Obs 3a Flashcards
Ectopic Pregnancy Pathophysiology
Implantation of a fertilized ovum outside the uterus results in ectopic
RF: Damage to fallopian tubes (PID), Previous Ectopic Pregnancy, Smoking, Increasd Maternal Age, IVF, Endometriosis, IUCD,POP
- Pregnanxy which occurs in fallopian tube - more so ampulla (95%); can also occur at the cornu, cervix, ovary, and abdominal cavity.
- Can also implant in previous Caesarean section scars.
- trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo - bleeds into lumen which can be catastrophic
- More dangerous if in isthmus more likely to rupture
Ectopic Pregnancy Signs And Symptoms
- 6-8 weeks amenhorroea, lower RLQ pain, vaginal bleeding (dark brown colour - usually less than normal period amount)
- peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
- dizziness, fainting or syncope may be seen
- Breast tenderness
- Diagnosis of a ruptured ectopic is usually clear, with signs of shock and acute abdomen. (rare presentation)
Examination findings
- abdominal tenderness
- cervical excitation (also known as cervical motion tenderness)
- adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
Ectopic Pregnancy Investigations & Management
Three methods of management: Expectant, Medical & Surgical
- Pregnancy test: +ve
- Transvaginal USS investigation of choice
Expectant
- Asymptomatic, <35mm, unruptured, no fetal heart beat, hCG <1000,
- can co exist with another pregnancy
- assumption that significant portion will resolve without treatment. keep monitoring
Medical
- <35mm, unruptured, no fetal heartbeat, minor symptoms, hCG <1500
- no co-existing pregnancy
- IM methotrexate with follow up!
Surgical
- > 35mm, can rupture, very painful,
- visible heart beat on USS
- B hCG >5000
- can co exist with another pregnancy
- Salpingectomy (complete removal of fallopian tube): no risk of infertility
- Salpingotomy: there is risk of infertility such as damage to contralateral fallopian tube, thats why this procedure is done
Anti-D often given with ectopic management if the woman is rh D negative
around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
Miscarriage Pathophysiology & Symptoms
5 types
Pregnancy which ends spontaneously before 24wks.
- Threatened: Vaginal bleeding (less than menstruation), Fetus alive, Cervical OS closed
- Inevitable: Heavy bleeding with clots and pains. OS open
- Complete: All fetal tissue has passed. OS closed with Uterus back to normal
- Missed: Delayed, dead fetus before 20 weeks without the symptoms of expulsion or pregnancy, light bleeding. OS closed
- Incomplete: pain & vaginal bleeding, not all fetus been discharged. OS open.
Signs
- Most common sign of miscarriage is vaginal bleeding.
- There can be abdominal pain as well. These will both resolve with a complete miscarriage.
Perform vaginal speculum to see whether OS is closed or opened.
Septic miscarriageis where the contents of the uterus are infected, causing endometritis. Vaginal loss is usually offensive, uterus tender; fever may be absent in some cases. With pelvic infection there is abdominal pain and peritonism.
Miscarriage Management
Expectant, Medical & Surgical
Some situations are better managed surgically. NICE list the following:
- increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
- previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- evidence of infection
Expectant
- after spontaneous miscarriage, bleeding and pain resolve, repeat USS not required.
- Women advised to take pregnancy test after 3 weeks and attend if positive. if fails then require med or surgical.
Medical
- Vaginal misoprostol
- expected clearance within 24h. if not then contact Dr.
- Pregnancy test @ 3wks
Surgical
- vacuum aspiration (suction curettage) or surgical management in theatre
- Under general anasthetic
Misoprostol: Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
9wk, 13wk, 15wk
Termination of Pregnacy
Abortion Action 1967
Upper limit of termination is 24wks
two registered medical practitioners must sign a legal document
only one rquired in emergency
- <9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
- Oral mifepristone and vaginal misoprostol
- <13 weeks: surgical dilation and suction of uterine contents
- > 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
- Multi-level pregnancy test is required in 2 weeks to confirm that the pregnancy has ended. This should detect the level of hCG dropping (rather than just be positive or negative)
Method Depends on gestation period.
Complications post-TOP
- Infection can happen in up to 10% of TOP cases. Prophylactic Abx given
- Retained tissue 1%
- Haemorrage 1%
- Urine (shop) pregnancy tests often remain positive for up to 4 weeks post TOP - any longer indicates incomplete abortion
consultant led care
Multiple pregnancy
Twins:1 in 80 & Triplets: 1 in 1000. Incidence of twins is increasing
dizygotic (non-identical, develop from two separate ova that were fertilized at the same time - more common)
monozygotic (identical, develop from a single ovum which has divided to form two embryos)
- Vomiting may be more marked in early pregnancy.
