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.
What factors increase the likelihood of placenta praevia?
It is more common in multiparous women, in multiple pregnancies, and in women who have had a previous caesarean section.
What is the cause of placenta praevia?
Due to delay in the implantation of the blastocyst, causing it to implant in the lower part of the uterus.
What are the grades of placenta praevia?
- Grade I: Placenta encroaches on the lower segment but not the internal cervical os.
- Grade II: Placenta reaches the internal os.
- Grade III: Placenta covers the cervical os, with some placental tissue in the upper segment.
- Grade IV: Entire placenta is in the lower segment, with the central portion close to the cervical os.
How does placenta praevia affect delivery options?
Grade I or anterior Grade II often allows normal vaginal delivery.
Posterior Grade II, Grade III, and IV usually require caesarean section due to obstruction or risk of bleeding.
What causes bleeding in placenta praevia?
Bleeding results from the separation of the placenta as the lower uterine segment forms and the cervix effaces, causing bleeding from venous sinuses in the uterine wall.
What are the symptoms and signs of placenta praevia?
- Painless vaginal bleeding.
- Lower abdominal discomfort.
- Malpresentation of the fetus.
- Normal uterine tone.
How is placenta praevia diagnosed?
- Clinical findings: Painless bleeding and possible profuse haemorrhage if labour starts.
- Ultrasound scanning: Transabdominal or transvaginal ultrasound is used to localize the placenta.
When should a vaginal examination be performed in the acute setting for antepartum hemorrhage?
A vaginal examination should only be performed in an operating theatre prepared for caesarean section with blood cross-matched, and only when there is serious doubt about the diagnosis due to inadequate ultrasound facilities, and labour appears to have commenced.
What is abruptio placentae?
Abruptio placentae is defined as haemorrhage resulting from premature separation of the placenta.
What does the term “accidental” imply in the context of abruptio placentae?
The term “accidental” implies separation as the result of trauma, but most cases occur spontaneously and do not involve trauma.
What are the common risk factors associated with abruptio placentae?
Risk factors include social deprivation, dietary deficiencies (especially folate deficiency), tobacco use, hypertensive disease, maternal thrombophilia, fetal growth restriction, and male fetus.
How common is trauma as a cause of abruptio placentae?
Trauma, such as motor vehicle accidents, falls, or blows to the abdomen, is a relatively uncommon cause of abruptio placentae.
What are the clinical types of placental abruption?
The three clinical types of placental abruption are revealed, concealed, or mixed, with the classification made after delivery when the concealed clot is discovered.
How does placental abruption typically present?
Placental abruption presents with pain, vaginal bleeding of variable amounts, and increased uterine activity.
What are the clinical signs of a severe placental abruption (Couvelaire uterus)?
In severe cases, haemorrhage penetrates through the uterine wall, causing the uterus to appear bruised (Couvelaire uterus), with the uterus becoming tense, hard, and with a higher fundus than normal for gestational age.
How is the diagnosis of abruptio placentae made?
The diagnosis is made based on the history of vaginal bleeding, abdominal pain, increased uterine tonus, and commonly, the presence of a longitudinal lie of the fetus.
What is the management strategy for mild cases of abruptio placentae in preterm pregnancy?
Mild cases in preterm pregnancy (where the mother is stable and CTG is normal) may be treated conservatively, with ultrasound used to assess fetal growth and wellbeing, and to confirm the placental site.
What is the aim of management in preterm abruptio placentae when the maternal and fetal conditions allow?
The aim is to prolong the pregnancy if the maternal and fetal condition allows.
What is the first priority when managing a severe haemorrhage from abruptio placentae?
The first priority is the resuscitation of the mother, followed by addressing the fetal condition.
What initial treatments are given for a mother with severe haemorrhage from abruptio placentae?
Intravenous infusion with normal saline, Hartmann’s solution, or blood substitutes should be started until blood is cross-matched and transfusion can be commenced.
When is surgical induction of labour performed in abruptio placentae?
Surgical induction is performed if the fetus is alive and close to term with no signs of fetal compromise, or if the fetus is dead.
Why is labour typically induced at 37–38 weeks in cases of abruptio placentae?
Labour is induced at 37–38 weeks due to the increased risk of further abruption.
What complication occurs due to the release of thromboplastin into the maternal circulation from a severe placental abruption?
Afibrinogenaemia may occur, leading to DIC (disseminated intravascular coagulation). It is treated with infusion of FFP (fresh frozen plasma), platelet transfusion, and fibrinogen transfusion after delivery of the fetus.
What renal complication can arise from undertreated hypovolaemia and DIC in placental abruption?
Renal tubular or cortical necrosis can occur, making careful assessment of urinary output essential.
What is vasa praevia?
Vasa praevia is a rare condition where one of the branches of the fetal umbilical vessels lies in the membranes and crosses the cervical os, posing a risk of vessel rupture and rapid fetal exsanguination when the membranes rupture.
How is vasa praevia diagnosed?
Vasa praevia is diagnosed with colour Doppler ultrasound during the fetal anatomy scan.
What percentage of antepartum haemorrhage cases are unexplained, and what are the associated risks?
In nearly 50% of cases, the cause of antepartum haemorrhage is unexplained. Regardless of the cause, there is a significant increase in perinatal mortality, requiring close monitoring of placental function and fetal growth for the remainder of the pregnancy.
