses are affected if the mother has the illness
Earlier in pregnancy -> more damage
Sx: fever, rash, eosinophilia
If symptomatic CNS prognosis is poor
Diagnose affected babies by serology
Can cause intracranial calcification, hydrocephalus, choroidoretinitis in severely affected babies; encephalitis, epilepsy, mental and physical retardation, jaundice, hepatosplenomegaly, thrombocytopenia, and skin rashes occur
Hep B in pregnancy?
Maternal screening
Carriers have persistent HBsAg for >6months
Anti-HBe antibodies are negative
Without immunisation 95% of babies born to these mothers might develop hepatitis B; 93% would be chronic carriers at 6 months
Give immunoglobulin and vaccinate babies of carriers & infected mothers at birth
Do serology of vaccinated baby at 12-15 months; if HBsAg negative and anti-HBs is present, the child is protected
Herpes in pregnancy?
Neonatal infection can cause blindness, low IQ, epilepsy, jaundice, respiratory distress DIC and death
Past infection recurrence is not usually a problem due to maternal antibodies
If the mother develops primary HSV infection in pregnancy give oral acyclovir ± elective c-section if infection within 6 weeks of due date
If a mother with primary lesions delivers vaginally give mother and newborn high-dose acyclovir
Varicella in pregnancy?
If chickenpox in last 7 days, of preg, aim for delivery after 7 days + give neonate VZIG at birth + monitor for 28/7 + treat with acyclovir if Sx
Babies of non-immune mothers if contact in 1st 7 days of life: VZIG
Mother with no history of chicken pox + contact - check varicella Abd, if -ve, give VZIG and mx as infectious. Notify doctor if rash develops
Women developing chickenpox in pregnancy: : acyclovir 800mg 5 times daily for 7 days PO if >20wks and presenting within 24hrs of rash
Hospitalise if chest, CNS, haemorrhagic rash or immunocomp
Fetal varicella syndrome complicates 1% of mothers infected at 3-28 wksof pregnancy by reactivation in utero: Skin scarring, eye defects and neurological abnormalities
Fetal varicella syndrome?
Fetal varicella syndrome complicates 1% of mothers infected at 3-28 wksof pregnancy by reactivation in utero:
Skin scarring, eye defects and neurological abnormalities
Parvovirus & pregnancy?
Virus suppresses foetal erythropoiesis causing anaemia and thrombocytopenia
Foetal death occurs in 10%
Ix: Maternal IgM, US
Chlamydia / gonococcal complications of pregnancy?
Chlamydia:
- 30% of infected mothers have affected babies
- Conjunctivitis develops 5-14 days after birth and may show minimal inflammation or purulent D/C
Complications: chlamydia pneumonitis, pharyngitis or otitis media
Gonococcal conjunctivitis:
- Occurs within 4 days of birth
- Purulent d/c + lid swelling , corneal hazing/rupture
Preventing GBS sepsis in neonate?
Streptococcus agalactiae is carried (without symptoms) by 25% of women
Foetus can be infected during labour after membranes have ruptured
Common with preterm labour, prolonged labour or if there is maternal fever
Give all women IV antibiotics (penicillin) at start of labour or on rupture of membranes if:
Positive GBS swab from vagina and anus at 35-37 weeks
Any baby previously infected with GBS
Documented GBS bacteriuria
Recent swab result unknown and gestation
Most common cause of puerperial sepsis?
GAS
Sx: chorioamnionitis, abdo pain, diarrhoea + severe sepsis
mx: Early recognition, culture, high dose Abx and ITU
Causes of maternal abdo pain in pregnancy?
Gynecological:
- Abruption (tender woody uterus)
- Uterine rupture
- Uterine Fibroids
- Uterine torsion
- Ovarian tumours
- Pre-eclampsia (liver congestion)
Abdominal: Pylonephritis Appendicitis Cholecystitis Pancreatitis
Pre-eclampsia
Sx?
PIH + Proteinuria + oedema
- Failure of trophoblastic invasion of spiral arteries leaving them vasoactive
Develops after 20 wks and usually resolves within 10 days post delivery
Flu like: chest pain, headache, epigastric pain, vomiting, tachycardia
- Visual disturbance
- Shaking
- Hyper-reflexia
- irritability
O/E: HTN, Oedema, epigastric tenderness, Urine dipstick
Liver involvement: HELLP Syndrome
Late: HTN/Renal failure
Eclampsia
Foetal:
- Asphyxia
- Abruption
- IUGR
- Hydrops
Pre-eclampsia risk factors?
High risk:
- Chronic HTN/ HTN in previous pregnancy
- CKD
- DM
- AI disease
Moderate:
- 1st pregnancy
- Age >40
- Pregnancy interval >10 yrs
- BMI >35
- FH
- Multiple pregnancy
If 1 high risk, or 2 moderate, take aspirin 75mg OD PO from 12th week until delivery
HELLP syndrome?
