OBS - pregnancy & labour/birth Flashcards
1
Q
Obstetrics
Definition: Prematurity
A
Onset of labour before 37 weeks gestation
- < 28 weeks: Extremely preterm
- 28-32 weeks: Very preterm
- 32-37 weeks: Moderate to Late preterm
2
Q
What are the 4 phases of cervical remodelling?
A
- Softening
- Ripening
- Dilation
- Repair
3
Q
What is the aetiology of preterm birth?
A
- Term labour results from physiological activation of the pathway
- Preterm labour results from pathological processes that activate one or more components of the common pathway
4
Q
Name 4 causes of preterm birth
A
- Infection - most common
- Ischaemia
- Uterine overdistension
- Cervical disease - cervical weakness
5
Q
What are two preventative measures for preterm birth?
A
Given to women with a cervical length < 25mm between 16 and 24 weeks gestation / had previous preterm birth
- Progesterone- daily vaginal suppositories
- Cervical cerclage: stitch into the cervix
6
Q
What is done to determine when management can be offered to treat a preterm?
A
< 30 weeks gestation
* clinical assessment alone is enough
> 30 weeks gestation:
- Cervical length screening (< 15)
- Foetal fibronectin
7
Q
What is the management of a preterm labour?
A
- Tocolysis: stop uterine contractions (Nifedipine or atosiban)
- Antenatal steroids: 2 IM betamethasone injections 24 hrs apart, reduces neonatal mortality, reduces NEC
- IV magnesium sulphate: protects baby’s brain, reduces risk of cerebral palsy
-
Delayed cord clamping: increases circulating blood vol & Hb
-intrapartum antibiotics - to stop group B strep infections
-thermoregulation
8
Q
Definition: Prelabour rupture of membranes (PROM)
A
Rupture of membranes after 37 weeks gestation
9
Q
Definition: Preterm prelabour rupture of membranes (P-PROM)
A
Amniotic sac has ruptured before onset of labour and before 37 weeks gestation, releasing amniotic fluid
10
Q
How is preterm prelabour rupture of membranes diagnosed?
A
Speculum exam - shows pooling of amniotic fluid in vagina
If in doubt:
* Insulin-like growth factor-binding protein-1 (IGFBP-1): protein in amniotic fluid
* Placental alpha-microglobin-1 (PAMG-1)
11
Q
What is the management of preterm prelabour rupture of membranes?
A
- Prophylatic antibiotics: prevent chorioamnionitis (erythromycin)
- Induction of labour: from 34 weeks
12
Q
What is a low birth weight infant defined as?
A
Born with birthweight < 2.5kg (regardless of gestational age)
13
Q
What is a very low birth weight infant defined as?
A
Babies weighing < 1.5kg
14
Q
What is an extremely low birth weight infant defined as?
A
Babies weighing < 1kg
15
Q
How do you manage a low birth weight infant?
A
- NICU
- Temp-controlled bed
- Special feeding: tube in stomach/IV
16
Q
What are some common problems of low birth weight babies?
A
- Low O2 levels at birth
- Trouble staying warm
- Trouble feeding/gaining weight
- Infection
- Breathing problems
- Nervous system problems, e.g. haemorrhage
- Digestive problems e.g.necrotising enterocolitis
- sudden infant death syndrome (SIDS)
17
Q
What are some long-term complications of of being a very low birthweight baby?
A
- Cerebral palsy
- Blindness
- Deafness
- Developmental delay
18
Q
What is placental insufficiency?
A
- Oxygen/nutrients are not sufficiently transferred to the foetus via placenta during pregnancy
- Leads to foetal hypoxemia & restricted foetal growth
19
Q
What causes placental insufficiency?
A
- Disturbances to perfusion of placenta
Diabetes
Pre eclampsia
Cociane
Smoking
* Reduction in surface area of placenta that becomes integrated in uterine walls
* Placentation can be negatively affected by lateralisation (placenta favours one side instead of being implanted centrally): blood isn’t equally distributed = distribution of nutrients affected
20
Q
What is gestational diabetes
A
diabetes triggered by pregnancy due to reduced insulin sensitivity which resolves after birth
21
Q
Complications of gestational diabetes (3)
A
Large fetus + Macrosomia (large newborn)
Shoulder dystocia - during birth
Maternally
Higher risk of developing type two diabetes after pregnancy
22
Q
Risk factors for gestational diabetes (5)
A
-Previous gestational diabetes
-Previous macrosomic baby (≥ 4.5kg)
-BMI > 30
-Ethnic origin (black Caribbean, Middle Eastern and
South Asian)
-Family history of diabetes (first-degree relative)
-polycystic ovarian syndrome
23
Q
Screening test for gestational diabetes
A
Oral glucose tolerance test at 24-28 weeks
24
Q
What features suggest gestational diabetes? (3)
A
-Large for date fetus
-Polyhydramnios
-Glucose on urine dipstick
25
How is oral glucose to test carried out?
-In the morning after a fast
-Drink 75 g of glucose
-Blood sugar levels are measured before and 2 hours after
26
What are normal results for OGTT
Fasting <5.6 mmol/L
2 hours after glucose < 7.8 mmol/L
remember 5-6-7-8
27
Mx of gestational diabetes
4 weekly ultrasound scans - measure amniotic fluid volume and fetal growth for **macrosomia**
Fasting glucose less than 7 mmol/l -
- trial of diet and exercise for 1-2 weeks
- followed by metformin
- then insulin
Fasting glucose above 7 mmol/l - start - insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications) - -start insulin ± metformin
Insulin should be short acting
28
What is given to women with gestational diabetes who can’t tolerate metformin
Glibenclamide (a sulfonylurea)
29
What’s the measures done for those with pre existing diabetes during pregnancy (5)
Pre conception
-5mg folic acid
Aspirin 150mg daily from 12 weeks - reduce pre eclampsia
During pregnancy
Women with pre existing diabetes still want same insulin levels as in gestational diabetes
**Retinopathy screening - check for diabetic retinopathy**
Planned pregnancy at 37-38+6 weeks with pre existing diabetes
Sliding scale insulin regime - with type 1 diabetes/poorly controlled type 2/ gestational
30
Postnatal care of gestational diabetes for:
Women with gestational diabetes
Women with pre existing diabetes
Babies
Women with only gestational diabetes
Stop medication immediately
Women with existing diabetes
Lower insulin doses to avoid hypoglycaemia
Pre pregnancy counselling
Babies
-neonatal hypoglycaemia - regular BG tests + frequent feeds
-IV dextrose or nasogastric feeding if blood sugar below 2.6
31
What is an antepartum haemorrhage
•Bleeding from anywhere within the genital tract after the 24th week of pregnancy
32
Causes of Antepartum haemorrhage (4)
-low lying placenta/ placenta praevia
-vasa praevia
-minor/major abruption
-infection
33
What is low lying placenta
Any part of the placenta that has implanted into the lower segment of the uterus
34
What classes as a major and minor low lying placenta
Major - covering the Os
Minor - in lower segment not covering os
35
How to diagnose low lying placenta
20 week abdo Ultrasound scan
Repeated at 32 weeks + 36 weeks
RCOG recommend transvaginal USS
36
Mx of placenta praevia
•Advise to present if pain / bleeding - if bleeding emergency c section + ABCDE
•Advise to avoid sexual intercourse
•If recurrent bleeds may require admission until delivery and ensuring has cross-match in date
•Remember to give anti-D if Rh negative
•**Elective Caesarean section around 37/40**
37
What is placenta praevia?
