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Phase 3a - Arun&Erin > OBS - pregnancy & labour/birth > Flashcards

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
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2
Q

What are the 4 phases of cervical remodelling?

A
  1. Softening
  2. Ripening
  3. Dilation
  4. Repair
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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
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4
Q

Name 4 causes of preterm birth

A
  • Infection - most common
  • Ischaemia
  • Uterine overdistension
  • Cervical disease - cervical weakness
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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
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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

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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
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8
Q

Definition: Prelabour rupture of membranes (PROM)

A

Rupture of membranes after 37 weeks gestation

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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

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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)

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11
Q

What is the management of preterm prelabour rupture of membranes?

A
  • Prophylatic antibiotics: prevent chorioamnionitis (erythromycin)
  • Induction of labour: from 34 weeks
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12
Q

What is a low birth weight infant defined as?

A

Born with birthweight < 2.5kg (regardless of gestational age)

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13
Q

What is a very low birth weight infant defined as?

A

Babies weighing < 1.5kg

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14
Q

What is an extremely low birth weight infant defined as?

A

Babies weighing < 1kg

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15
Q

How do you manage a low birth weight infant?

A
  • NICU
  • Temp-controlled bed
  • Special feeding: tube in stomach/IV
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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)
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17
Q

What are some long-term complications of of being a very low birthweight baby?

A
  • Cerebral palsy
  • Blindness
  • Deafness
  • Developmental delay
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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
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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

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20
Q

What is gestational diabetes

A

diabetes triggered by pregnancy due to reduced insulin sensitivity which resolves after birth

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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

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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

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23
Q

Screening test for gestational diabetes

A

Oral glucose tolerance test at 24-28 weeks

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24
Q

What features suggest gestational diabetes? (3)

A

-Large for date fetus
-Polyhydramnios
-Glucose on urine dipstick

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25
Q

How is oral glucose to test carried out?

A

-In the morning after a fast

-Drink 75 g of glucose

-Blood sugar levels are measured before and 2 hours after

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26
Q

What are normal results for OGTT

A

Fasting <5.6 mmol/L
2 hours after glucose < 7.8 mmol/L

remember 5-6-7-8

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27
Q

Mx of gestational diabetes

A

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

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28
Q

What is given to women with gestational diabetes who can’t tolerate metformin

A

Glibenclamide (a sulfonylurea)

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29
Q

What’s the measures done for those with pre existing diabetes during pregnancy (5)

A

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

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30
Q

Postnatal care of gestational diabetes for:

Women with gestational diabetes
Women with pre existing diabetes
Babies

A

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

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31
Q

What is an antepartum haemorrhage

A

•Bleeding from anywhere within the genital tract after the 24th week of pregnancy

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32
Q

Causes of Antepartum haemorrhage (4)

A

-low lying placenta/ placenta praevia
-vasa praevia
-minor/major abruption
-infection

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33
Q

What is low lying placenta

A

Any part of the placenta that has implanted into the lower segment of the uterus

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34
Q

What classes as a major and minor low lying placenta

A

Major - covering the Os
Minor - in lower segment not covering os

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35
Q

How to diagnose low lying placenta

A

20 week abdo Ultrasound scan
Repeated at 32 weeks + 36 weeks

RCOG recommend transvaginal USS

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36
Q

Mx of placenta praevia

A

•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

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37
Q

What is placenta praevia?

A

When the low-lying placenta partially/completely covers opening of cervix

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38
Q

Signs and symtoms of placenta praevia

A

-painless vaginal bleeding
-light contractions
-tense uterus

-lie and presentation of baby maybe abnormal

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39
Q

What is placental abruption

A

the complete or partial detachment of the placenta before delivery.

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40
Q

Cause of placental abruption

A

Unknown
Maybe trauma or injury

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41
Q

Risk factors of placental abruption

A

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

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42
Q

Clinical presentation of placental abruption (5)

A

-Abdominal pain (most common) – posterior

-placental abruptions may present with back pain

-Vaginal bleeding

-Uterine contractions

-Dizziness and/or loss of consciousness

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43
Q

Clinal findings upon examination for placental abruption

A

-woody, tense uterus

-fetal heart may be absent or distressed

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44
Q

Investigations for placental abruption

A

Diagnostic - ultrasound scan to locate the bleed

Other
-vital signs
-FBC
-Clotting profile
-kelihauer test - fetal haemoglobin transferred from fetus to mother

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45
Q

Mx of placental abruption

A

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

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46
Q

Complications of placental abruption in:
Mother
Foetus

A

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

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47
Q

What is vasa praevia

A

Fetal blood vessels (the two umbilical arteries and single umbilical vein) are within the fetal membranes and run across the internal cervical os.