Liver involvement in pre-eclampsia:
Haemolysis
Elevated liver enzymes
Low platelets
Pre-eclampsia General Mx
Admit if:
- BP rises >30/20mmHg over booking BP
- BP > 160/100
- BP > 140/90 + proteinuria
- Growth restriction
Measure BP 2-4hrly Weigh daily Test urine for protein Monitor fluid balance Bloods: U&E, LFT, platelets CTG on admission USS to check growth, amniotic fluid volume and umbilical artery velicometry
If mild HTN & No complications, delivery by 37 weeks
If severe:
- Prophylactic MgS04
- Prophylactic steroids
- Deliver foetus ASAP
HTN: BP> 160/110, Labetalol 20mg IV, increasing after 10 min intervals to 40mg then 80mg until 200mg total is given; aim for 150/80 - Alternative = hydralazine - Prophylactic H2 blockers - restrict fluid to 80ml/hr
Pre-eclampsia, RX of seizures?
First seizure – 4g magnesium sulphate (beware decreased respiration)
Recurrent seizure – 2g magnesium sulphate IVI over 5 minutes
Check tendon reflexes and respiratory rate every 15 minutes
Stop magnesium sulfate IVI if respiratory rate
When is Anti-D given?
Anti-D is given to all rhesus D negative mothers at 28 weeks
Anti-D is also given within 72h of any sensitising event e.g. miscarriage or threatened miscarriage after 12 weeks, ERPC, termination of pregnancy, ectopic pregnancy, amniocentesis, after ECV, foetal death or antepartum haemorrhage
Rhesus disease?
If mild – neonatal jaundice
Severe disease – in utero anaemia leading to cardiac failure, ascites, and oedema (hydrops) followed by foetal death
Ix: assess severity by doing Doppler of foetal middle cerebral artery
Mx: blood transfusion in utero or delivery if >36 weeks
Postnatal Mx: check FBC, bilirubin and rhesus group
Prevention of preterm labour
Cervical stitch to strengthen the cervix and keep it closed:
At 12-14 weeks for women with a history of preterm delivery
If cervix is regularly scanned and there is significant shortening
Rescue suture to prevent delivery when the “incompetent” cervix is dilated
Progesterone supplementation: suppositories from early pregnancy reduce risk of preterm labour in women at high risk
Foetal reduction – for multiple pregnancies
Needle aspiration of polyhydramnios
Preterm labour Sx?
Painful contractions
Painless cervical dilatation
Increased D/C
Antepartum haemorrhage and fluid loss (ruptured membranes)
Preterm labour Mx?
Ix; CTG, foetal fibronectin assay, TVUS of cervical length, vaginal swabs (for infection)
In 50% contractions cease spontaneously Treating the cause may make it cease
1) corticosteroids
2) Tocolysis (suppression of contractions) - unlikely to succeed if membranes are ruptured or cervix is >4cm dilated – nifedipine or atosiban
What is the foetal fibronectin assay?
Fetal fibronectin “leaks” into the vagina if a preterm delivery is likely to occur and can be measured in a screening test.
When the fFN test is positive, it is an inconclusive result. A positive result can indicate that a woman will go into preterm labor soon, but she may not go into labor for weeks. When the fFN test is negative, the result is a better predictor. A negative result means that there is little possibility of preterm labour within the next 7 to 10 days, and the test can be repeated weekly for women who remain at high risk. A negative fetal fibronectin test gives a more than 95% likelihood of remaining undelivered for the next 2 week
PROM Mx?
Admit
Assess for causes eg. infection
If liquor not obvious, use nitrazine stick (turns black if present)
Give corticosteroids (betamethasone 12mg IM with a 2nd dose 12-24 hrs later)
In 80%, PROM initiates labour
- In remaining, balance advantages of remaining in utero against threat of infection
- If chorioamnionitis suspected give erythromycin
Nb. MgSO4 can be neuroprotective if given antenatally for babies
Preterm delivery?
NVD reduces incidence of RDS
C-section if breech
Do not rupture membranes
Slow delivery allows more time for steroids to act
Babies delivered at 28 weeks gestation should be delivered in a room with temperature of 26°C, wrapped in food grade plastic wrap without drying after birth and placed under heat; cord should not be clamped for 45s
Preterm delivery complications?
Neonate
- NICU admission
- Death
- Cerebral palsy
- CLD
- Blindness
- Minor disabilities
Maternal:
- Infection
- Endometritits
Small for gestational age - definition + causes?
Postmaturity?
Problems?
Mx
Exceeding 42 weeks of pregnancy
Problems: Possible placental insufficiency Larger foetuses Foetal skull more ossified Increased meconium passage in labour Increased foetal distress in labour Increased C-section rates for labour
Mx:
Membrane sweep
Induction with prostaglandin followed by syntocinon
If induction declined, arrange twice weekly CTGs and US estimation of amniotic fluid depth to try to detect fetuses that may be becoming hypoxic
Foetal distress?
Mx?
Signifies hypoxia
Prolonged/repeated hypoxia causes foetal acidosis
Early signs may be the passage of meconium in labour, foetal tachycardia, loss of variability, irregularity of the heart rate, CTG changes
Hypoxia may be confirmed by the use of foetal blood sampling (severe hypoxia -> foetal scalp blood pH proceed to:
Level 2: continuous CTG; if sustained bradycardia -> deliver; if other abnormalities, treat cause; if they fail -> proceed to:
Level 3: FBS – if abnormal proceed to:
Level 4: delivery by quickest route
What is Sheehan’s?
