O&G Flashcards
What are the two types of multiple pregnancies, which is most common and explain how each occurs
- Monozygotic (Genetically Identical)
- Result of division of the fertilized oocyte into two embryonic layers
- 1/3 of all twins
- Dizygotic (Genetically Different)
- Result of fertilization of two oocytes with two spermatozoa
- 2/3rds of twins
What are the different ways in which the amniotic sac and placenta can be arranged in multiple pregnancies?
For Dizygotic Pregnancies
- Always Dichorionic-Diamniotic (DCDA)
For Monozygotic Pregnancies:
- Dichorionic-Diamniotic (DCDA) (20-30%) - each twin has own individual placenta and amniotic sac. Embryo seperates before 4 days.
- Monochorionic-Diamniotic (70%). Embryo seperates between 4-8 days
- Monochorionic-Monoamniotic (1-5%). Embryo seperates between 8-12 days.
- Monochorionic-Monoamniotic (Conjoined). Embryo seperates >12 days
Complications of multiple pregnancies to the fetus
Fetal
- Spontaneous Reduction or Vanishing Twin Syndrome
- Twin-Twin transfusion Syndrome
Occurs in Monochorionic Twin Pregnancies (Monozygotic). Blood flowing in a fixed direction from from one twin results in the transfer of blood from the donor twin to the recipient twin. Risk to both fetuses:
i) Recipient Twin –> Polycythemia, polyhydramnios in diamniotic pregnancies
ii) Donor Twin –> anaemia, dehydration, growth retardation, oligohydramnios in diamniotic pregnanies - Growth Restrictions
- Congenital Abnormalities
Complications of multiple pregnancies for the mother
- hyperemesis gravidarum
- gestational diabetes
- gestational hypertension, pre-eclampsia, eclampsia
- pervical incompitence, premature birth, preterm labour, PROM
- placenta previa
- miscarriage or loss of one fetus in first trimester
- birth complications - placental abruption, prolonged first stage of labour
- Uterine atony and PPH
Describe the anatomy of the cervix, including Endocervix, ectocervix, transformation zone and cercival ectropion
- Cervical canal communicates with the corpus by the internal os and the vagina by the external os
- Ectocervix – exposed to vagina (stratified squamous epithelium)
- Endocervix – within cervical canal between external and internal cervical os (Columnar epithelium)
- Squamocolumnar junction – meeting point of ecto and endocervical mucosa
- Transformation zone – area of squamous metaplasia between originally squamous and originally columnar epithelium, the area at most risk of cervical neoplasia
- Cervical ectropion – is when columnar epithelial cells are exposed to the vagina
What are the four degrees of perineum laceration during childbirth
- First degree laceration – involves the perineal skin or vaginal mucosa
- Second degree laceration – includes muscles of perineal body, including superficial transverse perineal, bulbovcavernosus and ischiocavernosus. If the laceration is deep it may also include the levator ani muscles (pubococcygeus and ileococcygeus.
- Third degree lacerations – in addition to the muscles of the perineum, will also involve disruption of the anal sphincter. There are three degrees
- Less than 50% of external sphincter thickness torn
- More than 50% of external sphincter thickness torn
- Internal anal sphincter torn
- Fourth degree laceration – extends into the anal epithelium
What is Endometriosis, endometrioma, chocolate cyst and adenomyosis
Endometriosis – the lining of the uterus (endometrium) developing outside the uterus
Endometrioma – area of endometriosis large enough to be considered a lump
Chocolate cyst – entometrioma filled with old blood, usually an ovarian cyst
Adenomyosis – presence of endometrial tissue in the uterine muscle
Symptoms of Endometriosis
Up to 1/3 of patients are asymptomatic
- Chronic pelvic pain that worsens before the onset of menses
- Dysmenorrhoea
- Pre- or post-menstrual bleeding – premenstrual spotting, heavy periods, mid cycle bleeding
- Dyspareunia – pain during or after sex
- Infertility/ subfertility
- Dyschezia – difficult or painful defecation (usually due to hard stools or constipation)
- Urinary symptoms – blood, dysuria, Bowel symptoms – pain opening bowels
- Tiredness
*Intensity of symptoms does not correlate with severity or amount of endometriosis
Examination findings for endometriosis
- Rectovaginal tenderness
- Adnexal masses
- Fixed retroflexed uterus
- Immobility of the pelvis
Investigations for endometriosis
- Transvaginal U/S - make pick up ovarian cysts, not too likely to pick up endometriosis
- Laparoscopy - Gold Standard
Treatment for endometriosis
Medical therapy
- Analgesia - NSAIDs, paracetamol, tramadol
- Induce no periods - COCP, Mirena, Depot Provera, GnRH agonist
Surgical
- Laparoscopic excision and ablation
- Hysterectomy +/- bilateral salpingo-oopherectomy
Definitions of premenopause, menopause and postmenopause
- Premenopause – period from first occurrence of climacteric irregular menstruation cycles to the last menstrual period. Characterized by increasingly infrequent menstruation
- Menopause – time at which menstruation ceases permanently. Confirmed after 12 months of amenorrhoea. Average age at menopause is 49-52 years.