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48
Q

Risk factors for vasa praevia (3)

A

IVF pregnancy
Multiple pregnancy
Low lying placenta

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49
Q

Sx of vasa praevia

A

-Painless vaginal bleeding
-Rupture of membranes
-Fetal bradycardia

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50
Q

Investigations for vasa praevia

A

Diagnostic - ultrasound scan

Others:
Vital signs
FBC
Clotting profile
Kleihauer test

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51
Q

Mx of vasa Praevia (3)

A

-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

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52
Q

What is pre eclampsia

A

New high blood pressure 140/90 in pregnancy with at least one of
-end organ dysfunction
-proteinuria

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53
Q

Triad of pre eclampsia

A

Oedema
Proteinuria
Hypertension

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54
Q

Whats the pathology of pre eclampsia

A

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

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55
Q

What is eclampsia

A

When seizures occur as a result of pre-eclampsia.

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56
Q

What is gestational HTN

A

Hypertension occurring after 20 weeks gestation, without proteinuria.

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57
Q

High Risk factors for pre eclampsia (5)

A

Pre existing HTN
HTN before in pregnancy
Existing autoimmune conditions e.g lupus
Diabetes
CKD

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58
Q

Treatment of eclampsia (2)

A

Deliver baby after mum is stabilised
-IV MgSO4 for 24 hours

-Treat HTN - labetelol or nifedipine

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59
Q

Risk factors 5 for maternal sepsis (10)

A

-obesity
-diabetes
-anaemia

-history of pelvic infection
-history of group strep B infection
-group A strep infection
-immunosuppressant meds

-PROM
-vaginal discharge
-amniocentesis

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60
Q

Maternal sepsis management

A

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

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61
Q

What is cord prolapse

A

umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes

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62
Q

Main complication of cord prolapse

A

Fetal hypoxia

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63
Q

Biggest risk factor for cord prolapse

A

fetus is in an abnormal lie after 37 week gestation as it allows room for cord to descend

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64
Q

How to diagnosis cord prolapse (3)

A

-CTG showing signs of fetal distress
-vaginal examination
- speculum

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65
Q

Management of cord prolapse + cord compression

A

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)

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66
Q

What is umbilical cord compression

A

Babies umbilical cord becomes flattened by pressure leading to vasoconstriction and fetal hypoxia due to lack of oxygenated blood

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67
Q

What is hyperemesis gravidarum

A

Exhaggerated, long in duration, nausea and vomiting in early pregnancy

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68
Q

What weeks does hyperemesis gravidarum usually occur

A

4-8 weeks of gestation

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69
Q

Causes of hyperemesis gravidarum

A

-rapidly rising HCG levels
-pregnancy related decreased gastric motility

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70
Q

Risk factors of hyperemesis gravidarum

A

-previous hyperemesis gravidarum
-increased hCG levels
-multiple pregnancy
-biologically female foetus
-hyperthyroidism

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71
Q

Complications for hyperemesis gravidarum

A

-dehydration
-weight loss
-Mallory Weiss tear
-metabolic alkalosis
-electrolyte imbalance

If prolonged
-intrauterine growth restriction

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72
Q

Signs and symptoms of hyperemesis gravidarum

A

-frequent N+V

-signs of dehydration- tachycardia, palpitations, hypotension, decreased skin turgor

-malaise

-increased sensitivity to smell

-weight loss

-ketoacidosis odour - pear drops

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73
Q

How to diagnose hyperemesis gravidarum

A

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

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74
Q

Tx of hyperemesis gravidarum (3)

A

-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

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75
Q

What is placenta accreta

A

Placenta implants deeper, through and past the endometrium - makes it hard to remove the placenta after delivery

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76
Q

What are the three layers of the uterine wall

A

Endometrium - inner layer - connective tissue layer

Myometrium - middle layer - smooth muscle layer

Perimetrium - outer layer - serous membrane

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77
Q

What are the three levels of severity of placenta accreta

A

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

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78
Q

Management of placenta accreta

A

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

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79
Q

How to diagnose placenta accreta

A

Ultrasound - allows for planning

MRI scans - assess depth and width

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80
Q

What is uterine rupture

A

A complication of labour where the myometrium layer of the uterus ruptures

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81
Q

What’s the difference between complete and incomplete uterine rupture

A

Complete - the perimetrium also ruptures so the content of the uterus is released into the peritoneal cavity

Incomplete - the perimetrium remains in tact

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82
Q

5 Risk factors for uterine rupture (7)

A

-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

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83
Q

Presentation of uterine rupture

A

-Abnormal CTG
-abdo pain
-vaginal bleeding
-ceasing of uterine contractions
-hypotension
-tachycardia
-collapse

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84
Q

What is the treatment of uterine rupture?