How should a pregnancy with unexplained antepartum haemorrhage be managed as it approaches term?
The pregnancy should not be allowed to proceed beyond term due to increased perinatal risks.
What infections may cause bloodstained vaginal discharge during pregnancy?
Vaginal moniliasis (yeast infection) or trichomoniasis can cause bloodstained discharge and should be treated with appropriate therapy once diagnosed.
How are benign cervical polyps managed during pregnancy?
Benign cervical polyps are treated by removal of the polyp.
What is the management approach for cervical erosions during pregnancy?
Cervical erosions are best left untreated during pregnancy.
How is carcinoma of the cervix managed if diagnosed early in pregnancy?
If carcinoma of the cervix is diagnosed early in pregnancy, termination is indicated, followed by staging of the cancer and definitive therapy.
How is cervical carcinoma managed when diagnosed late in pregnancy?
When cervical carcinoma is diagnosed late in pregnancy, a biopsy should be performed, the baby delivered when mature, and the lesion treated based on staging, including caesarean section and radical hysterectomy for early-stage disease.
- Why is a pregnancy with twins, triplets, or higher considered high risk?
A pregnancy with twins, triplets, or higher is considered high risk due to the increased risk of maternal and fetal morbidity and mortality.
What is the prevalence of twin pregnancies in Europe?
The prevalence of twin pregnancies in Europe is intermediate, with rates of 5–13 twin births per 1000 live births.
What is a monozygotic multiple pregnancy?
A monozygotic multiple pregnancy occurs when a single ovum results in multiple embryos, also known as uniovular or identical twins. This happens when the zygote divides after conception.
How common are monozygotic twins, and what factors influence their occurrence?
Monozygotic twins occur in approximately 1/280 pregnancies, unaffected by race but increased by reproductive technology.
What are the types of monozygotic twin pregnancies based on the timing of zygote division?
0–4 days: 2 embryos, 2 amnions, 2 chorions (25–30%)
4–8 days: 2 embryos, 2 amnions, 1 chorion (65–70%)
9–12 days: 2 embryos, 1 amnion, 1 chorion (1–2%)
13+ days: Conjoined twins, 1 amnion, 1 chorion (<1%)
How is monozygosity determined in a pregnancy?
Monozygosity is determined by early ultrasound, preferably before 14 weeks of gestation.
What are dizygotic twins, and what are their characteristics?
Dizygotic twins result from the fertilization of two separate ova by two different sperm. They may have separate placentas or a single placenta with a thick membrane and typically display a “twin peak” sign.
What is the rate and gender distribution of dizygotic twins?
Dizygotic twins occur in 50% male-female, 25% male-male, and 25% female-female combinations.
What factors influence the occurrence of dizygotic twins?
Factors influencing dizygotic twins include familial tendencies on the maternal side, increased parity and maternal age, and the use of ovulation-inducing drugs such as gonadotrophin therapy.
What complications can arise from monochorionic diamniotic twin pregnancies?
Monochorionic diamniotic twins may have placental vascular anastomosis, leading to complications like twin-to-twin transfusion syndrome.
What are some complications of twin pregnancies unrelated to zygosity?
Complications include increased total weight gain, anaemia due to expanded plasma volume, maternal cardiac output increased by 20%, nausea, vomiting, and the vanishing twin syndrome (resorption of a twin).
What is vanishing twin syndrome?
Vanishing twin syndrome refers to the resorption of one fetus between 6 and 10 weeks of gestation, occurring in over 15% of twin pregnancies.
What is the incidence of pre-eclampsia and gestational hypertension in twin pregnancies?
Twin pregnancies have an increased incidence of gestational hypertension, pre-eclampsia, and eclampsia.
What percentage of twin pregnancies experience intra-uterine growth restriction (IUGR)?
IUGR occurs in 20% of twin pregnancies, where one fetus is significantly smaller than the other, defined by a difference in abdominal circumference of more than 20%.
What is the most important complication of twin pregnancy?
The most important complication of twin pregnancy is preterm labour, which occurs before 37 weeks in over 40% of twin pregnancies.
What is twin-to-twin transfusion syndrome (TTTS) and how does it affect the donor and recipient twin?
TTTS occurs in 10-15% of monochorionic diamniotic twin pregnancies. The donor twin becomes oliguric and growth-restricted with oligohydramnios, while the recipient has polyhydramnios and is at risk for cardiomegaly and hydrops fetalis.
What are the treatment options for twin-to-twin transfusion syndrome (TTTS)?
Treatment options for TTTS include serial amniocenteses to remove fluid, selective feticide, or laser ablation of communicating vessels via fetoscopy. Laser treatment has a survival rate of 49-67%.
What is the survival rate for monoamniotic twins, and what complication is common?
The survival rate for monoamniotic twins is around 50%, with cord entanglement by 22 weeks being a common complication.
What is the risk for conjoined twins, and how does fusion occur?
Conjoined twinning is rare, with fusion occurring at different sites on the bodies of the fetuses.
What is the management approach for complications in twin pregnancies?
Management includes treating antenatal complications as in singleton pregnancies but with earlier and more frequent interventions, regular ultrasounds every 2–4 weeks, and early induction if intrauterine growth restriction (IUGR) is detected.