When the low-lying placenta partially/completely **covers opening of cervix**
38
Signs and symtoms of placenta praevia
-painless vaginal bleeding
-light contractions
-tense uterus
-lie and presentation of baby maybe abnormal
39
What is placental abruption
the complete or partial detachment of the placenta before delivery.
40
Cause of placental abruption
Unknown
Maybe trauma or injury
41
Risk factors of placental abruption
A- previous abruption
B- blood pressure (HTN/pre eclampsia)
R - PROM
U- uterine injury (trauma)
P- polyhydramnios
T- twins - multiparity
I- infection
O- older maternal age
N- narcotics e.g cocaine/ smoking
42
Clinical presentation of placental abruption (5)
-Abdominal pain (most common) – posterior
-placental abruptions may present with back pain
-Vaginal bleeding
-Uterine contractions
-Dizziness and/or loss of consciousness
43
Clinal findings upon examination for placental abruption
-woody, tense uterus
-fetal heart may be absent or distressed
44
Investigations for placental abruption
Diagnostic - ultrasound scan to locate the bleed
Other
-vital signs
-FBC
-Clotting profile
-kleihauer test - fetal haemoglobin transferred from fetus to mother
45
Mx of placental abruption
Foetus alive
-fetal distress - immediate C-section
-no fetal distress - observe closely
Foetus dead - induce signal delivery unless mother heamodynamically unstable - then do C-section
46
Complications of placental abruption in:
Mother
Foetus
Complications in mother:
-Major haemorrhage
-Shock: can result in Sheehan syndrome - pituitary gland necrosis
-Compression of uterine muscles prevents good contraction of muscles during labour
-disseminated intravascular coagulation (DIC)
-Post-partum haemorrhage
Complications for the fetus:
Placental insufficiency: results in hypoxia and intrauterine growth restriction (IUGR) due to lack of nutrients
-Premature birth
-Stillbirth
47
What is vasa praevia
Fetal blood vessels (the two umbilical arteries and single umbilical vein) are within the fetal membranes and run across the internal cervical os.
48
Risk factors for vasa praevia (3)
IVF pregnancy
Multiple pregnancy
Low lying placenta
49
Sx of vasa praevia
-Painless vaginal bleeding
-Rupture of membranes
-Fetal bradycardia
50
Investigations for vasa praevia
Diagnostic - ultrasound scan
Others:
Vital signs
FBC
Clotting profile
Kleihauer test
51
Mx of vasa Praevia (3)
-if found on US then elective casearean section at 34-36 weeks
-corticosteroids given to promote fetal lung maturity
If Antepartum haemorrhage then emergency caesarean
52
What is pre eclampsia
New high blood pressure 140/90 in pregnancy with **at least one of**
-end organ dysfunction
-proteinuria
53
Triad of pre eclampsia
Oedema
Proteinuria
Hypertension
54
Whats the pathology of pre eclampsia
after 20 weeks gestation, when the spiral arteries of the placenta form abnormally (more tangled), leading to a high vascular resistance in these vessels and poor perfusion of placenta.
Leads to oxidative stress in the placenta
Release of inflammatory chemicals into systemic circulation and impaired endothelial function of blood vessels
55
What is eclampsia
When seizures occur as a result of pre-eclampsia.
56
What is gestational HTN
Hypertension occurring after 20 weeks gestation, without proteinuria.
57
High Risk factors for pre eclampsia (5)
Pre existing HTN
HTN before in pregnancy
Existing autoimmune conditions e.g lupus
Diabetes
CKD
58
Treatment of eclampsia (2)
Deliver baby after mum is stabilised
-IV MgSO4 for 24 hours
-Treat HTN - labetelol or nifedipine
59
Risk factors 5 for maternal sepsis (10)
-obesity
-diabetes
-anaemia
-history of pelvic infection
-history of group strep B infection
-group A strep infection
-immunosuppressant meds
-PROM
-vaginal discharge
-amniocentesis
60
Maternal sepsis management
Within first hour sepsis 6
•1) O2 as required to achieve SpO2 over 94%
•2) Take blood cultures
•3) Commence IV antibiotics
•4) Commence IV fluid resuscitation
•5) Take blood for Hb, lactate (+glucose)
•6) Measure hourly urine output
Stabilise mother then deliver baby
61
What is cord prolapse
umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes
62
Main complication of cord prolapse
Fetal hypoxia
63
Biggest risk factor for cord prolapse
fetus is in an abnormal lie after 37 week gestation as it allows room for cord to descend
64
How to diagnosis cord prolapse (3)
-CTG showing signs of fetal distress
-vaginal examination
- speculum
65
Management of cord prolapse + cord compression
Cord prolapse
-Emergency C- section
**If cord compression**
1) push presenting fetus upward to prevent compression
If below the introitus then keep moist and wet
2) Positions:
-put woman in left lateral position
-on all fours (gravity reduces compression)
3) medication:
-terbutaline (tocolytic - minimises contractions)
66
What is umbilical cord compression
Babies umbilical cord becomes flattened by pressure leading to vasoconstriction and fetal hypoxia due to lack of oxygenated blood
67
What is hyperemesis gravidarum
Exhaggerated, long in duration, nausea and vomiting in early pregnancy
68
What weeks does hyperemesis gravidarum usually occur
4-8 weeks of gestation
69
Causes of hyperemesis gravidarum
-rapidly rising HCG levels
-pregnancy related decreased gastric motility
70
Risk factors of hyperemesis gravidarum
-previous hyperemesis gravidarum
-increased hCG levels
-multiple pregnancy
-biologically female foetus
-hyperthyroidism
71
Complications for hyperemesis gravidarum
-dehydration
-weight loss
-Mallory Weiss tear
-metabolic alkalosis
-electrolyte imbalance
If prolonged
-intrauterine growth restriction
72
Signs and symptoms of hyperemesis gravidarum
-frequent N+V
-**signs of dehydration**- tachycardia, palpitations, hypotension, decreased skin turgor
-malaise
-increased sensitivity to smell
-weight loss
-ketoacidosis odour - pear drops
73
How to diagnose hyperemesis gravidarum
**Pelvic ultrasound** - to exclude molar pregnancy + identify multiple pregnancy
**Lab results**
-blood urea nitrogen - increased
-creatinine - increased
-potassium - decreased
-sodium - decreased
-urinalysis - increased ketones
**excessive vomiting history** - clinical dehydration signs
74
Tx of hyperemesis gravidarum (3)
-Antiemetics - cyclizine and antihistamine
-Vitamin B6 - decreases nausea pyrodoxine
-Pabrinex
-Fluid, electrolyte replacement
Trigger avoidance
-small, frequent meals
-avoid spicy food
2nd line - ondasetron - can cause cleft lip and palate
- metaclopromide (not be used for more than 5 days) - extra pyramidal SE
75
What is placenta accreta
Placenta implants deeper, through and past the endometrium - makes it hard to remove the placenta after delivery
76
What are the three layers of the uterine wall
Endometrium - inner layer - connective tissue layer
Myometrium - middle layer - smooth muscle layer