A

!!Obstetric emergency!!
* Resuscitation & transfusion may be required
* Emergency C section necessary to remove baby, stop bleeding & repair/remove uterus

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85
Q

What is cervical show?

A

‘Show’ is a blood-stained discharge from uterus, often mixed with mucus

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86
Q

How does cervical show originate?

A
  • Slow cervical dilation in early labour
  • Causes loosening & expulsion of thick mucus plug that blocks the cervical canal throughout normal pregnancy
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87
Q

Definition: postpartum haemorrhage

A

Bleeding after delivery of the baby and placenta. With blood loss of:
1000ml in C section
500ml in normal delivery

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88
Q

What is a major haemorrhage and what are the two classifications

A

Major PPH is anything ABOVE 1000ml blood loss
Further classified into:

Moderate PPH - 1000-2000ml blood loss

Severe PPH - over 2000ml blood loss

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89
Q

What are primary and secondary PPH

A

Primary - bleeding within the first 24 hours of delivery

Secondary - bleeding from 24 hours to first 12 weeks after birth

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90
Q

4 causes of postpartum haemorrhage

A

T – Tone (uterine atony – the most common cause)

T – Trauma (e.g. perineal tear)

T – Tissue (retained placenta)

T – Thrombin (bleeding disorder)

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91
Q

Give 5 risk factors for PPH

A

-previous PPH
-multiple pregnancy
-obesity
-large baby
-pre eclampsia
-placenta accreta
-placenta retained
-instrumental delivery
-general anasesthesia
-episiotomy or perineal tear

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92
Q

How do you prevent a PPH (4)

A

-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

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93
Q

Initial Mx of PPH

A

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)

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94
Q

Management of PPH if cause is atony (6)

A

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

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95
Q

What the Mx of PPH if cause is thrombin is cause

A

Tranexamic acid

Vitamin K ( discuss with haematology)

Fresh frozen plasma

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96
Q

Most common cause of secondary PPH (2)

A

Endometritis - inflammation of the uterine endometrium

Retained products of conception e.g placenta

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97
Q

Complications following PPH (7)

A

-anaemia
-hypovolaemic shock - leading to organ failure
-PTSD
-hysterectomy
-DIC
-sheehans syndrome
-death

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98
Q

What are the three categories of postpartum mental health illness (3)

A

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

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99
Q

Symtoms of baby blues (5)

A

-mood swings
-low mood
-anxiety
-irritability
-tearfulness

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100
Q

Causes of baby blues

A

-Significant hormonal changes
-Recovery from birth
-Fatigue and sleep deprivation
-The responsibility of caring for the neonate
-Establishing feeding

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101
Q

Classical triad of postnatal depression (3)

A

Low mood
Anhedonia (lack of pleasure in activities)
Low energy

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102
Q

Mx of postpartum depression

A

Mild cases - GP appointment, self help

Moderate cases - SSRIs and CBT

Severe cases - psychotherapy, CBT, SSRI/ SNRI

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103
Q

Sx of puerperal psychosis (6)

A

Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder

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104
Q

Tx of pueperal psychosis (4)

A

-Admission to the mother and baby unit

-Cognitive behavioural therapy

-Medications e.g antipsychotics (risperidone), mood stabilisers (lithium+lamotrigine)

-Electroconvulsive therapy (ECT)

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105
Q

How to prepare for mental health illnesses during pregnancy

A

perinatal mental health services which includes:

-medications management - **SSRIs, antipsychotics, lithium

-care plan after delivery - Health vistors, GPs, family and friends

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106
Q

What is a complication of SSRIs taken during pregnancy

A

Neonatal abstinence syndrome
- presents with poor feeding and irritability in first few days

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107
Q

What is the scale used to assess depression in postnatal mothers

A

Edinburgh postnatal depression scale - 10+ out of 30 suggests postnatal depression

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108
Q

Risk factors for VTE in pregnancy give 6 (11)

A

-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)

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109
Q

What is the preventative measures of VTE during pregnancy

A

VTE prophylaxis

-if 3+ risk factors give from 28 weeks

-if 4+ risk factors give from first trimester

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110
Q

What does VTE prophylaxis consist of

A

-LMWH e.g dalteparin, tinzaparin, enoxaparin

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111
Q

What is given as VTE prophylaxis if LMWH is contraindicated

A

-Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs

-Anti-embolic compression stockings

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112
Q

Presentation of DVT in pregnancy

A

-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

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113
Q

Presentation of Pulmonary embolism in pregnancy

A

-SOB
-Tachycardia
-chest pain
-cough (can be haemoptysis)
-resp rate Increased
-low grade fever
-hypotension if heamodynamically unstable