- Postmenopause – the time period beginning 12 months after LMP
Treatment options for menopause
Lifestyle
- Atrophic vaginal symptoms –> Vaginal oestrogen cream (vagifem)
- Impaired sleep –> exercise, relaxation, treating hot flushes
- Preventing osteoporosis –> vitamine D, exercise, stop smoking
Hormone Replacement Therapy
- Oestrogen therapy –> for women who have a hysterectomy
- Oestrogen plus progesteron –> for women with uterus (unopposed oestrogen could lead to endometiral cancer)
Can give transdermally, or oral.
Can give sequentially (If still having irregular periods/ first year of menopause - have bleeding) OR Continuous
If still having any periods, even if irregular, consider adding a mirena for contraception
Risks of HRT –> DVT/ PE, breast cancer, endometrial cancer
Advantages of HRT –> CVD benefit?, increase bone mineral density
Non-hormonal
- Selective oestrogen receptor modulator - tamoxifen (treats dyspareunia), Raloxifene (osteoporosis)
- For hot flushes and mood - venlafaxine
- For hot flushes and slightly high BP - clonidine
- For hot flushes - gabapentin
Symptoms of menopause
- Irregular menses –> complete amenorrhoea
- Autonomic symptoms
- Increased sweating, hot flushes, heat intolerance
- Vertigo
- Headache
- Mental symptoms
- Impaired sleep (insomnia and/or night sweats)
- Depressed mood or mood swings
- Anxiety/ irritability
- Loss of libido
- Atrophic features
- Breast tenderness and reduced breast size
- Vulvovaginal atrophy
- Atrophy of vulva, cervix, vagina
- May present with features that mimic a uti
Causes of preterm labour
Maternal factors
- Infection and Inflammation - UTI, BV, Systemic Infections (malaria, listeria)
- Cervical Trauma such a iatrogenic dilation or previous cervical intra-epithelial neoplasm
- Short cervical legnth
- Uterine anomalies - fibroids
- Placental abruption, Placenta previa
- Medical conditions - pre-eclampsia, diabetes
- premature rupture of membranes
Fetal factors
- multiple pregnancies
- fetal abnormalities and polyhydramnios
What is the difference between labour and threatened premature labour
Labour is diagnosed by regular cervical contractions resulting in cervical change or dilation. However, once these changes have occurred the opportunity to intervene is limited. Management may therefore be investigated before confirmation of labour. Threatened premature labour refers to those women who present with preterm uterine contractions but without cervical effacement or dilation.
Differences between Braxton Hicks Contractions and Labour Contractions
Braxton Hicks Contractions
- Usually last 30 seconds
- Can be uncomfortable but usually aren’t painful
- Come are irregular times
- Usually occur no more than once or twice an hour (until late in pregnancy)
- Usually stop if you change position or activity
Might start to feel them at 16 weeks. These contractions help prepare uterus for birth.
Labour contractions
- Get closer together
- Last longer as time goes by
- Get stronger or come more often when you walk
- Get stronger over time
Investigations for possible Preterm Labour
- Cardiotocogram
* Detection of fetal heartbeat - Tocography
* Frequency of contractions - Transvaginal U/S of cervix
* Indicates likelihood of imminent delivery, as cervical length under 2cm are associated with much higher risk of delivery - Cervico-vaginal swab for fetal fibronectin
* 20% of those with positive fibronectin test deliver within 1 week, compared with only 1% with a negative test - FBC
* Threatened preterm labour should have FBC to look for elevated WBC indicative of infection and check haemoglobin levels in cases of suspected antepartum haemorrhage - CRP
* Infection screen - Urine dipstick
* Proteinuria in pre-eclampsia, leukocytes and nitrites in infection - High vaginal/ rectal swab
* Test for group B streptococcus
Diagnosis of premature labour involves establishing the likelihood of delivery, determining fetal well-being with a non-stress cardiotocogram (CTG), and looking for an underlying cause such as placental abruption or infection. One third of women who deliver preterm will present with preterm premature rupture of membranes (PPROM). Making a diagnosis of labour on a single examination is unreliable. However, frequent uterine contraction, a positive fetal fibronectin test, cervical dilation to >3 cm, and ruptured membranes all increase the likelihood that labour has started.
Management for a women with with high risk of imminent delivery without PPROM (Labour Contractions, with cervical changes)
- Maternal evaluation and assessment of fetal viability
- Corticosteroid
- 11.4g betamethasone IM repeated after 24 hours – halves the rate of respiratory distress syndrome and death. Given from 23+ to 34 weeks. Repeated courses highly controversial and may affect brain development.