Pituitary necrosis caused by post-partum haemorrhage.
Leads to lack of pituiatry insufficiency: Lack of TSH, ACTH and GnRH leads to hypothyroidism, addisonian symptoms and genital atrophy
Antepartum haemorrhage - causes?
Dangerous:
Abruption
Praevia
vasa praevia
Other uterine causes:
- Circumvallate placenta
- Placental sinuses
- Fibroids
Lower genital track sources:
- Cervical polyps
- Erosions and carcinoma
- Cervicitis
- Vaginitis
- Vulval varicosities
Placenta praevia Mx?
Mx:
Admit if bleeding
Elective C-section at 39 weeks
Complications:
Intraoperative haemorrhage and postpartum haemorrhage are common – may require hysterectomy
If placenta implants deep in a previous C-section scar it may prevent placental separation – placenta accreta or may penetrate through the uterine wall into a surrounding structure (e.g. bladder) – placenta percreta
Placental abruption?
Consequences?
Occurs in 1% of pregnancies
Posterior abruption may present with backache
May be uterine hypercontractility
May recur in subsequent pregnancies
Consequences:
Placental insufficiency -> foetal anoxia/death
Compression of uterine muscles by blood -> tenderness and prevention of good contractions -> can precipitate PPH
Concealed loss may cause maternal shock after which beware DIC, renal failure and Sheehan’s syndrome (pituitary necrosis)
Placental abruption: Sx, Oe, Ix , Mx?
Sx: painful bleeding (degree of vaginal bleeding does not reflect severity of obstruction)
OE: tachycardia, hypotension (if massive blood loss), tender uterus,; if severe uterus will be woody hard; foetal heart tones are abnormal or absent
Ix: CTG, FBC, coagulation screen, cross match, catheter, U&Es, CVP
Mx:
Admit
Give O2 at 15L/min
If mild bleeding – get IV access, bloods (Hb, crossmatch, coagulation studies, U&Es), BP, pulse, monitor blood loss; ultrasound, speculum; give steroids if 37 weeks -> induce labour with amniotomy
If bleeding is severe or there is foetal distress -> deliver by C-section
Placenta praveia ?
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
Epidemiology
5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
Associated factors
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
Clinical features 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
Classical grading
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 - placenta completely covers the internal os
Placental abruption associations?
Pre-eclampsia Smoking IUGR PROM Multiple pregnancy polyhydramnios Increased maternal age Thrombophilia Abdominal trauma Assisted reproduction Cocaine/amphetamine use Infection non-vertex presentation
Abruption vs previa?
Abruption: shock out of proportion with visible loss
Abruption: Constant pain with tender tense uterus, vs painless, non-tender uterus in praevia
Abruption - normal lie & presentation
Praevia: both may be abnormal
Abruption - fetal heart absent/distressed
Paevia - fetal heart usually normal
Abruption - coagulation problems
Paevia - coagulation problems rare
Abruption: Beware Pre-eclampsia, DIC, anuria
Paevia - small bleeds before large
Vasa praevia?
Foetal vessels run in membranes in front of presenting part
Typically occurs when cord is attached to membranes rather than the placenta
Vessels may rupture when membranes rupture
Sx: painless moderate vaginal bleeding at amniotomy or SROM with severe foetal distress
Normal labour: Factors?
The powers (Degree of force expelling the foetus)
The passage (dimensions of pelvis and resistance of soft tissues)
The passenger (diameters of the foetal head)
Labour: The powers?
In established labour the uterus contracts for 45-60 seconds every 2-3 minutes
Pulls the cervix up (effacement) and causes dilatation
Aided by pressure of head as uterus pushes the head down into the pelvis
Poor uterine activity is common in nulliparous women and induced labour
Labour: the passage?
Inlet: transverse diameter is 13cm; AP diameter is 11cm
Midcavity: almost round – transverse and AP diameters are similar
Outlet: AP diameter (12.5cm) is greater than the transverse diameter (11cm)
Descent measured in relation to the ischial spines (in the mid pelvis) which can be palpated vaginally:
-2 = 2cm above spines
0 = at level of spines
+2 = 2cm below spines
Soft tissues of vagina and perineum need to be overcome in the second stage; perineum often tears or is cut (episiotomy) to allow the head to deliver
Labour: The passenger?
Presenting part: cephalic (vertex, brow or face) or breech
Head is oblong in transverse section
Attitude: degree of flexion of head on the neck; ideal is maximal flexion (vertex presentation) with diameter of 9.5cm; extension cases an increase in diameter
Position: degree of rotation of head on neck; at inlet sagittal suture is transverse and at outlet it is vertical (occipito-anterior) – head must rotate 90° during labour
Head can be compressed in pelvis because of sutures; reduces the diameters of the head (moulding); pressure of the scalp on the cervix or pelvic inlet can cause localised swelling (caput)
Diagnosis of labour?
Involuntary contractions of uterine smooth muscle occur throughout the 3rd trimester (often felt as Braxton-Hicks contractions)
Prostaglandin production reduces cervical resistance
Increasing release of oxytocin from the posterior pituitary
Labour is diagnosed when painful regular contractions lead to effacement and dilatation of the cervix
Effacement is accompanied by a “show” (pink/white mucus plug from the cervix) and/or rupture of membranes
Labour: First stage?