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114
Q

Dx of DVT + PE (5)

A

-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)

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115
Q

How does VQ perfusion scan work for PE

A

-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
Q

Why isn’t the wells score not used in pregnancy

A

In pregnancy there is a raised D Dimer so is not helpful

117
Q

Mx of VTE

A

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
Q

Definition: miscarriage

A

is the spontaneous termination of a pregnancy in the first 20 weeeks of pregnancy

119
Q

What the difference between early and late miscarriage

A

Early miscarriage is before 12 weeks gestation

Late miscarriage is between 12 and 24 weeks gestation

120
Q

Definition: missed miscarriage

A

Fetus no longer alive but no symptoms occurred - hasn’t been expelled

121
Q

Definition: Threatened miscarriage

A

vaginal bleeding with a closed cervix and a fetus that is alive

122
Q

Definition: Inevitable miscarriage

A

vaginal bleeding with an open cervix

123
Q

Definition: incomplete miscarriage

A

retained products of conception remain in the uterus after the miscarriage

124
Q

Definition: complete miscarriage

A

a full miscarriage has occurred, and there are no products of conception left in the uterus

125
Q

Definition: Anembryonic pregnancy

A

a gestational sac is present but contains no embryo

126
Q

Dx for miscarriage

A

Gold standard - transvaginal ultrasound scan

127
Q

What three measurement do you look for to determine pregnancy is viable

A

-Mean gestational sac diameter (25mm+)
-Fetal pole and crown-rump length (7mm+)
-Fetal heartbeat (outweighs the other two)

128
Q

Mx of miscarriage in less than 6 weeks gestation

A

Expectant management - no treatment or investigation

Repeat urine pregnancy test after 7-10 days and if negative a miscarriage can be confirmed

129
Q

Management of miscarriage More Than 6 Weeks Gestation

A

-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
Q

What is expectant management and when is expectant management offered in miscarriage

A

-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
Q

Medical management for miscarriage

A

Misoprostol - prostaglandin analogue (activates prostaglandin receptors) - either Vaginal suppository/ oral

-stimulates uterine contractions + softens the cervix

132
Q

Side effects of misoprostol (4)

A

Heavier bleeding
Pain
Vomiting
Diarrhoea

133
Q

Surgical management of miscarriage

A

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
Q

What is the risk of retained products remain in the uterus after miscarriage

A

Infection

135
Q

Two methods used for incomplete miscarriage

A

Medical management (misoprostol)

Surgical management (evacuation of retained products of conception)

136
Q

Key complication of evacuation of retained products of conception surgical procedure

A

Endometritis (infection of endometrium)

137
Q

Presentation of aneamia in pregnancy

A

Pallor
SOB
Dizziness

138
Q

Which type of anemia is indicated for each MCV during pregnancy
Low
Normal
Raised

A

Low MCV - iron deficiency

Normal MCV - physiological anaemia due to the increased plasma volume of pregnancy

Raised MCV - B12 or folate deficiency

139
Q

What anaemias are women screened for during pregnancy

A

Thalassaemia (all women)

Sickle cell disease (if higher risk e.g black)

140
Q

Managment of iron deficiency in pregnancy

A

Ferrous sulphate - 200mg three times daily

141
Q

Tx of B12 deficiency anemia in pregnancy

A

-checked for intrinsic factor antibodies - pernicious aneamia

-Intramuscular hydroxocobalamin injections
-Oral cyanocobalamin tablets

142
Q

Folate deficiency anaemia tx

A

-Folate acid 400mcg all women should be taking anyway
- with a deficiency Folic acid 5mg daily

143
Q

Risks of UTI in pregnancy

A

Preterm delivery

Low birth weight baby

Maternal sepsis

Pre eclampsia

144
Q

What is asymptomatic bacteriuria

A

bacteria present in the urine, without symptoms of infection

145
Q

How to diagnose asymptomatic bacteruria

A

microscopy, culture and sensitivities (MC&S) routinely throughout pregnancy

146
Q

Presentation of LUTI in pregnancy

A

Dysuria
Suprapubic pain
Increased frequency of urination
Incontinence
Haematuria (blood in urine)
Urgency

147
Q

Presentation of pyelonephritis

A

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
Q

Causes of UTI

A

KEEPS
Klebsiella pneumoniae (gram-negative anaerobic rod)
E.coli
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus

*And Candida albicans (fungal)

149
Q

Most common cause of UTI in pregnancy

A

E.coli - found in faeces and can easily spread to the bladder

150
Q

Mx of UTI in pregnancy

A

-Nitrofurantoin (avoid in the third trimester)
-trimethoprim (avoid in first trimester)
-Amoxicillin (only after sensitivities are known)
-Cefalexin

151
Q

Contraindications of trimethoprim

A

Folate antagonist - can lead to neural tube defects such as spina bifida and anencephaly

152
Q

Contraindications of nitrofurantoin

A

Avoid in third trimester - neonatal haemolysis

153
Q

What is shoulder dystocia

A

when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered

154
Q

What is essential hypertension?

