Obgyn T9-21 Flashcards
- What is the ICD-10 definition of maternal death?
A maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
What are the two main types of maternal deaths according to ICD-10?
- Direct deaths: Resulting from conditions or complications unique to pregnancy during antenatal, intrapartum, or postpartum periods.
- Indirect deaths: Resulting from previously existing diseases or conditions developed during pregnancy that are aggravated by physiological effects of pregnancy.
What is classified as a late maternal death?
Late maternal deaths occur between 42 days and 1 year after abortion, miscarriage, or delivery due to direct or indirect maternal causes.
What is the international definition of the maternal mortality ratio (MMR)?
The maternal mortality ratio (MMR) is defined as the number of direct and indirect deaths per 100,000 live births.
How is the maternal mortality rate defined in the UK?
In the UK, the maternal mortality rate is defined as the number of direct and indirect deaths per 100,000 maternities, which includes live births and stillbirths occurring at or after 24 completed weeks of gestation.
What are the four major causes of maternal death globally?
The four major causes of maternal death globally are:
- Severe bleeding after childbirth
- Infections
- Hypertensive disorders
- Unsafe abortion
What are the major causes of maternal death in the UK?
In the UK, the major causes of maternal death, in order of importance, are:
- Sepsis
- Pre-eclampsia and eclampsia
- Thrombosis and thromboembolism
- Amniotic fluid embolism
- Early pregnancy deaths
What concerning trend has been observed in maternal deaths in the UK?
There has been a worrying rise in deaths related to genital tract sepsis, particularly from community-acquired Group A streptococcal disease, making it the most common cause of direct maternal deaths in the UK.
What are the commonest indirect causes of maternal death in the year following delivery?
The commonest indirect causes of maternal death in the year following delivery include:
- Cardiac disease (often linked to lifestyle-related risk factors such as obesity, smoking, and maternal age)
- Other indirect causes
- Neurological conditions
- What should be the initial focus when taking an obstetric history?
Start by eliciting details of the current (or index) pregnancy, followed by previous obstetric history (including modes of birth and complications) and gynecological history.
Why is the date of the last menstrual period (LMP) important in obstetric history?
The LMP provides the clinician with an idea of how advanced the current pregnancy is (i.e., period of gestation). However, this information may often be inaccurate, as most women do not record the exact days.
What aspects should be included in the menstrual history during obstetric history taking?
Menstrual history should include:
- Duration of the menstrual cycle (typically varies from 21 to 35 days, with most women having a 28-day cycle).
- Age of onset of menstruation (menarche), relevant for teenage pregnancies.
- Method of contraception prior to conception, as hormonal contraception can delay ovulation in the first cycle after discontinuation.
How can the estimated date of delivery (EDD) be calculated from the LMP?
The EDD can be calculated by:
Adding 9 months and 7 days to the first day of the LMP.
Alternatively, subtracting 3 months from the LMP and adding 7 days.
Only about 40% of women deliver within 5 days of the EDD.
What is the significance of a history of secondary amenorrhea in obstetric history?
A history of secondary amenorrhea in a woman with a regular menstrual cycle serves as a self-diagnostic tool for pregnancy.
What are some common symptoms of early pregnancy?
Common symptoms associated with early pregnancy include:
- Nausea and vomiting (morning sickness), often occurring within 2 weeks of missing the period.
- Increased frequency of micturition due to pressure on the bladder, which tends to diminish after the first 12 weeks.
- Excessive lethargy or lassitude, often disappearing after 12 weeks.
- Breast tenderness and heaviness.
- Quickening: the first perception of fetal movements, typically at 20 weeks in first pregnancies and 18 weeks in subsequent pregnancies.
- Pica: an abnormal desire for specific foods.
What condition is characterized by severe and persistent vomiting in pregnancy?
Hyperemesis gravidarum is characterized by severe and persistent vomiting leading to maternal dehydration, ketonuria, and electrolyte imbalance, requiring prompt diagnosis and treatment.
What is pseudocyesis?
Pseudocyesis refers to the development of symptoms and many signs of pregnancy in a woman who is not pregnant, often due to an intense desire for or fear of pregnancy, which may result in hypothalamic amenorrhea.