What are the commonest fetal presentations during delivery in twin pregnancies?
The commonest presentation is cephalic/cephalic (50%), followed by cephalic/breech (25%), breech/cephalic (10%), and breech/breech (10%).
What are the delivery methods for twin pregnancies?
Delivery methods include caesarean section and vaginal delivery. Labour duration is similar to singleton labour, with careful monitoring of both twins and checking the presentation of the second twin immediately after the first is delivered.
What should be done if the uterus does not contract within a few minutes during twin delivery?
An oxytocin infusion should be started if the uterus does not contract within a few minutes.
How should fetal heart rate anomalies be managed during twin delivery?
If fetal heart rate anomalies occur, delivery should be expedited by forceps or breech extraction.
What is the delivery method for higher-order multiple births, such as triplets or quadruplets?
Higher-order multiple births, like triplets or quadruplets, are delivered by caesarean section due to preterm labour, low birth weights, and uncertain presentations.
What is a locked twins complication, and how is it managed?
Locked twins occur when the first twin is breech and the second is cephalic, resulting in their chins locking during descent. This requires an urgent caesarean section for survival.
What is the most common cause of perinatal mortality in twins?
The most common cause of perinatal mortality in twins is prematurity, with over 50% of twins and 90% of triplets delivering before 37 weeks.
What increases the risk of intrapartum asphyxia in second-born twins?
Second-born twins are more likely to die from intrapartum asphyxia due to placental separation after the first twin is delivered or cord prolapse in cases of malpresentation or a high presenting part.
How much greater is the risk of cerebral palsy in twins and triplets compared to singletons?
The risk of cerebral palsy is 8 times greater in twins and 47 times greater in triplets compared to singleton pregnancies.
Why might a vertical incision be preferred over a transverse incision in some caesarean sections involving twins?
A vertical incision may be preferred if there is an obstructed transverse lie, to avoid extending into the uterine vessels and broad ligaments, which could cause uncontrollable haemorrhage.
- At what gestational age does the incidence of breech presentation significantly decrease?
The incidence of breech presentation decreases from 16% at 32 weeks to 3-5% at term.
What are the three types of breech presentation?
The three types of breech presentation are:
- Frank breech (legs extended along the fetal trunk, buttocks presenting)
- Flexed breech (legs flexed at hips and knees, sitting on feet)
- Footling/knee presentation (one or both lower limbs descend through the cervix).
What are the hazards associated with breech presentation?
Hazards include:
Increased risk of cord compression or prolapse
Entrapment of the head behind the cervix
Risk of intracranial hemorrhage
Trauma to fetal viscera (e.g., rupture of spleen or gut).
What is the main risk of head entrapment in a breech delivery?
In preterm infants, the bitrochanteric diameter of the breech is smaller than the biparietal diameter of the head, leading to head entrapment if the cervix is incompletely dilated.
What is External Cephalic Version (ECV) and when is it indicated?
ECV is the manual rotation of a breech fetus to a cephalic presentation, indicated when breech presentation persists after 36 weeks gestation.
What are the contraindications for performing External Cephalic Version (ECV)?
Contraindications include a history of antepartum hemorrhage, placenta praevia, abnormal CTG, previous uterine scar, and multiple pregnancy.
What technique is used for External Cephalic Version (ECV)?
The technique involves the mother lying supine with a slight tilt, confirming presentation and placental position with ultrasound, monitoring fetal heart rate, administering tocolytics, and manually rotating the fetus.
What is the purpose of administering a tocolytic agent during ECV?
Tocolytic agents, such as nifedipine or terbutaline, relax the uterus and improve the success rate of External Cephalic Version (ECV).
What are the risks associated with External Cephalic Version (ECV)?
Risks of ECV include cord entanglement, placental abruption, rupture of membranes, and persistent fetal bradycardia (occurring in 1% of cases), which may necessitate urgent delivery by caesarean section.
What is the preferred method of delivery for a fetus with an estimated weight greater than 4 kg?
Delivery by caesarean section is preferred for fetuses with an estimated weight exceeding 4 kg, especially in cases of breech presentation.
What are the steps involved in a vaginal breech delivery during the second stage of labor?
Steps in vaginal breech delivery include:
- Encouraging the mother to push until fetal buttocks and anus are visible.
- Performing an episiotomy if needed.
- Lifting the fetal legs out of the vagina by flexing the hips and knees.
- Delivering the trunk and ensuring the fetal back remains anterior.
- Delivering the arms using the Loveset’s maneuver.
- Allowing the trunk to remain suspended for 30 seconds to facilitate head engagement.
- Grasping and swinging the legs upwards to deliver the head.
What is the purpose of allowing the trunk to remain suspended for 30 seconds during a vaginal breech delivery?
Suspending the trunk allows the fetal head to enter the pelvis, facilitating easier delivery of the head.
When is caesarean section indicated for breech presentation?
Caesarean section is indicated when:
Fetal weight is less than 1.5 kg or greater than 4 kg.
Footling presentation or deflexed head on ultrasound.
Lack of expertise in vaginal breech delivery.
Additional complications like pre-eclampsia, placental abruption, placenta previa, or previous caesarean section.
What is the preferred method of delivery for very-low-birth-weight infants in breech presentation?