A

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
Q

What are secondary causes of HTN?

Pneumonic ROPED

A
  • Renal disease (MC)
  • Obesity
  • Pregnancy-induced HTN / pre-eclampsia
  • Endocrine
  • Drugs (alcohol, steroids, NSAIDs, oestrogen)
156
Q

What is chronic hypertension obs

A
  • High blood pressure that exists before 20 weeks gestation & is longstanding
  • Not caused by placental dysfunction
  • Not classified as pre-eclampsia
157
Q

What is puerperal infection (post-partum infection)?

A

Bacterial infections of the female reproductive tract following childbirth/miscarriage

158
Q

What are some common types of puerperal infections?

A
  • Endometritis (uterine lining) - MC
  • Myometritis (uterine muscle)
  • Parametritis/pelvic cellulitis (supporting tissue around uterus)
159
Q

What are the symptoms of puerperal infections?

A

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
Q

What are the chances of developing an infection after different types of delivery?

vaginal, scheduled C section, emergency C section

A
  • 1-3% of standard vaginal deliveries
  • 5-15% of scheduled C sections
  • 15-20% of emergency C sections
161
Q

What are some risk factors for puerperal infections?

A
  • obesity
  • DM
  • HTN
  • anaemia
  • immune system problems
162
Q

How are puerperal infections treated?

A

Broad-spectrum ABx

163
Q

What is rhesus disease of the newborn?

A
  • 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
Q

What causes rhesus disease of the newborn?

A
  • 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
Q

How does rhesus disease present in an unborn baby?

A

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
Q

How does rhesus disease present in a newborn baby? (3)

A
  • Haemolytic anaemia
  • Newborn jaundice
  • sometimes hypotonia

Sx can develop up to 3 months after birth

167
Q

Why does haemolytic anaemia occur in rhesus disease?

A
  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
Q

Why does jaundice occur in rhesus disease?

A
  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
Q

How is rhesus disease diagnosed?

A

During routine antenatal checks/tests
* If RhD negative, blood will be checked for anti-D antibodies (destroy RhD positive RBC)

170
Q

What is the treatment of rhesus disease of the newborn?

A

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
Q

What is phototherapy? And how does it work?

A
  • 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
Q

How does blood transfusion for rhesus disease work?

A

Helps remove some of the bilirubin in baby’s blood & also removes antibodies that cause rhesus disease

173
Q

What is intrauterine foetal blood transfusion?

A
  • 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
Q

What is IVIG? And why is it used to treat rhesus disease?

A
  • 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
Q

What are some complications of rhesus disease in unborn babies?

A

Severe anaemia can lead to:
* Foetal HF
* Fluid retention & swelling (foetal hydrops)
* Stillbirth

Kernicterus

176
Q

What are some complications of rhesus disease in newborn babies?

A

Excessive build-up of bilirubin in brain = Kernicterus
* can lead to hearing loss, vision loss, brain damage, learning diff., death

177
Q

How can rhesus disease be prevented?

A

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
Q

What is RAADP?

A

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
Q

What is shoulder dystocia

A

anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis (of the mother), after the head has been delivered.

180
Q

What condition is shoulder dystocia commonly associated with

A

Macrosomia (big baby) caused by gestational diabetes

181
Q

Presentation of shoulder dystocia

A

Failure of restitution - head remains facing downwards

Turtle neck sign - head is delivered but retracts back into the vagina

182
Q

Management of shoulder dystocia (6)

A

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
Q

What is Rubin’s manoeuvre for shoulder dystocia

A

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
Q

What is Wood’s screw manoeuvre shoulder dystocia

A

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
Q

What is Zavanelli manoeuver in shoulder dystocia

A

involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

186
Q

Give 4 complications of shoulder dystocia

A

Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

187
Q

Who is typically affected by group B strep infection?

A
  • Newborns during first week of life, but can develop weeks later
  • Vulnerable adults
188
Q

What are the symptoms of group B strep infection in newborns?

A
  • Fever
  • Irritability
  • Lethargy
  • Breathing difficulties
  • Blue tint to skin
  • Difficulty feeding
189
Q

How is group B strep infection aqcuired?

A
  • Labour & delivery
  • Nursing
  • Community spread
190
Q

Who is at a greater risk of group B strep diseases?

A
  • Newborns & adults > 65
  • Diabetes
  • Obesity
  • Heart disease
  • Cancer
  • HIV
191
Q

How many pregnant people carry group B strep bacteria?