First stage
- Latent phase
Painful contractions
Cervix effaces – becomes softer and shorter
Cervix dilates to 4cm
- Established phase
Contractions with dilatation from 4cm to 10cm
Satisfactory rate of dilatation is 0.5cm/h
Membranes usually rupture in this stage 1st stage usually takes 8-18h in a primip and 5-12h in a multip
First stage of labour: duration?
1st stage usually takes 8-18h in a primip and 5-12h in a multip
First stage of labour: Mx?
Allow mother to drink & eat; give freedom to move
Assess contractions every 30 mins (strength & frequency – ideally 3-4/10mins)
Check maternal pulse every hour
Check maternal BP and temperature 4 hourly
Offer VE every 4h to assess cervical dilatation, position and station of head and degree of moulding
Note the state of the liquor
Auscultate FHR for 1 minute every 15 minutes
Second stage of labour?
Passive stage
Complete cervical dilatation but no desire to push
Head reaches the pelvic floor and mother experiences need to push
Active stage
Baby can be seen
Full dilatation with expulsive contractions and maternal effort
Pressure of head on cervix produces desire to push
Foetus is delivered in 40 minutes (nulliparous) or 20 minutes (multiparous)
Second stage of labour, Mx?
Discourage supine maternal position
Monitoring:
Record urination
Auscultate for 1 minute after a contraction every 5 minutes
Assess contractions every 30 minutes
Offer VE hourly
Check BP and pulse hourly
Check temperature 4 hourly
If contractions wane, oxytocin augmentation may be needed
Birth should be expected within 3 hours for primips and 2 hours for multips
1 minute delay in cord clamping is recommended for term babies
3 minute delay in cord clamping for premature babies
Labour: third stage?
Delivery of the placenta
Takes about 15 minutes
Normal blood loss is 500ml
Uterus contracts to a
Induction of labour: indications/ CI?
Indications:
- HTN/ Pre-eclampsia
- prolonged pregnancy
- Rhesus disease
- DM/GDM
- Still birth
- Abruption
- Foetal death in utero/ placental insuffiency
CI:
- Cephalopelvic disproportion
- Malpresentations (other than breech or face)
- Foetal distress
- Placenta praevia
- Cord presentation
- Vasa praevia
- PElvic tumour
- previous repair to cervix
Measurement of cervical ripeness:
Modified bishops score:
- Cervical dilation
- Length of cervix
- Station of head
- Cervical consistancy
- Position of cervix
5 = ripe
- An unripe cervix may be ripened using prostaglandin vaginal gel
- If this fails, may be repeated 6-8hrs later
Induction of labour?
Problems?
An unripe cervix may be ripened using prostaglandin vaginal gel
If this fails it may be repeated 6-8h later
Once the cervix is ripe rupture the membranes (amniotomy) and monitor FHR
Given oxytocin in 5% dextrose; increase dose until 3-4 contractions occur every 10 minutes
Monitor FHR and stop oxytocin if signs of foetal distress or uterine hyperstimulation
Problems of induction:
Failed induction
Uterine hyperstimulation
Iatrogenic prematurity
Infection
Bleeding (vasa praevia)
Cord prolapse (e.g. with high head at amniotomy)
C-section and instrumental delivery rates are higher
Uterine rupture (rare)
Active Management of first stage of labour?
Delay in 1st stage of labour
Active management of second stage of labour?
Delay in 2nd stage of labour
Delivery not imminent within 1 hour (multips) or 2 hours (primips) after onset of active 2nd stage
Call senior obstetrician
Offer amniotomy
If prolonged or foetal compromise consider instrumental delivery or c-section
Meconium liquor?
Meconium in liquor at amniotomy suggests placental insufficiency
Do foetal blood sample and scalp clip monitoring
If low foetal blood pH or very thick meconium -> c-section
Pain relief in labour?
Waterbirth
Narcotic injectinos eg. PethidineUsed in first stage of labour
Not given in birth is expected within 2-3h as it can cause neonatal respiratory depression
Doses frequently produce vomiting but no pain relief
SE: disorientation, nausea, vomiting, drowsiness
G&A (Entonox)
Can be inhaled throughout labour
CI: pneumothorax
SE: light-headedness and nausea
Pudendal block
Blocks S2-4 nerve roots using lidocaine
Injected 1cm inferior and medial to the ischial spine
Used with perineal infiltration for instrumental delivery
Spinal anaesthesia
LA injected through the dura mater into the CSF
Rapidly produces short lasting but effective analgesia for C-section or mid-cavity instrumental vaginal delivery
SE: hypotension; total spinal analgesia causing respiratory paralysis
Epidural anaesthesia
Anaesthesia of pain fibres carried by t11-S5
Started during latent 1st phase and continued until placenta delivered and any perineal tear is repaired
SE: postural hypotension, urinary retention, paralysis
What is the amniotic sac?
Pair of membranes which contain the fetus, composed of:
- Inner amnion - encloses the amniotic cavity
- Outer chorion - contains the amnion and is part of the placenta
Mono vs dizygotic twins?
Monozygotic twins: Identical twins - due to fertilisation of a single ovum that then separates into two.