Caesarean section is the preferred method of delivery for very-low-birth-weight infants presenting as breech, as their narrower buttocks and trunk may lead to head entrapment during vaginal delivery.
What is Loveset’s maneuver in breech delivery?
Loveset’s maneuver is the technique of rotating the fetus’s body to deliver the extended arms during a breech delivery by flexing the elbow and shoulders.
What is the risk of head entrapment during breech delivery for very-low-birth-weight infants?
The head may become entrapped during delivery due to the narrower buttocks and trunk of very-low-birth-weight infants unless an adequate uterine incision is made during caesarean section.
- What is an unstable lie?
An unstable lie is one that is constantly changing.
What conditions are commonly associated with an unstable lie?
Common conditions associated with an unstable lie include multiparity (lax maternal abdominal wall), low placental implantation, uterine anomalies (e.g., bicornuate uterus, uterine fibroids), and polyhydramnios.
What complications can arise from an unstable lie that persists until the onset of labor?
Complications include cord prolapse, shoulder presentation with a prolapsed arm, and compound presentation (both an arm and a leg may present).
When is no action required for an unstable lie during pregnancy?
No action is required until 37 weeks gestation unless labor starts spontaneously.
What investigations should be done for an unstable lie before 37 weeks?
An ultrasound scan should be done to check placental localization, the presence of pelvic tumors, and fetal abnormalities.
What management is recommended for an unstable lie after 37 weeks if no cause is found?
After 37 weeks, external cephalic version should be attempted to correct the lie.
What is the recommended management if an unstable lie persists after 39 weeks gestation?
The mother should be admitted to hospital after 39 weeks in case spontaneous rupture of membranes occurs, to allow rapid delivery by caesarean section if necessary.
What are the three possible approaches if no specific factor like a low-lying placenta is identified for an unstable lie?
The three approaches are:
- Keep the mother in hospital and await spontaneous correction or correct the lie at labor onset.
- Perform stabilizing induction by correcting the lie to cephalic, rupturing membranes, and starting oxytocin infusion.
- Deliver by caesarean section at term.
What is the recommended course of action if the mother arrives in established labor with a shoulder presentation or prolapsed arm?
Delivery should be performed by caesarean section.
18.
- Management of unstable lie
Unstable lie associated with
What are minor complaints of pregnancy?
Minor complaints of pregnancy are symptoms that do not cause significant medical problems and are often related to physiological adaptations of the body to pregnancy.
What should women be reassured about regarding minor complaints of pregnancy?
Women should be reassured that minor complaints represent normal pregnancy changes, once pathology has been excluded.
What are common physiological causes of abdominal pain during pregnancy?
Common physiological causes of abdominal pain during pregnancy include stretching of abdominal ligaments and muscles, pressure of the gravid uterus on abdominal contents, and constipation.
What are the pathological causes of severe, atypical, or recurrent abdominal pain in pregnancy?
Pathological causes include ectopic pregnancy, miscarriage, ovarian torsion, urinary tract infections, appendicitis, pancreatitis, placental abruption, and labor.
What social cause should be considered in women with recurrent abdominal pain when organic pathology is excluded?
Domestic abuse should be considered as a social cause.
Why is gastro-oesophageal reflux (heartburn) more common during pregnancy?
Heartburn is more common due to delayed gastric emptying, reduced lower oesophageal sphincter pressure, and raised intragastric pressure.
What percentage of pregnant women are affected by heartburn, and when is it most common?
Heartburn affects up to 80% of pregnant women, especially in the third trimester.
What are some differential diagnoses for heartburn in pregnancy?
Differential diagnoses include angina, myocardial infarction, muscular pain, pre-eclampsia, acute fatty liver of pregnancy, and gallstones.
What conservative management strategies can help alleviate heartburn during pregnancy?
Dietary advice to avoid spicy/acidic foods, not eating before bed, and changing sleeping position to a more upright posture can help alleviate heartburn.
What medications can be safely used for heartburn in pregnancy if conservative measures fail?
Antacids, histamine-receptor blockers (e.g., ranitidine), and proton pump inhibitors are safe to use during pregnancy.
What causes constipation during pregnancy?
Constipation in pregnancy is caused by elevated progesterone levels slowing colonic motility and pressure from the uterus on the rectum.
How can women manage constipation during pregnancy?
Women should increase fluid and dietary fiber intake. Most laxatives are safe in pregnancy and can be used if conservative management is ineffective.
What rare complication can severe constipation cause in late pregnancy?
Severe constipation can cause an unstable lie by preventing the fetal head from descending into the pelvis.
What causes backache during pregnancy?
Backache is caused by pressure from the gravid uterus leading to exaggerated lumbar lordosis and hormonal effects on soft tissues.
What are the differential diagnoses for backache in pregnancy?
Differential diagnoses include urinary tract infection, pyelonephritis, and early labor.
How can backache in pregnancy be managed?
Physiotherapy for posture and exercises, and simple analgesics like paracetamol or codeine (avoid aspirin and NSAIDs).
What physiological change leads to syncope during pregnancy?
Progesterone causes vasodilation, leading to postural hypotension and syncope, with additional risk from caval compression by the gravid uterus.
What should be avoided in late pregnancy to reduce the risk of syncope?
Lying supine should be avoided to reduce caval compression and supine hypotension.
What conditions should be excluded in recurrent syncope during pregnancy?
