obs & gynae Flashcards
Causes of postpartum haemorrhage
(4 T’s)
Tissue (retained placenta)
Tone (uterine atony)
Trauma
Thrombin (coagulation disorders, DIC)
Complications of multiple pregnancy
(HI PAPA)
Hydramnios (poly)
Intrauterine growth restriction
Preterm labour
APH
Pre-eclampsia
Abortion
Postpartum haemorrhage risk factors
(PARTUM)
Prolonged labour/ Polyhydramnios/ Previous C-section
APH
Recent Hx of bleeding
Twins
Uterine fibroids
Multiparity
Criteria for forceps delivery
(FORCEPS)
Foetus alive
Os dilated
Ruptured membrane, Rotation complete
Cervix take up
Engagement of head
Presentation suitable
Sagittal suture in AP diameter of inlet
what should all women with heavy menstrual bleeding recieve ?
full blood count to check for anaemia
Migraine during pregnancy - what should you give and what should you not ?
paracetamol 1g is first-line
NSAIDs can be used second-line in the first and second trimester
avoid aspirin and opioids such as codeine during pregnancy
uti in pregancy - how to manage ?
o 1st line = nitrofurantoin 50mg QDS or 100mg modified-release BD for 7 days
Avoid in women at term.
o 2nd line (if no improvement after 48 hours) =
Amoxicillin (only if culture results available and susceptible) 500mg TDS for 7 days
Cefalexin 500mg BD for 7 days
N.B. trimethoprim is a folate antagonist and contraindicated throughout pregnancy.
Trimethoprim is contraindicated in the first 12 weeks of pregnancy as it is a folate antagonist and can increase the risk of neural tube defects
22 week preg woman has high BP, clonus, brisk reflexes - what initial meds ??
- magnesium sulphate
- labetolol
pre eclampsia vs eclampsia
in eclampsia it is presecnce of seizure
what is Anencephaly
is a fatal condition where a baby is born without parts of the brain and skull.
type of NTD
make sure to take folic acid
how much in cm do you expect a primipip to progress in 1st stage of labour ?
0.5cm per hour
nuchal translucency scan measures what fluid ?
lymph
ovarian cyst with hair teeeth and random stuff?
mature cystic teratoma
features of molar pregnancy
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen
bleeding in first / early 2nd trimester, hyperemesis, uterus large for dates, high BP, high b-HCG
molar pregnancy
classify early and late miscarriage ?
Miscarriages can be classified as follows:
Early miscarriage: < 13 weeks
Late miscarriage: 13-24 weeks
outline Complete miscarriage
Both fetus and all pregnancy tissue have been expelled from the uterus
Bleeding stops and further treatment is not needed. cervical os closed / uterus empty
more common < 12 weeks (placenta unliekly to have developed)
outleine Incomplete miscarriage
Fetus and parts of the membranes are expelled from the uterus
Placenta is not fully expelled and bleeding persists
Surgical management is often needed to remove the remaining products of conception (manual vacuum aspiration)
more common 12-24 weeks
outline Missed miscarriage
Usually identified via ultrasound with a small for dates uterus
Fetus in the uterus that did not develop or has died
Often do not have typical clinical symptoms of pain or vaginal bleeding
outline Threatened miscarriage
Viable pregnancy with symptoms (such as vaginal bleeding) and a closed cervical os
75% of threatened miscarriages will settle
Carry a higher risk of preterm delivery and preterm rupture of membranes
return for further asssessment if bleeding persists > 14 days
outline Inevitable miscarriage
Non-viable pregnancy with vaginal bleeding and an open cervical os
Progresses to an incomplete or complete miscarriage
this will progress to complete/incomplete miscrraige
define Recurrent miscarriage
Occurs in 1% of patients
3 or more consecutive miscarriages
Offered a referral for further investigation
examination findings in ectopic pregnancy
Examination findings
* abdominal tenderness
* cervical excitation (also known as cervical motion tenderness) - excrutiatting pain on bimanual
* 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
medical and surg management for miscarriage ?
med = o Offer vaginal misoprostol (or oral preparation)
surg = manual vacuum aspiration
(NB Vaginal or sublingual misoprostol if often used to ripen the cervix to facilitate cervical dilatation for suction insertion )
miscarriage risk factors
- Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight
define ectopic pregnancy
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
how does ectopic preg present ?
abdo pain
amenorhhea
vaginal bleeding
- peritoneal bleeding –> shoulder tip pain
- dizziness, fainting, syncope
types of management for ectopic ?
expectant - make sure you do serial bHCG measures
medical - IM methotrexate (if able to attend follow up)
surgical - salpingectomy / salpingotomy
indications for surgical mx for ectopic ?
- Significant pain
- Ruptured ectopic
- Adnexal mass > 35 mm
- Ectopic pregnancy with a foetal heartbeat visible on ultrasound scan
- Serum β-HCG > 5000 iU/L
indications for medical mx for ectopic ?