The time at which the separation occurs determines the chorionicity and amnionicity of the pregnancy
Dizygotic twins: Fraternal twins, resulting from independent fertilisation of two ova. Always dichorionic - diamniotic
- AS up to 20% of monozygotic pregnancies are also DCDA - 80% of all twin pregnancies are DCDA
Risk factors for dizygotic:
- IVF
- Advanced maternal Age
- Advanced parity
- Maternal FH
- Ethnicity (eg. Nigerians)
Monozygotic twins types?
Division at:
1-4 days (morula) results in dichorionic-diamniotic twins (di-di) (DCDA):
20-30% of monozygotic twin pregnancies
76% of all twin pregnancies
4-8 days (blastocyst) results in monochorionic-diamniotic twins (mono-di) (MCDA):
70-75% of monozygotic twin pregnancies
30% of all twin pregnancies
1-2 weeks results in monochorionic-monoamniotic twins (mono-mono) (MCMA):
1-5% of monozygotic twin pregnancies
1.5% of all twin pregnancies
> 2 weeks results in conjoined twins:
Multiple pregnancy features and signs?
Early pregnancy: Uterus large for dates, hyperemesis
Later: Polyhydramnios
Signs: > 2 poles felt, multiplicity of etal parts, 2 FHS
Dx: US
Nb. Higher foetal loss rate in monochorionic twins
Multiple pregnancy complications?
PPH Malpresentation Vasa previa rupture Cord prolapse Premature placental separation Cort entaglement Higher risk of GDM/Pre-E Greater mortality/miscarriage rates Preterm labour IUGR Twin-Twin transfusion syndrome if monochorionic
Twin-Twin Transfusion?
In monochorionic pregnancies:
Unequal blood distribution in shared placenta leading to discordant blood volumes, liquor and growth
Sx; recipient twin is large, polyhydramnios, fluid overload, heart failure; donor twin is smaller, stuck, oligohydramnios
Mx: ultrasound surveillance from 12 weeks; laser therapy
Complications: late miscarriage, preterm delivery, IUD, neurological damage
Multiple pregnancy Mx?
Ultrasound at 11-13 weeks Iron & folic acid Check FBC at 20-24 weeks Antenatal visits weekly from 30 weeks TVUS to monitor cervical length Delivery: C-section is increasingly used If first foetus is cephalic then vaginal delivery can be attempted First twin is delivered as normal Contractions often diminish after the first twin but usually return; start oxytocin if not ECV may be needed if 2nd twin is not longitudinal C-section may be needed Induction
Breech?
Risk Fx?
Types?
Dx?
Commonest malpresentation (40% at 20 weeks but only 3% at term)
Risk factors: contracted pelvis, bicornuate uterus, fibroid uterus, placenta praevia, oligohydramios, spina bifida, hydrocephalic foetus
Extended breech: commonest; flexed at the hips but extended at the knees
Flexed breech: hips and knees both flexed; buttocks, external genitalia and feet all present
Footling breech: feet are the presenting part; highest risk of cord prolapse
Dx:
Mother may complain of pain under the ribs
On palpation: longitudinal lie, head in fundus which can be balloted
Breech Mx?
External cephalic version:
Turning the breech by manoeuvring it through a forward somersault
Turn baby only if vaginal delivery is planned
Attempt ECV at 36 weeks in primips or 37 weeks in multips
Success rate: 40% primips; 60% multips
CI: placenta praevia, multiple pregnancy, APH in last 7 days, ruptured membranes, growth restricted babies, abnormal CTG, uterine scars/abnormalities, foetal abnormality; pre-eclampsia or HTN, unstable lie
Complications: foetal damage, placental abruption, uterine rupture
Vaginal breech birth
Pushing not encouraged until buttocks are visible
CTG monitoring advised
Slow cervical dilatation in 1st stage and poor descent in 2nd stage – may be better to do a C-section
Episiotomy may be needed
C-section may provide better outcome vs vaginal delivery
Prolapsed cord?
Descent of cord through the cervix alongside (occulta) or in front (overt) of the presenting part in the presence of ruptured membranes
Emergency – cord compression causes foetal asphyxia
Incidence: 0.1-0.6%
Increased risk if: twin, footling breech, shoulder presentation, polyhydramnios, unengaged head, transverse/unstable lie, male
If cord presentation is noted prior to rupture -> C-section
Signs: foetal bradycardia, variable FH decelerations
Mx:
Displace presenting part by putting a hand in the vagina and pushing the cord back up during contractions
Either place the woman head down (left lateral position) or get her into knee-elbow position
Tocolysis to reduce contractions and help bradycardia
Immediate c-section is best
Shoulder dystocia?
Impacted shoulders – inability to deliver shoulders after the head has been delivered
Incidence: 0.6%
Associated with high rate of foetal mortality and morbidity
PPH occurs in 11% of mothers
4th degree tears occur in 4%
Risk of brachial plexus injury and permanent disability to baby
Common cause of litigation: only anterior shoulder can be injured by this
Associations: large/postmature foetus, maternal BMI >30, induced labour, prolonged labour or secondary arrest, assisted delivery, previous shoulder dystocia, macrosomia due to diabetes
Can squash cord at pelvic inlet and cause death from asphyxia
Shoulder Dystocia Mx?
