Obs & Gynae Flashcards
Menopause definition
Absence of menses for 12 months without another reason for amenorrhoea (pregnancy, hormone therapy, medical condition)
Menopause symptoms
Amenorrhoea Irregular menstrual cycle Hot flushes Night sweats Vaginal symptoms (dryness, itching, dyspareunia) Mood changes Sleep disturbance Mild memory impairment Heavy menstrual bleeding
Premature menopause definition
Menopause before age 40
Premature menopause causes
Spontaneous Idiopathic Surgery (e.g. bilateral oophorectomy) Radiation of the pelvis Chemotherapy Autoimmune disease Fragile x syndrome
Premature ovarian insufficiency definition
Amenorrhoea, hypo-oestrogenic status and elevated gonadotrophins due to decline in ovarian function before the age of 40
Perimenopause definition
The transition from cyclic menstrual bleeding to a total cessation of menses which may occur over several years; marked by menstrual irregularity and periods of amenorrhoea due to declining progesterone and oestradiol levels
(Premature) Menopause investigations
Pregnancy test (negative) FSH (>30) Serum estradiol (<110)
Menopause management: mild vasomotor symptoms
Lifestyle changes - weight loss; exercise; avoid alcohol, caffeine, spicy food, warm environments, stress.
Menopause management: moderate/severe vasomotor symptoms +/- reduced libido
Menopausal, with a uterus: continuous combined regimen
Menopausal, without a uterus: oestrogen
Perimenopausal: sequential regime (oestrogen + cyclical progestin)
SSRIs (paroxetine), gabapentin or clonidine may also improve vasomotor symptoms
Menopause management: urogenital atrophy only
Vaginal oestrogen
Vaginal moisturiser
Oral ospemifene (selective oestrogen receptor modulator)
Menopause management: reduced libido only
Combination oestrogen-androgen
Menopause management: urinary stress incontinence only
Pelvic floor rehabilitation
HRT complications
Vaginal bleeding (common within first 6 months of oestrogen-progestogen)
Breast tenderness
VTE and stroke (transdermal has lower risk than oral)
Oestrogen (combination therapy only)
Premature menopause management
Continuous combined HRT
Counselling and support
If pregnancy is desired: donor oocyte and embryo transfer
Premature menopause complications
Osteoporosis
Cardiovascular disease
Barrier contraceptive options
Diaphragm and cervical cap - initially fitted by clinicians, must be filled and coated with spermicide before intercourse
Male condom
Female condom
Diaphragm: adverse effects/disadvantages
Skin irritation
Spermicide may increase HIV transmission risk
Increased risk of UTIs
Cervical cap: adverse effects/disadvantages
Skin irritation
Spermicide may increase HIV transmission risk
Condoms: adverse effects/disadvantages
Friction/noise (female) Latex allergy (male) Slippage/breakage (female>male) Loss of sensation Inconvenience
Behavioural contraceptive options
Lactational amenorrhoea (breast feeding 4-hourly during the day and 6-hourly at night; until first menstrual period/6 months postnatal/infant nursing less often) Periodic abstinence (5 days before ovulation to 2 days after: charting menstrual cycles; checking cervical mucus, urinary hormone levels, basal body temperature) Withdrawal
Hormonal contraceptive options
Combined oestrogen/progestogen contraception
-pills (3 weeks + 1 placebo week)
-patch (1/week for 3 weeks, one week off, repeat)
-vaginal ring (insert for 3 weeks, take out for 1, then new ring and repeat)
Progestogen-only contraception
-pill (24 active tablets, 4 inactive tablets)
-injection (LARC - 8 weeks)
-implant (LARC - 3 years)
-IUS (LARC - 3-6 years)
Absolute contraindications to oestrogen-containing contraceptives
Migraine with aura Smoking (if age >35 and >15/day) Hx of ischaemic heart disease Stroke Severe cirrhosis/liver tumour Major surgery with prolonged immobilisation (stop oestrogen 4-6 weeks before) Hx of DVT Hypertension (>160/100) Postnatal (<21 days) Breast cancer within past 5 years
Relative contraindications to oestrogen-containing contraceptives
Smoking (age >35 and <15 cigarettes/day)
Concurrent treatment with hepatic enzyme-inducing drugs
Hypertension (140/90 - 159/99)
Hx of breast cancer (>5 years ago)
COC side effects
Irregular bleeding (all) Nausea (pill, patch) Headaches (pill, patch) Breast tenderness (pill, ring) Skin irritation (patch) Increased vaginal discharge (ring) Low abdominal pain (ring)
Progestogen-only contraceptives: mechanism
Thickening cervical mucus +/- suppression of ovulation +/- make endometrium less hospitable to implantation
Progestogen-only contraceptives: absolute contraindications
Current breast cancer
Progestogen-only contraceptives: relative contraindications
Anti-phospholipid antibodies
Severe liver cirrhosis
Hx of breast cancer
Progestogen-only contraceptives: adverse effects
Changes in bleeding patterns (all) Headaches (all) Mood changes (all) Nausea (IUS) Breast tenderness (pill, IUS) Weight changes (implant, injection) Acne (implant, IUS) Abdominal pain (implant, injection) Decreased libido (injection) Loss of bone mineral density (injection) Up to 1 year delay in fertility returning (injection)
IUD risks