- No significant pain
- Unruptured ectopic pregnancy with adnexal mass < 35 mm with no visible heartbeat
- Serum β-hCG < 1500 iU/L
- Not suitable if co-existing intrauterine pregnancy (confirmed by USS)
- Able to return for follow up
indications for expectant mx for ectopic ? *
This can only be done if:
o Size < 35 mm
o Unruptured
o Asymptomatic
o No foetal heartbeat
o Serum hCG < 1000 IU/L (may consider 1000-1500)
o Able to return for follow up
o Compatible if there is another intrauterine pregnancy
mx for gestational trophoblastic disease
1st line: Suction curettage for complete and partial* molar pregnancies
molar pregnancies
Levonorgestrel overview emergency contraception
Must be within 72hrs of UPSI (95% effective 0-24hrs, 84% effective 48-72hrs)
- Class: progestogen
- 1.5 mg single oral dose
- Mechanism: Inhibits ovulation for next 5 days – less effective in late follicular phase (just before ovulation)
- Safe and well tolerated (may cause slight menstrual cycle disturbance) Levonorgestrel
- Can be used more than once in a menstrual cycle if needed
- Warning: If vomiting occurs within 2 hours of dose, should be repeated
Ulipristal acetate overview emergency contraception
Must be within 120hrs of UPSI (95% effective)
- Class: selective progesterone receptor modulator
- 30 mg single oral dose
- Mechanism: Delays ovulation until sperm no longer viable
- Should NOT be used with levonorgestrel
- If patient normally uses hormonal contraception, they should restart it 5 days after ulipristal (and use barrier contraception in the meantime. This is between 2-9 days depending on the type of contraception)
- Caution if severe asthma
- Can be used in more than one cycle if needed
- Warning: If vomiting occurs within 3 hours of dose, should be repeated
Copper Coil (Cu-IUD) emergency contraception overview
Ideally within 120hrs of UPSI or within 5 days after the earliest estimated date of ovulation (99% effective)
- Class: intrauterine contraceptive method
- Most effective method of emergency contraception, only method effective after ovulation
- Mechanism: Spermicide and prevents fertilisation and implantation
- STI screening if at high risk of STI
- May be left in for long-term contraception
- Not known to be affected by BMI/weight or by other drugs
why would you not be able to have copper IUD for emergency contraceptions ?
- Explain that Cu-IUD is most effective and most recommended. If a woman cannot have Cu-IUD (e.g. because of current STI) then explain why
important things to remember for termination of pregnancy
- IMPORTANT: with all abortion patients, discuss the insertion of long-acting reversible contraception (e.g. copper IUD, LNG-IUS, Nexplanon)
- IMPORTANT: 2 doctors need to sign a form agreeing to termination of pregnancy (they don’t both need to see the patient)
important things to remember for fat women taking the morning after pill ?
- Important: for women with a bodyweight > 70 kg or a BMI > 26
o EllaOne is the recommended method (continue oral contraception after 5 days)
o Levonelle: if Levonelle is taken, give a double dose (3 mg) and the woman should start ongoing contraception immediately
PCOS features
Features
* subfertility and infertility
* menstrual disturbances: oligomenorrhoea and amenorrhoea
* hirsutism, acne (due to hyperandrogenism)
* obesity
* acanthosis nigricans (due to insulin resistance)
criteria for PCOS ?
- Diagnosis using Rotterdam Criteria for PCOS (at least 2 of the following)
o Oligo/anovulation (> 2 years)
o Clinical or biochemical features of hyperandrogenism
o Polycystic ovaries on ultrasound (> 12 in one/both ovaries measuring 2-9 mm or ovarian volume > 10cm3)
PCOS mx
- lifetsyle advice (weight/ diet )
- COCP
- treat hirsutism / androgenic sx
if planning pregnancy
1. clomiphene
2. gonadotropins
mx for termination fo pregnancy
medical=
* 200 mcg Mifepristone (oral) followed 24-48 hours later by misoprostol (vaginal, buccal, or sublingual)
surgical
< 14 weeks vacuum aspiration
13- 24 weeeks - dilatation and evacuation (D&E) NB - misoprostol is used to ripen cervix
causes of primary and secondary amenorrhea
Primary amenorrhoea
- gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
- testicular feminisation
- congenital malformations of the genital tract
- functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
- congenital adrenal hyperplasia
- imperforate hymen
Secondary amenorrhoea (after excluding pregnancy)
* hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
* polycystic ovarian syndrome (PCOS)
* hyperprolactinaemia
* premature ovarian failure
* thyrotoxicosis*
* Sheehan’s syndrome
* Asherman’s syndrome (intrauterine adhesions)
drug for ovulation induction in subfertility ?
- Ovulation induction - clomiphene or FSH
important blood hormones to look at when assessing for subfertitlity
- Look at early follicular phase FSH, LH and oestradiol levels (day 2-3)
- Anti-Mullerian hormone (AMH) is helpful for assessing ovarian reserve
o It is independent of the menstrual cycle
o Produced by granulosa cells and does not change in response to gonadotrophins, so it is the most successful biomarker of ovarian reserve - Mid-luteal progesterone should also be measured to confirm ovulation
- If irregular menstrual cycle: TFTs, prolactin and testosterone may also be useful
outline ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment
Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS
features of bacterial vaginosis + ix + mx
Bacterial vaginosis (BV) describes an 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.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.