- Uterus will be larger than expected from the date and palpable before 12 weeks.
- Folic acid + iron + aspirin (if RF of Pre-eclampsia)
- Induction is usual at 37 weeks (DC twins) or 36 weeks (MC twins).
- In higher order pregnancies (>3) then try and recommend parents to reduce them to twins to avoid complications
- constant monitoring to avoid complications.
- When one twin has a congenital abnormality, selective termination should also be discussed here.
Antenatal complications
* polyhydramnios
* pregnancy induced hypertension
* anaemia
* antepartum haemorrhage
* Miscarriage,
* preterm labour
* intrauterine growth restriction
* Malpresentation
* twin-twin transfusion syndrome (TTTS) is where there ins unequal blood distribution between the twins – one twin depleted and other becomes overloaded.
Gestational Diabetes
RF
- Previous gestational diabetes
- Previous macrosomic baby (>4.5kg)
- BMI >30
- Ethnic origin of Black Caribbean, Middle Eastern and South Asian
- Family history of diabetes (first degree)
- Glucose tolerance decreases in pregnancy due to altered carbohydrate metabolism and antagonistic effects of human placental lactogen, progesterone and cortisol.
- four weekly ultrasound scans to monitor fetal growth and amniotic fluid levels from 28 to 36 weeks gestation.
- trial of diet and exercise for 1-2 weeks, followed by metformin and then insulin.
- For the fetus, congenital abnormalities are more common.
- Birthweight is increased which has implications for birth, mainly posing a risk of shoulder dystocia.
- In addition, neonates at risk of neonatal hypoglycaemia which needs to be monitored for and managed appropriately.
- fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Hypertension in Pregnancy
Raised BP without proteinuria
In normal pregnancy:
* blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
* after this time the blood pressure usually increases to pre-pregnancy levels by term
- Pregnancy-induced hypertension can be due to either pre-eclampsia or transient hypertension. This is when blood pressure rises above 140/90mmHg after 20 weeks gestation.
- Risks are worsening hypertension in the pregnancy, and the risk of developing pre-eclampsia – the risk is increased 6x. In
* No proteinuria, no oedema, resolves following birth.
- Ideally antihypertensive medications changed before pregnancy if pre-existing hypertension.
- ACE inhibitors avoided as these are teratogenic. Labetalol is normally used, with nifedipine as second-line agent.
- Prophylactic Aspirin started from wk12 as risk of pre eclampsia
Pre-Eclampsia
1. New HTN 2. Oedema 3.Proteinuria
Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things (above)
NICE guidelines state diagnosis made with:
- Systolic BP above 140mm/Hg
- Diastolic BP above 90mm/Hg
Plus any one of:
1. Proteinuria (1+ or more on urine dipstick)
1. Organ dysfunction (i.e. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
1. Placental dysfuncton (i.e. fetal growth restriction or abnormal Doppler studies)
- Symptoms occur late: headache, bluriness, nausea, epigastric pain, vomitting, oedema, reduced urine, brisk reflexes
- Aspirin used for prophylaxis; given from 12 weeks gestation until birth in women with a single high-risk factor or two or more moderate-risk factors.
- Labetalol first line, 2nd line: nifedipine
- IV hydralzine in critical cases
- Urgent secondary care management and ≥ 160/110 mmHg are likely to be admitted and observed
Patho: narrow spiral arteries..
Potential consequences of pre-eclampsia
* eclampsia
* other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
* fetal complications
* intrauterine growth retardation
* prematurity
* liver involvement (elevated transaminases)
* haemorrhage: placental abruption, intra-abdominal, intra-cerebral
* cardiac failure
Risk factors of Pre-Eclampsia and Management
High Vs Moderate Risk.
High risk factors
* hypertensive disease in a previous pregnancy
* chronic kidney disease
* autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
* type 1 or type 2 diabetes
* chronic hypertension
Moderate risk factors
* first pregnancy
* age 40 years or older
* pregnancy interval of more than 10 years
* body mass index (BMI) of 35 kg/m² or more at first visit
* family history of pre-eclampsia
* multiple pregnancy
IV magnesium sulphate given during labour and in the 24 hours after to prevent seizures. Fluid restriction also used in severe cases to avoid fluid overload.
Planned early birth may be necessary – corticosteroids should be given in premature births before 34 weeks.
Eclampsia
defined as the development of seizures in association pre-eclampsia.