- Transfer to neonatal unit
- Intravenous antibiotics
- Benzylpenicillin sodium: 3g IV initially, followed by 1.5g every 4 hours
- Clindamycin: 900mg IV every 8 hours
- Used as GBS prophylaxis
- Tocolytic agent
- Nifedipine 30mg orally, followed by 10-20mg every 4-6 hours
- Tocolytic agents do not prevent preterm birth, but may delay birth for 48 hours to enable transfer to a tertiary centre and give corticosteroids for lung maturation
How do you Diagnose PPROM
- Sterile speculum examination
- Positive pool - amniotic fluid exiting the cervix and pooling in the vaginal fornix
- Detection of amniotic fluid
- Litmus test – turns blue
- Positive fern test
- Positive IGF1 (present in amniotic fluid)
- U/S – oligohydramnios
Management of PPROM
Stable patients
- < 23 weeks
Expect management
Bed rest, antenatal corticosteroids (to avoid fetal lung hypoplasia or immaturity), antibiotic prophylaxis (GBS) and planned delivery > 34 weeks
Outcome is usually poor and termination may be considered - 23-33 weeks
Same as above
+ Tocolysis may be used to delay delivery up to 48 hours (Contraindicated in advanced labour), chorioamniotis, nonreassuring fetal signs, abrupto placentae, risk of cord prolapse - > 34 weeks
Delivery of fetus is usually recommended
risk of prematurity are diminished compared to the risk of infection
Unstable
- Prompt delivery of fetus
- Due to - abruptio placentae, cord prolapse, chorioamniotis, nonreasuring heart rate
The 7 Things used to prevent preterm delivery
- Measurement of the length of the cervix at all mid-pregnancy scans
- Natural vaginal progesterone 200mg each evening if cervix < 25mm
- If cervix < 10mm, consider cerclage or progesterone
- Vaginal progesterone if prior history of spontaneous preterm birth
- No pregnancy to be ended until at least 39 weeks unless there is obstetric or medical justification
- Women who smoke should be identifies and offered quit line support
- A new preterm birth prevention clinic
Causes of Malpresentation and malposition
Uterus
- Uterine abnormalities e.g. fibroids
- Laxity of muscular layer in the walls of the uterus
- Abnormally increased or decreased amniotic fluid
- plecenta previa
- multiple pregnancy
Outside Uterus
- Abnormal shape pelvis
- Masses e.g. ovarian cysts, tumours
Previous Breech Delivery
Hydrocephaly
Consequences of Malpresentation
- PROM and premature labour
- Uncoordinate, pain ful contractions
- Prolonged and obstructed labour –> Ruptured uterus
- PPH
- fetal and maternal distress
- Cord prolapse
- Placental Abruption
- Birthing Injury
Causes of obstructed labour
Fetal
- Malpresentation
- malposition
- Macrosomia
- Congneital anomalies
Maternal
- Bony or soft tissue masses in maternal pelvis
- small pelvis
Clinical features of obstructed labour
Maternal
- Oedematous vulva
- High temperature
- Frequent uterine contractions
Fetus
- high presenting part, not engaged; ruptured membranes
- moulding (extent of overlap of the foetal skull bones; excessive during obstructed labour)
- Caput succedaneum - scalp swelling
Risk factors for breast cancer
- Gender, Age
- Previous Breast carcinoma and other benign proliferative breast disease
- Family Hx
- Radiation
- Dense Breasts
- Oestrogen exposure
- Early menarche, late menopause
- Nulliparity, did not breastfeed
- HRT, COCP
- obesity
Which Breast Lesions have no increased risk have no risk for breast cancer
- Inflammatory conditions
- fibrocystic change
- fibroadenoma
- PASH (Pseudoangiomatous stromal hyperplasia)
- Sclerosing Adenosis
Which proliferative breast conditions increase the risk of breast cancer
- Epithelial hyperplasia
- Columnar cell change
- Complex Sclerosing Lesion/ radial scar
- Intraductal papilloma
Note: the magnitude of risk is related to degree of histological atypia
Explain the screening for breast cancer in Australia
- Target group 50-74yo women
- involves 2 yearly mammograms
If 2000 women are offered mammography over 10 years
- 1 woman would have her life prolonged
- 10 women would be treated unnecessarily (biopsy)
- 200 women would undergo psychological distress of additional testing (false positive)
What is the triple assessment of a breast lump
- Medical History and Clinical Breast Examination
- Imaging
> 35 –> Mammogram +/- U/S
<35 –> U/S - FNA biopsy or core biopsy
What are the two types of breast carcinoma in situ (Pre-malignant)
- Ductal CIS
BC cells confined to ductal space. Management is surgical Excision with clear margins +/- radiotherapy. - Lobular CIS
BC cells confined within lobular space. RISK OF SUBSEQUENT BC IS BILATERAL. Management involves surgical excision + INCREASED SURVEILLANCE, consider anti-oestrogen medication.
Clinical features of invasive breast cancer
- Discrete mass/ lumpiness
- Pain
- Nipple changes (inversion)/ discharge
- Skin changes (tethering, peau d-orange, ulceration etc.)
