Obs 7 Flashcards
What are the indications for a termination of a pregnancy?
Illegal unless under specific conditions:
The Abortion Act, 1967
- [A] Continuation of pregnancy involves risk to pregnant woman greater than if pregnancy were terminated
- [B] Termination necessary to prevent grave permanent injury to physical/mental health of pregnant woman
- [C; majority] Pregnancy has not exceeded 24th week and continuance of the pregnancy would involve risk, greater than if pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
- [D] Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing children of the family of the pregnant woman
- [E] There is substantial risk that if the child were born it would suffer from physical or mental abnormalities
- [EMERGENCY; F] To save the life of the pregnant woman; or
- [EMERGENCY; G] To prevent grave permanent injury to the physical or mental health of the pregnant woman
What are the complications of a TOP?
Generic:
- Infection (10%)
- Bleeding (1%)
- Damage to local structures
- Failure / retained products of conception
- Anaesthetic complications
- Cervical trauma (increased risk of cervical incompetence with late terminations)
- Uterine perforation
How is a TOP request dealt with?
2 doctors need to sign the form agreeing to TOP (unless emergency)
Before TOP:
- STI screen if indicated
- Check Rh status
- Assess VTE risk
- Bloods – FBC, GS, haemoglobinopathy
- ABx prophylaxis
General:
- All of this needs to be offered within 5 working days of referral
- Time from seeing GP to having a TOP should be less than 2 weeks
- Offer referral to counselling service at abortion clinic
- Council all patients on long-term contraceptive advice (copper IUD, LNG-IUS, Nexplanon)
What is the medical management for a TOP?
1. Oral MIFEPRISTONE (terminates foetus)
2. Vaginal/sublingual MISOPROSTOL (24-48hrs later) (expulsion of foetus)
+Offer NSAID for analgesia
- 0-9 weeks = administer at home (bleeding for 2w after)
- 9-24 weeks = administer in clinic + repeat misoprostol 3-hourly until expulsion (max: 5 doses)
- ≥22 weeks = use FETICIDE (intracardiac KCl injection)
SEs: Nausea, diarrhoea, light PV bleed, cramps
Anti-D if Rh- and after 10w GA
What is the surgical option for a TOP?
<14 weeks:
- Misoprostol (400mcg vaginal/sublingual > dilate)
- ERPC (vacuum aspiration) + hCG level
- Local anaesthetic and can go home same day
>14 weeks:
- Misoprostol (400mcg vaginal/sublingual > dilate)
- Dilatation + curettage
- Under LA or GA > may be able to go home same day
- SE: cramps
Council patient: Call the 24hr helpline if…
- Smelly discharge
- Fever
- Symptoms of pregnancy (nausea, mastalgia)
What is the most common cause of direct maternal death in the UK?
Venous thromboembolic disease (VTE)
What must you do if there are any S/S suggestive of a VTE?
Objective testing and treatment with LMWH (until the diagnosis is excluded)
What is the aetiology of VTE in pregnancy?
Pregnancy is a hypercoagulable state because of an alteration in the thrombotic and fibrinolytic systems.
This is thought to be evolutionary so as to reduce the chances of haemorrhage post-delivery.
- 6-10 fold increased risk of DVT
What are RFs for VTE in pregnancy?
General:
- Hx or FHx of DVT
- Maternal age
- Thrombophilia
- Obesity, smoking, immobility
Pregnancy:
- C- section
- Instrumental delivery
- Infection
- Pre-eclapsia
- Multiple pregnancy
- Hyperemesis
- Dehydration
What are the investigations for VTE in pregnancy?
Compression duplex ultrasound should be performed if there is clinical suspicion of DVT
- If -ve then stop anticoagulants
- If still high clinical suspicion > repeat USS on days 3 and 7
Pulmonary embolism:
- ABG (hypoxia or hypercapnia)
- ECG (sinus tachycardia or S1Q3T3)
- CXR
- If CXR abnormal and clinical suspicion of PE > CTPA (better than a VQ scan)
- If DVT suspected alongside PE > compression duplex USS
- Alternative or repeat testing if VQ scan and CTPA normal, but clinical suspicion of PE remains
- CTPA (higher breast dose) > V/Q scan (higher baby dose)
- Bloods (before anticoagulation) – FBC, U&Es, LFTs, clotting
D-dimer not useful (naturally elevated in pregnancy)
What is the difference between LMWH and unfractionated heparin?
LMWH = SC, irreversible* > *protamine can reverse a little
Unfractionated heparin = IV, adjustable, protamine reversible
What is the immediate treatment of a VTE?
LMWH + elevate leg + graduated elastic stockings
- Monitor treatment with anti-Xa levels only in women of extremes of weight (<50kg, >90kg) or if complicating factors (i.e. renal impairment or recurrent VTE)
What is the immediate treatment of a PE?
Minor PE:
- LMWH (SC, i.e. enoxaparin)
- Anticoagulant treatment should be continued until PE is definitively excluded
Massive PE:
- ABC, multidisciplinary management
- 1st line = IV unfractionated heparin (monitor with APTT)
- 2nd line = thrombolytic therapy, thoracotomy or surgical embolectomy
Describe a central venous sinus thrombosis
(more common post-partum):
- Sagittal sinus most commonly
- S/S: headache and varying neurology
- Ix: MRI (CT may be first to exclude stroke, etc.)
- Tx: IV unfractionated heparin > thrombolysis > 3-6m anticoagulation
What is the maintenance treatment of a VTE?
- SC LMWH until at least 6 weeks postnatally and until ≥3 months of treatment
- Breastfeeding is fine
- 2nd line: oral anticoagulants (requires routine INR monitoring)
SEs = heparin-induced thrombocytopaenia, heparin allergy