Perimetrium - outer layer - serous membrane
77
What are the three levels of severity of placenta accreta
**superficial placenta accreta** - placenta implants in the myometrium
**placenta increta** - placenta attaches **deeply** to the myometrium
**placenta percreta**- placenta invades into perimetirum and can reach other organs
78
Management of placenta accreta
**C-section** 35-36 weeks gestation to reduce spontaneous delivery
Surgery
-hysterectomy - preserving the placenta
-uterus preserving surgery - resection of part of the myometrium and the placenta
-expectant management - leaving the placenta to be reabsorbed over time
**antenatal steroids for fetal lung maturation**
79
How to diagnose placenta accreta
Ultrasound - allows for planning
MRI scans - assess depth and width
80
What is uterine rupture
A complication of labour where the myometrium layer of the uterus ruptures
81
What’s the difference between complete and incomplete uterine rupture
Complete - the perimetrium also ruptures so the content of the uterus is released into the peritoneal cavity
Incomplete - the perimetrium remains in tact
82
5 Risk factors for uterine rupture (7)
-having a vaginal birth after a C section (VBAC)
-previous surgery on uterus
-induction of labour
-high parity (number of times they have given birth to live baby)
-increased BMI
-increased age
-using oxytocin to stimulate contractions
83
Presentation of uterine rupture
-Abnormal CTG
-abdo pain
-vaginal bleeding
-ceasing of uterine contractions
-hypotension
-tachycardia
-collapse
84
What is the treatment of uterine rupture?
**!!Obstetric emergency!!**
* Resuscitation & transfusion may be required
* **Emergency C section** necessary to remove baby, stop bleeding & repair/remove uterus
85
What is cervical show?
'Show' is a **blood-stained discharge** from uterus, often mixed with **mucus**
86
How does cervical show originate?
* Slow cervical dilation in early labour
* Causes **loosening & expulsion** of **thick mucus plug** that blocks the **cervical canal** throughout normal pregnancy
87
Definition: postpartum haemorrhage
Bleeding after delivery of the baby and placenta. With blood loss of:
1000ml in C section
500ml in normal delivery
88
What is a major haemorrhage and what are the two classifications
Major PPH is anything ABOVE 1000ml blood loss
Further classified into:
Moderate PPH - 1000-2000ml blood loss
Severe PPH - over 2000ml blood loss
89
What are primary and secondary PPH
Primary - bleeding within the **first 24 hours of delivery**
Secondary - bleeding from **24 hours to first 12 weeks after birth**
90
4 causes of postpartum haemorrhage
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
91
Give 5 risk factors for PPH
-previous PPH
-multiple pregnancy
-obesity
-large baby
-pre eclampsia
-placenta accreta
-placenta retained
-instrumental delivery
-general anasesthesia
-episiotomy or perineal tear
92
How do you prevent a PPH (4)
-treat underlying **anaemia** during the antenatal period
-giving birth with an **empty bladder** ( as with a full bladder it reduces uterine contractions)
-**IM oxytocin during third stage of labour** - promotes contractions
-**IV tranexamic acid used during C section** in higher risk patients
93
Initial Mx of PPH
**obstetric emergency**
-ABCDE resuscitation
-woman lay flat and kept warm
-insert TWO large bore cannulas to take Bloods for FBC, U+E, clotting screen
-group and cross match (blood transfusion)
-warmed IV fluid and blood resuscitation
-oxygen
-fresh frozen plasma if clotting abnormalities (DIC)
94
Management of PPH if cause is atony (6)
Initial MX steps and then in sequence:
bimanual uterine compression to manually stimulate contraction
intravenous oxytocin and/or ergometrine
intramuscular carboprost
intramyometrial carboprost
rectal misoprostol
surgical intervention such as balloon tamponade
95
What the Mx of PPH if cause is thrombin is cause
Tranexamic acid
Vitamin K ( discuss with haematology)
Fresh frozen plasma
96
Most common cause of secondary PPH (2)
Endometritis - inflammation of the uterine endometrium
Retained products of conception e.g placenta
97
Complications following PPH (7)
-anaemia
-hypovolaemic shock - leading to organ failure
-PTSD
-hysterectomy
-DIC
-sheehans syndrome
-death
98
What are the three categories of postpartum mental health illness (3)
Baby blues is seen in the majority of women in the first week or so after birth
Postnatal depression is seen in about one in ten women, with a peak around three months after birth
Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth
99
Symtoms of baby blues (5)
-mood swings
-low mood
-anxiety
-irritability
-tearfulness
100
Causes of baby blues
-Significant hormonal changes
-Recovery from birth
-Fatigue and sleep deprivation
-The responsibility of caring for the neonate
-Establishing feeding
101
Classical triad of postnatal depression (3)
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
102
Mx of postpartum depression
Mild cases - GP appointment, self help
Moderate cases - SSRIs and CBT
Severe cases - psychotherapy, CBT, SSRI/ SNRI
103
Sx of puerperal psychosis (6)
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
104
Tx of pueperal psychosis (4)
-Admission to the mother and baby unit
-Cognitive behavioural therapy
-Medications e.g antipsychotics (risperidone), mood stabilisers (lithium+lamotrigine)
-Electroconvulsive therapy (ECT)
105
How to prepare for mental health illnesses during pregnancy
perinatal mental health services which includes:
-medications management - **SSRIs, antipsychotics, lithium
-care plan after delivery - Health vistors, GPs, family and friends
106
What is a complication of SSRIs taken during pregnancy
**Neonatal abstinence syndrome**
- presents with poor feeding and irritability in first few days
107
What is the scale used to assess depression in postnatal mothers
Edinburgh postnatal depression scale - 13+ out of 30 suggests postnatal depression
108
Risk factors for VTE in pregnancy give 6 (11)
-smoking
-parity above 2
-pregnancy above 35
-BMI +30
-multiple pregnancy
-pre eclampsia
-gross varicose veins
-immobility
-FHX of VTE
-thrombophilia
-IVF pregnancy (elevated estradiol and hCG)
109
What is the preventative measures of VTE during pregnancy
VTE prophylaxis
-if 3+ risk factors give from 28 weeks
-**if 4+ risk factors give from first trimester**
110
What does VTE prophylaxis consist of
-LMWH e.g dalteparin, tinzaparin, enoxaparin
111
What is given as VTE prophylaxis if LMWH is contraindicated
-Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
-Anti-embolic compression stockings
112
Presentation of DVT in pregnancy
-Unilateral calf or leg swelling
-dilated superficial veins
-calf tenderness
-oedema
-colour changes to the leg
-difference in calf circumferences by more than 3cm when measured
113
Presentation of Pulmonary embolism in pregnancy