Features
vaginal discharge: ‘fishy’, offensive
asymptomatic in 50%
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
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)
mx =
asymptomatic = nothing
sompotamic = oral metronidazole
features of vulvovaginal candidiasiss + ix + mx
Features
* ‘cottage cheese’, non-offensive discharge
* vulvitis: superficial dyspareunia, dysuria
* itch
* vulval erythema, fissuring, satellite lesions may be seen
Investigations
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
mx
pregnant = clotrimazole pessary or cream (local)
non-pregnant= itraconazole 200 mg PO BD for 1 day or fluconazole 150 mg PO stat
pathogen + features + ix + mx for PID
Causative organisms
* Chlamydia trachomatis
* + the most common cause
* Neisseria gonorrhoeae
* Mycoplasma genitalium
* Mycoplasma hominis
Features
* lower abdominal pain
* fever
* deep dyspareunia
* dysuria and menstrual irregularities may occur
* vaginal or cervical discharge
* cervical excitation
Investigation
* a pregnancy test should be done to exclude an ectopic pregnancy
* high vaginal swab
* these are often negative
* screen for Chlamydia and Gonorrhoea
mx =
* Outpatient Antibiotic Regimen
o Ceftriaxone 1g IM (single dose),
o Doxycycline 100 mg BD (oral) for 14 days, &
o Metronidazole 400 mg BD (oral) for 14 days
follow up for patient treated for PID
Follow-Up
* If managed as outpatients, should be seen within 72 hours to assess response
* If no improvement, admit for IV antibiotics
* Further follow-up at 2-4 weeks to:
o Ensure resolution
o Reiterate importance of STIs
o Reassure that if compliant, fertility is not affected
* Complications:
o Infertility
o Ectopic pregnancy
o Chronic pelvic pain
outline genital herpes features + ix + mx
There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap
Features
* painful genital ulceration
* may be associated with dysuria and pruritus
* the primary infection is often more severe than recurrent episodes
* systemic features such as headache, fever and malaise are more common in primary episodes
* tender inguinal lymphadenopathy
* urinary retention may occur
Investigations
* nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture
* HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
Management
* general measures include:
* saline bathing
* analgesia
* topical anaesthetic agents e.g. lidocaine
* oral aciclovir
* some patients with frequent exacerbations may benefit from longer-term aciclovir
mx for vaginal prolapse
General lifestyle advice
* Losing weight if BMI >30kg/m2
* Avoiding heavy lifting
* Prevent/ treat constipation
Medical
* Pelvic floor exercises (16-week course)
* Oestrogens – pill, patch, cream or implant (can help with symptom relief + if woman also has signs of vaginal atrophy)
* Vaginal ring pessary (changed every 6 months)
o Side-Effects: unpleasant discharge, irritation, UTI, interference with sex (sex is not possible with a shelf pessary)
Surgical
* No preference regarding preservation of uterus
o Vaginal hysterectomy ± vaginal sacrospinous fixation (removal of the uterus ± stitching the top of the vagina to a ligament in the pelvis)
o Vaginal sacrospinous hysteropexy (cervix is stitched to a ligament in the pelvis)
o Manchester repair (shortening of the cervix to support the uterus)
o Sacro-hysteropexy with mesh (mesh used to attach the uterus to sacral vertebra)
* Preservation of uterus
o Vaginal sacrospinous hysteropexy
o Manchester repair (unless the woman wishes to have children in the future)
* Vault prolapse
o Vaginal sacrospinous fixation
o Sacrocolpopexy (mesh used to attach the vagina to sacral vertebra)
* Colpocleisis = only offered if the woman does not intend to have penetrative sex or they are at high surgical risk (the procedure involves closure of the vagina)
what is ashermanns syndrome and mx
This patient is presenting with secondary amenorrhoea and infertility on a
background of extensive gynaecological surgery. Asherman syndrome is
characterised by the formation of intrauterine adhesions leading to amenorrhoea
due to physical obstruction of the cervix or destruction of the endometrial lining.
It typically occurs in patients who have had several gynaecological operations
(e.g. caesarean section, myomectomy, dilatation, and evacuation). As it causes
amenorrhoea by creating a mechanical obstruction, the hormone profile will be
normal. It is diagnosed by hysteroscopy, during which adhesiolysis can be
performed to help relieve symptoms.
- Surgical breakdown of intrauterine adhesions (hysteroscopic adhesiolysis) + insertion of paediatric Foley catheter or intrauterine device for 4-8 weeks to prevent re-formation
- 2 cycles of cyclical oral oestrogen and progesterone given after to aid endometrial proliferation
mx for atrophic vaginitis
vaginal dryness, dyspareunia and occasional spotting. On examination, the vagina may appear pale and dry.
Must exclude malignancy (endometrial cancer)
* Vaginal lubricants before intercourse and regular moisturisers
* Topical oestrogens and inform patient will be relieved after 3 weeks of treatment
o Ring can be inserted into vaginal posterior fornix and changed every 3 months
* Systemic HRT if co-existent menopausal Sx
* Reconsider alternative Dx if continued treatment failure
mx for bartholin’s cyst
- Asymptomatic (smaller) cyst = conservative approach with sitz bath/ warm compression
- Symptomatic (larger) cyst = marsupialisation/ catheter drainage ± oral broad-spectrum antibiotics. May also be managed using surgical excision, silver nitrate cauterisation or sclerotherapy
o Marsupialisation of the cyst = involves suturing the internal aspect of the cyst to the outside of the cyst to prevent the cyst from reforming
o Catheter drainage = uses a Word catheter, which is in place for 4-6 weeks - Abscess = conservative management (sitz bath and analgesia) or incision and drainage may be required + broad spectrum antibiotics
o May require marsupialisation or catheter insertion
endometriosis features + ix + mx
chronic pelvic pain
secondary dysmenorrhoea
pain often starts days before bleeding
deep dyspareunia
subfertility
non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria.
Dyschezia (painful bowel movements)
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
Investigation
laparoscopy is the gold-standard investigation
o Conservative: NSAIDs
o Medical: COCP, LNG-IUS, GnRH agonsits (not suitable if trying to conceive)
o Surgical: diagnostic laparoscopy and excision/ablation (can offer hysterectomy if completed family)
fibroids presentation + ix + mx
Features
* may be asymptomatic
* menorrhagia
* lower abdominal pain: cramping pains, often during menstruation
* bloating
* urinary symptoms, e.g. frequency, may occur with larger fibroids
* subfertility
ix = TVUSS
mx =
Explain the management – in the context of their fertility plans
* 1st line symptomatic: LNG-IUS
o Other options: tranexamic acid, COCP
o GnRH agonists may be used to reduce the size of the fibroid (usually only in the short-term prior to surgery)
* Surgery: minimally invasive hysteroscopy, myomectomy, hysteroscopic endometrial ablation, hysterectomy
* Interventional Radiology: uterine artery embolisation
premenstrual syndrome mx
- conservative (stress , alchol , exercise etec)
- COCP
- SSRI if severe
pruritus vulvae differentials and mx
- General advice
o Shower vulval area with emollient (avoid using water only or soap), dab dry after
o Avoid OTC, wet wipes, perfumed products, tight-fitting clothes, fabric softener, spermicide condoms
o Liberal use of emollients
o Antihistamine at bedtime to help if sleep affected
* Manage underlying cause
o Contact dermatitis – remove irritant exposure and use emollients as soap substitutes
1% hydrocortisone if mild
Betamethasone or clobetasol if severe/lichenified
Refer to dermatology if irritant removal has not resolved the condition
o Lichen simplex – treat underlying sin condition
Potent topical corticosteroid betamethasone for 14 days
Emollient as soap substitute
o Lichen sclerosus – see condition above
o Unknown cause – emollient and mildly anxiolytic antihistamine hydroxyzine for symptomatic treatment
Consider 1% hydrocortisone
Refer to derm/gynae/vulval clinic AND use emollient + antihistamine while waiting if Sx persist
* Refer to secondary care if symptom persist despite known cause + treatment/unclear cause/pre-malignant condition
* Refer to specialist under 2 week wait if cancer suspected/lymphoma
features of cervical ectropion + mx
increased vaginal discharge
vaginal bleeding
dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding.