Menstruation usually returns after the woman is informed of her condition.
Define the terms “gravidity” and “parity” in obstetrics.
Gravidity: The number of times a woman has been pregnant, regardless of the outcome (including terminations, miscarriages, or ectopic pregnancies).
Parity: The number of live-born children and stillbirths a woman has delivered after 24 weeks or with a birth weight of 500 g.
What do the terms primigravida and multigravida refer to?
Primigravida: A woman who is pregnant for the first time.
Multigravida: A woman who has been pregnant two or more times.
What do the terms primipara and multipara refer to?
Primipara: A woman who has given birth to one infant after 24 weeks.
Multipara: A woman who has given birth to two or more infants.
What should be recorded about previous pregnancies during history taking?
A record should include:
Previous miscarriages and the duration of gestation for each pregnancy.
Antenatal complications, details of induction of labor, duration of labor, presentation, method of delivery, birth weight, and sex of each infant.
The condition of each infant at birth and any need for care in a special care baby unit.
Complications during labor and the puerperium (e.g., postpartum hemorrhage, infections, DVT, perineal trauma).
Why is it important to inquire about previous medical history in obstetric history taking?
The natural course of various medical conditions (like diabetes, renal disease, hypertension, cardiac disease, and infectious diseases such as TB, HIV, HBV, HCV) may be altered by pregnancy, which can impact management during pregnancy and postpartum.
What information is important regarding family history in obstetric history taking?
A general inquiry about any known inherited conditions in the family is sufficient. It’s not necessary to list all possible conditions to the mother as this may increase anxiety.
However, if one or both partners are adopted and unaware of their family history, more detailed information may be needed.
What demographic information is relevant during obstetric history taking?
Detailed and relevant information regarding:
Maternal age
Increased BMI
Past obstetric, medical, and surgical history (e.g., laparotomy, cesarean section, myomectomy).
- What should be included in a complete physical examination during antenatal care?
A complete physical examination should identify any physical problems relevant to antenatal care.
Key components include recording height and weight to calculate Body Mass Index (BMI) and measuring blood pressure in different positions.
How should blood pressure be measured in pregnant women, and why?
Blood pressure should be measured with the patient supine and in the left lateral position to avoid vena cava compression by the gravid uterus. If measured sitting, it should be consistent across visits and on the same arm.
This helps prevent supine hypotensive syndrome, which can lead to fetal compromise.
What cardiovascular findings are common in pregnancy?
Benign flow murmurs due to hyperdynamic circulation are common and usually insignificant.
Other murmurs should be evaluated by a cardiologist, as early identification of valvular pathology can affect management during pregnancy, labor, and postpartum.
What respiratory assessments are important during pregnancy?
The respiratory examination should assess the rate of respiration and use of accessory muscles.
Identifying gross lung pathology early is crucial as it may adversely affect maternal and fetal outcomes.
What are some common signs observed during the head and neck examination in pregnant women?
Chloasma (brownish pigmentation) over the forehead and cheeks, particularly in sunlight exposure.
Examination for pallor of mucosal surfaces and conjunctivae to check for anemia.
Assessment of dental hygiene due to potential hypertrophic gingivitis.
Some thyroid enlargement may occur but is usually not significant unless other thyroid disease signs are present.
What changes in the breasts are expected during pregnancy?
Characteristic signs include:
Enlargement in size and increased vascularity.
Development of Montgomery’s tubercles and increased pigmentation of the areolae.
Routine breast examination is not indicated, but inquire about nipple inversion and look for any pathology in symptomatic women.
What are the common abdominal findings during a physical examination in pregnancy?
Common findings include:
Stretch marks or striae gravidarum, which appear purplish initially and turn silvery-white in subsequent pregnancies.
The linea alba may become pigmented (linea nigra), often persisting after the first pregnancy.
Exclusion of hepatosplenomegaly and any evidence of renal enlargement.
The uterus becomes palpable as an abdominal organ typically after 12 weeks of gestation.
What complications should be noted in the abdominal examination during pregnancy?