-SOB
-Tachycardia
-chest pain
-cough (can be haemoptysis)
-resp rate Increased
-low grade fever
-hypotension if heamodynamically unstable
114
Dx of DVT + PE (5)
-Doppler ultrasound - DVT
-CXR- PE increased lung transparency in the areas near the occluded vessel
-ECG- PE - S1Q3T3 (large S wave in lead 1/ Q wave in lead 3/ inverted T wave in lead 3)
CT pulmonary angiogram - identifies blood clots
Ventilation perfusion scan - shows perfusion (or lack of)
115
How does VQ perfusion scan work for PE
-radioactive isotopes are inhaled to fill the lungs
-picture taken to demonstrate ventilation
-contrast containing tracer is injected
-picture taken to demonstate perfusion
Images are compared if PE then **deficit in PErfusion** as thrombus will block blood flow to lung tissue
116
Why isn’t the wells score not used in pregnancy
In pregnancy there is a raised D Dimer so is not helpful
117
Mx of VTE
Initial - **LMWH starts immediately if suspected DVT/PE**
- Carried on for 6 weeks postnatally/ 3 months in total
Women with big PE and haemodynamically unstable :
-unfrationated heparin
-thrombolysis
-surgical embolectomy
118
Definition: miscarriage
is the spontaneous termination of a pregnancy in the first 20 weeeks of pregnancy
119
What the difference between early and late miscarriage
Early miscarriage is before 12 weeks gestation
Late miscarriage is between 12 and 24 weeks gestation
120
Definition: missed miscarriage
Fetus no longer alive but no symptoms occurred - hasn’t been expelled
121
Definition: Threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive
122
Definition: Inevitable miscarriage
vaginal bleeding with an open cervix
123
Definition: incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
124
Definition: complete miscarriage
a full miscarriage has occurred, and there are no products of conception left in the uterus
125
Definition: Anembryonic pregnancy
a gestational sac is present but contains no embryo
126
Dx for miscarriage
Gold standard - transvaginal ultrasound scan
127
What three measurement do you look for to determine pregnancy is viable
-Mean gestational sac diameter (25mm+)
-Fetal pole and crown-rump length (7mm+)
-Fetal heartbeat (outweighs the other two)
128
Mx of miscarriage in less than 6 weeks gestation
Expectant management - no treatment or investigation
Repeat urine pregnancy test after 7-10 days and if negative a miscarriage can be confirmed
129
Management of miscarriage More Than 6 Weeks Gestation
-ultrasound scan - to determine location and viability of the pregnancy - EXCLUDES ECTOPIC
3 options for managing miscarriage:
1)Expectant management (do nothing and await a spontaneous miscarriage)
2)Medical management (misoprostol)
3)Surgical management
130
What is expectant management and when is expectant management offered in miscarriage
-1/2 weeks given to allow miscarriage to happen spontaneously with repeat urine pregnancy to confirm its happened
-offered to women without risk factors for heavy bleeding or infection
131
Medical management for miscarriage
Misoprostol - prostaglandin analogue (activates prostaglandin receptors) - either Vaginal suppository/ oral
-stimulates uterine contractions + softens the cervix
132
Side effects of misoprostol (4)
Heavier bleeding
Pain
Vomiting
Diarrhoea
133
Surgical management of miscarriage
1)Manual vacuum aspiration under local anaesthetic
2)Electric vacuum aspiration under general anaesthetic
**Given during surgery
Anti rhesus prophylaxis to rhesus negative women
Prostaglandins to soften surgery**
134
What is the risk of retained products remain in the uterus after miscarriage
Infection
135
Two methods used for incomplete miscarriage
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
136
Key complication of evacuation of retained products of conception surgical procedure
Endometritis (infection of endometrium)
137
Presentation of aneamia in pregnancy
Pallor
SOB
Dizziness
138
Which type of anemia is indicated for each MCV during pregnancy
Low
Normal
Raised
Low MCV - iron deficiency
Normal MCV - physiological anaemia due to the increased plasma volume of pregnancy
Raised MCV - B12 or folate deficiency
139
What anaemias are women screened for during pregnancy
Thalassaemia (all women)
Sickle cell disease (if higher risk e.g black)
140
Managment of iron deficiency in pregnancy
Ferrous sulphate - 200mg three times daily
141
Tx of B12 deficiency anemia in pregnancy
-checked for intrinsic factor antibodies - pernicious aneamia
-**Intramuscular hydroxocobalamin injections**
-**Oral cyanocobalamin tablets**
142
Folate deficiency anaemia tx
-Folate acid 400mcg all women should be taking anyway
- with a deficiency Folic acid 5mg daily
143
Risks of UTI in pregnancy
Preterm delivery
Low birth weight baby
Maternal sepsis
Pre eclampsia
144
What is asymptomatic bacteriuria
bacteria present in the urine, without symptoms of infection
145
How to diagnose asymptomatic bacteruria
microscopy, culture and sensitivities (MC&S) routinely throughout pregnancy
146
Presentation of LUTI in pregnancy
Dysuria
Suprapubic pain
Increased frequency of urination
Incontinence
Haematuria (blood in urine)
Urgency
147
Presentation of pyelonephritis
Fever (more prominent than in lower urinary tract infections)
Loin, suprapubic or back pain (this may be bilateral or unilateral)
Looking and feeling generally unwell
Vomiting
Loss of appetite
Haematuria
Renal angle tenderness on examination
148
Causes of UTI
**KEEPS**
Klebsiella pneumoniae (gram-negative anaerobic rod)
E.coli
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
*And Candida albicans (fungal)
149
Most common cause of UTI in pregnancy
E.coli - found in faeces and can easily spread to the bladder
150
Mx of UTI in pregnancy
-Nitrofurantoin (avoid in the third trimester)
-trimethoprim (avoid in first trimester)
-Amoxicillin (only after sensitivities are known)
-Cefalexin
151
Contraindications of trimethoprim
Folate antagonist - can lead to neural tube defects such as spina bifida and anencephaly
152
Contraindications of nitrofurantoin
Avoid in third trimester - neonatal haemolysis
153
What is shoulder dystocia
when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered
154
What is essential hypertension?
**Primary HTN** means high blood pressure that has developed on its own & doesn't have a secondary cause
* Essential HTN accounts for **90%** of HTN
155
What are secondary causes of HTN?
## Footnote
Pneumonic ROPED
* **R**enal disease (MC)
* **O**besity
* **P**regnancy-induced HTN / **p**re-eclampsia
* **E**ndocrine
* **D**rugs (alcohol, steroids, NSAIDs, oestrogen)
156
What is chronic hypertension obs
* High blood pressure that exists **before 20 weeks** gestation & is longstanding
* **Not** caused by placental dysfunction
* **Not** classified as pre-eclampsia
157
What is puerperal infection (post-partum infection)?