Examination of the cervix will reveal a well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone.
Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill.
Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.
ovarian torsion features + ix + mx
Features
* Usually the sudden onset of deep-seated colicky abdominal pain.
* Associated with vomiting and distress
* fever may be seen in a minority (possibly secondary to adnexal necrosis)
* Vaginal examination may reveal adnexial tenderness
IX
Ultrasound may show free fluid or a whirlpool sign
(do a pregnancy test as well)
Mx
Laparoscopy is usually both diagnostic and therapeutic.
heavy menstrual bleeding causes + ix + mx
causes =including fibroids, adenomyosis, pelvic inflammatory disease, and polyps,
however, often there is no identifiable cause
ix = fbc to check for anaemia + other ix
mx =
1. intrauterine system (Mirena) should be considered first-line
2. combined oral contraceptive pill
3. long-acting progestogens
risk factors for cervical cancer
Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer.
Other risk factors include:
* smoking
* human immunodeficiency virus
* early first intercourse, many sexual partners
* high parity
* lower socioeconomic status
* combined oral contraceptive pill
ix for suspsteced endometrial cancer and what is an important threshold for next steps of ix
Women are investigated first using a transvaginal ultrasound scan (TVUSS) to evaluate endometrial thickness.
Those with an endometrial thickness of >5mm undergo endometrial biopsy as confirmatory diagnostic testing.
causes of endometrial cancer
Unopposed oestrogen action: may be a result of both endogenous and exogenous oestrogen production. It results in the proliferation of the glandular endometrial cells, producing a greater gland:stroma ratio than is seen in normal endometrium.
Factors include:
* Polycystic ovary syndrome (PCOS)
* Nulliparity
* Early menarche and late menopause
* Unopposed exogenous oestrogen action
* Hormone replacement therapy
* Tamoxifen therapy used in the management of breast cancer
* Metabolic syndrome
* Includes obesity and T2DM
* Fat cells contain the enzyme aromatase which enables them to synthesise extra-ovarian oestrogen.
* As well as this, anabolic insulin can stimulate the proliferation of endometrial cells via IGF-1 activation.
ovarian cancer - features, ix , dx
Clinical features are notoriously vague (can sometimes be similar to IBS symptoms but IBS won’t present at like 50 y/o- that’s your clue)
* abdominal distension and bloating
* abdominal and pelvic pain
* urinary symptoms e.g. Urgency
* early satiety
* diarrhoea
Ix
* NICE recommend a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
* if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
Dx
* Diagnosis is difficult and usually involves diagnostic laparotomy
Risk of malignancy index (RMI) can help to derive the risk of ovarian cancer.
* RMI = U X M X Ca125 (>250 then referral to gynae)
o M = menopausal status (1 – pre, 2 – post)
o U = ultrasound score inc: multilocular cyst, solid areas, mets, ascites, bilateral lesions (0 - no features, 1 – 1 feature, 2 - ≥2 features)
o Ca125 = units/ml
endometrial cancer summary
Summary
* Localised disease: total abdominal hysterectomy with bilateral salpingo-oophorectomy
* High risk patients may receive radiotherapy
* Progestogen therapy is used in frail elderly women who are not suitable for surgery
what levels of stuff do you expect for downs syndrome scan ?
- Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
what are the trimesters of pregnancy ?
The first trimester is from the start of pregnancy until 12 weeks gestation.
The second trimester is from 13 weeks until 26 weeks gestation.
The third trimester is from 27 weeks gestation until birth.
when do fetal movements start?
It is worth noting that fetal movements start from around 20 weeks gestation, and continue until birth.
outline the key milestones in antenatal appointments
Before 10 weeks
Booking clinic
Offer a baseline assessment and plan the pregnancy
Between 10 and 13 + 6
Dating scan
An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified
16 weeks
Antenatal appointment
Discuss results and plan future appointments
Between 18 and 20 + 6
Anomaly scan
An ultrasound to identify any anomalies, such as heart conditions
25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks
Antenatal appointments
Monitor the pregnancy and discuss future plans
classify 1st stage of labour
- Subdivided into:
o Latent phase
Begins with the onset of contractions and ends with 3-4cm cervical dilatation and full effacement
o Active phase
Begins with 3-4cm cervical dilatation and ends with full (10cm) cervical dilatation
Normal progress = cervical dilatation of at least 1cm every 2 hours
Abnormal progress = cervical dilatation of <2cm in 4 hours
classify second stage of labour
- Begins with full cervical dilatation (10cm) and ends with the birth of the baby
- Subdivided into:
o Passive phase
Begins with full dilatation until head reaches pelvic floor and ends with the onset of involuntary expulsive contractions
o I.e. there is no maternal urge to push
o Active phase
Begins with the onset of involuntary expulsive contractions and ends with the birth of the baby
o I.e. there is maternal urge to push
Prolonged = lasting >2 hours in a nulliparous woman, or >1 hour in a multiparous woman (allow an extra hour if the woman has an epidural)
classify 3rd stage of labour ?