Biomarkers for breast cancer
Hormone receptor status (Oestrogen and Progesteroen Receptors)
- 80% of BC are ER +ve
- 65% of BC are PR +ve
- ER+/PR+ have 80% response rate, compared to 10% for ER-/PR-
- Assessed by immunohistochemistry
HER2
- Assessed by immunohistochemistry or silver in situ hybridisation
- Prognostically HER2 + BC has poorer survival than HER2 -ve BC
Treatments for breast cancer
- Surgical excision with clear margins – mastectomy or wide local excision (WLE)
- +/- axillary surgery – SLN biopsy, with axillary clearance if SLN positive
- +/- radiotherapy
- to the chest wall – if WLE, locally advanced disease or positive margins on mastecotomy
- to the axilla or supraclavicular nodes – if nodal burden > 4
- +/- chemotherapy – if high risk clinopathological features
Adjuct therapy
- Selective Estrogen Receptor Modulators (SERMs) for ER+ve BC
- Compounds that exhibit tissue-specific ER agonists or antagonist activity: molecularly diverse, non-steroidal (except fulvestrant), varying effects in different tissue but often anti-oestrogenic effect on breast epithelium, oestrogenic effect on bone
- Tamofixen – antagonistic effect on E2
- Used in prevention and treating ER+ve BC in premenopausal women
1. Aromatase Inhibitors (Anastrozole, letrozole, exemastane) For ER+ve BC - Blocks conversion of androgen to oestrogen
- Used to treate ER positive invasice BC
- Post-menopausal women (contraindicated in premenopausal women)
- Survival benefit > tamoxifen
- Side effects include:
- Hot flushes
- Arthralgia
- Accelerated OP
- But no increase in DVT or EC
- Herceptin (Trastusumab) for HER2 +ve BC
A monoclonal antibody that fits the shape of the HER2 binding site to prevent gorwth factor molecules from binding and causing unwanted cell growth
Treatment for Mastitis
- Frequent breast feeding with both breasts (every 2-3 hours)
- Analgesia (ibuprofen)
- Cold compresses
- Antibiotics (Pathogen usually Staphylococcus aureus) –> flucloxacillin or dicloxacillin
May need drainage of abscess if no response to initial treatment
Primary Dysmenorrhoea Treatment
Primary dysmenorrhoea is a diagnosis of exclusion, must rule out secondary causes.
Treatment
- NSAIDs, topical application of heat
- hormonal contraceptives (COCP, IUD)
Secondary dysmenorrhoea causes
- Endometriosis
- PID
- Intrauterine device
- Uterine leiomyoma
- Adenomyosis
- Psychological
Causes of primary amenorrhoea
- Patients with normal puberty
- Anatomic anomalies: hymenal atresia, vaginal septum, Mayer-Rokitansky-Kuster-Hauser syndrome
- Competitive athlete
- Patients with growth delay and developmental retardation
* Hypogonadism
- Hypergonadotropic hypogonadism (primary hypogonadism)
Insufficiency sex steroid production in the gonads - Primary gonadal insufficiency – Turner syndrome, androgen insensitivity syndrome, anorchia
- Secondary gonadal insufficiency – chemotherapy, pelvic irradiation, trauma/ surgery, autoimmune disease, infections (mumps, TB)
- Hypogonadotropic hypogonadism
Insufficient GnRH from HPA axis - Genetic – Kallmann syndrome, Prader-Willi syndrome
- Hypothalamic/ pituitary lesion – tumour, trauma, surgery, infection
- Easting disorders
- Patients with virilisation (male secondary characteristics)
- Congenital adrenal hyperplasia
- Polycystic ovary syndrome
Causes of Secondary amenorrhoea
- Pregnancy - most common cause of secondary amenorrhoea
- Ovarian disorders (e.g. polycystic ovary syndrome)
- Hypogonadism
- Hypergonadotropic hypogonadism
- Hypogonatotropic hypogonadism e.g. functional hypothalamic amenorrhoea
- Excessive exercise, reduced calorie intake, stess
- Treat with lifestyle changes e.g. improve nutrition, increase BMI or offer pulsatile GnRH therapy
iv. Hypothyroidism (Decrease T3/4, Increase TRH à increase prolastin - decrease GnRH - decrease oestrogens)
PMS (Premenstrual Syndrome) Clinical featues
- Onset of symptoms 5 days before menstruation; symptoms end within 4 days of start of menstruation
- Pain - dyspareunia, breast tenderness, headache, back pain, abdominal pain
- GI - Nausea, diarrhoea, changes in appetite
- Tendency to oedema formation
- Neurological - migraine, increased sensitivity to stimuli
- Psychiatric - mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness
*Premenstrual dysphoric disorder (PMDD) - severe form of affective symptoms that interferes with daily life, including abnormal disagreements with family and friends
Treatment of PMS
- Lifestyle changes e.g. exercise, healthy diet, avoiding triggers like alcohol and smoking
- NSAIDs
- Oral Contraceptive
- If PMDD à SSRIs (Fluoxetine)
What is gravidity and parity?