Anaemia, hypoglycaemia, dehydration, and arrhythmias should be excluded in cases of recurrent syncope.
What causes varicosities in the legs or vulva during pregnancy?
Varicosities are caused by pressure on the pelvic veins from the gravid uterus, reducing venous return from the lower limbs, combined with the progestogenic effect that relaxes vascular smooth muscle.
What conditions should be excluded if varicosities are painful?
Thrombophlebitis and deep vein thrombosis should be excluded if varicosities are painful.
What can improve symptoms of varicosities in pregnancy?
Elevating the legs while sitting or lying, and using compression stockings can improve symptoms.
When should heparin prophylaxis be considered for varicosities in pregnancy?
Heparin prophylaxis may be considered if severe varicosities are present along with other risk factors for venous thromboembolism.
Why does carpal tunnel syndrome occur or worsen during pregnancy?
Carpal tunnel syndrome occurs or worsens due to fluid retention caused by increased capillary permeability in pregnancy.
What is the primary treatment for carpal tunnel syndrome in pregnancy?
Wrist splints that reduce wrist flexion are the main treatment for carpal tunnel syndrome during pregnancy.
What treatment can be used for severe cases of carpal tunnel syndrome in pregnancy?
Steroid injections can be used in severe cases of carpal tunnel syndrome and are safe during pregnancy.
What causes pelvic girdle dysfunction (symphyseal pelvic dysfunction, SPD) in pregnancy?
Pelvic girdle dysfunction is caused by raised relaxin levels that increase joint mobility, allowing pelvic expansion for birth, which can be exaggerated in some women causing discomfort.
What are the characteristic symptoms of pelvic girdle dysfunction?
Characteristic symptoms include pain on walking or standing and tenderness over the pelvic ring.
What condition should be excluded in cases of pelvic girdle dysfunction with anterior pain?
Urinary tract infection should be excluded in cases of anterior pain.
What can help alleviate symptoms of pelvic girdle dysfunction?
Physiotherapy for exercises to improve stability, techniques for minimizing daily activity symptoms, and positions for birth, along with simple analgesics, can help alleviate symptoms.
Does pelvic girdle dysfunction resolve after pregnancy?
Yes, pelvic girdle dysfunction usually resolves after pregnancy.
- Why is anaemia common during pregnancy?
Anaemia is common due to an increase in plasma volume and red cell mass, leading to a ‘physiological anaemia,’ along with increased iron and folate demand for fetal development and red cell mass expansion.
What factors contribute to iron deficiency anaemia, especially in the third trimester?
Iron deficiency anaemia occurs due to the increased demand for iron and folate in pregnancy, especially in the third trimester, to support the mother’s red cell mass and the fetus.
What are some pre-pregnancy risk factors for anaemia?
Pre-pregnancy risk factors include poor diet, menorrhagia, short intervals between pregnancies, and pre-existing anaemic conditions like sickle cell disease, thalassaemia, and haemolytic anaemia.
What risk factors within pregnancy can contribute to anaemia?
Risk factors within pregnancy include multiple pregnancy due to the increased iron demand.
What are the clinical features and diagnostic criteria for anaemia in pregnancy?
Symptoms include shortness of breath and lethargy. Anaemia is diagnosed with haemoglobin levels less than 11 g/dL in the first trimester and less than 10.5 g/dL in the second and third trimesters.
How does iron-deficiency anaemia affect the pregnancy and fetus?
Mild anaemia usually does not affect the fetus, but severe anaemia increases the risk of preterm birth, low birth weight, and iron deficiency in the baby during the first year of life.
What are the maternal implications of anaemia in pregnancy?
Maternal implications include fatigue, reduced work performance, increased susceptibility to infections, and a strong association between severe anaemia and maternal mortality.
What is the first-line treatment for anaemia in pregnancy?
Oral iron supplementation is the first-line treatment, best absorbed with ascorbic acid, avoiding tea and coffee during ingestion.
Why is compliance with iron supplementation often poor?
Compliance is poor due to side effects such as constipation and gastric irritation.
What additional treatments and prevention strategies are recommended for anaemia?
Parenteral iron may be considered, and routine iron supplementation and dietary changes are recommended for prevention.
What is gestational diabetes and how common is it?
Gestational diabetes is a common antenatal condition affecting 2–9% of pregnancies.
What causes gestational diabetes?
Gestational diabetes is caused by pregnancy-induced insulin resistance, driven by placental production of anti-insulin hormones (HPL, glucagon, and cortisol), and increased maternal glucocorticoids and thyroid hormones.
What are some risk factors for gestational diabetes?
Risk factors include previous large infant (over 4.5 kg), previous gestational diabetes, first-degree relative with diabetes, obesity (BMI over 30 kg/m²), or booking weight over 100 kg.
What screening should be offered for gestational diabetes in women with risk factors?
A 75 g oral glucose tolerance test (OGTT) should be offered to women with one or more risk factors for gestational diabetes.
What are the clinical features and diagnostic method for gestational diabetes?
Gestational diabetes may be asymptomatic. Screening is done with a 75 g OGTT at 28 weeks, or earlier in the second trimester if high risk, and repeated at 28 weeks if the first test is normal.
What are the maternal implications of gestational diabetes in pregnancy?