Bacterial infections of the female reproductive tract following childbirth/miscarriage
158
What are some common types of puerperal infections?
* **Endometritis** (uterine lining) - MC
* **Myometritis** (uterine muscle)
* **Parametritis**/pelvic cellulitis (supporting tissue around uterus)
159
What are the symptoms of puerperal infections?
General Sx:
* fever
* chills
* body aches
* appetite loss
Specific Sx:
* pelvic pain (due to inflamed uterus)
* pale/clammy skin (due to large blood loss)
* foul-smelling discharge
160
What are the chances of developing an infection after different types of delivery?
## Footnote
vaginal, scheduled C section, emergency C section
* **1-3%** of standard vaginal deliveries
* **5-15%** of scheduled C sections
* **15-20%** of emergency C sections
161
What are some risk factors for puerperal infections?
* obesity
* DM
* HTN
* anaemia
* immune system problems
162
How are puerperal infections treated?
**Broad-spectrum ABx**
163
What is rhesus disease of the newborn?
* Antibodies in a mother's blood destroy her baby's blood cells
* Causes **haemolysis** & **jaundice** in the neonate
* Only affects baby, mother won't experience Sx
164
What causes rhesus disease of the newborn?
* Mother has rhesus **negative** blood & baby has rhesus **positive** blood
* Mother must have been **previously sensitised** to **RhD positive** blood (usually during previous pregnancy with an RhD positive baby)
* Woman's body responds to RhD positive blood by **producing antibodies** that recognise the foreign blood cells and destroy them
* If sensitisation occurs, the next time the woman is exposed to RhD positive blood, her body produces antibodies **immediately**
* If she's pregnant with an RhD positive baby, the antibodies can **cross placenta** causing rhesus disease in the unborn baby
* Antibodies can continue attacking baby's RBC for a few months after birth
165
How does rhesus disease present in an unborn baby?
**Anaemic** (iron deficiency anaemia) - RBC are being destroyed **faster than usual** by antibodies
* If baby is anaemic, their blood will be thinner & flow at a faster rate (can be detected with **doppler USS**)
* If severe, Cx of rhesus disease may be detected during scans (e.g. internal swelling)
166
How does rhesus disease present in a newborn baby? (3)
* **Haemolytic anaemia**
* **Newborn jaundice**
* sometimes **hypotonia**
## Footnote
Sx can develop up to 3 months after birth
167
Why does haemolytic anaemia occur in rhesus disease?
1. Antibodies from mother's RhD negative blood cross placenta into baby's blood
2. Antibodies attack baby's RhD positive blood
3. Destroys red blood cells
168
Why does jaundice occur in rhesus disease?
1. Build-up of bilirubin in blood
* Bilirubin = yellow substance made naturally in body when RBC are broken down
2. Bilirubin normally removed from blood by liver so it can be passed out in urine
3. In babies with rhesus disease, liver can't process high levels of bilirubin that build up as a result of RBC being destroyed
169
How is rhesus disease diagnosed?
During routine **antenatal checks/tests**
* If RhD negative, blood will be checked for **anti-D antibodies** (destroy RhD positive RBC)
170
What is the treatment of rhesus disease of the newborn?
In severe cases:
* **Phototherapy**
* **Blood transfusions**
In serious cases:
* Blood transfusion whilst baby **still in womb** and **IVIG** may be used when born if phototherapy doesn't work
* If necessary - baby can be delivered early so Tx can start ASAP
171
What is phototherapy? And how does it work?
* Tx with **light** - newborn placed under halogen/fluorescent lamp
* Light absorbed by skin **lowers bilirubin levels** in baby's blood through **photo-oxidation** (oxygen added to bilirubin helping it dissolve in water = easier for baby's liver to break down bilirubin & remove it from blood)
* During phototherapy, **fluids** usually given into a vein (IV hydration) - because more water is lost through baby's skin & more urine is produced as bilirubin expelled
172
How does blood transfusion for rhesus disease work?
Helps remove some of the **bilirubin** in baby's blood & also removes **antibodies** that cause rhesus disease
173
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What is intrauterine foetal blood transfusion?
* Blood transfusion **before birth**
* Needle inserted into **umbilical cord** through mother's abdomen so donated blood can be injected into baby (**USS** used to guide needle)
* Small risk of **miscarriage** so only used in severe cases
174
What is IVIG? And why is it used to treat rhesus disease?
* Sometimes used alongside phototherapy if **bilirubin levels** in baby's blood continue to rise at an **hourly rate**
* Immunoglobulin = solution of **antibodies** taken from healthy donors
* IVIG helps **prevent RBC being destroyed**, so bilirubin levels stop rising (reduces need for blood transfusion)
* Risks = anaphylaxis
* Only used when bilirubin levels are rising rapidly **despite phototherapy**
175
What are some complications of rhesus disease in unborn babies?
**Severe anaemia** can lead to:
* Foetal **HF**
* **Fluid retention** & swelling (foetal hydrops)
* **Stillbirth**
Kernicterus
176
What are some complications of rhesus disease in newborn babies?
Excessive build-up of bilirubin in brain = **Kernicterus**
* can lead to **hearing loss**, **vision loss**, **brain damage**, **learning diff.**, death
177
How can rhesus disease be prevented?
**Anti-D immunoglobulin injections**
* Helps avoid **sensitisation**
* Anti-D IG **neutralises** any RhD positive antigens that may have entered the mother's blood during pregnancy
* If antigens neutralised - mother's blood won't produce **antibodies**
178
What is RAADP?
**Routine antenatal anti-D prophylaxis**
* Given during 3rd trimester (week 28 ish) of pregnancy if mothers blood type is RhD negative
* (likely that small amounts of baby's blood will pass into mother's blood during this time)
179
What is shoulder dystocia
anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis (of the mother), after the head has been delivered.
180
What condition is shoulder dystocia commonly associated with
Macrosomia (big baby) caused by **gestational diabetes**
181
Presentation of shoulder dystocia
Failure of restitution - head remains facing downwards
Turtle neck sign - head is delivered but retracts back into the vagina
182
Management of shoulder dystocia (6)
**Episiotomy** - to enlarge the vaginal opening and reduce the risk of perineal tears
**McRoberts manoeuvre** - hyperflexion of the mother at the hip (bringing her knees to her abdomen). provides posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
**Pressure to the anterior shoulder** - pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.
**Rubins manoeuvre**
**Wood’s screw manoeuvre**
**Zavanelli manoeuvere**
183
What is Rubin’s manoeuvre for shoulder dystocia
reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
184
What is Wood’s screw manoeuvre shoulder dystocia
**performed during Rubin’s manoeuvre**
The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder.