1) McRoberts (hyperflexed lithotomy position) - successful n 90%
- Abduct, rotate outwards and flex maternal femurs so each thigh touches the abdomen (1 assistant to hold each leg)
- Straightens sacrum relative to lumbar spine and rotates sypmhasis superiorly, helping the impacted shoulder enter the pelvis without manipulating the fetus.
2) Apply suprapubic pressure for 30s, with flat of hand laterally in the direction baby is facing and towards mother’s sacrum - aims to displace anterior shoulder allowing it to enter the pelvis
3) If this fails, check ant shoulder is under symphysis via VE. If not, rotate it to be so and repeat traction
4) If this fails, rotate by 180 deg so post. shoulder now lies anterior. Episiotomy helps rotation/arm delivery
5) if all failed, get mother in all 4, maternal symphisiotomy or replacement of the foetal head by firm pressure of the hand to reverse the movements of labour and return the head to the fleed OA position + caesarean delivery. Baby severely acidotic by this stage
- If babies dies prior to delivery, cutting through both clavicles (cleidotomy) with strong scissors assists delivery.
- Check baby for dmg eg. Erb’s plasy or fractured clavicle
Meconium stained liquour?
Babies may pass fresh meconium during labour (dark green, sticky & lumpy)
May be a response to the stress of normal labour or sign of distress/hypoxia -> commence continuous FHR monitoring
Complications: aspiration of meconium can cause pneumonitis
Operational vaginal delivery - indications?
Used only when:
Head is deeply engaged and cannot be palpable abdominally
Membranes have ruptured
Position of head is known and presentation is suitable i.e. vertex or face
Cephalo-pelvic disproportion is absent
Cervix is fully dilates
Uterus is contracting
Adequate analgesia has been given
Bladder is empty
Inidcations:
Delay or maternal exhaustion in second stage
Dense epidural block with diminished urge to push
Rotational instrumental delivery needed for malposition of head
Suspected foetal distress
Types of forceps delivery?
Forceps
Designed with a cephalic head (to fit around the foetal head) and a pelvic curve (to fit around the pelvis)
Wrigley’s (short-shanked) – for lift out deliveries when head is on perineum
Neville Barnes (long shanked) – for higher deliveries when sagittal suture lies in the AP diameter
Kielland’s – suitable for rotation
Indications: delay in second stage (failure of maternal effort, epidural analgesia, malpositions of foetal head), foetal distress, prolapsed cord, eclampsia, delivery of head in breech deliveries
Complications: maternal trauma (vaginal laceration, blood loss or 3rd degree tears), foetal facial brusing, foetal CN VII paralysis or brachial plexus injury
Ventouse
Cup is placed over posterior fontanelle with a suction force of 0.8kg/cm2
CI: head is above ischial spines, face presentations, babies
Indications for emergency C-section?
Failure to progress Foetal distress Breech Previous section Severe pre-eclampsia Placental abruption
Indications fo elective section?
Knwon cephalo-pelvic disproportion Placenta praevia Placenta accreta/percreata Breech Twins where 1st chephalic After vaginal surgery Maternal infections Maternal request
Mendelson’s syndrome?
Inhalation of gastric acid during general anaesthesia (eg. for C-section) leading to cyanosis, bronchospasm, pulmonary oedema and tachycardia
Prevention: pre-operative H2 antagonists, sodium citrate, gastric emptying, cricoid pressure, cuffed ET tubes during anaesthesia and pre-extubation emptying of stomach
Mx:
Tilt patient head down and to one side
Aspirate the pharynx
Give 100% oxygen
Still birth?
Causes?
Mx?
Babies are born dead after 24 weeks gestation
Rate 1:200 births
Causes:
Antepartum: malformation, congenital infection (TORCH), pre-eclampsia, maternal disease, hyperpyrexia, postmaturity
Intrapartum: abruption, maternal & foetal infection, cord prolapse/knots, uterine rupture
Dx: absent foetal movements, no heart sounds
Mx:
Do Kleihauer on all women to diagnose foetomaternal haemorrhage
Check maternal temperature, BP, urine for protein, blood clotting screen
Deliver away from sound of babies and ensure good pain relief
Offer baby to mother to see and to hold if she wishes
Primary PPH?
Causes?
Risk Fx?
Primary PPH: >500ml in first 24 hrs after delivery.
Major PPH = >1L
Causes: Uterine Atony
Genital trauma
Clotting disorders
Risk factors:
- Previous PPH
- Prolonged labour
- Pre eclampsia
- Increased maternal age
- Polyhydramnios
- Emergency C-section
- Placenta praevia
- Macrosomia
- Ritodrine (a b2 agonist used for tocolysis)
Primary PPH mx?
ABC
IV syntocinon (Oxytocin) 10U or IV ergometrine 500ug
IM carboprost (induces contractions and reduces post partum bleeding)
Other options:
- B lynch suture
- Ligation of uterine arteries/ Internal Iliac arteries
- Rusch balloon if persistent haemorrhage
- If severe, unontrolled haemorrhage, then a hysterectomy is sometimes performed as a life saving procedure
Secondary PPH?
Occurs between 24 hrs - 12 weeks
- Due to retained placental tissue or endometritis
Retained placenta?
