Obstetric Procedures

Question 1

What are the indications for IUD insertion?

Answer 1

• Desire for long-term contraception
• Menorrhagia
• Endometriosis
• HRT

Question 2

What are the complications of IUD insertion?

Answer 2

• Generic
  
  • Bleeding
  • Infection
  • Procedural failure/necessity to repeat
• Perforation

Question 3

Describe Chorionic Villi Sampling.

Answer 3

• USS-guided needle aspirate of placental tissue
• Performed 10-13/40
• 1% miscarriage rate
• Foetal viability confirmed and anti- RHD given to RH-neg women (sensitising event)

Question 4

Describe Amniocentesis.

Answer 4

• USS guided needle small aspirate of amniotic fluid
  
  • Avoid entry of placenta,
• Performed ≥15/40
• 1% miscarriage rate
• Foetal viability confirmed and anti-RhD given to Rh-neg women (sensitising event)

Question 5

What are indications for CVS/amniocentesis?

Answer 5

• Demonstrated risk at antenatal screening
• Suspected foetal anomaly on USS
• FHx of inherited disorder
• Known carrier status for inherited disorder
• Previous pregnancy with chromosomal disorder
• Increased maternal age

Question 6

What are the complications of CVS/amniocentesis?

Answer 6

• Generic
  
  • Bleeding
  • Infection
  • Damage to local structures
  • Procedural failure
• Abdominal pain
• Miscarriage - 1%
• Chorioamnionitis
• Limb abnormalities - if CVS performed before 10/40

Question 7

Describe Evacuation of Retained Products of Conception.

Answer 7

Surgical procedure to remove ‘retained products of conception’ after delivery, miscarriage or TOP.

Question 8

What are the indications for ERPC?

Answer 8

• Miscarriage - maternal preference or necessity
• Persistent bleeding, haemodynamic instability after miscarriage or delivery
• Gestational trophoblastic disease
• Infected products of conception after Abx

Question 9

What are the complications of ERPC?

Answer 9

• Intrauterine adhesions
• Perforation of uterus (0.5%)
• Generic
  
  • Bleeding
  • Infection
  • Procedural failure
  • Necessity to repeat

Question 10

Describe External Cephalic Version.

Answer 10

External manipulation of foetus through maternal abdomen to achieve a cephalic presentation.

Question 11

What is the success rate of ECV and when is it offered?

Answer 11

• Success rate = 50-60%
• Nulliparous → offered at 36 weeks
• Multiparous → offered at 37 weeks

Question 12

What can be offered to improve the success rate of ECV?

Answer 12

• Tocolysis and Beta agonists
  
  • Tocolytics
    
    • Nifedipine (CCB)
    • Atosiban (oxytocin receptor antagonist)
    • Terbutaline (beta-agonist) - not given in asthma

Question 13

What are the contraindications for ECV?

Answer 13

• Absolute contraindications:
  
  • Previous C-section regardless of reason
  • Abnormal CTG
  • APH <7 days
  • Major uterine abnormality
  • Ruptured membranes
  • Multiple pregnancy
• Relative contraindications (ECV may be complicated):
  
  • SGA
  • Pre-eclampsia
  • Oligohydramnios
  • Major foetal abnormalities
  • Scarred uterus
  • Unstable lie

Question 14

What are the complications of ECV?

Answer 14

• Placental abruption
• Uterine rupture
• Foeto-maternal haemorrhage
• Procedural failure
• Necessity to repeat

Question 15

What are the indications for Termination of Pregnancy?

Answer 15

• Pregnancy has not exceeded 24th week - Majority of case
• Continuation of pregnancy involves risk to pregnant woman greater than if pregnancy were terminated
• Termination necessary to prevent grave permanent injury to physical/mental health of pregnant woman
• There is substantial risk that if the child were born it would suffer from physical or mental abnormalities
• Emergency
  
  • To save the life of the pregnant woman
  • To prevent grave permanent injury to the physical or mental health of the pregnant woman

Question 16

What are the complications of surgical TOP?

Answer 16

• Cervical trauma - increased risk of cervical incompetence with late terminations
• Retained products of conception
• Uterine perforation
• Generic
  
  • Infection (10%)
  • Bleeding (1%)
  • Damage to local structures
  • Failure
  • Anaesthetic complications

Question 17

What is the process preceding a TOP?

Answer 17

• 2 doctors need to sign the form agreeing to TOP (unless emergency)
• Before TOP:
  
  • Screen for Chlamydia and other STI if indicated
  • Check Rh status
  • Assess VTE risk
  • Bloods – FBC, G&S, haemoglobinopathy
  • Discuss future contraceptive needs – OCP or IUCD
  • ABx prophylaxis
  • All of this needs to be offered within 5 working days of referral
• Time from seeing GP to having a TOP should be less than 2 weeks
• Offer referral to counselling service at abortion clinic
• Council all patients on long-term contraceptive advice

Question 18

Describe the medical management of TOP?

Answer 18

• 200mg MIFEPRISTONE + MISOPROSTOL (24-48hrs later)
  
  • 0-9 weeks = administer at home (bleeding for 2w after abortion)
  • 9-24 weeks = administer in clinic + repeat misoprostol 3-hourly (max: 5 doses) until expulsion
  • ≥22 weeks = intracardiac KCl injection - Feticide
• Offer NSAID for analgesia

Question 19

What are the side effects of medical management TOP?

Answer 19

• Nausea
• Diarrhoea
• Light PV bleed
• Cramps

Question 20

Describe the surgical management of TOP?

Answer 20

• <14 weeks = Misoprostol + ERPC + hCG level
  
  • Local anaesthetic and can go home same day
• >14 weeks = Misoprostol + D+C (dilatation + curettage)
  
  • Under LA or GA - may be able to go home same day

Question 21

What are the side effects of surgical management TOP?

Answer 21

Cramps

Question 22

When should a women who has had a TOP call the 24hr helpline/report to medical services?

Answer 22

• Smelly discharge
• Fever
• Symptoms of pregnancy - nausea, mastalgia etc