- Begins with the birth of the baby and ends with complete delivery of the placenta and membranes
- Average duration = 5-10 mins
- Management of the 3rd stage can be described as:
o Physiological
Where the placenta is delivered by maternal effort
Associated with heavier bleeding
Prolonged = lasting >60mins
o Active
Recommended to all women
Involves administering 10 iU oxytocin IM to the mother (with the birth of the anterior shoulder or immediately after delivery)
Controlled traction of umbilical cord after signs of separation of the placenta
Reduces incidence of PPH (from 15% → 5%)
Prolonged = lasting >30mins
how long should second stage of labour take ?
Prolonged = lasting >2 hours in a nulliparous woman, or >1 hour in a multiparous woman (allow an extra hour if the woman has an epidural)
what classfies preterm labour ?
< 37 weeks
PPROM vs PROM ?
Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour.
Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
in the case of pre term labour what can you do ?
- admit antenatal ward
- IM betamethasone (fetal lung maturation)
- tocolytics (nifidepine) - delay delivery
- magnesium sulphate - for neural protection of neonate if birth within 24 hours
(beware mag sulph tox can cause resp depression/arryhtmias) - calcium gluconate is antidote
what happens if you give too much mag sulp in pre term labour ?
o Beware: toxicity can result in respiratory depression and arrhythmias
Monitor for signs of toxicity every 4 hours (HR, BP, RR, deep tendon reflexes)
Antidote: 10ml 10% calcium gluconate over 10mins (and stop magnesium sulphate infusion)
manage PPROM
- admit
- do not perform bimanual due to increased risk of infection
- give oral erythromycin
- IM betamethasone - fetal lung maturation
- Offer IV magnesium sulphate (for neuroprotection of the neonate) if birth is expected within the next 24 hours
what to do if baby is breech presentation ?
breech at <36 weeks, wait and re-scan at 36/40 at which point if foetus is still breech:
* Offer external cephalic version (ECV) to all women – unless absolute contraindication
o Performed at 36 weeks if nulliparous, or 37 weeks if multiparous
manage shoulder dystocia
- emergency buzzer
- tell them stop pushing
- external manouvre - mcroberts (thighs to abdo on back) +/- suprapubic pressure
- consider episiotomy
- internal manouevres (rubin II manouevre, wood screw manouevre, devlier posterior arm)
- chnage position to all fours
- Third-line manoeuvres (foetal cleidotomy, maternal symphisiotomy or Zavanelli)
outline Induction of labour ?
Summary:
* Induction:
o Membrane sweep to stimulate physiological prostaglandins
for bishops < 6
o Vaginal PGE2 or Mechanical balloon
for bishops > 6
o If still no ROM, then ARM (amniotomy - using amnihook)
o After 2hrs of ARM, start IV Syntocinon
bishops > 8 then likely to go into spontaneous labour
contraindications for VBAC
- Contraindications of VBAC:
o RELATIVE:
≥2 previous C-sections
Need for IOL
Previous labour outcome suggestive of cephalopelvic disproportion
o ABSOLUTE:
Previous classical C-section
Previous uterine rupture
Other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta praevia)
mx for cord prolapse
When diagnosed:
* Call for senior help, continue foetal monitoring with CTG, theatre for immediate delivery.
* If the cord is out of introitus → avoid handling the cord (as this can cause cord vasospasm)
o Keep warm and moist, but do not force it back inside
- Prevent further cord compression by:
o Elevating the presenting part (manually or by filling the urinary bladder)
o Re-positioning mother into either:
All fours
Knee-to-chest position
Left lateral position (with head down) - Consider tocolysis while preparing for C-section if after attempts to prevent compression there are still foetal heart rate abnormalities,
- ASAP delivery by quickest route possible – Emergency CS (recommended if vaginal delivery is not imminent) or expedited vaginal delivery.
Postpartum haemorrhage (PPH) is defined as ….
blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
when uterine atony predicted for caused of PPH what do you do …
When uterine atony is the suspected cause, follow:
* Massage the uterus to stimulate uterine contractions
* Stepwise approach to pharmacological and surgical options:
o Phamacological:
Step 1: 5iU oxytocin (syntocinon) slow IV infusion
Step 2: 0.5mg ergometrine/ syntometrine slow IV infusion or IM (contraindicated in HTN)
Step 3: Oxytocin IV infusion (40iU in 500ml isotonic crystalloids)
Step 4: IM Carboprost (contraindicated in asthmatics)
o Surgical:
Step 5: intrauterine balloon tamponade i.e. Bakri balloon.
Step 6: other surgical measures (e.g. B lynch sutures, iliac artery ligation, uterine artery embolization IR, hysterectomy)
how much blood after delivery long term …
Lochia is vaginal discharge consisting of blood, mucus, and uterine tissue that
occurs for up to 4–6 weeks following delivery. The bleeding is initially heavy,
bright red, and may contact clots. Over a matter of weeks, it gradually becomes
dark brown and lighter. The bleeding may become heavier when breastfeeding,
as a neuroendocrine reflex arc stimulates the uterus to contract. This may be
accompanied by crampy period-like pain. The patient should be reassured that
this is a normal process, however, they should be discouraged from using
tampons as this increases the risk of infection.