Ectopic pregnancy (increased relative risk but decreased overall risk) Expulsion (5% in first year, more if nulliparous or insertion postnatal or after termination) Uterine perforation (2 in 1000, higher in breastfeeding women)
Emergency contraception options
Progestogen-only (levonorgestrel) - within 96 hours of UPSI
Selective progesterone-receptor modulator (ulipristal)
Copper IUD
Oestrogen/progestogen (Yuzpe regimen)
Progestogen-only emergency contraception
52-100% effective
Single dose or two doses 12 hours apart
Adverse effects: headaches, nausea, dysmenorrhoea
Repeat if vomiting within 3 hours of taking
Available OTC if age >16
Ulipristal emergency contraception
90% effective
Take within 5 days
Contraindications: severe asthma controlled by oral steroids
Adverse effects: headache, nausea, dysmenorrhoea
Copper IUD as emergency contraception
Nearly 100% effective within 5 days
Adverse effects: changes in bleeding patterns (prolonged/heavy/irregular/painful)
Oestrogen/progestogen emergency contraception
75% efficacy
Take within 72 hours
Two doses 12 hours apart
Adverse effects: nausea and vomiting (more than POP/ulipristal)
Repeat if vomiting within 3 hours of taking
Endometriosis definition
Chronic inflammatory condition defined by endometrial strong outside of the uterine cavity, most commonly affecting the pelvic peritoneum and ovaries
Endometriosis aetiology
Retrograde menstruation
Deficient cell-mediated immune response (ineffective mechanism for clearing menstrual effluent)
Differentiation of coelomic epithelium into endometrial glands
Vascular and lymphatic dissemination
Endometriosis signs and symptoms
Dysmenorrhoea (particularly if progresses to become acyclic)
Chronic/cyclic pelvic pain
Dyspareunia (distorted pelvic anatomy, rectovaginal involvement)
Subfertility (scarring, prostaglandin over-production)
Pelvic mass (endometrioma)
Fixed, retroverted uterus (peritoneal fibrosis, pelvic adhesions)
-> uterine tenderness
Depression
Endometriosis investigations
TVUSS (endometrioma, deep pelvic endometriosis)
MRI pelvis
Diagnostic laparoscopy
Endometriosis management (immediate fertility not desired; pain without endometrioma or suspected severe/deep disease)
COCP or POP to induce atrophy of endometrial implants
NSAIDs
GnRH agonists to induce hypo-oestrogenic state; >6 months use can lead to irreversible decrease in bone mineral density)
Androgen to induce hypo-oestrogenic state
Laparoscopy
Hysterectomy with bilateral salpingo-oophorectomy and excision of visible peritoneal disease + HRT
Endometriosis management (immediate fertility not desired; pain with endometrioma or suspected severe/deep disease)
Surgery (radical excision of affected areas with restoration of normal anatomy; risk of reintervention is 50%)
If surgery does not result in complete removal of implants, postoperative therapy with GnRH agonist/progestogen/androgen may be indicated
Endometriosis management (immediate fertility desired)
Controlled ovarian hyper stimulation (clomifene or letrozole; risk of ovarian hyperstimulation syndrome and higher-order multiple gestations) IVF Surgery (endometrioma excision carries a small risk of ovarian failure)
Calculating estimated date of delivery
Naegele’s rule – add 7 days and 9 months from the first day of the last menstrual period; if cycle is longer than 28 days, add the additional number of the days to the date calculated
Diagnosis of confirmed miscarriage
Can be diagnosed on ultrasound if there is no cardiac activity and:
- The crown-rump length is greater than 7mm or
- The gestational sac is greater than 25mm
Management of confirmed miscarriage
Expectant management:
- First-line for the first 7 to 14 days after a confirmed diagnosis of miscarriage
- Consider other options if:
- Increased risk of haemorrhage (e.g. in late 1st trimester)
- Previous adverse and/or traumatic experience associated with pregnancy (stillbirth, miscarriage, antepartum haemorrhage)
- Increased risk from the effects of haemorrhage
- Evidence of infection
- Expectant management is not acceptable to the patient
- If pain and bleeding resolve in 7-14 days, advise to take a UPT after 3 weeks and return if positive
- Offer a repeat scan if, after the period of expectant management, bleeding and pain:
- Have not started (suggesting process of miscarriage has not yet begun) or
- Are persisting and/or increasing (suggesting incomplete miscarriage)
Medical management:
- Vaginal or oral misoprostol for missed or incomplete miscarriage
- Inform the woman what to expect, including:
- Length and extent of bleeding
- Potential side effects (pain, diarrhoea, vomiting)
- Offer pain relief and anti-emetics as needed
Surgical management:
- Manual vacuum aspiration under local anaesthetic in an outpatient or clinic setting or
- Surgical management in theatre under general anaesthetic
What is a threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
The bleeding is often less than menstruation
Cervical os is closed
Complicates up to 25% of all pregnancies
Threatened miscarriage investigations
TVUSS to confirm intrauterine pregnancy and look for fetal heartbeat
Threatened miscarriage management
If bleeding gets worse, or persists beyond 14 days, return for further assessment
If bleeding stops, start/continue routine antenatal care
What is a missed miscarriage?