Gravidity - the number of times a woman has been pregnant
Parity - number of times a women has given birth
Common clinical symptoms of pregnancy
- Amenorrhoea
- Nausea and vomiting
- Breast enlargement and tenderness
- Hyperpigmentation or the areola and formation of linea nigra
- Increased urinary frequency
- Fatigue
- Cravings or aversions for certain foods
- Abdominal bloating and constipation
Confirmatory tests for pregnancy
- Pregnancy test
- Urine beta-hCG (home pregnancy test) - beta-hCG may be detected in urine 14 days after fertilization
- Serum beta-hCG (higher sensitivity) - detectable 6-9 days after fertilization. Beta-hCG doubles every 2.5 days in early pregnancy, peaks at 10 weeks gestation and then declines
- Low value may indicate ectopic pregnancy or abortion, high value may indicated beta-hCG secreting tumour or twins
- U/S (abdominal or transvaginal)
- At 5-6 weeks - detection of embryo
- 10-12 weeks - detection of fetal heart beat with Doppler U/S
- 18-20 weeks - fetal movements
What are the 5 ways you can determine gestational age and date of delivery?
- Gestational age à the age (in weeks and days) of the fetus calculated from the first day of the last menstrual period
- Embryonic age à the age of the fetus calculated from the day of conception (fertilization)
- Naegele’s rule à used to calculate the delivery date
- First day of the last menstrual period + 7days + 1 year – 3 months
- Inaccurate if:
- The date of the last menstrual period is uncertain or unknown
- The patient has irregular menstrual cycles
- The patient conceived while taking contraceptive pills
- Ultrasound à more accurate than Naegele’s rule
- Measurement of the crown-rump length in the first trimester
- Measurement of biparietal diameter, femur length, and abdominal circumference (starting at 14 weeks)
- Fundal height during pregnancy à correlated with gestational age
What physiological changes take place in pregnancy?
- Cardiovascular - progesterone decreases peripheral vascular resistance –> Increases CO, SV, CO
- Resp - Increase oxygen consumption, diaphragm displaced up so decreased TLC, RV
- Renal - Increased GFR so decreased creatinine, increase glucose in urine
- Endocrine - increase insulin, triglycerides and cholesterol
- Haem - haematocrit decreases (dilutional anaemia), increase RBC, platelets and WBC
- GI - constipation, increase salivation
- Skin - hyperpigmentation, striae gravidarum, palmar erythema, spider angioma
Investigations for Nausea and vomiting; hyperemesis gravidarum
Occurs in 90% of pregnancies, onset at 5-6 weeks gestation, peaking at 9 weeks, usually abating by 16-20 weeks. Caused by surge in b-hCG
Clinical diagnosis
- Urinalysis – look for ketonuria or signs of infection
- Blood glucose
- Blood tests: FBC, UEC’s, LFTs, TFTs
- U/S scan – arrange if this has not already been performed to exclude molar pregnancies which precipitate hyperemesis
- In sever vomiting or electrolyte abnormality:
- Serum magnesium, phosphate and calcium
- Bicarbonate level
- Blood gases if required
*Women with diabetes should be monitored carefully as dehydration increases risk of diabetic ketoacidosis
Treatment for Nausea and vomiting; Hyperemesis gravidarum
- Diet and lifestyle changes
- Stay hydrated and try have small meals regularly
- Avoid fatty and spicy foods
- Referral to dietitian if severe
- IV Fluid therapy
- 0.9% sodium chloride 1000mL
- IV multivitamins if needed
- First line pharmacotherapy
- Ginger – 250mg orally four times per day to reduce nausea
- Pyridoxine (Vitamin B6) - 25mg OD at night to reduce nausea
- Doxylamine 25mg OD night (start with 12.5mg) – Sedating antihistamine
- Second line pharmacotherapy
If nausea and vomiting persists then a second sedating antihistamine should be added. H1 antagonists safe in pregnancy - Promethazine (H1 antagonist and weak dopamine agonist effect) 10-25mg tabled TD
- Third line therapy
- Metoclopramide 5-10mg orally TD (dopamine agonist)
- Prochloroperazine (sedating antihistamine for short term use only) 5-10mg TD
- Fourth line therapy
- Odansetron (5HT3 antagonist) 4-8mg tablet orally (max 16mg in 24 hours)
- Fifth line
If all else fails… - Hydrocortisone 100mg IV BD or prednisolone 50mg orally faily for 3 days with ranitidine 300mg
Causes of oligohydramnios
Definition: amount of amniotic fluid < 500mL in the third trimester
Aetiology:
- Fetal anomalies
- Urethral obstruction
- Bilateral renal agenesis
- Autosomal recessive polycystic kidney disease
- Chromosomal aberrations e.g. trisomy 18
- Intrauterine infections e.g. TORCH
- Maternal conditions
- Late or post-term pregnancies (>42 weeks)
- Placental insufficiency
- Preeclampsia
- Premature rupture of membranes
Treatment
- Amnioinfusion: infusion of fluid into the amniotic cavity through amniocentesis
- Treat underlying cause
- Delivery is advised if fetus is close to term
What is the definition of labour
Labour is the process by which regular, painful contractions bring about effacement and dilation of the cervix and descent of the presenting part ultimately leading to expulsion of the foetus and the placenta from the mother.