A

~ 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
Q

What are the symptoms of group B strep in adults?

A

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
Q

What is the management of group B strep in pregnancy?

A

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
Q

What can gonorrhoea during pregnancy put you at a higher risk of?

A
  • PID–> chronic pelvic pain, infertility, ectopic preg
  • Miscarriage
  • PRoM
  • Preterm birth
195
Q

What complications in the newborn can occur due to gonorrhea during pregnancy?

A

Neonatal gonococcal conjunctivitis
* can lead to severe eye damage/blindness if not treated promptly

196
Q

How does gonococcal conjunctivitis present?

A
  • Eyelid swelling
  • Discharge from eye
  • Sensitive to touch eyes
197
Q

What is the management of gonorrhoea in pregnancy?

A

ABx - ceftriaxone / azithromycin
* screening for other STIs & HIV

198
Q

What is cephalopelvic disproportion?

A

When baby’s head doesn’t fit through opening of pelvis

199
Q

What might cause cephalopelvic disproportion? (3)

A
  • Baby’s head too big
  • Baby not in proper position when entering pelvis
  • Small/abnormal shaped pelvis
200
Q

How is cephalopelvic disproportion diagnosed?

A
  • 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
Q

How is cephalopelvic disproportion treated?

A

Various assisted delivery techniques:
* Vacuum extraction / forceps to ease baby through pelvis
* C-section

202
Q

What are 3 complications of cephalopelvic disproportion?

A
  • Shoulder dystocia (requires C section)
  • Vaginal tears
  • Postpartum haemorrhage
203
Q

What is uterine hypoplasia (hypoactive uterus)?

A

Abnormally small/underdeveloped uterus

204
Q

What causes hypoplastic uterus?

A

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
Q

What are the symptoms of uterine hypoplasia? (4)

A
  • Abnormal menstrual cycle
  • Infertility
  • Miscarriage
  • Pelvic pain/discomfort
206
Q

What are the three degrees of hypoplastic uterus?

A
  • 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
Q

What investigations are done for hypoplastic uterus?

A
  • USS
  • Hysterosalpingography (HSG): type of xray uses dye to evaluate shape/patency of fallopian tubes & uterus
  • MRI
208
Q

What is the treatment of hypoplastic uterus?

A
  • 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
Q

What is obstructed labour?

A

Baby not exiting pelvis due to mechanical obstruction despite good contractions

210
Q

What causes obstructed labour?

A
  • 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
Q

What are the complications of obstructed labour?

A
  • Intrauterine infection, Septicaemia, Peritonitis
  • Compression injuries to bladder rectum = fistulae
  • Postpartum haemorrhage
  • Uterine rupture
  • Sepsis
  • Maternal/foetal mortality
  • Perinatal asphyxia
212
Q

What is the treatment of obstructed labour?

A
  • C section
  • Vacuum extraction with possible surgical opening of the symphysis pubis
213
Q

What are the 2 ways that multiple pregnancies can happen?

A
  • One fertilized egg splits before it implants in the uterine lining
  • Two or more separate eggs fertilized by different sperm at same time
214
Q

What is the difference between how identical and fraternal siblings come about?

A
  • Identical: when single egg is fertilised then later splits
  • Fraternal: separet eggs fertilised by different sperm
215
Q

What increases the chance of a multiple pregnancy?

A
  • 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
Q

What are some complications of multiple pregnancy?

A
  • Premature labour
  • Preeclampsia / Gestational HTN
  • Gestational diabetes (2 placentas = increased resistance to insulin)
  • Placental abruption (placenta detaches from uterus wall)
  • Foetal growth restriction
217
Q

What is malpresentation?

A

When baby is not in a head-first position towards the birth canal
* MC type is breech (feet facing downwards)

218
Q

What are some risk factors for malpresentation?

A
  • Low lying placenta
  • Too much/too little amniotic fluid
  • Abnormally shaped uterus / fibroids
  • Previous pregnancies making muscles of uterus less stable
  • Multiple pregnancy
219
Q

What is the management of malpresentation?

A
  • For breech presentation: external cephalic version (turn baby into head-first position after 36 weeks)
  • Most babies born by C section
220
Q

What is the risk to the mother when her waters break whilst baby is not head-first?

A

Cord prolapse = medical emergency

221
Q

What are the risks to the baby during vaginal breech birth?

A
  • Erb’s palsy
  • Fractures/dislocations
  • Bleeding in baby’s brain
  • Head getting stuck (medical emergency)
222
Q

What can be used in an instrumental delivery?

A
  • Forceps
  • Ventouse suction cup
223
Q

Why might a ventouse or forceps be needed?