The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery
185
What is Zavanelli manoeuver in shoulder dystocia
involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
186
Give 4 complications of shoulder dystocia
Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
187
Who is typically affected by group B strep infection?
* Newborns during first week of life, but can develop weeks later
* Vulnerable adults
188
What are the symptoms of group B strep infection in newborns?
* **Fever**
* Irritability
* Lethargy
* Breathing difficulties
* Blue tint to skin
* Difficulty feeding
189
How is group B strep infection aqcuired?
* **Labour & delivery**
* Nursing
* Community spread
190
Who is at a greater risk of group B strep diseases?
* **Newborns** & adults **> 65**
* Diabetes
* Obesity
* Heart disease
* Cancer
* HIV
191
How many pregnant people carry group B strep bacteria?
~ 1 in 4
* most will experience **no Sx**
* Testing is done around **36**/**37 weeks**
* ~ **half** of birthing parents carrying group B strep will pass bacteria to their babies
* only ~ **1 - 2%** of those infants will develop early-onset group B strep infections
192
What are the symptoms of group B strep in adults?
Depends on body part affected:
* **Bacteremia** (bloodstream) = fever/fatigue/aches/rapid HR/low BP
* **Bone/joint infections** = fever/aches/pain & rash along affected bones and joints
* **Bact meningitis** = sudden headache/fever/neck stiffness
* **Pneumonia** = cough/excess mucus/breathing difficulties
* **Sepsis** = confusion/rapid HR/breathing changes
* **Skin infections** (MC) = rash/swelling/painful skin
* **UTI** = pain/burning during urination/freq urination/bloody urine/pain around kidneys
193
What is the management of group B strep in pregnancy?
**Screening** during pregnancy
* If positive for group B strep = **IV ABx during labour** (Tx withheld until you go into labour due to risk of bacteria coming back)
* Typically **penicillin** unless allergic
194
What can gonorrhoea during pregnancy put you at a higher risk of?
* **PID**--> chronic pelvic pain, infertility, ectopic preg
* **Miscarriage**
* **PRoM**
* **Preterm birth**
195
What complications in the newborn can occur due to gonorrhea during pregnancy?
**Neonatal gonococcal conjunctivitis**
* can lead to severe eye damage/blindness if not treated promptly
196
How does gonococcal conjunctivitis present?
* Eyelid swelling
* Discharge from eye
* Sensitive to touch eyes
197
What is the management of gonorrhoea in pregnancy?
ABx - **ceftriaxone** / azithromycin
* screening for other STIs & HIV
198
What is cephalopelvic disproportion?
When baby's head doesn't fit through opening of pelvis
199
What might cause cephalopelvic disproportion? (3)
* Baby's head too big
* Baby not in proper position when entering pelvis
* Small/abnormal shaped pelvis
200
How is cephalopelvic disproportion diagnosed?
* Apply pressure to abdomen to determine baby's position
* Check cervix to see if it's opening as it should
* Using foetal monitor to assess contractions
201
How is cephalopelvic disproportion treated?
Various assisted delivery techniques:
* **Vacuum extraction** / forceps to ease baby through pelvis
* **C-section**
202
What are 3 complications of cephalopelvic disproportion?
* **Shoulder dystocia** (requires C section)
* **Vaginal tears**
* **Postpartum haemorrhage**
203
What is uterine hypoplasia (hypoactive uterus)?
Abnormally small/underdeveloped uterus
204
What causes hypoplastic uterus?
External uterine hypoplasia causes:
* **Genetic abnormalities** (e.g.Turner's syndrome)
* Exposure to **environmental toxins/meds** that affect foetal development
* **Hysterectomy** / uterine artery embolization
Internal causes:
* **Hormonal imbalances** (puberty / menopause)
* **Infections** of uterus/reproductive system
* **Intrauterine adhesions/scarring**
* **Chronic endometriosis**
205
What are the symptoms of uterine hypoplasia? (4)
* **Abnormal menstrual cycle**
* **Infertility**
* **Miscarriage**
* Pelvic pain/discomfort
206
What are the three degrees of hypoplastic uterus?
* First degree hypoplasia: uterus **small** but retains its **normal shape/structure**
* Second degree hypoplasia: **significantly smaller**, may have **abnormal shape**. More complications.
* Third degree hypoplasia: **extremely small/absent**, unable to concieve **naturally**. May also have associated reproductive tract anomalies e.g. absent cervix/vagina
207
What investigations are done for hypoplastic uterus?
* **USS**
* **Hysterosalpingography** (**HSG**): type of xray uses dye to evaluate shape/patency of fallopian tubes & uterus
* **MRI**
208
What is the treatment of hypoplastic uterus?
* **Hormonal meds** to stimulate endometrial growth & regulate menstrual cycles
* **Intrauterine insemination** (IUI): placing sperm directly into uterus during ovulation to increase chances of fertilisation
* **IVF**
* **Surrogacy**
* **Uterine reconstruction surgery**: in 2nd degree hypoplasia
* **Psychological counselling**
209
What is obstructed labour?
Baby not exiting pelvis due to mechanical obstruction despite good contractions
210
What causes obstructed labour?
* Large baby
* Abnormally positioned baby
* Small pelvis
* Problems with birth canal e.g. bony (contracted pelvis) or soft tissue (prolapse/past scarring)
* Shoulder dystocia
211
What are the complications of obstructed labour?
* **Intrauterine infection**, **Septicaemia**, **Peritonitis**
* Compression injuries to bladder rectum = **fistulae**
* **Postpartum haemorrhage**
* **Uterine rupture**
* **Sepsis**
* Maternal/foetal mortality
* **Perinatal asphyxia**
212
What is the treatment of obstructed labour?
* **C section**
* **Vacuum extraction** with possible surgical opening of the **symphysis pubis**
213
What are the 2 ways that multiple pregnancies can happen?
* One fertilized egg **splits** before it implants in the uterine lining
* Two or more **separate eggs** fertilized by different sperm at same time
214
What is the difference between how identical and fraternal siblings come about?
* Identical: when single egg is fertilised then later splits
* Fraternal: separet eggs fertilised by different sperm
215
What increases the chance of a multiple pregnancy?
* **Older** (30s): because body starts releasing multiple eggs at one time
* Are a twin yourself or have twins in family
* Using **fertility drugs** + IVF
216
What are some complications of multiple pregnancy?
* **Premature labour**
* **Preeclampsia** / **Gestational HTN**
* **Gestational diabetes** (2 placentas = increased resistance to insulin)
* **Placental abruption** (placenta detaches from uterus wall)
* Foetal growth restriction
217
What is malpresentation?
When baby is not in a **head-first position** towards the birth canal
* MC type is **breech** (feet facing downwards)
218
What are some risk factors for malpresentation?
* Low lying placenta
* Too much/too little amniotic fluid
* Abnormally shaped uterus / fibroids
* Previous pregnancies making muscles of uterus less stable
* Multiple pregnancy
219
What is the management of malpresentation?