how to manage PPH (thoroughly()
Minor PPH (500-1000 mL without shock)
* Alert midwife in charge and first-line obstetric and anaesthetic staff
* ABCDE approach
o 1x IV access
o Urgent bloods for: FBC, clotting (including fibrinogen), G&S (if not done previously) and cross-match 4 units
o Commence warmed crystalloid infusion
* HR, RR and BP every 15 mins
Major PPH (>1000 mL)
* Call for senior help and initiate major obstetric haemorrhage MOH protocol (obstetric consultant, anaesthetic team, haematologist and blood transfusion lab)
* ABCDE approach
o Position the patient flat
o Keep patient warm
o 2x large bore IV cannulae
o Urgent bloods for: FBC, clotting, G&S (if not done previously) and cross-match 4 units, baseline U&E and LFTs
o Transfuse blood as soon as possible
o Until blood is available, infuse upto 3.5L of warmed clear fluids (initially 2L warmed crystalloid)
* Continuous HR, BP and RR monitoring
* Monitor temperature every 15minutes
* Catheterise
* If the placenta is undelivered → attempt removal by controlled cord traction
* If the placenta is delivered → check for completeness (empty uterus and vagina of clots)
pre-existing hyperternsion - what is it and how to manage?
any hypertension before 20 weeks gestation (>140 / 90)
- Antenatal
o Conservative
Give advice regarding weigth management, exercise, healthy eating and salt intake.
o Monitoring
BP monitoring (weekly if HTN poorly controlled, every 2-4 weeks if HTN well controlled)
Aim for BP <135/85 mmHg
Serial growth scans every 4 weeks from 28-36 weeks
o Medical
Labetalol, nifedipine or methyldopa based on side effect profile as above.
Low-dose aspirin 75-150mg OD from 12 weeks gestation until birth (to prevent pre-eclampsia).
- Intrapartum
o As long as BP is <160/110, induction <37 weeks gestation should not be offered
o If >160/110 mmHg, senior input and patient involvement is required - Postnatal
o Monitoring
BP monitoring - Daily for the first 2 days after birth
- At least once between day 3 and day 5 after birth
- As clinically indicated if antihypertensive treatment is changed after birth
Aim to keep BP <140/90 mmHg
Arrange F/U at 2 weeks with GP or specialist for antihypertensive review.
If prescribed methyldopa intrapartum, stop within two days after birth and change to an alternative antihypertensive (due to risk of postnatal depression)
what meds are good for epilepsy in pregnancy and what ones are contraindicated ?
lamotrigine and carbamazepine is good
sodium valproate is contraindicated
also these patients should be on high dose folic acid
syphalis mx during pregnancy
o 1st line = IM stat benzylpenicillin or doxycycline BD for 14 days.
* Note: If the woman is not treated during pregnancy, treat the baby immediately after delivery
toxoplasmosis mx during pregnancy
o 1st line = spiramycin (3-week course of 2-3g OD) which may reduce the risk of transmission to the foetus
cmv mx for mum during pregnancy ?
summary = no tx
- No prenatal treatment available
- Refer to foetal medicine specialist for regular foetal surveillance
o Foetal US examination every 2-4 weeks from diagnosis
o ± Foetal MRI at 28-32 weeks gestation
o Audiology + ophthalmology F/U - If there is evidence of foetal infection on US discuss the options:
o Continuation of pregnancy with expectant management
o TOP - Offer postnatal antiviral therapy for the baby (e.g. valganciclovir, ganciclovir) for 6 months and start within 4 weeks of life.
chickenpox in pregnancy
exposure
non-immune women exposed to chickenpox (if there is doubt about immunity check maternal varicella antibodies):
o If <20 weeks’ gestation, give VZIG immediately (only effective up to 10 days post-contact).
o If >20 weeks’ gestation, give either VZIG or antivirals (acyclovir or valacyclovir) 7-14 days after exposure.
rash
* If ≥20 weeks’ gestation and presents within 24hrs onset of rash:
o Prescribe oral acyclovir (800mg 5/day for 7 days).
o If <20 weeks’ gestation, consider oral acyclovir “with caution”.
if you’ve got something complex during pregnancy who would you refer to ?
fetal medicine specialist
parvovirus b19 during pregnancy management
conservative mx
listeria mx during pregnancy
Antibiotics
* 1st line = IV amoxicillin 2g every 6 hours for 14 days, as gram-positive bacilli.
Prevention: avoid high-risk foods (unpasteurised milk, uncooked soft cheeses, pâté, undercooked food)
herpes simplex virus during pregancny management
Refer to GUM clinic (to confirm or refute infection using PCR and to screen for other STIs)
- If first episode of genital HSV:
o Treat HSV infection with oral acyclovir (400mg TDS for 5 days)
o If infection occurred in the 1st or 2nd trimester (until 27+6 weeks’ gestation):
Recommend daily suppressive oral acyclovir (400mg TDS) from 36 weeks’ gestation until delivery
Offer vaginal delivery
o If infection occurred in the 3rd trimester (from 28 weeks’ gestation):
Prescribe oral acyclovir (400mg TDS) until delivery
Recommend delivery by elective C-section, particularly if infection within 6 weeks of delivery.
If the woman chooses vaginal delivery:
* Recommend intrapartum IV acyclovir to the mother (and IV acyclovir to the neonate after birth)
o Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions
- If recurrent episode of genital HSV:
o 400mg TDS oral acyclovir from 36 weeks’ gestation until delivery
o Episodes are usually self-limiting, and resolve in 7-10 days without treatment
o Offer vaginal delivery
o Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions
group b strep infection during pregnancy mx
- Intrapartum antibiotic prophylaxis
o 1st line = IV benzylpenicillin 3g as soon after the onset of labour, and 1.5g 4-hourly thereafter until delivery
o Alternatives if penicillin allergic:
If mild allergy = cephalosporin
If severe allergy = vancomycin
o Note: antibiotics are not required if undergoing an elective C-section in the absence of labour and with intact membranes - Monitor newborn baby for the first 12 hours of life
o If there is evidence of neonatal infection, treat with postnatal antibiotics
o 1st line = IV penicillin and gentamicin
pregnancy induced hypertension definiton
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
gestational HTN management
Antenatal
- Consider admission to antenatal ward if severe hypertension (>160/110 mmHg) until BP is controlled
- Monitoring
o BP and urinalysis 1-2x/week until BP is controlled, thereafter weekly
o Bloods (FBC, LFTs, U&Es) weekly
o US foetal surveillance (growth, liquor, UA blood flow) every 2-4 weeks
o PlGF-based testing on 1 occasion if suspicion of pre-eclampsia - Medical
o Antihypertensives (1st line = labetalol, 2nd line = nifedipine, 3rd line = methyldopa) if blood pressure consistently >140/90 mmHg
Aim for BP <135/85 mmHg
how to prevent pre eclampsia (who is at risk and what do you do ?)