The examination should include checking for:
Hepatosplenomegaly and any signs of renal enlargement.
Monitoring for changes such as striae gravidarum and the presence of the linea nigra.
What changes in posture are observed during pregnancy?
As the abdomen expands, posture changes typically involve:
Development of kyphosis and increased lumbar lordosis.
The upper trunk is often thrown backward to compensate for the weight of the developing fetus.
This can result in backache and sometimes sciatic pain.
When is a pelvic examination indicated in early and late pregnancy?
Early Pregnancy: A speculum examination is indicated to assess any bleeding.
Late Pregnancy: Pelvic examination is performed for cervical assessment, diagnosing labor, and confirming ruptured membranes.
What is a contraindication for digital vaginal examination in late pregnancy?
Digital vaginal examination is contraindicated in cases of antepartum hemorrhage until placenta previa is excluded to prevent potential complications.
What changes occur in the vaginal walls during pregnancy?
During pregnancy, the vaginal walls become:
More rugous due to thickening of the stratified squamous epithelium and increased glycogen content.
Purplish-red in appearance due to increased vascularity of the paravaginal tissues.
There is also an increase in vaginal secretions and cervical mucus production.
How does the cervix change during pregnancy?
The cervix undergoes several changes:
It becomes softened and shows increased vascularity.
There is oedema of connective tissues and hyperplasia/hypertrophy of cells.
The glandular content of the endocervix increases, producing a thick plug of viscid cervical mucus that occludes the cervical os.
What anatomical distinctions are made when assessing the pelvis?
The false pelvis is the area above the iliopectineal line, while the true pelvis is below the pelvic brim and important for childbirth.
The true pelvis consists of the sacrum, ischial bones, and pubic rami, among other structures.
What is the significance of the plane of the pelvic inlet?
The pelvic inlet (or brim) is important for childbirth and is defined by the sacral promontory, iliopectineal lines, and superior pubic rami.
In a normal gynaecoid pelvis, this plane is nearly circular, being slightly wider transversely than anteroposteriorly.
What is the true conjugate, and why is it clinically significant?
The true conjugate is the anteroposterior diameter between the midpoint of the sacral promontory and the superior border of the pubic symphysis, measuring approximately 11 cm.
It is the shortest distance and of greatest clinical significance for assessing pelvic dimensions related to childbirth.
What are the clinical diameters assessed in the pelvis during obstetric examination?
Transverse (Interspinous) Diameter: The narrowest space in the pelvis, measuring approximately 10 cm.
Anteroposterior Diameter: Also clinically assessed, along with palpating the ischial spines to estimate the interspinous diameter.
What routine assessments are performed during subsequent obstetrical visits?
Record blood pressure and test urine for protein.
Monitor maternal weight, which should increase by approximately 0.5 kg/week after 18 weeks.
Note that rapid weight gain may indicate fluid retention, while static weight or loss may suggest failure of normal fetal growth.
What is the significance of abdominal palpation in assessing gestational age?
Fundal Height Measurement: The fundus becomes palpable above the symphysis pubis at 12 weeks, reaches the umbilicus at 24 weeks, and is at the xiphoid process by 36 weeks.
Symphysial-Fundal Height: Measured to assess fetal growth; should be approximately 20 cm at 20 weeks and increases by 1 cm/week.
How is the abdominal girth measured, and what are the expected changes during pregnancy?
Measure abdominal girth at the maternal umbilicus.
No significant increase is noted until 24 weeks, after which it should increase by 2.5 cm weekly to reach approximately 100 cm at full term.
What techniques are used for palpating fetal parts during an examination?
Fetal parts are typically not palpable before 24 weeks.
Use dipping movements with finger flexion due to the presence of amniotic fluid.
The lie of the fetus (relationship of the fetal long axis to the uterine long axis) is assessed through systematic palpation.
Describe the differences between the types of fetal lie and their palpation findings.
Longitudinal Lie: Head or breech palpable over the pelvic inlet.
Oblique Lie: Fetal long axis at 45° to the uterus; presenting part palpable in the iliac fossa.