A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
Cervical os is closed
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What is an inevitable miscarriage?
Heavy bleeding with clots and pain
Cervical os is open
What is an incomplete miscarriage?
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open
Investigation of a lower UTI in pregnancy
Send MSU for culture
Management of a lower UTI in pregnancy
Advise paracetamol for pain, and to keep well hydrated
Offer immediate antibiotics:
-First-line: nitrofurantoin for 7 days (avoid at term)
-Second-line: amoxicillin (only if culture results show susceptibility) or cefalexin for 7 days
-Treatment of asymptomatic bacteriuria: nitrofurantoin, amoxicillin or cefalexin, depending on culture and susceptibility results
Management of pyelonephritis in pregnancy
Paracetamol for pain +/- weak opioid e.g. codeine
Offer antibiotic
-First-line oral antibiotics: cefalexin for 7-10 days
-First-line IV antibiotics: cefuroxime
-Second-line: consult microbiologist
Seek medical help if symptoms worsen, or do not improve after 48 hours of Abx
Fibroids: definition
Benign tumours of the uterus primarily composed of smooth muscle and fibrous connective tissue; round, firm, and well-circumscribed nodules; subserosal/intramural/submucosal
Fibroids: signs and symptoms
Asymptomatic
Menorrhagia
Irregular firm central pelvic mass
Pelvic pain/pressure
Fibroids: investigations
USS (TV is preferable) Endometrial biopsy (normal; rule out endometrial cancer)
Fibroids: differential diagnosis
Adenomyosis may present with the same symptoms; distinguished by uterine biopsy and histopathology
Fibroids: management (fertility desired)
Medical therapy: leuprorelin (GnRH agonist) or mifeprostine (antiprogestogen) – both cause vasomotor symptoms
Levonorgestrel IUD
Myomectomy
Fibroids: management (fertility not desired)
Medical therapy then: -Uterine preservation desired: • Uterine artery embolization • Myomectomy -Uterine preservation not desired: • Hysterectomy
Urogenital prolapse: definition
Loss of anatomical support for the uterus, typically surrounding the apex of the vagina; the anterior and/or posterior vaginal wall may also be involved
Cystocoele – bladder prolapse
Rectocoele – rectum/large bowel prolapse
Enterocoele – small bowel
Urogenital prolapse: risk factors
Vaginal childbirth Advancing age Increasing BMI Prior pelvic surgery Excessive straining
Urogenital prolapse: signs and symptoms
Vaginal protrusion/bulge
Sensation of vaginal pressure
Urinary incontinence or retention (cystocoele)
Constipation (rectocoele)
Urogenital prolapse: investigations
Assessment of post-void residual volume (>100mL)
Urinalysis (normal unless concomitant UTI)
Urodynamics (distinguishes stress incontinence and/or urge incontinence)
Urogenital prolapse: management
Asymptomatic:
-Observation
-Pelvic floor exercises
Symptomatic:
-Pessary (restores prolapsed organs to their normal position; may require oestrogen cream if erosion occurs)
-Reconstructive surgery (often performed with concomitant hysterectomy; ureteral injury is the most common complication)
• Sacrocolpopexy (abdominally or laparoscopically)
• Uterosacral ligament suspension (vaginally or abdominally)
• Sacrospinous ligament suspension
• +/- continence procedures (mid-urethral sling or Burch urethropexy)
Infertility: causes
Ovulatory dysfunction
Tubal or other anatomical disorders
Endometriosis
Unexplained failure to conceive over a 2-year period
Infertility: risk factors
Age >35 Irregular/absent menses Inflammatory pelvic processes (Hx of STI, previous surgery) Pelvic pain, dyspareunia (endometriosis) Very high or low body fat Smoking (may accelerate menopause) IBD SLE Dopaminergic medications increasing prolactin
Infertility: investigations
TVUSS
Urinary LH (positive indicates imminent ovulation)
Luteal-phase progesterone (<9.5nm/L if anovulatory)
Hysterosalpingogram (tubal blockage)
Semen analysis
Infertility: management
Lifestyle modification (obesity, smoking, UPSI with multiple partners)
Regular UPSI
Optimisation of medical management if associated with medical condition
Counselling, controlled ovarian stimulation/oocyte donation, IVF
Medical termination up to 10+0
Interval treatment (24-48 hours) with mifepristone and misoprostol Consider expulsion at home and offer clinic or telephone follow-up
Medical termination between 10+1 – 23+6