Prevention
* Measure BP and test urine for proteinuria at each antenatal appointment
o If dipstick 1+ → use albumin:creatinine or protein:creatinine ratio to quantify proteinuria
30mg/mol threshold for protein:creatinine
8mg/mol threshold albumin:creatinine
- Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors:
o High-risk risk factors:
Hypertensive disease in a previous pregnancy
Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome])
o Moderate-risk risk factors:
First pregnancy (primigravid)
Age >40 years
Pregnancy interval of >10 years
BMI >35 at booking visit
FH of pre-eclampsia
Multiple pregnancy
o N.B. NICE states to consider more frequent BP measurements for women with any of the above risk factors
which pregnant ladies get aspirin?
- Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors:
o High-risk risk factors:
Hypertensive disease in a previous pregnancy
Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome])
o Moderate-risk risk factors:
First pregnancy (primigravid)
Age >40 years
Pregnancy interval of >10 years
BMI >35 at booking visit
FH of pre-eclampsia
Multiple pregnancy
define pre eclampsia
Definition; The current formal definition is as follows
- new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
define eclampsia and mx
Eclampsia is a serious complication of pregnancy characterized by the onset of seizures or convulsions in a woman with preeclampsia
- IV magnesium sulphate
- labetalol
- expedite delivery
features of pre eclampsia + severe pre eclapmsia
Features
- 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
Features of severe pre-eclampsia
* hypertension: typically > 160/110 mmHg and proteinuria as above
* proteinuria: dipstick ++/+++
* headache
* visual disturbance
* papilloedema
* RUQ/epigastric pain
* hyperreflexia
* platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
diagnosis of gestational diabetes + mx
- fasting glucose is >= 5.6 mmol/L
- 2-hour glucose is >= 7.8 mmol/L
mx
1st line = diet and exercise if fasting glucose < 7
2nd line = metformin
3rd line = add insulin (if fasting glucose > 7 go straight for insulin, if fasting glucose 6-6.9 + macrosomia, hydramnios), offer insulin staright away )
anaemia thresholds in pregnancy + mx
defined by Hb
<110g/l in 1st TM,
<105g/l in 2nd/3rd TM ,
<100g/l postpartum
mx =
Once Hb in normal range, continue oral iron for 3 months and until 6 weeks postpartum (to replenish iron stores)
o Increased animal food in diet and advice
Iron – green leafy vegetables, nuts, beans, seeds
B12 – meat and dairy
Folate – green leafy vegetables, nuts, yeast, liver
- Intrapartum
o Advise to deliver in labour ward
o IV access and group and screen on admission
o Active management of 3rd stage
o Active management of PPH
o Consider prophylactic syntocinon infusion
mx for obstestric cholestais
- conservative measures like clothing loose
- topical emollients
3, ursodeoxycholic acid
diagnosis of placenta praevia + some important things to rememebr
Diagnosis
digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
causes of intra uterine growth restriction of fetus ?
Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta:
* Idiopathic
* Pre-eclampsia
* Maternal smoking
* Maternal alcohol
* Anaemia
* Malnutrition
* Infection
* Maternal health conditions
Non-placenta medicated growth restriction refers to pathology of the fetus, such as:
* Genetic abnormalities
* Structural abnormalities
* Fetal infection
* Errors of metabolism
mx for placenta praevia with painless bleeding
- Symptomatic placenta praevia (with painless bleeding):
o ABCDE approach
Gain IV access
Bloods (FBC, Rhesus status, cross-match, clotting screen)
Continuous foetal monitoring
o Give anti-D immunoglobulin in Rh-negative women
o Decide on delivery:
If mother is haemodynamically unstable or there is evidence of foetal distress
* Emergency C-section (irrespective of gestation)
If mother is haemodynamically stable, with no evidence of foetal distress →
* Give steroids and admit until bleeding has stopped (and for a further 48 hours for observation)
* Re-scan at 36 weeks
o If still low-lying/praevia → recommend elective C-section at 34-36 weeks gestation and a history of vaginal bleeding or other factors at risk of preterm delivery
low lying placenta vs placenta praevia
- Definitions: (apply after 16 weeks)
o Placenta praevia = placenta lies directly over the internal os
o Low-lying placenta = placental edge lies <2 cm from the internal os
how does placental abruption present ?
- Heavy bleeding leads to faintness and collapse, as may signs of shock.
- Abdominal discomfort
- Back pain
tense / woody uterus ?
placental abruption
when is a Kleihauer Test indicated
Kleihauer Test
The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
types of twins with the stuff in womb
Dichorionic-diamniotic twin
Monochorionic-diamniotic twin
in pregnancy
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
what is it ?
Amniotic fluid embolism (AFE) is an obstetric emergency that occurs when
foetal antigens enter the maternal circulation
exposure to foetal antigens during delivery triggers an inflammatory cascade that
results in organ damage and activation of the coagulation cascade, resulting in
disseminated intravascular coagulation (DIC).