40% of seizures occur post partum
- IV magnesium sulphate given during labour and in the 24 hours after to prevent
- Respiratory depression can occur
- calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Anaemia in pregnancy
Pregnant women are screened for anaemia at:
* the booking visit (often done at 8-10 weeks), and at
* 28 weeks
NICE use the following cut-offs to determine whether a woman should receive oral iron therapy:
* First trimester < 110 g/L
* Second/third trimester < 105 g/L
* Postpartum < 100 g/L
Management
* oral ferrous sulfate or ferrous fumarate
* treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
DVT/PE in pregnancy
- Compression duplex ultrasound should be done where there is suspicion of DVT
- ECG and chest x-ray should be performed in all patients suspcion of PE
- D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.
- CT Pulmonary Angiogram (CTPA) slightly increases the lifetime risk of maternal breast cancer
- Pregnancy makes breast tissue particularly sensitive to the effects of radiation
- V/Q (see clot in lung) scanning carries a slightly increased risk of childhood cancer
the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
- The patient should receive LMWH immediately to avoid delay if PE is suspected. PE in pregnancy can cause hypoxia to the foetus and mother and potential cardiac arrest.
Group B Strep
RF: Premature, previous sibling infxn, Maternal pyrexia
- Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period.
- It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS.
- Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.
*
- women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
- women with a pyrexia during labour (>38ºC) should also be given IAP
- benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Syphilis
8-12wk test for syphilis in pregnancy
- sexually transmitted infection caused by the spirochaete Treponema pallidum
- incubation period 9-90days
Primary
* chancre - painless ulcer at the site of sexual contact
* local non-tender lymphadenopathy
* often not seen in women (the lesion may be on the cervix)
Secondary (6-10wks)
* systemic symptoms: fevers, lymphadenopathy
* rash on trunk, palms and soles
* buccal ‘snail track’ ulcers (30%)
* condylomata lata (painless, warty lesions on the genitalia )
Tertiary
* Tertiary features
* gummas (granulomatous lesions of the skin and bones)
* ascending aortic aneurysms
* general paralysis of the insane
* tabes dorsalis
* Argyll-Robertson pupil
Diagnosis clinical features serology & microscopic examination of tissue
Management
intramuscular benzathine penicillin is the first-line management
- jarisch-Herxheimer reaction is sometimes seen following treatment (fever, rash) - self limiting
congenital Syphilis
in preganant lady there is risk of miscarriages and still birth if she is infected with syphils
inflammation and hardening of the umbilical chord, rash, fever, low birth weight, high levels of cholesterol at birth, aseptic meningitis, anemia, monocytosis (an increase in the number of monocytes in the circulating blood), enlarged liver and spleen, jaundice (yellowish color of the skin), shedding of skin affecting the palms and soles, convulsions, mental retardation, periostitis (inflammation around the bones causing tender limbs and joints), rhinitis with an infectious nasal discharge, hair loss, inflammation of the eye’s iris and pneumonia.
Treat with penicillin
Bacterial Vaginosis
not an STI
- overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Features
- vaginal discharge: ‘fishy’, offensive
- asymptomatic in 50%
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
- No treatment for asymptomatic patients
- oral metronidazole for 5-7 days
- Topical Clindamycin alternative
- Relapse is common (within 3M)
Bacterial vaginosis in pregnancy
- results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
- Still treat with oral metronidazole
Puerperal Infection
usually happens after the trauma of vaginal birth or caesarian delivery.
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes:
* endometritis: most common cause
* urinary tract infection
* wound infections (perineal tears + caesarean section)
* mastitis
* venous thromboembolism
MANAGEMENT
* if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
Varicella Zoster Exposure in pregnancy
fetal varicella syndrome
- 5 times greater risk of pneumonitis in mother
- risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
- studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
- features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
If exposure occured
- Blood test for mother for Antibodies if unsure of previous Ix
- IV immunoglobulin for not previously exposed mother. Within 10days (less than 20wks)
- more than 20wks then Accyclovir. 7-14 days post exposure
Management of chickenpox in pregnancy
* if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
* there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk
* >20wks give accyclovir
* <20wks procede with caution when giving accyclovir
What is a Hypoactive Uterus
Low resting tone and weakly propagated contractions. There is often a long interval between contractions and they are not particularly painful.
What is Oligohydraminos and its Causes
- Reduction of Amniotic Fluid
- <500ml at 32-36 weeks + amniotic fluid index (AFI) < 5th percentile.
Causes
* premature rupture of membranes
* fetal renal problems e.g. renal agenesis
* intrauterine growth restriction
* post-term gestation
* pre-eclampsia
Renal agenesis is a complete absence of one (unilateral) or both (bilateral) kidneys, whereas in renal aplasia the kidney has failed to develop beyond its most primitive form.