Transverse Lie: Fetus lies at right angles to the mother; fetal poles are palpable in the flanks.
What are the characteristics of the fetal head and breech during palpation?
Fetal Head: Hard, round, discrete; can be ‘bounced’ and is described as ballotable; typically found in the lower abdomen or uterine fundus.
Breech: Softer and more diffuse; not ballotable, making it distinguishable from the head.
What are the different types of fetal presentation based on the lie of the fetus?
Longitudinal Lie: Presenting part may be:
Cephalic: Head presenting.
Podalic: Breech presenting.
Transverse Lie: Presenting part is the shoulder.
What defines the presentation of the fetal head in relation to flexion and deflexion?
Vertex Presentation: Well-flexed head; area between anterior and posterior fontanelles presents.
Face Presentation: Head fully extended; face presents to the pelvic inlet.
Brow Presentation: Head partially flexed; brow (area between the base of the nose and anterior fontanelle) presents.
Deflexed Head: Occipitofrontal diameter presents.
How can the presentation and position of the fetus be accurately determined?
Vaginal Examination: Most accurate when the cervix is dilated, allowing palpation of suture lines and fontanelles.
During Established Labor: This examination is most relevant when the mother is well into labor.
What is the definition of the position of the fetus?
The position of the fetus describes the relationship of the denominator (presenting part) to the inlet of the maternal pelvis.
What are the denominators for various fetal presentations?
Presentation
Denominator
Vertex
Occiput
Face Chin (mentum)
Breech
Sacrum
Shoulder
Acromion
What are the six different positions described for a vertex presentation?
Left Occipito-Anterior (LOA)
Right Occipito-Anterior (ROA)
Left Occipito-Transverse (LOT)
Right Occipito-Transverse (ROT)
Left Occipito-Posterior (LOP)
Right Occipito-Posterior (ROP)
How can the position of the fetus be determined through abdominal palpation?
Palpate the anterior shoulder of the fetus:
If easily palpable near the midline, the position is anterior.
If not easily palpable and limbs are prominent, the position is likely posterior.
What is meant by “station” and “engagement” in labor?
Engagement: The greatest transverse diameter (biparietal diameter) of the head passes through the inlet of the true pelvis.
Station: Refers to the position of the fetal head in relation to the ischial spines, which are zero station.
What is the significance of fetal head size in relation to engagement?
A small head may remain mobile even when engaged.
A large head may be fixed at the pelvic brim but not yet engaged.
How is fetal heart sound auscultation performed, and where are they best heard?
Method: Using a hand-held Doppler ultrasound device, confirmed with a Pinard fetal stethoscope.
Location:
Best heard below the level of the umbilicus over the anterior fetal shoulder or midline in posterior position.
In breech presentation, heart sounds are best heard at the level of the umbilicus.
- What are the basic aims of antenatal care?
To ensure optimal health of the mother throughout pregnancy.
To detect and treat disorders affecting both the mother and fetus.
To promote a healthy outcome for both mother and infant.
How does the initial health and history of the mother affect antenatal care?
The initial health and history influence the combination of screening tests, educational support, emotional support, and monitoring of fetal growth and maternal health throughout the pregnancy.
What is the significance of timing in antenatal visits during the first 28 weeks of pregnancy?
Timing is closely aligned with attendance for essential screening tests to monitor the health of the mother and fetus.
What are some key components of preconceptual care?
Immunization assessment for rubella, varicella, and pertussis.
Serological tests if vaccination or infection history is uncertain.
Seasonal administration of the influenza vaccine.
Routine cervical cytology (Papanicolou smear) if due.
What dietary and vitamin supplementation is recommended prior to conception and during early pregnancy?
Folic Acid: 400 μg daily for at least 1 month before conception and the first three months of pregnancy to reduce neural tube defects. Higher doses (5 mg) for at-risk groups.
Iodine: 150 μg daily in regions with dietary deficiency to aid fetal brain development.
How can medications be managed during preconceptual care?
Medications can be reviewed and optimized, with alterations or dose reductions as needed to ensure safety during pregnancy.
What are the adverse effects of smoking during pregnancy?