* For breech presentation: **external cephalic version** (turn baby into head-first position after 36 weeks)
* Most babies born by **C section**
220
What is the big risk to the mother when her waters break whilst baby is not head-first?
**Cord prolapse** = medical emergency
221
What are the risks to the baby during vaginal breech birth?
* Erb's palsy
* Fractures/dislocations
* Bleeding in baby's brain
* Head getting stuck (medical emergency)
222
What can be used in an instrumental delivery?
* **Forceps**
* **Ventouse suction cup**
223
Why might a ventouse or forceps be needed?
* Advised not to push out baby due to **underlying health condition** e.g. HTN
* Concers about **baby's HR**
* Baby in **awkward position**
224
What are complications of instrumental delivery?
* Vaginal tearing / episiotomy
* 3rd/4th degree vaginal tear (involves muscle or wall of anus / rectum)
* Blood clots
* Urinary incontinence
* Anal incontinence
225
What are the risks of instrumental delivery to the baby?
* **Chignon**: mark on baby's head made by ventouse cup (disappears within 48 hours)
* **Bruise** on baby's head
* Marks from forceps on baby's face
* Small cuts on baby's face/scalp
* Jaundice
* cephaloheamatoma
226
What is polyhydramnios?
Excessive accumulation of amniotic fluid in uterus during pregnancy
227
What are the symptoms of polyhydramnios?
Doesn't usually cause Sx
* Indigestion/heartburn
* Constipation
* Breathlessness
* Swollen feet/legs
* UTIs
228
How is polyhydramnios diagnosed?
* Clinically: look larger than expected for due date
* USS: see extra fluid
* Harder to hear baby's heartbeat
229
What can cause polyhydramnios?
* **Gestational diabetes**
* Multiple pregnancy
* Infection during pregnancy
* Problem with baby swallowing
230
What is the management of polyhydramnios?
Doesn't need treatment
* Extra checkups to monitor
* If severe: fluid drained from womb using thin needle
* If caused by gestational diabetes, treat underlying cause
231
What are some complications of polyhydramnios?
## Footnote
These are rare
* Waters breaking early
* Placental abruption
* Umbilical cord prolapse
* Premature labour
* Low birth weight
232
What is oligohydramnios?
Low amniotic fluid during pregnancy
233
What can contribute to low amniotic fluid?
* Placenta problems
* Congenital anomalies affecting baby's kidneys/urinary tract
* Going >2 weeks past due date
* HTN / pre eclampsia
* Diabetes
* Dehydration
* PRoM
* Twin-to-twin transfusion syndrome
234
What are some signs of low amniotic fluid?
* Leaking fluid from vagina
* Uterus measures small
* Don't feel baby move enough
* Not gaining enough weight
235
What are some complications of oligohydramnios?
* Deformities due to being compressed in the uterus
* Preterm birth
* Miscarriage
* Stillbirth
* Infection if water breaks early
236
What are two ways to measure amniotic fluid?
* Amniotic fluid index (AFI)
* Maximum vertical pocket (MVP)
237
Why does obesity lead reduced chance of conception
- longer to conceive
- lower success with IVF
- anovulation – losing weight improves chance
-Men with BMI >30 reduced fertility
238
How do you test for fertility in males and females
Males - semen analysis
Females - FSH levels
- antral follicle count
- Antimullerian hormone
239
Treatment in males for infertility
LIFESTYLE ADVICE- alcohol, excess heat, boxers, smoking, obesity
•Mild - Intrauterine Insemination (IUI) - ?
•Moderate abnormality - IVF
•Severe – Intracytoplasmic Sperm Injection (ICSI)
•Azoospermia
–Surgical Sperm Recovery
–Donor Insemination
•Surgery
–Correction of epidymal block
–Vasectomy reversal
•Hormonal
–Hypogonadotrophic hypogonadism - Gonadotrophins
–Hyperprolacinaemia - Bromocriptine with sexual dysfunction
240
Risks of IVF
-**Multiple Pregnancy**
•Miscarriage
•Ectopic
•Fetal abnormality
•Ovarian Hyperstimulation Syndrome (OHSS) 1-5%
•Egg Collection (1:2000)
241
What is ectopic pregnancy?
When a pregnancy is implanted **outside the uterus**
242
Where is the most common site for an ectopic pregnancy to implant? And name 4 other places it can occur
**Fallopian tube**
* Cornual region (entrance to fallopian tube)
* Ovary
* Cervix
* Abdomen
243
What are the risk factors for ectopic pregnancy?
* **Previous** ectopic pregnancy
* Previous **PID**
* Previous **surgery** to fallopian tubes
* **IUD**
* **Older**
* **Smoking**
244
When does ectopic pregnancy typically present?
**~6-8 weeks gestation**
245
What is the presentation of ectopic pregnancy?
* Missed period
* Constant lower abdo pain in left/right iliac fossa
* Vaginal bleeding
* Lower abdo/pelvic tenderness
* Cervical motion tenderness (pain when moving cervix during bimanual)
* Ask about **dizziness/syncope** = blood loss
* Ask about **shoulder tip pain** = peritonitis
246
What is the investigation of choice for diagnosing a miscarriage?
**Transvaginal USS**
247
What are the ultrasound findings for ectopic pregnancy?
* **Gestational sac** containing a **yolk sac** or **foetal pole** may be seen in fallopian tube
* Sometimes a non-specific mass may be seen in tube (mass containing an empty gestational sac = **blob sign** / **bagel sign** / **tubal ring sign**)
* A mass representing a tubal ectopic pregnancy may look similar to a **corpus luteum**, however it will move **separately** to the ovary, whereas a corpus luteum will move **with** the ovary
* An **empty uterus**
* **Fluid filled uterus** - can be mistaken as a gestational sac (pseudogestational sac)
248
What is a pregnancy of unknown location (PUL)?
When the woman has a **positive pregnancy test** but there is no evidence of prgnancy on the **USS**
249
How is a pregnancy of unknown location monitored?
**Serum hCG**
* Repeated after **48 hours** to measure change from baseline
* Developing **synctiotrophoblast** produces **hCG**
**intrauterine pregnancy**
- hCG will roughly **double every 48 hrs**
- Rise of **more than 63%** indicates intrauterine pregnancy,
- repeat USS required 1-2 weeks later to confirm
**Ectopic pregnancy**
- Rise of **less than 63%** after 48 hrs indicates ectopic pregnancy, pt needs close monitoring
**Miscarriage**
- Fall of **more than 50%** indicates miscarriage,
- urine pregnancy test performed after 2 weeks to confirm miscarriage is complete
250
What is the management of ectopic pregnancy
All ectopic pregnancies need to be **terminated**: ectopic pregnancy = **not a viable pregnancy**
* **Expectant Mx** = await natural termination
* **Medical Mx** = methotrexate
* **Surgical Mx** = salpingectomy / salpingotomy
251
What should you do with any women who present with abdo or pelvic pain?