A
  • Advised not to push out baby due to underlying health condition e.g. HTN
  • Concers about baby’s HR
  • Baby in awkward position
224
Q

What are complications of instrumental delivery?

A
  • Vaginal tearing / episiotomy
  • 3rd/4th degree vaginal tear (involves muscle or wall of anus / rectum)
  • Blood clots
  • Urinary incontinence
  • Anal incontinence
225
Q

What are the risks of instrumental delivery to the baby?

A
  • 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
Q

What is polyhydramnios?

A

Excessive accumulation of amniotic fluid in uterus during pregnancy

227
Q

What are the symptoms of polyhydramnios?

A

Doesn’t usually cause Sx
* Indigestion/heartburn
* Constipation
* Breathlessness
* Swollen feet/legs
* UTIs

228
Q

How is polyhydramnios diagnosed?

A
  • Clinically: look larger than expected for due date
  • USS: see extra fluid
  • Harder to hear baby’s heartbeat
229
Q

What can cause polyhydramnios?

A
  • Gestational diabetes
  • Multiple pregnancy
  • Infection during pregnancy
  • Problem with baby swallowing
230
Q

What is the management of polyhydramnios?

A

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
Q

What are some complications of polyhydramnios?

These are rare

A
  • Waters breaking early
  • Placental abruption
  • Umbilical cord prolapse
  • Premature labour
  • Low birth weight
232
Q

What is oligohydramnios?

A

Low amniotic fluid during pregnancy

233
Q

What can contribute to low amniotic fluid?

A
  • 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
Q

What are some signs of low amniotic fluid?

A
  • Leaking fluid from vagina
  • Uterus measures small
  • Don’t feel baby move enough
  • Not gaining enough weight
235
Q

What are some complications of oligohydramnios?

A
  • Deformities due to being compressed in the uterus
  • Preterm birth
  • Miscarriage
  • Stillbirth
  • Infection if water breaks early
236
Q

What are two ways to measure amniotic fluid?

A
  • Amniotic fluid index (AFI)
  • Maximum vertical pocket (MVP)
237
Q

Why does obesity lead reduced chance of conception

A
  • longer to conceive
  • lower success with IVF
  • anovulation – losing weight improves chance
    -Men with BMI >30 reduced fertility
238
Q

How do you test for fertility in males and females

A

Males - semen analysis
Females - FSH levels
- antral follicle count
- Antimullerian hormone

239
Q

Treatment in males for infertility

A

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
Q

Risks of IVF

A

-Multiple Pregnancy
•Miscarriage
•Ectopic
•Fetal abnormality
•Ovarian Hyperstimulation Syndrome (OHSS) 1-5%
•Egg Collection (1:2000)

241
Q

What is ectopic pregnancy?

A

When a pregnancy is implanted outside the uterus

242
Q

Where is the most common site for an ectopic pregnancy to implant? And name 4 other places it can occur

A

Fallopian tube
* Cornual region (entrance to fallopian tube)
* Ovary
* Cervix
* Abdomen

243
Q

What are the risk factors for ectopic pregnancy?

A
  • Previous ectopic pregnancy
  • Previous PID
  • Previous surgery to fallopian tubes
  • IUD
  • Older
  • Smoking
244
Q

When does ectopic pregnancy typically present?

A

~6-8 weeks gestation

245
Q

What is the presentation of ectopic pregnancy?

A
  • 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
Q

What is the investigation of choice for diagnosing a miscarriage?

A

Transvaginal USS

247
Q

What are the ultrasound findings for ectopic pregnancy?

A
  • 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
Q

What is a pregnancy of unknown location (PUL)?

A

When the woman has a positive pregnancy test but there is no evidence of prgnancy on the USS

249
Q

How is a pregnancy of unknown location monitored?

A

Serum hCG (human chorionic gonadotropin)
* Repeated after 48 hours to measure change from baseline
* Developing synctiotrophoblast produces hCG
* In 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
* Rise of less than 63% after 48 hrs indicates ectopic pregnancy, pt needs close monitoring
* Fall of more than 50% indicates miscarriage, urine pregnancy test performed after 2 weeks to confirm miscarriage is complete

250
Q

What is the management of ectopic pregnancy

A

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
Q

What should you do with any women who present with abdo or pelvic pain?

A

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
Q

What is the criteria for expectant management for ectopic pregnancy?

A
  • 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
Q

What is the criteria for medical management (methotrexate) for ectopic pregnancy?

A

Same as expectant management, but:
* HCG level < 1500 IU/L
* Confirmed absence of intrauterine pregnancy on USS

254
Q

Why is methotrexate used to terminate pregnancy?

A
  • 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
Q

What are some common side effects of methotrexate?