Mifepristone, followed by misoprostol 36-48 hours later then every 3 hours until expulsion
Anti-D prophylaxis
Surgical termination up to 13+6
Cervical priming with misoprostol
Anti-D prophylaxis from 10+0
Surgical termination between 14+0 – 23+6
Cervical priming with misoprostol or osmotic dilators or mifepristone
Anti D prophylaxis
Support after termination
What aftercare and follow-up to expect
What happens if they have any problems, including who to contact out-of-hours
Explain that it is common to experience a range of emotions after a termination
Advise women to seek support if they need it – friends and family, support groups, counselling or psychological interventions
Discuss contraception
Molar pregnancy (hydatidiform moles): definition
Chromosomally abnormal pregnancies have the potential to become malignant (gestational trophoblastic neoplasia)
Complete hydatidiform moles (46XX/46XY) are typically the result of fertilisation of a chromosomally empty egg with a haploid sperm that then duplicates
Partial hydatidiform moles (69XXX/69XXY) usually arise from fertilisation of a haploid ovum by a single sperm, and duplication of paternal haploid chromosomes
Molar pregnancy: signs and symptoms
First trimester
Vaginal bleeding
Unusually large uterus for gestational age
Hyperemesis gravidarum
Molar pregnancy: investigations
Serum beta HCG (often >100,000; abnormally elevated for gestational age) Pelvic USS (abnormal with uterine enlargement; snow-storm appearance of uterine cavity and absence of fetal parts (complete); small placenta with partial fetal development (partial))
Molar pregnancy: management
Dilation and evacuation with IV oxytocin and suction
Strict adherence to contraception during 12-month period of follow-up
Serum beta HCG monitoring over this period for gestational trophoblastic neoplasia
If future fertility is not desired, hysterectomy may be appropriate
Ovarian cyst: definition
A fluid-filled sac in the ovarian tissue, which may be physiological, infectious, benign, neoplastic, malignant neoplastic, or metastatic
Ovarian cyst: signs and symptoms
Pelvic pain
Bloating and early satiety
Palpable adnexal mass
Ovarian cyst: investigations
TVUSS (enlarged ovary or portion of ovarian tissue; may be cystic, solid, or mixed)
Ovarian cyst: management
Suspected torsion or rupture – laparoscopy or laparotomy
Non-pregnant, pre-menopausal – conservative management with serial USS
-If solid cyst – laparotomy and gynae-oncology referral
Post-menopausal, simple cyst – conservative management with serial USS
-If complex or solid cyst – laparotomy and gynae-oncology referral
Pregnant:
- Asymptomatic, <8cm – conservative
- Symptomatic and/or >8cm – laparoscopy
- Solid cyst – laparotomy
Ovarian cancer: risk factors
Age
Family history of breast and/or ovarian cancer
Never used OCP
BRCA1 and BRCA2 mutations
Ovarian cancer: signs and symptoms
Pelvic mass
GI symptoms (bloating, nausea, dyspepsia, early satiety, diarrhoea, constipation)
Urinary urgency
Ovarian cancer: investigations
Pelvic USS (solid, complex, septated, multi-loculated mass; high blood flow)
CT scan
CA-125 (>35 units/mL)
Histopathology
Ovarian cancer: management
Early: comprehensive surgical staging +/- chemotherapy
Advanced: debaulking surgery + IV chemotherapy +/- intraperitoneal chemotherapy
Cervical cancer: risk factors
Age 45-59 HPV infection Multiple sexual partners Early onset of sexual activity (<18) Immunosuppression
Cervical cancer: signs and symptoms
Abnormal vaginal bleeding Postcoital bleeding Dyspareunia Pelvic/back pain Cervical mass Cervical bleeding
Cervical cancer: investigations
Colposcopy (abnormal vascularity, white change with acetic acid)
Biopsy
HPV testing
Cervical cancer: management
Non-metastatic: surgery (radical hysterectomy + lymphadenectomy) + chemo
Metastatic: chemo
HPV strains covered by vaccine
6, 11, 16, 18
CIN I definition
low-grade lesion with mildly atypical cellular change in lower third of epithelium
CIN II definition
high-grade lesion with moderately atypical cellular changes confined to basal two-thirds of epithelium
CIN III definition
severely atypical cellular changes encompassing greater than two-thirds of the epithelial thickness and includes full-thickness lesions (severe dysplasia and carcinoma-in-situ)
Most common type of endometrial cancer
Adenocarcinoma
Endometrial cancer: risk factors