- Cervical effacement refers to the gradual inclusion of the cervix into the lower uterine segment. The muscle fibres surrounding the internal os are drawn upwards and the cervix merges into the lower segment.
- Cervical dilatation is the opening of the cervix from closed to full dilatation. Cervical dilatation is measured in cm from 1-10cm
Causes of polyhydramnios
Definition: excessive amniotic fluid (>2000mL in the third trimester) that results in uterine distention and is associated with an increased risk of fetal complications
Aetiology:
- Fetal anomalies
- Gastrointestinal anomalies (Tracheo-oesophageal fistula, oesophageal atresia, duodenal atresia and stenosis)
- CNS anomalies e.g. anencephaly, meningomyelocele
- Chromosomal aberrations
- Intrauterine infections e.g. TORCH
- Maternal conditions
- Diabetes mellitus
- Rhesus incompatibility
Treatment
- Amnioreduction – drain excess amniotic fluid
- Treat underlying cause
What are the three stages of labour and their duration
-
First Stage
* Time of onset of labour - full dilatation of the cervix (10cm) -
Latent Labour – is the time between the onset of labour to 4cm dilatation
* No time frame -
Active labour – describes the time from 4cm to 10cm dilatation (full dilatation).
* 1cm/hour
* Average duration – 12-14hours in a nullipara and 8 hours in a multipara (6 hours active) - Second Stage
- Full dilatation of the cervix until expulsion of the foetus from the birth canal (delivery of the baby)
- Average duration – 1-2 hours in nulliparae and < 1 hour in multipara
- Third Stage
- Begins after the delivery of the foetus and ends expulsion of the placenta and membranes
- Average duration – no more than 50 minutes, often 5 minutes depending on management employed
What hormonal changes occur to induce labour
Glucocorticoids produced by foetus
- –> Decreases progesterone –> Increase uterine stretching
- –> Increases oestrogen –> increasing uterine contractions, softening the cervix and increased uterine sensitivity to oxytocin
What are the three P’s of labour
- Pelvis - size and shape of maternal pelvis
- Passanger - size and position of infant
- Lie - long axis of fetus to long axis of mother
- Presentation - cephalic or breech
- Attitude of head - should be flexed
- Station - relationship of bony presenting part to maternal ischial spines (if passed ischial spines by 2 cms –> +2)
- Power - stregnth and frequency of contractions
Management in the 3 stages of labour
First stage
- Analgesia as requested
- Epidural, heat backs, hypnotherapy. nitrous oxide and oxygen administration
- Fetal heart rate monitoring
- Determine fetal position with abdominal and pelvic examination
- Regular assessment of cervical dilation and descent of the fetal head
- Amniotomy may be performed during the active phase if the fetal head is well applied
Second stage
- Warm compresses and perineal massage
- Assist the mother to find any comfortable and safe position
- Episiotomy
- Usually a midline incision of the perineum to enlarge the vaginal opening during delivery
- Indications - shoulder dystocia, forceps or vacuum-assisted delivery, or vaginal breech delivery
- Delay cord clamping for 1 minute
Third stage
- Oxytocin – administered after cutting the umbilical cord (reduces blood loss by inducing stronger uterine contractions)
- Controlled traction while allowing the placenta to separate spontaneously (Brandt-Andrews manouvre)
- Examine the placenta to confirm completeness (regular surface with complete cotyledons), which should consist of the umbilical, complete amniotic membranes, and 3 blood vessels (one vein, two arteries)
8 Stages of delivery - the cardinal movements
- Before engagement
- Engagement, flexion, descent
- Further descent, internal rotation
- Complete rotation, beginning extension
- Complete extension
- Restitution/ external rotation
- Delivery of anterior shoulder
- Delivery of posterior shoulder
Indications for induction of labour
- Post-term pregnancy (>= 42 weeks)
- Preterm premature rupture of membranes after 34 weeks
- Repature rupture of membranes at term
- Hypertension during prengnancy, pre-eclampsia, eclampsia, HELLP syndrome
- Maternal diabetes to avoid post-term pregnancy
- Maternat request at term
- Intrauterine death
- Reduced fetal movements, changes in heart rate, not growing well
- Multiple pregnancies
What is a bishop score and what is its use
- Used to assess the cervix and the likelihood of a successful induction
- Interpretation
- Bishop score >= 8 - favourable cervix for vaginal delivery
- Bishop score <= 6 - unripe or unfavourable cervix; not ready for vaginal delivery
Approach to inducing labour
- Artificial rupture of membranes (shortens time to onset of labour)
* Amniotomy hook - If the cervix is still unfavourable: cervical ripening with prostaglandin E1 or E2 (e.g. misoprostol)
- Cervidil (Dinoprostone PGE2 10mg) continuous release vaginal pessary
- Foleys Catheter (balloon catheter)
- Prostin (PGE2) vaginal gel
- Membrane sweeping (stretch and sweep) - best used in multipara. Examining finger passes through cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. Placenta previa is absolute contraindication, not recommended if GBS carriage.
