Obs & Gynae

Question 1

Multiple Pregnancy

Answer 1

Definition: pregnancy involving more than 1 foetus

RF: occurs 1 in 80 pregnancies (higher in IVF)

• advanced maternal age
• IVF

monozygous twins = 20% twins
dizygous twins = 80% of twins

Complications:
Foetal 
- HIGH RISK = Intra-uterine death
- IUGR
- Down syndrome
- Structural abnormalities
- Twin-twin transfusion syndrome
Maternal
- pre-eclampsia
- hyperemesis 
- GDM

Management
Antenatal: 2 extra appointments with specialist obstetrician
- FBC at 20-24w (query extra supplementation of iron or folic acid) and repeat at 28 weeks
- BP (increased eclampsia)
- GTT (increased diabetes)

• Serial growth scans
  Monochorionic twins: scan at 12, 16 and every 2 weeks until delivery
  Dichorionic twins: scan at 12, 20 and every 4 weeks until delivery

Delivery:
Induction (if declined offer weekly obstetrician appointments). Explain that continuing pregnancy beyond these points is associated with an increased risk of foetal death.
Uncomplicated monochorionic twin – from 36 weeks (after course of steroids)
Uncomplicated dichorionic twin – from 37 weeks
Vaginal delivery - 1st twin cephalic but 2nd

IUGR Management:
Start diagnostic monitoring with USS from 16-24 weeks on a 2-weekly basis
Delivered by 34-37 weeks

<26w –> foetoscopic laser ablation of vascular anastomoses
>26w –> delivery

Question 2

Ectopic pregnancy

Answer 2

Definition: An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes.

RF:
• PID
• Previous tubal surgery
• IVF
• Previous ectopic (10% recurrence)
• Pregnancy with IUD/IUS

Complications:
• rupture
• haemorrhage
• death
• tubal infertility

Ix: pregnancy test –> speculum –> TVUSS

1) located ectopic
2) pregnancy of unknown location –> serial BHCG

Management:
1) call the gynaecology on-call

Conservative: only if
• asymptomatic
• no fetal HR
• <35 mm
• low BHCG (<1000)/declining
Have to be haemodynamically stable and asymptomatic.

Medical: have to be able to attend follow up. Methotrexate is 1st line!
x1 IM methotrexate injection
Same criteria as conservative + unruptured

F/U with serial hCG
• Day 4 & 7 then once/week until -ve
• Avoid sexual intercourse during treatment
• Avoid conceiving for 3/12 after methotrexate
• Avoid alcohol and prolonged exposure to sunlight

Surgical
laparoscopic salpingectomy or salpingotomy = not much difference in infertility
• Significant pain
• Adnexal mass > 35 mm
• Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
• Serum β-HCG > 5000 iU/L

Question 3

Abruption

Answer 3

Definition: Separation of the placenta from the uterine wall before delivery (>24 weeks; if <24w, miscarriage)

RF:
• HTN
• Previous APH
• PPROM
• Abdominal trauma
• Smoking, cocaine
• Polyhydramnios

Complications: Maternal (PPH, DIC, renal failure), Foetal (death, birth asphyxia)

Management:
• ABCDE approach
• 2x IV access (14 gauge)
• URGENT venepuncture
FBC, clotting screen
G&S cross-match 4 units of blood + rhesus
Commenced crystalloid infusion/blood product replacement.

Decide on delivery: based on CTG
Fetus alive and < 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: observe closely (admit), steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

• fetal distress: immediate caesarean
• no fetal distress: deliver vaginally