Reduces fetal growth and development.
Increases perinatal mortality and low birth weight.
Causes structural changes in the placenta affecting oxygen transfer due to carbon monoxide.
What is fetal alcohol syndrome and what are its associated risks?
A syndrome caused by excessive alcohol intake during pregnancy.
Features include growth retardation, structural defects, facial abnormalities, joint anomalies, and cardiac defects.
Risk associated with consumption of 80 g of alcohol/day, often coupled with poor dietary intake.
What types of illicit drug use are common during pregnancy, and what are their risks?
Common drugs: heroin, amphetamines, cocaine, and marijuana.
Risks include intrauterine growth restriction, perinatal death, and preterm labor.
Many adverse effects are related to lifestyle choices and malnutrition.
What are the risks associated with amphetamine use during pregnancy?
Increased risk of miscarriage
Preterm birth
Growth restriction
Placental abruption
Fetal death in utero
Developmental anomalies
What complications can cocaine use cause during pregnancy?
Cardiac arrhythmias and CNS damage in mothers
Placental abruption
Fetal growth restriction
Preterm labor
What routine haematological investigations are recommended during pregnancy?
Haemoglobin concentration and full blood count: At first visit, then at 28 and 34 weeks.
Haemoglobinopathies screening: Offered to at-risk racial groups (e.g., thalassaemia, sickle cell).
Blood group and antibodies determination: In all pregnant women; Rh-negative women screened for Rh antibodies at the first visit and again at 28 weeks.
What is the significance of anti-D immunoglobulin for Rh-negative women?
Around 15% of Caucasian women are Rh-negative and at risk of developing anti-D antibodies.
These antibodies can cross the placenta and harm a Rh-positive fetus, leading to complications such as anemia, hydrops, jaundice, and fetal death.
What screening is recommended for rubella during pregnancy?
Seronegative women should receive immunization with a live attenuated rubella vaccine in the immediate puerperium.
Pregnancy should be avoided for 1 month following vaccination.
What is the approach to syphilis screening during pregnancy?
Routine screening is recommended.
Non-specific tests include Wasserman reaction, VDRL, RPR; specific tests include TPI, FTA, and TPHA.
What are the guidelines for hepatitis screening during pregnancy?
Universal screening for hepatitis B and C is performed.
Passive and active vaccination for at-risk infants is recommended, which can protect infants from hepatitis B infection in 90% of cases.
How is HIV screening and management handled during pregnancy?
Seropositive mothers can have seropositive babies, but it may not indicate active infection.
Effective treatments to reduce transmission include caesarean section, avoidance of breastfeeding, and antiretroviral therapy for mothers and newborns.
What is the significance of Group B Streptococcus (GBS) screening during pregnancy?
GBS can be cultured from up to 25% of pregnant women and may cause UTIs.
There is a risk of neonatal transmission during vaginal delivery, especially with preterm delivery or prolonged rupture of membranes.
Intrapartum antibiotic treatment (IV penicillin) is recommended; screening occurs via vaginal swab at 34-36 weeks.
Why is screening for urinary tract infections (UTIs) important during pregnancy?
Asymptomatic bacteriuria screening is crucial because ascending UTIs can lead to pregnancy loss and preterm birth.
Early treatment of asymptomatic bacteriuria reduces infection incidence and improves maternal health.
What are the guidelines for screening for gestational diabetes?
Screening programs may follow one of two pathways based on risk history:
History of previous gestational diabetes or impaired glucose tolerance.
First-degree relative with diabetes.
Previous unexplained perinatal loss.
What are the indications for performing a full glucose tolerance test (GTT) during pregnancy?
Stillbirth
Macrosomic infant (birth weight > 4 kg)
Maternal weight > 100 kg or BMI > 35
Repeated episodes of glycosuria
Maternal age > 30 years
What is the protocol for screening for gestational diabetes?
Perform a full glucose tolerance test (GTT) at booking visit and again at 28 weeks if there’s uncertainty.
Universal screening at 26–28 weeks using a modified GTT with a 50 g loading dose; a blood glucose level > 7.7 mmol/L is considered positive.