A
  • Vaginal bleeding
  • N+V
  • Abdo pain
  • Stomatitis (inflammation of mouth)
256
Q

Which patients will require surgical management for an ectopic pregnancy?

A
  • Anyone that doesn’t meet the criteria for expectant or medical Mx
  • Pain
  • Adnexal mass > 35mm
  • Visible heartbeat
  • HCG levels > 5000 IU/L
257
Q

What are the surgical options for removing an ectopic pregnancy?

A

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
Q

What are the stages of labour?

A
  • Latent phase
  • 1st stage
  • 2nd stage
  • 3rd stage
259
Q

What happens in the latent phase of labour?

A
  • Contractions (may be irregular)
  • Mucus plug (‘show’)
  • Cervix starts to dilate (0-4cm)
  • Can last up to 2-3 days
260
Q

What happens in the first stage of labour?

A
  • Stronger uterine contractions
  • Cervix dilates up to 10cm
261
Q

What is the second stage of labour?

A

From full dilation to birth

262
Q

What is the third stage of labour?

A

From birth to expulsion of the placenta

263
Q

Name some hormones of labour (6)

A
  • Oxytocin
  • Prolactin
  • Oestrogen
  • Prostaglandins
  • Beta-endorphins
  • Adrenaline
264
Q

What is the role of oxytocin in labour?

A

A surge in oxytocin levels at the onset of labour will contract the uterus

265
Q

What is the role of prolactin in labour?

A

Begins the process of milk production in the mammary glands

266
Q

What is the role of oestrogen in labour?

A

Surges at the onset of labour to inhibit progesterone to prepare the smooth muscles for labour

267
Q

What is the role of prostoglandins in labour?

A

Aid with cervical ripening by simulating myometrium contractions and softening of the cervix

268
Q

What is the role of beta-endorphins in labour?

A

natural pain relief

269
Q

What is the role of adrenaline in labour?

A

Released as birth is imminent to give the woman the energy to give birth

270
Q

What is cervical effacement/cervical ripening?

A

Thinning of the cervix

271
Q

What are the mechanisms of labour? (7)

A
  • Descent
  • Flexion
  • Internal rotation
  • Extension
  • Restitution
  • External rotation
  • Delivery of body
272
Q

Mechanisms of labour: Descent

A
  • Fetus descends into pelvis
  • Can occur from 37 weeks gestation onwards
  • Encouraged by increased abdominal muscle tone and increased freq & strength of contractions
273
Q

Mechanisms of labour: Flexion

A
  • 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
Q

Mechanisms of labour: Internal Rotation

A
  • 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
Q

Mechanisms of labour: Extension

A
  • Fetal occiput will slip beneath suprapubic arch allowing head to extend
  • Fetal head is now born and usually facing maternal back
276
Q

Mechanisms of labour: Restitution/External rotation

A
  • 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
Q

Mechanisms of labour: Delivery of the body

A
  • 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
Q

What is delayed cord clamping?

A

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 to214g of blood

279
Q

What are the benefits of delayed cord clamping?

A
  • 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
Q

What are some pain management options for labour?

A
  • Non-invasive: water immersion, aromatherapy, massage
  • Analgesia: Etonox (gas & air), Paracetamol, Codeine
  • Opiods: Diamorphine, Pethidine, Remifentanyl
  • Epidural: mixture of bupivacaine + fentanyl
281
Q

When do you admit in hyperemesis gravidarum

A

More than 5% weight loss
Diabetes
Nulliparous
Unable to keep water

282
Q

How do you diagnose hyperemeisis gravidarum

A
  1. > 5% pre-pregnancy weight loss
  2. Dehydration
  3. Electrolyte imbalances
  4. Pregnancy-Unique Quantification of Emesis (PUQE) Score ≥13
283
Q

Complications of pre eclampsia (5)

A
  • eclampsia

Fetal complications
- Intrauterine growth restriction
- prematurity

Haemorrhage
- placental abruption
- intra abdominal/ cerebral haemorrhage

Cardiac failure

284
Q

Prevention for pre eclampsia

A

If has 1 high RF/ 2 moderate RF then:

Aspirin 75mg/150mg from 12 weeks until birth

285
Q

Mx of pre eclampsia

A

160/100 BP then admit

1st line - labetelol
2nd line- nifedipine/hydralazine

IV mgS04 for eclampsia

**monitor BP, urine dip and fetal growth

286
Q

Sx of pre eclampsia

A

Headache
Upper abdomen/ epigastric pain - liver swelling
N+V
Oedema
Visual disturbances
Reduced urine output
Hyperreflexia

287
Q

How to diagnose pre eclampsia

A

-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

Phase 3a - Arun&Erin (15 decks)

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