- Maternal oxytocin infusion (syntocinin)
* Exogenous oxytocin can be used to induce labor, strengthen uterine contractions during labor, contract uterine muscle after delivery of the placenta, and control postpartum hemorrhage. - Consider amniotomy (only if cervix is partially dilated and completely affaced, and the fetal head is well applied)
- Administer under fetal heart rate monitoring
What are two options for assisted delivery
- Obstetric forceps delivery
- A forcep is a metal device that enables gentle rotation and/ or traction of the fetal head during vaginal delivery
- Instrument of choice when: can effect more rapid delivery, can be used in malpresentations, can be used for rotation
- Vacuum extractor
- A vacuum extractor is a metal or plastic cup, attached to the fetal head with a suction device, that enables traction of the fetal head during vaginal delivery
- Instrument of choice: easier to apply, follows pelvic curve automatically, less force applied to fetal head, fewer cervical and vaginal lacerations
Indications for assisted delivery
Maternal
- Maternal exhaustion
- Drug-induced analgesia
- Soft tissue resistance with failure to descend
- Maternal illness – haemorrhage
Materno-fetal indications
- Relative cephalopelvic disproportion
- Melposition – e.g. occiput posterior
- Malpresentation – e.g. presentation
- Non-reassuring FHR tracing
Complications of vaccum and forceps delivery
Vacuum
- Scalp emphysema
- Caput formation, cephalohaematoma
- Hyperbilirubinaemia
- Subgleal haematoma
Forceps
- Fractured clavicle
- Caphalohaematoma
- Lacerations – abrasions
- Facial nerve palsy
- Forceps marks normal and benign
What complications can occur with the umbilical cord in labour
-
Umbilical cord compression
* Part of the umbilical cord lies between the antecendent part of the fetus and the pelvic wall; the amniotic sac is intact -
Umbilical cord prolapse
* Acute, life-threatening emergency for the fetus, in which a part of the umbilical cord lies between the antecendent part of the fetus and the pelvic wall, causing rupture of membranes
iii. Knotting of umbilical cord
What perineal injuries can be sustained in labour
- First degree - cutaneous and subcutaneous skin tear
- Second degree –> + perineal muscles
- Third degree –> + involvement of external anal sphincter
- fourth degree –> + anterior wall of anal canal
Indications of C/S
What are the hypertensive disorders that can occur in pregnancy?
Gestational hypertension: pregnancy-induced hypertension with onset after 20 weeks’ gestations. Defined as a SBP >= 140mmHg or DBP >=90 on 2 separate measurements at least 4 hours apart
Chronic hypertension: Diagnosed < 20 weeks’ gestation or before pregnancy
Pre-eclampsia: Gestational hypertension with proteinuria, renal insufficiency, thrombocytopenia, evidence of liver damage (e.g. elevated liver enzymes, epigastric pain), pulmonary oedema, and/ or cerebral oedema (headache, visual blurring, vomiting, an altered mental status)
- Superimposed pre-eclampsia: pre-eclampsia that occurs in a patient with chronic hypertension
- HELLP syndrome: a life-threatening form of pre-eclampsia
- (H = haemolysis, EL = elevated liver enzymes, LP = low platelets)
Eclampsia: Severe form of pre-eclampsia with convulsive seizures and/ or coma
Risk factors for developing pre-eclampsia
Moderate risk
- Age 40 years or more
- First pregnancy
- Multiple pregnancy
- Interval since last pregnancy of more than 10 years
- BMI > 35
- Family history of pre-eclampsia
High risk
- Chronic hypertension
- Chronic kidney disease
- Hypertensive disease during a previous pregnancy
- Diabetes
- Autoimmune disease
Clinical features of pre-eclampsia
90% occur after 34 weeks’ gestation
- Without severe features
- Usually asymptomatic
- Non-specific symptoms – headaches, visual disturbances, RUQ/ epigastric pain, rapid development of oedema
- Hypertension
- Proteinuria
- With severe symptoms
- Severe hypertension (Systolic >=160mmHg or Diastolic >=110mmHg)
- Proteinuria, oliguria
- Headache
- Visual disturbances (e.g. blurred vision, scotoma)
- RUQ or epigastric pain
- Cerebral symptoms (altered mental state, nausea, vomiting, hyperreflexia, clonus)
Clinical features of Eclampsia
- Onset - the majority of cases occur in the intrapartum and postpartum period