**Pregnancy test**
* Could be caused by ectopic pregnancy
* Women with pelvic pain/tenderness and a positive pregnancy test need to be referred to an **early pregnancy assessment unit** (EPAU) or gynaecology service
252
What is the criteria for expectant management for ectopic pregnancy?
* **Follow up** needs to be possible to ensure successful termination
* Ectopic needs to be **unruptured**
* Adnexal mass **< 35mm**
* **No visible heartbeat**
* No significant **pain**
* HCG level **< 1500 IU/L**
253
What is the criteria for medical management (methotrexate) for ectopic pregnancy?
Same as expectant management, but:
* HCG level **< 1500 IU/L**
* Confirmed absence of intrauterine pregnancy on **USS**
254
Why is methotrexate used to terminate pregnancy?
* Highly **teratogenic**
* Given as **IM injection** into butt
* Halts progress of pregnancy & results in spontaneous termination
* These women are advised not to get pregnant for **3 months** following Tx
255
What are some common side effects of methotrexate?
* Vaginal bleeding
* N+V
* Abdo pain
* Stomatitis (inflammation of mouth)
256
Which patients will require surgical management for an ectopic pregnancy?
* Anyone that doesn't meet the criteria for expectant or medical Mx
* **Pain**
* Adnexal mass **> 35mm**
* **Visible heartbeat**
* HCG levels **> 5000 IU/L**
257
What are the surgical options for removing an ectopic pregnancy?
**Laparoscopic salpingectomy**:
* 1st line
* General anaesthetic
* Key-hole surgery w/ removal of affected fallopian tube
**Laparoscopic salpingotomy**:
* Used in women at increased risk of infertility due to damage to the other tube
* Cut is made in fallopian tube and ectopic pregnancy removed, then tube closed
* Aim is to avoid removing entire affected fallopian tube
**Anti-rhesus D prophylaxis** is given to **rhesus negative** women having surgical Mx of ectopic pregnancy
258
What are the stages of labour?
* **Latent phase**
* **1st stage**
* **2nd stage**
* **3rd stage**
259
What happens in the latent phase of labour?
* **Contractions** (may be irregular)
* **Mucus plug** ('show')
* Cervix starts to dilate (**0-4cm**)
* Can last up to **2-3 days**
260
What happens in the first stage of labour?
* **Stronger uterine contractions**
* Cervix dilates up to **10cm**
261
What is the second stage of labour?
From **full dilation** to **birth**
262
What is the third stage of labour?
From **birth** to **expulsion of the placenta**
263
Name some hormones of labour (6)
* **Oxytocin**
* **Prolactin**
* **Oestrogen**
* **Prostaglandins**
* **Beta-endorphins**
* **Adrenaline**
264
What is the role of oxytocin in labour?
A surge in oxytocin levels at the onset of labour will **contract the uterus**
265
What is the role of prolactin in labour?
Begins the process of milk production in the mammary glands
266
What is the role of oestrogen in labour?
Surges at the onset of labour to **inhibit progesterone** to prepare the **smooth muscles** for labour and contractions
267
What is the role of prostoglandins in labour?
Aid with **cervical ripening** by simulating myometrium contractions and softening of the cervix
268
What is the role of beta-endorphins in labour?
natural pain relief
269
What is the role of adrenaline in labour?
Released as birth is imminent to give the woman the energy to give birth
270
What is cervical effacement/cervical ripening?
**Thinning** of the cervix
271
What are the mechanisms of labour? (7)
* Descent
* Flexion
* Internal rotation
* Extension
* Restitution
* External rotation
* Delivery of body
272
Mechanisms of labour: Descent
* Fetus descends into pelvis
* Can occur from 37 weeks gestation onwards
* Encouraged by **increased abdominal muscle tone** and **increased freq & strength of contractions**
273
Mechanisms of labour: Flexion
* As fetus descends uterine contractions exert **pressure** down fetal spine towards occiput, forcing it to come into contact with **pelvic floor**
* When this occurs, the **fetal neck flexes** allowing **circumference** of fetal head to reduce
* In this position, the fetal skull has a **smaller diameter** which assists passage through pelvis
274
Mechanisms of labour: Internal Rotation
* With each contraction, fetal head is **pushed onto pelvic floor**
* Each time, a rebound effect supports a small degree of **rotation**
* Regular contractions eventually lead to fetal head completing the **90 degrees turn**
275
Mechanisms of labour: Extension
* Fetal **occiput** will slip beneath **suprapubic arch** allowing head to **extend**
* Fetal head is now born and usually facing maternal back
276
Mechanisms of labour: Restitution/External rotation
* At point of head delivery, the shoulders are only just reaching pelvic floor
* Fetus may naturally align its head with the shoulders
* May see head externally rotate to face the left or right
277
Mechanisms of labour: Delivery of the body
* Gentle downward traction may be conducted by midwife to assist with delivery of shoulder below the suprapubic arch
* May be followed by gentle upwards traction assisting delivery of posterior shoulder
278
What is delayed cord clamping?
Umbilical cord is not immediately clamped and cut at point of birth, but allowed at least **1 minute** to transfuse blood to baby
* baby could receive up to**214g** of blood
279
What are the benefits of delayed cord clamping?
* Allows baby time to transition to extra-uterine life
* Increase in **RBC**, **iron** & **stem cells**: can aid with growth & development up to 6 months old
* Reduced need for inotropic support
280
What are some pain management options for labour?
* Non-invasive: water immersion, aromatherapy, massage
* Analgesia: Etonox (gas & air), Paracetamol, Codeine
* Opiods: Diamorphine, Pethidine, Remifentanyl
* Epidural: mixture of bupivacaine + fentanyl
281
When do you admit in hyperemesis gravidarum
More than 5% weight loss
Diabetes
Nulliparous
Unable to keep water
282
How do you diagnose hyperemeisis gravidarum
1. >5% pre-pregnancy weight loss
2. Dehydration
3. Electrolyte imbalances
4. Pregnancy-Unique Quantification of Emesis (PUQE) Score ≥13
283
Complications of pre eclampsia (5)
- eclampsia
Fetal complications
- Intrauterine growth restriction
- prematurity
Haemorrhage
- placental abruption
- intra abdominal/ cerebral haemorrhage
Cardiac failure
284
Prevention for pre eclampsia
If has 1 high RF/ 2 moderate RF then:
**Aspirin 75mg/150mg from 12 weeks until birth**
285
Mx of pre eclampsia
160/100 BP then admit
1st line - labetelol
2nd line- nifedipine/hydralazine
IV mgS04 for eclampsia
**monitor BP, urine dip and fetal growth
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Sx of pre eclampsia
Headache
Upper abdomen/ epigastric pain - liver swelling
N+V
Oedema
Visual disturbances
Reduced urine output
Hyperreflexia
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How to diagnose pre eclampsia
-Blood pressure 140/90
-proteinuria on urine dip
- organ dysfunction - raises creatinine, raises liver enzymes, seizures
-PIGF will be low
-Placental dysfunction - fetal growth restriction or abnormal Doppler
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