Obesity, insulin resistance Age >50 Unopposed endogenous oestrogen (anovulation, low parity, early menarche, late menopause, obesity) Unopposed exogenous oestrogen (HRT) Tamoxifen use FHx of endometrial, breast or ovarian cancer PCOS o Lynch syndrome
Endometrial cancer: symptoms
Post-menopausal vaginal bleeding
Endometrial cancer: investigations
TVUSS (endometrial thickening >5mm) Outpatient endometrial biopsy (+/- hysteroscopy + histopathology) Cervical cytology (atypical glandular cells)
Endometrial cancer: management
Surgery +/- chemotherapy +/- radiotherapy
Antenatal care: 10-12 weeks
Comprehensive history
Lab work (FBC, blood type, Rhesus status and antibody screen)
Urine testing to detect asyptomatic bacteriuria (+ culture)
Screening (Rubella immunity, syphilis, gonorrhoea, chlamydia, hep B surface Ag, HIV antibody, cervical cytology if appropriate)
Education about pregnancy health
BMI
Physical examination
USS if unknown LMP or size-dates discrepancy on initial exam
Antenatal care: 11-13 weeks
First trimester USS
Maternal serum screening
Antenatal care: 16-18 weeks
Maternal serum alpha fetoprotein (elevated AFP associated with omphalocele, gastroschisis, and neural tube defects)
Antenatal care: 15-22 weeks
Quadruple marker serum screening
Amniocentesis (if required)
Antenatal care: 18-20 weeks
Fetal anatomy USS
Antenatal care: 28 weeks
FBC Antibody testing Glucose challenge testing Syphilis screen HIV antibody test Administer anti-D Ig if needed
Antenatal care: 33-36 weeks
Gonorrhoea and Chlamydia screen
Determine newborn care provider
Offer childbirth education classes
Antenatal care: 36+ weeks
Determine fetal presentation
Antenatal care: 35-37 weeks
Screen for Group B Streptococcus
Antenatal care: 41 weeks
Offer induction of labour
Vaccination during pregnancy
Influenza (October – May)
Tetanus, diphtheria, pertussis (27-36 weeks)
Routine antenatal testing:
FBC Blood type Urinary glucose Urine dipstick and culture Rhesus status Rubella status Review of last cervical screening Consider STI screening USS
Pregnancy complications related to obesity
Gestational hypertension Gestational diabetes Cardiac disease Pulmonary disease Obstructive sleep apnoea Caesarean delivery Venous thromboembolism Selected fetal malformations and stillbirth
Labour: definition
Painful contractions leading to dilatation of the cervix
First stage of labour
Initiation to full cervical dilatation
Latent phase – up to 4cm, may take several hours
Active phase – 4cm to fully dilated, at around 1cm/hour in nulliparous women and 2cm/hour in multiparous women
Monitor with a partogram
Second stage of labour
Full cervical dilatation to delivery of the fetus
Passive stage – from full dilatation until the head reaches the pelvic floor and the woman experiences the desire to push
Active stage – when the mother is pushing, around 40 minutes in nulliparous women and 20 minutes in multiparous women
If the active stage lasts >1 hour, spontaneous delivery becomes increasingly unlikely
Third stage of labour
Delivery of the fetus to delivery of the placenta
Normally lasts about 15 minutes
Normal blood loss is up to 500mL
Mechanical factors determining labour
Power (contractions)
Passage (pelvic dimensions)
Passenger (fetal head dimensions)
General care of women in labour
Temperature and blood pressure monitoring every 4 hours
Pulse check every 1 hour (first stage) then every 15 minutes (second stage)
Contraction frequency recorded every 30 minutes
Diagnosis of slow progress in labour
<2 cm dilatation in 4 hours
Most often caused by inefficient uterine action
Common in nulliparous women and induced labour
Managing slow progress in labour
Augmentation: artificial rupture of membranes; if this fails to further cervical dilatation in 2 hours, artificial oxytocin is administered, which will usually increase cervical dilatation within 4 hours if it is going to be effective
Types of fetal damage attributable to labour
Fetal hypoxia
Infection/inflammation in labour (e.g. GBS)
Meconium aspiration leading to chemical pneumonitis
Trauma, usually due to obstetric intervention (e.g. forceps)
Fetal blood loss
Active management of the third stage of labour
Oxytocin or Syntometrine (oxytocin + ergometrine)
Methods of induction of labour
Prostaglandin gel (either starts labour, or ripens the cervix to allow ARM)
ARM with amnihook; start IV oxytocin within 2 hours if labour has not ensued
Oxytocin alone following SROM