Third stage of labour is delayed if not complete by 30 minutes with active management or by 60 minutes with physiological 3rd stage
Danger with retained placenta is haemorrhage
Associated with: previous retained placenta or uterine surgery, preterm delivery, maternal age >35y, placental weight 5, induced labour, pethidine used in labour
Retained placenta Mx?
Avoid excessive cord traction
Check that the placenta is not in the vagina
Palpate the abdomen: if uterus is well contracted the placenta has probably separated but trapped by the cervix; if uterus is bulky the placenta has probably failed to separate
Rub up a contraction, put the baby to the breast to stimulate oxytocin production, give 20IU oxytocin and clamp cord
If placenta does not deliver within 30 mins examine (with analgesia or anaesthetic) to see if manual removal is needed
Manual removal
Place one hand on abdomen to stabilise the uterus
Insert other hand through cervix into uterus
Follow cord to find the placenta and work round the placenta separating it from the uterus using the ulnar border of the hand
When separated remove by cord traction
Start Abx: doxycycline and metronidazole
Cephalohaematoma?
Subperiosteal swelling on fetal head
Boundaries LIMITED by individual bone margins/suture lines
Spontaenous absorption occurs, but may takes weeks and may cause/contribute to jaundice
Caput Succedaneum
Oedematous swelling of the scalp, Superficial to cranial periosteum
Forms over vertex and crosses suture lines
Resolves within days
Subaponeurotic haematoma?
Blood lies between aponeurosis and periosteum - not limited by suture lines
Haematoma not contained, and collections of blood may be large enough to result in anaemia or jaundice
Associated with vacuum extractions
Perineal tears in labour?
1st degree tears – superficial tears which do not damage muscle; suture unless skin edges well apposed to aid healing
2nd degree – laceration involve perineal muscle; repair is similar to that of episiotomy
3rd degree – damage involves the anal sphincter muscle
3a – external anal sphincter (circular fibres) thickness 50% torn
3c – both external and internal anal sphincters (longitudinal fibres) torn
4th degree – involving external & internal anal sphincters and rectal mucosa; repair in theatre
Episiotomy
Performed to enlarge the outlet to hasten birth of a distressed baby, for instrumental or breech delivery, to protect a premature head and to try to prevent 3rd degree tears
Complications: bleeding, infection, breakdown, haematoma
Post-natal depression ; screening?
Two questions should be asked:
During the past month, have you often be bothered by feeling down, depressed or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
If the woman says yes, a third question should be asked: Is there something you feel you need or want help with?
May consider using further screening tests e.g. Edinburgh Post Natal Depression Scale (EPDS)
Subfertility Ix?
FSH, LH, E2, Testosterone, Prolactin, Thyroid, AMH, Luteal phase progesterone (day 20), TVUS (Ovaries/cysts), tubal patency - HyCosY (Foam squirted up vagina and watch for it to come out of tube)
If hx of endometriosis - laparoscopy
Men: Semen analysis:
- Good number of sperm
- Good morphology
- Swimming well
Rokitansky syndrome?
Paramesanephric ducts don’t form a uterus at all:
- Ovaries , no uterus, but bottom 3rd of the vagina.
Pc/ No periods
Endometriosis vs Adenomyosis O/E
immobile organs (endo), tender uterus (adeno)
Subfertility causes?
30% Anovulatory (PCOS,
hypothalamic/hypogonadotrophic
hypogonadism, hyperprolactinaemia)
25% Male factor (idiopathic,
varicocele, drugs/chemicals, funny
syndromes)
25% Tubal factor (infection, endo,
surgery)
HPV life history?
Prevalence 60% • 100 women become infected • 80 clear the virus in 8-18 months • 20 experience persistent infection • 10 women HG CIN • 1 woman will develop cancer
HPV vaccine counselling
Vaccine for a very common infection
• Occasionally it causes abnormal smears
• Cervical cancer is a rare complication
• Vaccine protects fully against the two most dangerous
types
• Some protection against other types (6,11)
• Still need screening
• Safe sex
• No protection against STDs
• 3 injections in the arm (0,2, 6 months)
• Immunity lasts at least 8 years
Ovarian Cancer PC?
Pelvic/abdo mass
Ascite
May present like:
IBS (Unlikely to present first time in post-menopausal women/ diagnosis of exclusion)
- Prolapse/urinary incontinence
- Krukenberg tumours - met from GIT
- Para-neoplastic syndrome: eg. dermatomyositis
Tumour markers in ovarian cancer?
Ca125 ovarian
Ca19-9 - Mucinos
CEA - Bowel (krukenberg)
Ca153 - Breast - may metastasise to ovary
AFP - Liver
LDH (not specific)
Inhibin (ovarian cancer)
Beta-HCG + AFP ovarian germcell tumours
Imaging in gyne cancer
USS Pelvis: Endometrial, ovary
MRI Pelvis: Endometrial, ovary + cervix
CT ACP: Endometrial, ovary, cervix, vulva (Useful to look for distant mets/peritoneal involvement)
Gyne cancer adjuvant tx?