Why is screening for fetal anomalies important during pregnancy?
Structural fetal anomalies account for 20–25% of perinatal deaths and about 15% of infant deaths in the first year of life.
Congenital anomalies are associated with socioeconomic deprivation.
Routine screening for trisomy 21 (Down syndrome) is conducted.
What dietary advice is recommended for pregnant women to prevent malnutrition-related complications?
Avoid high-risk foods (e.g., soft cheeses, deli meats, salad bars).
Total energy intake should be 2000–2500 kcal/day in the last two trimesters, increasing to 3000 kcal during lactation.
Aim for daily protein intake of 60–80 g.
Ensure adequate intake of essential fatty acids, carbohydrates, vitamins, and minerals (iron, calcium, iodine, magnesium, zinc).
What are the recommendations regarding exercise during pregnancy?
Reasonable activity should be encouraged, particularly early in pregnancy.
Limitations may arise due to physical changes in later pregnancy.
No specific limitations on sporting activities unless contraindicated.
What are the guidelines for coitus during pregnancy?
No contraindications for coitus in normal pregnancies.
Avoid intercourse if there’s evidence of threatened miscarriage or a history of recurrent miscarriage.
Women with placenta previa should avoid intercourse.
What should be considered for breast care during pregnancy?
Encourage breastfeeding unless there are specific contraindications (e.g., certain medications, infections like HIV).
Maintain good personal hygiene and breast care during the antenatal period.
Support breasts with appropriate maternity bras, especially as colostrum may leak during the third trimester.
What are the potential issues that could affect breastfeeding?
Previous breast damage or inverted nipples may complicate breastfeeding.
Certain medications may be hazardous if concentrated in breast milk.
Specific maternal infections, like HIV, contraindicate breastfeeding.
- What is the definition of hypertension in pregnancy?
Hypertension in pregnancy is defined as:
Systolic pressure of ≥140 mmHg, or
Diastolic pressure of ≥90 mmHg on two or more occasions.
What is the definition of proteinuria in pregnancy?
Proteinuria is defined as:
Urinary protein concentrations >0.3 g/L in a 24-hour collection, or
Concentrations >1 g/L in a random sample on two or more occasions, at least 6 hours apart
How is oedema defined in pregnancy?
Oedema is characterized by:
Development of pitting oedema, or
Weight gain >2.3 kg in a week, commonly in the feet, ankles, fingers, abdominal wall, or face.
What is gestational hypertension?
Gestational hypertension is:
New onset of hypertension after 20 weeks of pregnancy or within 24 hours postpartum.
No features of pre-eclampsia.
Blood pressure usually returns to normal within 10 days after delivery and should normalize by 12 weeks postpartum.
What is pre-eclampsia?
Pre-eclampsia is:
The development of hypertension with proteinuria after the 20th week of gestation.
Commonly affects primigravida women.
What is eclampsia?
Eclampsia is the development of convulsions as a result of pre-eclampsia.
What is chronic hypertensive disease in pregnancy?
Chronic hypertensive disease is hypertension that was present before pregnancy and may be due to various pathological causes.
What is superimposed pre-eclampsia?
Superimposed pre-eclampsia is the development of pre-eclampsia in a woman with chronic hypertensive disease or renal disease.
What are the key pathophysiological features of pre-eclampsia?
Arteriolar vasoconstriction, particularly affecting the uterus, placenta, and kidneys.
Disseminated intravascular coagulation (DIC).
Reduced sensitivity to angiotensin II.
Placental damage leading to intrauterine growth restriction, abruption, and possibly fetal death.
What are the key symptoms of pre-eclampsia?
Frontal headache
Blurred vision
Sudden vomiting
Right epigastric pain
What are the key renal lesions seen in pre-eclampsia?
Swelling and proliferation of endothelial cells causing capillary obstruction.
Hypertrophy and hyperplasia of mesangial cells.
Deposition of fibrillary material on the basement membrane.
Characterized by increased capillary cellularity and reduced vascularity.
What are the key renal lesions seen in pre-eclampsia?
Swelling and proliferation of endothelial cells causing capillary obstruction.