Gestational diabetes increases the risk of recurrent infections and pre-eclampsia for the mother.
What are the fetal implications of gestational diabetes?
Fetal risks include polyhydramnios, macrosomia (related to glucose control), stillbirth, and admission to the neonatal unit due to neonatal hypoglycaemia.
What birth complications are associated with gestational diabetes?
Women with gestational diabetes are more likely to need induction of labour, have a caesarean section, and experience complications like shoulder dystocia, instrumental delivery, and extended perineal tears during vaginal birth.
What causes neonatal hypoglycaemia in babies born to mothers with gestational diabetes?
Neonatal hypoglycaemia is caused by the over-activity of the fetal pancreas in response to maternal glucose crossing the placenta while insulin does not.
What are the key management strategies for gestational diabetes?
Management includes dietary measures focusing on low glycaemic index foods, use of metformin or glibenclamide to reduce insulin need, and insulin if needed to maintain glucose control (4.0-6.0 mmol/L fasting, 6.0-8.0 mmol/L post-prandial).
What is the recommended timing of delivery for women with gestational diabetes?
Delivery at term is recommended to reduce the risk of stillbirth.
How should blood glucose be monitored during labour in women with gestational diabetes?
Blood glucose should be regularly measured during labour to reduce the risk of neonatal hypoglycaemia.
What is the main concern regarding HIV infection in pregnancy?
The main concern is the high risk of vertical transmission of HIV from mother to baby, which can be up to 45% without medical intervention.
How can the risk of vertical HIV transmission be reduced during pregnancy?
With medical intervention, including HAART, caesarean section, and avoiding breastfeeding, the risk of vertical transmission can be reduced to less than 2%.
What are the potential complications of HIV infection for the fetus?
Complications include miscarriage, fetal growth restriction, prematurity, and stillbirth.
Can women with HIV deliver vaginally?
Women on HAART with viral loads less than 400 copies/mL can deliver vaginally, as the risk of vertical transmission is very low.
What are the key management strategies for HIV infection in pregnancy?
Management includes regular viral load and CD4 count monitoring, anti-HIV medications (e.g., zidovudine monotherapy or HAART), caesarean section, and avoiding invasive procedures like amniocentesis and fetal scalp blood sampling.
How does pregnancy affect the course of acute viral hepatitis?
Pregnancy does not usually change the course of an acute hepatitis infection, although HBV carriers may experience reactivation, and HCV may accelerate disease progression.
What is the main concern with acute hepatitis in pregnancy?
The main concern is the risk of transmission to the neonate, particularly with HAV in the last few weeks of pregnancy or perinatally with chronic HBV and HCV.
How is the vertical transmission of hepatitis B and C managed during delivery?
Vertical transmission is not reduced by caesarean delivery or avoiding breastfeeding. Vaginal delivery is advocated with avoidance of interventions that may increase blood contact.
What preventive measures can be taken for hepatitis B during and after pregnancy?
Hepatitis B immunization can be offered before pregnancy, and babies of hepatitis B-infected mothers can be treated with hepatitis B immunoglobulin and early hepatitis B immunization.
What percentage of pregnant women with bacteriuria develop pyelonephritis?
12–30% of pregnant women with bacteriuria will develop pyelonephritis, often due to ascending infection caused by structural and immune changes in the renal tract.
What bacteria commonly causes acute pyelonephritis in pregnancy, and how is it treated?
Acute pyelonephritis in pregnancy is usually caused by Escherichia coli. Most community-acquired infections are sensitive to amoxicillin or cefuroxime.
What makes pregnancy a prothrombotic state?
Pregnancy increases coagulation factors, reduces endogenous anticoagulants, and suppresses fibrinolysis, leading to a prothrombotic state. These effects start in the first trimester and last until a few weeks after birth.
What are some pre-existing risk factors for venous thromboembolism (VTE) in pregnancy?
Pre-existing risk factors include a personal or family history of VTE, thrombophilias, obesity, cigarette smoking, gross varicose veins, and increased maternal age.
What are some transient risk factors for VTE in pregnancy?
Transient risk factors for VTE include episodes of immobility, dehydration, ovarian hyperstimulation, and surgical procedures.
What obstetric risk factors increase the chance of VTE in pregnancy?
Obstetric risk factors for VTE include multiple pregnancy, pre-eclampsia, and operative delivery.
What are the common symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnancy?
Symptoms include swelling and tenderness of a leg, shortness of breath, pleuritic chest pain, and collapse. DVT is more likely to occur on the left due to compression of the left common iliac vein.
Where do the majority of DVTs in pregnancy occur, and why may symptoms be less obvious?
Most DVTs in pregnancy occur in the ileofemoral veins, where lower limb symptoms may be less obvious.
How is venous thromboembolism (VTE) managed in pregnancy?
Management includes postnatal prophylaxis with elastic compression stockings and low molecular weight heparin (LMWH). Warfarin is avoided due to its risks to the fetus.
What are the risk factors for obstetric cholestasis, and how is it diagnosed?
Risk factors include certain ethnicities and a past history of obstetric cholestasis. Diagnosis is confirmed by elevated bile acids or liver transaminases after excluding other causes.
What are the clinical features of obstetric cholestasis?
Intense itching, especially on the palms of the hands and soles of the feet, usually in the second or third trimester. Rarely a rash, but excoriation marks are present.