Chemo: Ovary/Cervix
Radiotherapy: Endometrial,cervical and vulval
nb. with cervical, chemotherapy first to sensitise to radiotherapy
Labour summary
1st stage:
Latent: Painful contractions + cervical effacement/dilatation up to 4cm
Established: Regular painful contractions + progressive cervical dilatation from 4cm
2nd Stage; Full dilatation to explusion of fetus
Latent: Cervix fully dilatated, but presenting part hasn’t reached outlet yet so no urge to push
Active phase: as fetus descends, pressure from presenting part stimulates the nerve receptors in the pelvic floor (Ferguson reflex), producing the urge to push
3rd stage: From delivery of baby to complete explusion of placenta
First labour length
Primip : 8 (Avg) - 18
Multip: 5 (avg) - 12
Partogram?
Single document available in labour that should have all information about labour
eg. Fetal condition (HR, Liquour) Cervical dilation Descent of head Uterine contractions Maternal condition (T, P, R, BP, Urinalysis)
DRAW: Alert line shows 1cm/dilation an hour. 4 hrs to the right of that is action line. If it hits this, you have to do something to promote labour progression
ONLY start using when in active labour (>4cm)
5 presumptive signs of second stage?
Transitional behaviour (irrational/erratic) SROM SHow Unctrolled urge to push DIlatation and gaping of anus OFten bowels open with pushing Appearnce of the rhomboid michaelis Women with an epidural may have upper abdominal pressure Perineum bulges and vagina gapes Presenting part becomes visible at vulva
2nd stage length:
nulliparous - birth within 3hrs of start of active 2nd stage
Parous: within 2 hrs of start of active 2nd stage
What are the 3 signs of separation of the placenta?
1) Cord lengthening
2) Fresh PV bleeding
3) Fundus rises up and becomes more globular (on palpation feels like a rugby ball)
Oxytocic drugs?
NICE recommend syntocinon 10U given IM for active management of the 3rd stage of labour (not syntometrine as ergometrine induces a strong sustained non-physiological spasm which can last 2-4hrs)
Length of 3rd stage?
Prolonged if not completed within 30 mins of birth in active mx or 60 mx in passive mx
Diagnosis of delay in establshed first stage?
Shoulder presentation?
Not compatible with vaginal birth, would have to be delivered by C section
PPH Mx?
S O A P S
Severe sepsis : New definition?
Life-threatening organ dysfunction caused by a dysregulated host response to infection
Suspected infection + organ dysfunction
qSOFA score of 2 points or more:
- Resp rate > 22
- Systolic BP 100 or less
- Alternation of mental state (from baseline)
Septic shock
A subset of sepsis:
- Profound disturbances of circulatory, cellular and metabolic function
- Greater mortality than sepsis alone
- Hospital mortality over 40%
Clinical findings in the presence of adequete volume resuscitation:
- Serum Lactate > 2mmol/L
- Requiring vasopressors to maintain BP
Puerperal sepsis?
Infection of the genital tract at any time from ROM or labour to 6 weeks postpartum
Fever + 1+ features:
- Pelvic pain
- Abnormal vaginal D/C
- Abnormal odour of discharge
- Delay in involution of uterus
Routine blood tests in pregnancy
booking: Blood group + Abds, FBC, Sickle / Thalassaemia screen, HBV, HIV, syphilis, rubella immunity
28 wks: FBC, G&S, Glucose (GCT/GTT)
34 weeks: FBC, Group and antibody screen
GTT indications
BMI > 30 Previous macrosomic baby (4.5kg or more) Previous GDM FH (1st degree relative) Ethnics Any stage in pregnancy if fetal abdomen or liquour volume > 95th centile
Or if there in an abnormal screening test.
GDM diagnosed if:
- Fasting plasma >5.6
- 2 hour GTT > 7.8
Pre-labour rupture of membranes?
Preterm - oral erythromycin 10/7 , steroids, monitor for infection, deliver at 34 wks
Term - IVAB (benpen/clindamycin in pen allergic) from 18-24 hrs PROM until delivery, do something to get labour started by 24 hrs
IF signs of chorioamnioitis, expedite delivery by the safest method for both mother and baby, depending on gestation
When are GBS swabs indicated?
No routine swabs in UK
Swabs indicated if:
- PROM (
Antibiotics in pregnancy
Pens/cephs are drugs of choice in pregnancy and breastfeeding
Clindamycin if pen allergic
Avoid quinolones, tetracyclines aminoglycosides unless severe
Avoid trimethoprim in 1st trimester: folate antagonist
Avoid nitrofurantoin at term: risk of neonatal haemolysis
Co-amoxiclav - Link with NEC in preterm, therefore avoid
NSAIDs
pregnancy : Aspirin 75mg okay, everything else not
Breastfeeding: aspirin not okay (Reye’s), ibuprofen Okay
CTG: Further mx?
Normal: Continue monitoring (if appropriate indication)
Suspicious:
- Inform obstetric staff/senior midwife
- Assess the woman
- Consider position, hydration
- Check not hyperstimulating (contraction every min)
- Treat maternal pyrexia if present
- Reassess in 30 mins
Pathological:
- Urgent obstetric review
- Examine the woman - is sje progressing? Is she fully dilated and deliverable in the room?
- Acute fetal compromise? Deliver without delay (eg. bradycardia not recovering)
- Not acute compromise? FBS now or delivery within 30 mins
FBS interpretation
Abnomral: FBS 7.25