Hypertrophy and hyperplasia of mesangial cells.
Deposition of fibrillary material on the basement membrane.
Characterized by increased capillary cellularity and reduced vascularity.
What renal complications are associated with pre-eclampsia?
Proteinuria
Reduced glomerular filtration rate
Elevated serum creatinine
Decreased renal blood flow
Hyperuricaemia
What is the effect of vasoconstriction in pre-eclampsia on uteroplacental blood flow?
Vasoconstriction between the radial artery and the decidual portion reduces uteroplacental blood flow, leading to placental hypoxia.
What happens in Disseminated Intravascular Coagulation (DIC) in severe pre-eclampsia/eclampsia?
In DIC:
Thrombosis occurs in the capillaries of many organs.
Increased fibrin deposition and elevated fibrin degradation products result from increased fibrin production and impaired fibrinolysis.
What is the HELLP syndrome?
HELLP syndrome is a severe variant of pre-eclampsia, characterized by:
Haemolysis (H)
Elevated Liver enzymes (EL)
Low Platelet count (LP)
It is an extension of DIC, leading to haemolysis, low platelets, and liver endothelial dysfunction.
What is the HELLP syndrome?
HELLP syndrome is a severe variant of pre-eclampsia, characterized by:
Haemolysis (H)
Elevated Liver enzymes (EL)
Low Platelet count (LP)
It is an extension of DIC, leading to haemolysis, low platelets, and liver endothelial dysfunction.
What are the dangers of HELLP syndrome?
Thrombocytopenia may rapidly progress and can cause haemorrhage into the brain and liver.
Requires urgent intervention and termination of pregnancy once hypertension is controlled.
What is the first sign of gestational hypertension or pre-eclampsia?
A rise in blood pressure (BP) is usually the first sign of gestational hypertension or pre-eclampsia.
What level of proteinuria indicates the need for hospital admission in pre-eclampsia?
More than 1+ proteinuria, or
A spot urinary/creatinine ratio greater than 30 mg/mmol requires hospital admission.
What level of proteinuria indicates the need for hospital admission in pre-eclampsia?
More than 1+ proteinuria, or
A spot urinary/creatinine ratio greater than 30 mg/mmol requires hospital admission.
When should delivery be considered in cases of gestational hypertension or pre-eclampsia?
If hypertension persists or is close to term, immediate delivery is advised unless it is deemed that the fetus would benefit from further time in utero.
What are the commonly used antihypertensive drugs in pregnancy?
Methyldopa (oral)
Hydralazine (oral/IV)
Labetalol (oral/IV)
Prazosin (oral)
Nifedipine (oral)
Note: ACE inhibitors are contraindicated in pregnancy.
What is the protocol for acute control of hypertension in pregnancy?
For acute hypertension control:
IV bolus of Hydralazine 5 mg or Labetalol 20 mg.
What is the purpose of administering steroids in pre-eclampsia before 34 weeks of gestation?
Steroids like betamethasone 11.4 mg IM (2 doses 12-24 hours apart) are given to:
Minimize neonatal complications such as respiratory distress syndrome (RDS), intraventricular haemorrhage, and necrotizing enterocolitis.
What is the frequency of blood pressure measurement in hypertensive disorders of pregnancy?
Blood pressure should be measured every 4 hours until it has returned to normal.
What urine tests are used in hypertensive disorders of pregnancy?
Dipsticks are used for regular checks for proteinuria.
What laboratory tests are essential for pre-eclampsia?
Full blood count (particularly platelet count)
Renal and liver function tests
Uric acid measurements (for disease progression)
Clotting studies (in severe pre-eclampsia)
Catecholamine measurements (in severe hypertension)
What fetoplacental investigations are used in pre-eclampsia?
Serial ultrasounds for fetal growth (every 2 weeks) and liquor volume (up to twice weekly)
Doppler flow studies (up to twice weekly) for assessing vascular resistance in the umbilical and uterine arteries
Antenatal CTG to monitor fetal heart rate and uterine activity
When should labor be induced in cases of hypertensive disorders in pregnancy?