- ABCDE approach
o Supportive management (largely in ITU)
Fluid resus
Inotropes
Correct coagulopathy (FFP, platelets, cryoprecipitate, transfuse etc)
Uterine atony PPH management
o No specific treatment available - If delivery hasn’t yet occurred:
o Aim to stabilise the mother’s condition first
o In a situation of peri-arrest → category 1 CS (with the aim to both save the foetus’ life and improve the effect of resuscitation on the mother)
`
placental abruption mx
- ABCDE approach
o Gain 2x IV access
o Bloods (FBC, Rhesus status, cross-match and clotting screen)
o Continuous foetal monitoring
o Kleihauer test and anti-D if needed
o Fluid, antifibrinolytics, blood, or blood-product replacement, as indicated - Give anti-D immunoglobulin in Rh-negative women
- Decide on delivery:
o Foetus alive <36 weeks and:
Foetal distress emergency C-section
No foetal distress observe closely, give steroids. No tocolysis, threshold to deliver depends on gestation
o Foetus alive >36 weeks and:
Foetal distress emergency C-section
No foetal distress vaginal delivery may be trialled
o Dead foetus induce vaginal delivery
can mutliple pregnancy women deliver vaginally ?
- For dichorionic-diamniotic and monochorionic-diamniotic twin pregnancies, vaginal delivery is possible provided the first twin is in a cephalic presentation
- Advise to deliver in labour ward, with continuous CTG monitoring
- If ‘suspicious’ or ‘pathological’ CTG, and vaginal birth cannot be achieved within 20 minutes, discuss caesarean section
- Inform of small 4% risk of second twin requiring C-section
- For monochorionic-monoamniotic twin pregnancies and triplet pregnancies, recommend delivery by elective C-section
hyperemesis gravidarum diagnosis ?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
mx for hyperemsis gravidarum /
- promethazine
- ondansetron
differentials for bleeding the first trimester
- miscarriage
- ectopic pregnancy
the most ‘important’ cause as missed ectopics can be potentially life-threatening - implantation bleeding
a diagnosis of exclusion - miscellaneous conditions
o cervical ectropion
o vaginitis
o trauma
o polyps
what happens to firboids in preganncy ?
Red’ degeneration describes the breakdown of myocytes secondary to ischaemia and is the most common form of fibroid degeneration. It most commonly presents in pregnancy, when fibroids tend to outgrow their blood supply owing to increased circulating oestrogen. Typical presentation is in the second trimester of pregnancy with acute pain and low-grade fever. Management during pregnancy consists of symptom management, and myomectomy can be performed after delivery.
how does symphasis pubis present ?
Symptoms of SPD include pain in the pubic area, lower back, hips, and thighs, difficulty walking or standing, and a clicking or popping sensation in the pelvis.
- discomfort and pain in the suprapubic or low back area, which may radiate to the upper thighs and the perineum
- discomfort can vary from mild to severe pain
- pain on walking, climbing stairs, turning in bed, standing on one leg or weight-bearing and rising from a chair.
- clicking of the lower back, hip joints and sacroilliac joints when changing position
Signs:
* tenderness of the symphysis pubis and/or sacroiliac joint
* pain on hip abduction
* pain at symphysis when standing on one leg
* waddling gait
what is average rate of contraction in labour looking at a CTG ?
C – Contractions – look for frequency, length and regularity of electrical activity (in labour aim for 4 contractions every 10 minutes; 4:10)
what is normal baseline rate for CTG >
BRA – Baseline Rate – calculated as the average heart rate over a period of 5-10mins (normal = 110 – 160 bpm)
what is normal variability on CTG trace ?
V – Variability – calculated as the heart rate variability over a period of 5-10mins, excluding decelerations and accelerations (normal = >5 bpm)
what are acceleration son CTG trace?
A – Accelerations – defined as a rise from baseline heart rate of at least 15bpm lasting at least 15 seconds (normal = >2 accelerations on a 20-30mins CTG trace)
* Absent accelerations = foetal hypoxia
what is the conlcuding thing when going through and ECG trace ?
O – Overall – each feature can be described as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’ and used to define the CTG overall as: normal, suspicious or abnormal
Normal = no amber or red features
Suspicious = any 1 feature is amber
Pathological = any 1 feature is red, or 2 or more features are amber
what are decelerations on CTG trace ?
D – Decelerations – defined as a fall from baseline heart rate of at least 15bpm lasting at least 15 seconds (normal = no decelerations)
* Decelerations present = foetal hypoxia, umbilical cord compression
* 3 types of decelerations:
o Early – when deceleration occurs during a uterine contraction
* Usually benign (uniform in depth, length and shape), due to a normal response to head compression during labour
o Variable – where the time and shape of decelerations varies in relation to uterine contraction
* Classically reflect cord compression
o Late – when decelerations occur during contractions and persist after the end of the contraction
* Always abnormal, suggestive of foetal hypoxia.
methodical way for going through CTG?
DR C BRAVADO
define risk - why are they getting the CTG
contractions - 4 every 10 mins normal
baseline rate - 110-160 = normal
accelerations - increase in 15bpm lasting 15 seconds
variability - 5bpm change 5/10 min period
decelerations - decrease in 15 bpm lasting 15 secs
overall - – each feature can be described as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’ and used to define the CTG overall as: normal, suspicious or abnormal
polyhydramnios causes
increased fetal urine production =
maternal cardiac or renal disease
maternal diabtes
multiple pregnancy
hydrops fetalis
inability for fetus to swallow or absorb =
neuro or muysclar absnormality
duodenal atresia
downs sx
idiopathic = 30-50% cases
oligohydramnios causes
leakage of amniotic fluid =
rupture of membranes
reduced fetal urine output =
post dates
renal tract malformation
intratuertine fgrwoth restriction
other =
pre eclampsia
where to refer suspect gynae stuff ?
rapid access clinic