Cervical sweep (passing a finger through the cervix to strip between the membranes and the lower segment of the uterus) – reduces chance of induction and post-dates pregnancy; may be uncomfortable
Indications for induction of labour
Prolonged pregnancy Suspected IUGR or compromise Antepartum haemorrhage Poor obstetric history PROM Pre-eclampsia Maternal diabetes
Absolute contraindications to induction of labour
Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
Relative contraindications to induction of labour
One previous c-section
Prematurity
Gestational diabetes: definition
Glucose intolerance diagnosed after the first trimester of pregnancy, most often at 24-28 weeks on the basis of abnormal glucose tolerance testing
Gestational diabetes: risk factors
Advanced maternal age (>40) Elevated BMI (>30) PCOS Non-white ancestry FHx of T2DM Previous gestational DM
Gestational diabetes: signs and symptoms
Polyuria
Polydipsia
Fetal macrosomia
Gestational diabetes: investigations
75g OGTT performed in the morning after an overnight fast (>=5.1 fasting; >=10.0 at 1 hour; >=8.5 at 2 hours)
Gestational diabetes: management
Diet (30kcal/kg), exercise, and glucose monitoring are often sufficient
Insulin therapy
Antepartum fetal monitoring from 32-34 weeks
Intrapartum glycaemic control during labour; anticipate large reduction in insulin requirement following placental delivery, which may cause a hypo
Gestational diabetes: complications
Maternal hypertension C-section Fetal macrosomia Birth injuries Neonatal death Neonatal hypoglycaemia Neonatal jaundice Neonatal polycythaemia Type 2 Diabetes
Gestational hypertension: definition
BP >=140/90 on two occasions at least 4 hours apart during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without features of pre-eclampsia
Gestational hypertension: risk factors
Nulligravidity Black or Hispanic ethnicity Obesity Mother being small for gestational age T1DM
Gestational hypertension: investigations
Urinalysis (negative or <1+ protein)
FBC, U+Es, LFTs (within pregnancy-specific thresholds)
Gestational hypertension: management
<37 weeks gestation, <159/109
- Lifestyle modification
- Antihypertensive treatment (labetalol, nifedipine, methyldopa)
<37 weeks gestation, >160/110
-Lifestyle modification and antihypertensive treatment (labetalol/nifedipine/methyldopa)
> 37 weeks gestation, <159/109
-Induction of labour
> 37 weeks gestation, >160/110
-Antihypertensive treatment (labetalol/hydralazine/nifedipine) and induction of labour
Indications for induction of labour/delivery in gestational hypertension
Labour or ROM
Abnormal fetal testing
IUGR
Development of pre-eclampsia (depending on gestational age and severity) or eclampsia
Evidence of end-organ damage (neurological, hepatic or renal dysfunction)
Gestational hypertension: complications
Cardiovascular disease in the mother in later life
Fetal/neonatal complications (macrosomia, c-section, NICU admission)
Pre-eclampsia: definition
A disorder of pregnancy associated with new-onset hypertension (>140/90), which occurs most often occurs after 20 weeks of gestation and frequently near term
Pre-eclampsia: pathophysiology
Failure of the normal invasion of trophoblast cells leading to maladaptation of maternal spiral arterioles
Pre-eclampsia: risk factors
Primiparity Pre-eclampsia in previous pregnancy FHx of pre-eclampsia BMI >30 Maternal age >40 Multiple pregnancy Pre-existing diabetes
Pre-eclampsia: signs and symptoms
Hypertension Headache (usually frontal; classifies pre-eclampsia as severe) Upper abdominal pain (usually RUQ; HELLP syndrome) Reduced fetal movement Fetal growth restriction Oedema Visual disturbances Hyperreflexia and/or clonus
Pre-eclampsia: investigations
Urinalysis (proteinuria; >0.3g protein in 24 hours) Fetal ultrasound (growth restriction) CTG FBC (low platelets in HELLP) LFTs (elevated transaminases in HELLP) Placental growth factor (low)
Pre-eclampsia: management
Hospital admission and monitoring Decision regarding delivery (delivery is the definitive management) Corticosteroids if <34 weeks Antihypertensive therapy Magnesium sulfate for eclamptic seizures
Pre-eclampsia: complications
IUGR Seizures Stillbirth Placental abruption Pulmonary oedema Pregnancy-associated stroke Renal failure in later life
Obstetric cholestasis: definition
A pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and placenta; bile acids have a vasoconstricting effect on human placental chorionic veins, which can cause sudden asphyxial events.