Induction is recommended when:
Gestation > 37 weeks
Uncontrollable blood pressure
HELLP syndrome
Deteriorating renal function (creatinine > 90 mmol/L)
Eclampsia
Acute pulmonary oedema
What fetal and placental indications require induction of labor in pre-eclampsia?
Fetal/placental indications for labor induction include:
Fetal compromise on CTG
Absent/reversed end-diastolic flow in the umbilical artery
No fetal growth over more than 2 weeks
Placental abruption
What are the major complications of hypertensive disorders in pregnancy for the fetus?
Fetal complications include:
Growth restriction
Hypoxia
Fetal death
What are the major maternal complications of hypertensive disorders in pregnancy?
Maternal complications include:
Renal, heart, and hepatic failure
Intrahepatic hemorrhage
Seizures
DIC
ARDS
Cerebral infarction
What placental complications are associated with hypertensive disorders in pregnancy?
Placental complications include:
Infarction
Abruption
What is eclampsia?
Eclampsia is the onset of convulsions in a pregnancy complicated by pre-eclampsia.
What are the risks associated with eclampsia?
Eclampsia risks include:
Intrauterine fetal death
Maternal death from cerebral hemorrhage, renal, or hepatic failure
How should any pregnant woman with convulsions be approached?
Any pregnant woman with convulsions or in a coma with hypertension should be considered to have eclampsia until proven otherwise.
What is the drug of choice for controlling fits in eclampsia?
Magnesium sulphate is the drug of choice for controlling fits. It also reduces platelet aggregation and minimizes DIC effects.
What is the magnesium sulphate dosing regimen for eclampsia?
Bolus dose: 4 g over 20 minutes as 20 mL of a 20% solution.
Maintenance dose: 1 g/hour with 5 g in 500 mL solution running at 100 mL/h.
What are the critical magnesium sulphate therapeutic levels and associated risks?
Therapeutic range: 2–4 mmol/L
Loss of patellar reflexes: > 5 mmol/L
Respiratory depression: > 6 mmol/L
What is the initial drug used to control blood pressure in eclampsia?
Hydralazine (IV) is commonly used, with a 5 mg bolus dose repeated after 15 minutes if needed.
What is an alternative drug for controlling blood pressure in eclampsia if hydralazine is not used?
Intravenous labetalol, starting with a 20 mg bolus, followed by 40 mg and 80 mg, up to a total of 200 mg.
What is the role of epidural analgesia in the management of eclampsia?
Epidural analgesia helps control blood pressure by causing vasodilation, reducing the tendency to fit by relieving pain in labor.
What is the definitive treatment for eclampsia?
Delivery of the infant is the definitive treatment.
What is the duration of management for pre-eclampsia and eclampsia after delivery?
Management continues for up to 7 days after delivery.
What steps should be taken in the management of eclampsia after delivery?
Maintain the patient in a quiet environment under constant observation.
Continue magnesium sulphate infusion for 24 hours after the last fit.
Continue antihypertensive therapy until blood pressure returns to normal.
Monitor fluid balance, blood pressure, and urine output hourly.
- What is the WHO definition of antepartum hemorrhage (APH)?
Haemorrhage from the vagina after the 24th week of gestation.
How is the distinction between a threatened miscarriage and antepartum hemorrhage made?
Based on whether the fetus is considered potentially viable.
What are the potential causes of vaginal bleeding in antepartum hemorrhage (APH)?
- Haemorrhage from the placental site and uterus: placenta praevia, placental abruption, uterine rupture.
- Lesions of the lower genital tract: cervical ectropion/carcinoma, cervicitis, polyps, vulval varices, trauma, infection.
- Bleeding from fetal vessels, including vasa praevia.
What are the approximate diagnostic causes of bleeding for women admitted with antepartum hemorrhage?
- Unclassified/uncertain cause: 50%
- Placenta praevia: 30%
- Placental abruption: 20%
- Vasa praevia: Rare.
What is placenta praevia?
A condition where all or part of the placenta implants in the lower uterine segment and lies beside or in front of the presenting part.
18.
- Management of unstable lie
Unstable lie associated with