- Most often associated with severe preeclampsia (but can be associated with mild preeclampsia)
- Eclampsia seizure - generalized tonic-clonic seizure
Investigations for a women presenting with hypertenion after 20 weeks gestation
Maternal Investigations
- Assess for signs and symptoms of pre-eclampsia - sever hypertension, headache, epigastric pain, oliguria, N+V, oedema
- FBC
- UEC
- LFTs
- Urinalysis - proteinuria
- IF evidence of thrombocytopenia or falling haemoglobin
- Peripheral smear (haemolysis)
- Coagulation studies (HELLP syndrome)
Fetal investigaitons
- U/S + AFI
- Doppler U/S
- CTG
Management of Hypertension in Pregnancy
Gestational hypertension and pre-eclampsia without severe symptoms
- Delivery if > 37 weeks
- Maternal monitoring (1-2x week BP, urine dipstick, blood tests)
- Fetal monitoring (U/S 3 weekly)
- Educate patients about symptoms (vaginal bleeding, RFM)
- Antihypertensives
- Labetalol 20-80mg
- Hydralazine 5-10mg
- Nifedipine 10mg
Severe Pre-eclampsia
- Delivery if > 34 weeks
- If before 34 weeks need to stabilise and give corticosteroids
- Oral Antihypertensives - Labetalol, Hydralazine, Nifedipine
- Magnesium Sulfate for prophylaxis of eclampsia
Only use diuretics if have pulmonary oedema
Eclampsia
- Stabilise - Airway management, supplemental oxygen
- Midazolam (0.1-0.2mg/kg IV or IM if long seizure)
- Magnesium sulfate to prevent further seizures
- Deliver once stable
HELLP syndrom
- IV fluids
- Blood trnasfusion
- Antihypertensive agents
- Magnesium sulfate
- Delivery if > 34 weeks
What are the 6 types of misscarriage (Pregnancy loss before 20 weeks)
- Complete miscarriage - all tissue passed
- Incomplete miscarriage - confirmed non-viable pregnancy on U/S with some product of conception passes, some remain in uterus
- Missed miscarriage - confirmed non-viable pregnancy on U/S with intact gestational sac. the cervix is closed an no products of conception have been passed
- Recurrent miscarriage - 3 or more successive pregnancies ended in spontaneous miscarriage
- Threatened miscarriage - the continuation of pregnancy is in doubt (vaginal bleeding with mild abdominal cramps and closed cervix)
- Inevitable miscarriage - it is inevitable that this pregnancy will end before viability (Vaginal bleeding, cervical dilation)
- septic miscarriage - products of conception become infected
What is a still birth
Absence of fetal movement and cardiac activity at greater than 20 weeks gestation
Causes of Miscarriage
Maternal
- Uterine abnormalities - fibroids, uterine adhesions, septate uterus, cervical incompitence
- systemic disease - DM, hyperthyroidism, infections, hypercoaguability
Feto-placental
- Chromosomal abrnoamlaities (account for 50%)
- congenital anomalites
Misc
- Trauma
- iatrogenic (amniocentesis or chorionic villus sampling)
- Environmental - alcohol, smoking, drugs
Causes of stillbirth
Maternal
- Fetal-maternal haemorrhage
- Diabtes mellitus
- Hypertensive pregnancy disorders
- Uterine rupture
- Advanced age
- Heavy smoking
Feto-placental
- Intrauterine growth restriction
- Placental abruption
- Infection
- Chromosomal abnormalities
- Congenital malformations
- Umbilical cord complications
- Placental abnormalities
- Fetal hydrops
Investigations if suspected miscarriage
- Dooppler U/S - abscence of fetal cardiac activity
- Pelvic examination - visualisation that bleeding from cervix
- Transvaginal U/S - do if cant find heart of transabdominal scan
- Downtrending b-hCG
Treatment for threatened miscarriages + inevitable, incomplete, missed miscarriage + Stillbirth
Threatened miscarriage
- Avoid strong physical activity
- weekly pelvic U/S
- rule out tratable causes for vaginal bleeding
- Rh(D) negative women need Rh9D) immunoglobulin
Inevitable, incomplete, missed misscariage
- Conservative - allow nature to take its course and review in 7-14 days
- Medical - misoprostol 800mg PV, review in 14 days
- Surgical - Dilation and Curretage
Stillbirth
- do not such delivery unless maternal health risk
- spontaneous labour usually begins within 2 weeks of intrauterine fetal death
- vaginal delivery is safer than C/S but most opt for C/S
- patients should be offered a fetal autopsy
Classification of Uterine leiomyomas (Fibroids)
- Intramural leiomyoma (most common)
- Subserosal leiomyoma
- Submucosal leiomyoma
- Diffuse uterine leiomyomatosis
APGAR score