Obstetric cholestasis: risk factors
Hx (personal or family) of obstetric cholestasis
Hx of hep C
Age >35
Obstetric cholestasis: signs and symptoms
Pruritis, sparing the face
Excoriations without rash
(Mild jaundice)
Obstetric cholestasis: investigations
o Bile acids (11-40 mmol/L – mild; >40 mmol/L – severe)
LFTs (elevated transaminases and alk phos)
Clotting (occasionally increased PT due to vitamin K depletion)
Fasting serum cholesterol (greater elevation than usually seen in pregnancy)
Hepatitis C virology
Obstetric cholestasis: management
Mild disease
- Antihistamines (to reduce pruritis)
- Consider colestyramine (to disrupt enterohepatic circulation and resorption of bile acids) and vitamin K (as colestyramine causes malabsorption of fat-soluble vitamins)
- Consider ursodeoxycholic acid
- Topical antihistamines
- Loose, cotton clothes
Severe disease -C-section or induction if >37 weeks -If <37 weeks: • Ursodeoxycholic acid • Weekly/twice-weekly fetal surveillance including USS • Corticosteroids if <34 weeks • C-section/induced delivery
Obstetric cholestasis: complications
Vitamin K deficiency in the mother
Premature labour
Intrauterine fetal demise
Respiratory distress syndrome in pre-term infants
Hyperemesis gravidarum: definition
Severe nausea and vomiting in pregnancy, characterised by persistent vomiting, volume depletion, ketosis, electrolyte disturbance, and weight loss
Hyperemesis gravidarum: risk factors
Hx (personal or family) of hyperemesis gravidarum
Multiple gestation
Gestational trophoblastic disease
Increased placental mass (triploidy, trisomy 18 or 21, hydrops fetalis)
Hyperemesis gravidarum: investigations
FBC, LFTs, (normal)
U+Es (hyponatraemia, hypochloraemia)
Urinalysis (ketonuria)
Fetal USS with nuchal translucency
Hyperemesis gravidarum: management
Ginger supplements (raw/tea/tablets)
Smaller, more frequent meals
Avoid trigger foods; preference bland-tasting, high-carb, low-fat foods
Sour/tart liquids (e.g. lemonade) may be tolerated better than water
Pyridoxine (vitamin B6) and/or doxylamine (antihistamine)
Anti-emetics
IV hydration
TPN in extreme cases
Hyperemesis gravidarum: complications
Symptoms may persist throughout pregnancy Fetal growth restriction Pre-eclampsia Mallory-Weiss tears Wernicke’s encephalopathy
Multiple pregnancy: management
Obstetric-led care
Consider selective fetal reduction
Monitoring: monochorionic – 2-weekly growth and Doppler from 16 weeks; dichorionic – 4-weekly growth and Doppler from 20 weeks
Monitor for IUGR – do not use SFH
Multiple pregnancy: complications
Greater likelihood of Down syndrome
Greater likelihood of needing invasive tests
Twin-twin transfusion syndrome
Hypertension
Preterm birth
Increased risk of foetal death after 38 weeks (twins) or 36 weeks (triplets)
Management of hypothyroidism in pregnancy
Check TFTs every 2-4 weeks
Increase thyroxine by 25 mcg as soon as pregnancy is confirmed
Management of hyperthyroidism in pregnancy
Check TFTs every 2-4 weeks
Carbimazole/propylthiouracil at lowest acceptable doses according to TFTs
Placental abruption: definition
The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the fetus
Placental abruption: risk factors
Direct abdominal trauma (causing separation of the placenta) Indirect trauma (shearing the placenta) Cocaine use (causing vasospasm leading to placental separation) Chronic hypertension Pre-eclampsia Smoking Chorioamnionitis Uterine malformations Oligohydramnios Prior placental abruption
Placental abruption: investigations
Fetal monitoring (abnormalities on CTG)
Hb and Hct (normal/low)
Clotting (abnormal)
USS
Placental abruption: management
Stabilise mother (prevent hypovolaemia, anaemia, DIC)
Monitor mother and fetus (initially continuous CTG)
Anti-D Ig if Rh-negative mother
If live fetus >34 weeks: delivery (c-section if unstable fetal/maternal status)
If live fetus <34 weeks: monitor, steroids, and tocolytics if stable; c-section if unstable
If fetal demise: vaginal delivery if mother stable; c-section if mother unstable
Prophylaxis of postpartum haemorrhage
Uterotonics in third stage and for c-section (IM/IV oxytocin)
Management of minor PPH (500-1000 mL, no shock)
IV access
Urgent bloods – G&S, Cross-match, FBC, clotting
Pulse, RR and BP monitoring every 15 minutes
Warm crystalloid infusion
Management of major PPH (>1000 mL)
Call for help ABC approach Position patient flat Keep patient warm 10-15L oxygen 2 large bore cannulae Urgent bloods – G&S, Cross-match, FBC, clotting Transfuse blood ASAP Foley catheter to measure urine output IV/IM syntocinon or IM ergometrine or syntometrine IM carboprost Bakri balloon tamponade Other surgical measure (B-lynch suture, hysterectomy)
Management of fetal demise
If membranes intact, offer expectant management or induction of labour
If rupture of membranes, infection or bleeding, immediate induction is preferred (mifepristone followed by prostin or misoprostol)