What are the implications of obstetric cholestasis for pregnancy?
It can cause debilitating pruritus, prolong blood clotting time, and slightly increase the risk of stillbirth and preterm birth due to early induction. The recurrence rate is over 90%.
How is obstetric cholestasis managed during pregnancy?
Management includes topical emollients, antihistamines, ursodeoxycholic acid to improve symptoms, and oral vitamin K supplementation.
What are the risk factors for acute fatty liver of pregnancy?
Risk factors include first pregnancy, multiple pregnancy, and obesity.
What are the clinical features of acute fatty liver of pregnancy?
Symptoms include nausea, vomiting, abdominal pain, general malaise, and jaundice in the third trimester. It can lead to rapid deterioration with liver failure, renal impairment, and coagulopathy.
What are the implications and management of acute fatty liver of pregnancy?
It is associated with high maternal and fetal mortality. Management is initially supportive to correct abnormalities, with expedited delivery once the mother is stable. Dialysis or liver transplantation may be required postnatally.
- What is the incidence of pre-existing diabetes in pregnancy, and what types are most common?
The incidence of pre-existing diabetes in pregnancy is around 0.4%. The majority of these women have type 1 diabetes, while those with type 2 tend to be older and more obese.
How do placental hormones affect insulin requirements in pregnancy?
Placental hormones have anti-insulin effects, resulting in a larger insulin requirement in pregnancy, sometimes up to threefold. These changes revert to pre-pregnancy levels within hours of birth.
What are the potential complications for women with diabetes during pregnancy?
Complications include an increased risk of congenital abnormalities (neural tube defects, congenital heart disease), hypoglycemia, accelerated progression of retinopathy and nephropathy, fetal loss, and fetal macrosomia.
What is the risk of fetal abnormalities in women with diabetes and high HbA1c levels?
Women with HbA1c levels above 10% have up to a 25% chance of a fetal abnormality.
What are the management goals for women with pre-existing diabetes before and during pregnancy?
Management includes achieving an HbA1c level less than 6.1% before conception, continuing insulin therapy, stopping ACE inhibitors, taking a higher periconceptual folic acid dose (5 mg), and fetal assessments for abnormalities and growth patterns.
What is the recommended timing of delivery for women with pre-existing diabetes?
Delivery is usually recommended at around 38-39 weeks, with vaginal birth often planned, but caesarean section rates are high.
How does pregnancy affect thyroid function, and what changes are seen in thyroid hormone levels?
Pregnancy increases oestrogen, leading to increased thyroid-binding globulin (TBG) and thyroid hormone production. There is also a fall in TSH levels and maternal iodine due to increased renal loss, resulting in thyroid gland enlargement.
What are the risks associated with hypothyroidism in pregnancy?
Hypothyroidism increases the risk of spontaneous abortion, pre-eclampsia, hypertension, postpartum hemorrhage, low birth weight, and slightly reduced IQ in infants. However, it does not increase the risk of congenital malformations.
How is hypothyroidism managed during pregnancy?
Management includes performing thyroid function tests every trimester and adjusting thyroid replacement therapy as T4 levels fall. Neonatal surveillance is needed for possible neonatal thyroid dysfunction due to transplacental transmission of thyroid antibodies.
What are the risks of untreated iodine deficiency in pregnancy?
Untreated iodine deficiency can lead to poor fetal outcomes, including miscarriage, stillbirth, neonatal death, and congenital abnormalities like cretinism.
What is the most common cause of hyperthyroidism in pregnancy, and how is it diagnosed?
Approximately 95% of hyperthyroidism cases in pregnancy are due to Graves’ disease. It is diagnosed by finding elevated T4 and T3 levels along with decreased TSH levels.
What are the risks of untreated hyperthyroidism during pregnancy?
Untreated hyperthyroidism can lead to thyroid crisis, heart failure, pre-eclampsia, fetal growth restriction, prematurity, stillbirth, and neonatal thyrotoxicosis.
How is hyperthyroidism managed in pregnancy?
Management includes thyroid function testing every 4-6 weeks, adjusting therapy as needed, using safe antithyroid medications, serial fetal growth measurements, regular fetal heart rate assessments, and possibly a prolonged postnatal hospital stay to monitor the neonate for signs of thyrotoxicosis.
What is the impact of obesity on pregnancy outcomes?
Obesity increases the risk of miscarriage, congenital abnormalities (especially neural tube defects), venous thromboembolism, preeclampsia, gestational diabetes, stillbirth, fetal macrosomia, childhood obesity, and neonatal death. It also increases the likelihood of caesarean section and postpartum hemorrhage.
How does obesity affect labor and delivery?
Obese women are more likely to require induction of labor, experience poor progress in labor, and have a caesarean section. If vaginal birth occurs, there is a higher risk of shoulder dystocia and extended perineal tears.
What are the management strategies for obesity in pregnancy?
Management includes hospital-based care, folic acid supplementation until 12 weeks, assessing for pre-eclampsia and venous thromboembolism risk factors, aspirin use as needed, and a glucose tolerance test in the late second trimester to screen for gestational diabetes.
What is thrombophilia, and what are its potential impacts during pregnancy?
Thrombophilia refers to a predisposition to blood clots and can be heritable or acquired. It is associated with an increased risk of venous thromboembolism and obstetric complications like fetal loss, pre-eclampsia, placental abruption, and fetal growth restriction.
How does antiphospholipid syndrome affect pregnancy?
Antiphospholipid syndrome, the most common acquired thrombophilia, is associated with adverse pregnancy outcomes, including venous thromboembolism, fetal loss, and pre-eclampsia.
What defines antiphospholipid syndrome in pregnancy?
Antiphospholipid syndrome is characterized by adverse pregnancy outcomes, including recurrent miscarriage, fetal death, and premature birth, secondary to placental disease.
How are women at risk for antiphospholipid syndrome screened?
Screening is recommended for women with a personal or family history of venous thromboembolism, or a poor obstetric history such as recurrent miscarriage, stillbirth, early-onset pre-eclampsia, or placental abruption.
What is the management of antiphospholipid syndrome in pregnancy?
Management includes antenatal and postnatal low molecular weight heparin (LMWH), avoiding dehydration, and using graduated compression stockings.
How common is epilepsy in pregnancy, and how can pregnancy affect seizure frequency?
Epilepsy affects approximately 1% of the obstetric population. Seizure frequency is usually unchanged but may increase due to non-compliance with medication or sleep deprivation.
What are the risks associated with epilepsy during pregnancy?
Epilepsy increases the risk of congenital abnormalities (3% compared to 1-2% in the general population), perinatal loss, and fetal loss due to tonic-clonic seizures or status epilepticus.
Which antiepileptic drugs are safest during pregnancy, and which should be avoided?
Carbamazepine and lamotrigine are considered safest. Sodium valproate should be avoided due to risks of congenital abnormalities, including neural tube defects and long-term neurodevelopmental issues.
What is the recommended management for pregnant women with epilepsy?
Management includes continuing medications, adjusting them if needed, and avoiding abrupt cessation. A 5 mg dose of folic acid is recommended in the first trimester to reduce neural tube defect risk, and vitamin K can be given to reduce the risk of hemorrhagic disease in the newborn.
How does cardiac disease affect pregnancy, and what are the risks?
Pregnancy increases cardiac output, which can worsen conditions like aortic stenosis. Risks include congestive heart failure, hypoxia, arrhythmias, sudden death, bacterial endocarditis, venous thromboembolism, angina, myocardial infarction, and aortic dissection.
What are the fetal risks associated with maternal cardiac disease during pregnancy?
Maternal cardiac disease increases the risk of pre-eclampsia, intrauterine growth restriction, preterm birth, fetal loss, and congenital heart disease in offspring (up to 5%).
Why might pregnancy be inadvisable for women with poor cardiac function, such as those with Eisenmenger’s syndrome?
For women with Eisenmenger’s syndrome, pregnancy may not be advised due to an extremely high maternal death rate (40-50%). The increased cardiac demand in pregnancy can cause severe complications, and management focuses on minimizing stressors like anemia and infection.
How is pregnancy managed for women with pre-existing cardiac disease?
Management includes altering medications, possibly requiring anticoagulation, regular fetal surveillance with serial growth scans and screening for cardiac defects, and maternal monitoring via echocardiograms. Pain management and fluid balance are crucial during labor.
What complications are associated with systemic lupus erythematosus (SLE) in pregnancy?
SLE increases the risk of early miscarriage, stillbirth, early-onset pre-eclampsia, intrauterine growth restriction, preterm birth, and venous thromboembolism. These risks are higher in women with lupus nephritis or antiphospholipid syndrome.
What risks do infants of mothers with systemic lupus erythematosus (SLE) face?
Infants are at risk for neonatal lupus and congenital heart block due to maternal SLE, especially if antiphospholipid syndrome coexists.
How is pregnancy managed for women with SLE?
Pregnancy should be delayed until at least six months after an SLE flare. Low-dose aspirin and LMWH may be used, particularly when antiphospholipid syndrome is present. Immunosuppressive therapy can continue if necessary, and labor is usually induced at 37–38 weeks to reduce thrombotic complications.
What are the risks and implications of pregnancy in women with chronic renal disease?
Pregnancy can cause deterioration in renal function, which may or may not recover postpartum. Risks to the pregnancy include increased chances of pre-eclampsia, fetal growth restriction, preterm birth, and cesarean section.
How is pregnancy managed in women with chronic renal disease?
Management includes baseline assessment of renal function, blood pressure, and proteinuria. Low-dose aspirin from 12 weeks helps reduce the risk of pre-eclampsia. Blood pressure and renal function are closely monitored, and growth scans are done in the third trimester. Prophylactic heparin may be required for women with proteinuria.
What special considerations are there for pregnant women with polycystic kidney disease or renal transplants?
Polycystic kidney disease poses an inheritance risk to the baby. For renal transplant patients, most immunosuppressive drugs are safe during pregnancy, but careful monitoring is essential.
How are renal calculi managed during pregnancy?
Women with renal calculi are at higher risk of urinary tract infections, which should be treated for longer periods. Management includes fluid loading, alkalinization of urine, pain relief, and avoiding lithotripsy during pregnancy.
How are renal calculi managed during pregnancy?
Women with renal calculi are at higher risk of urinary tract infections, which should be treated for longer periods. Management includes fluid loading, alkalinization of urine, pain relief, and avoiding lithotripsy during pregnancy.