Rhesus disease: definition
Destruction of fetal RBCs from transplacental passage of maternally derived IgG antibodies, usually against the RhD antigen, causing progressive fetal anaemia and eventually hydrops fetalis and death
Causes of maternal sensitisation to RhD antigen
History of delivery of a Rh-positive fetus to a Rh-negative mother
Fetomaternal haemorrhage
Invasive fetal procedures
Placental trauma
Abortion (threatened, spontaneous or induced)
Omission (or inadequate dosing) of appropriate Rh immunoprophylaxis following a potentially immunising obstetric event in a previous or current pregnancy
Multiparity (enhanced response to sensitisation when a secondary immune response is generated)
Rhesus disease: investigations
Maternal blood type (Rh-negative)
Maternal serum Rh antibody screen (positive)
Paternal blood type (Rh-positive)
Fetal USS (subcutaneous oedema, ascites, pleural effusion, pericardial effusion)
Fetal blood typing (amniocentesis or maternal circulation)
Rhesus disease: management
Give anti-D immunoglobulin at sensitising events, at 28 weeks, and at 40 weeks or delivery of a Rh-positive infant (whichever occurs first)
Can give the fetus intravascular intrauterine blood transfusions to treat hydrops fetalis
For neonates with erythroblastosis, consider exchange transfusion/phototherapy/ IVIG
Breech presentation: definition
Baby presents with the buttocks or feet rather than the head first (cephalic)
Breech presentation: risk factors
Premature fetus SGA Nulliparity (SGA) Fetal congenital abnormalities (SGA) Previous breech delivery Uterine abnormalities Oligohydramnios Polyhydramnios
Breech presentation: investigations
Transabdominal/transvaginal USS
Breech presentation: management
From 37 weeks, can attempt ECV
Give anti-D at ECV if Rh-negative
If ECV is unsuccessful, consider vaginal vs caesarean delivery
Contraindications to ECV
Multiple pregnancy (except after delivery of a first twin)
Ruptured membranes
Current/recent (<1 week) vaginal bleeding
Rhesus isoimmunisation
Other indications for a c-section (placenta praevia, uterine malformation)
Abnormal CTG
Complications of breech delivery
Cord prolapse Placental abruption Pre-labour rupture of membranes Perinatal mortality Fetal distress (HR<100) Preterm delivery Lower fetal weight 40% risk of needing an emergency c-section
Risks of ECV
50% failure rate
Placental abruption
Fetal distress requiring an emergency c-section
PROM: risks
Cord prolapse (rare) Infection – risk increased by vaginal examination, presence of GBS, and increased duration of membrane rupture
PROM: management
Wait for spontaneous labour for up to 24 hours
After 18-24 hours, prescribe antibiotics against GBS, and induce labour
PPROM: management
Offer oral erythromycin for a maximum of 10 days or until the woman is in established labour
Monitor for signs of chorioamnionitis and pre-term labour
Consider admission/regular outpatient monitoring
Consider corticosteroids
Offer IV magnesium sulphate to women between 24+0 – 29+6 who are in established preterm labour or have a planned preterm birth within 24 hours
Aim for delivery at 37 weeks
Risks of PPROM
Infection
Prematurity
PPROM: risk factors
Smoking
STIs
Previous PPROM
Multiple pregnancy
Indications for vaginal progesterone
TVUSS at 16-24 weeks showed cervical length <25mm with or without history of spontaneous preterm or mid-trimester loss
Indications for cervical cerclage
History of spontaneous preterm or mid-trimester loss (16-34 weeks) and TVUSS at 16-24 weeks showed cervical length <25mm
Placenta praevia: definition
The placenta overlying the cervical os; may be complete, partial, marginal, or low-lying (all except complete may resolve as the pregnancy progresses); may be associated with an abnormally adherent placenta (attaches to myometrial layer) in women with a scarred uterus
Placenta praevia: risk factors
Uterine scarring (usually due to prior c-section) IVF Prior placenta praevia Advanced maternal age Multiple pregnancy Smoking
Placenta praevia: investigations
Uterine USS with colour flow Doppler analysis
FBC (low Hb in acute bleeding)
Group and save, crossmatch
Placenta praevia (bleeding): management
Resuscitation and stabilisation; if not stabilised by resuscitation, urgent c-section
Stabilised, not in labour – corticosteroids (<34 weeks), anti-D
Stabilised, in preterm labour – tocolytics (terbutaline), corticosteroids, anti-D
Stabilised, at term – C-section, anti-D
Placenta praevia (no bleeding): management
Preterm, not in labour – monitoring, pelvic rest (no SI or pelvic douching), consider corticosteroids
Premature labour – tocolytics (terbutaline), corticosteroids, anti-D
At term – c-section; can consider vaginal delivery if marginal/low-lying placenta praevia
Placenta praevia: complications
Anaemia Preterm birth Haemorrhage and DIC IUGR Fetal death
Vasa praevia: definition
The fetal vessels lie over the internal cervical os
