Obstetrics Flashcards
Miscarriage
Miscarriage is the spontaneous termination of a pregnancy.
o Early miscarriage is before 12 weeks gestation.
o Late miscarriage is between 12 and 24 weeks gestation.
Missed miscarriage Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Anembryonic pregnancy
o Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred.
o Threatened miscarriage – vaginal bleeding with a closed cervix (closed os) and a fetus that is alive. Risk to pregnancy
o Inevitable miscarriage – vaginal bleeding with an open cervix (products sited at open os). Pregnancy can’t be saved
o Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage (closed os). Part of pregnancy is lost
o Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus (closed os)
o Anembryonic pregnancy – a gestational sac is present but contains no embryo
Miscarriage signs/symptoms
positive urine pregnancy test
• Bleeding primary symptom (more than cramping) and varied amount
• “period type cramps” are described
• Passed products may be brought in
• Cervical shock (products at cervical os and dilating it): Cramps, nausea/vomiting, sweating, fainting.
Miscarriage Ix
- Speculum exam to assess stage of miscarriage: is the os closed?
• A transvaginal ultrasound scan
o Mean gestational sac diameter
o Fetal pole and crown-rump length
o Fetal heartbeat
• When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.
• When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops. When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
• A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
• To confirm: Early foetal demise or non continuing pregnancy (pregnancy in-situ, no heartbeat: mean sac diameter > 25 mm, foetal pole > 7mm)
Miscarriage Mx
<6 weeks (no pain or risk of complicatons)
- expectant Mx: repeat preg test 7-10 days after miscarriage
> 6 weeks
- Expectant management: offered first-line for women without risk factors for heavy bleeding or infection.
• 1 – 2 weeks are given to allow the miscarriage to occur spontaneously.
• A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
Medical Management: Misoprostol
• is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
vaginal suppository or an oral dose. S/E heavy bleeding, pain, vomiting and diarrhoea
Surgical management: Misoprostol and 500 units of Anti-D Manual vacuum aspiration (<10 weeks gestation) or electric vacuum aspiration
Incomplete miscarriage Mx
o Medical management (misoprostol)
o Surgical management (evacuation of retained products of conception)
Recurrent miscarriage and Mx
- 3 or more pregnancy losses
- Independent risk factors – age and previous miscarriages
- Antiphospholipid syndrome (LAC, ACA, B2glycoproteinI)
- Thrombophilia link being researched in a national trial (factor V leiden and prothrombin gene mutations, Protein C, free protein S and antithrombin)
Mx
• Use of low dose aspirin and daily fragmin injections after confirmation of viable IUP in evidence of anti-phospholipid syndrome
• Use of progesterone pessary in unexplained cases if age >35 years and 2 or more losses
Ectopic pregnancy risk factors
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease e.g. female upper genital tract, including the womb, fallopian tubes and ovaries.
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking: kill of microvilli in the tube
- Infertility – more likely to be damaged
- Inferility treatment – IVF (egg in fluid and injected straight in – risk it will go up)
Ectopic signs/symptoms
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa (pain>bleeding)
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
Ectopic pregnancy Ix
FBC, Group and save and bhCG
transvaginal ultrasound scan: blob sign. Moves seperately to the ovary
Features that may also indicate an ectopic pregnancy are:
o An empty uterus
o Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
Pregnancy of unknown location
• positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan/amenorrhea
• Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location
o A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
o A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
o A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete
Ectopic pregnancy Mx
Expectant management:
- unruptured, adnexal mass <35mm, no HR, no pain, HCG<1500 IU/L
Medical management: Methotrexate
- same as above but HCG <5000 IU/L
- dont get pregnant for 6 months
- Vaginal bleeding, N&V, abdo pain and stomatitis
Surgical management:
- Pain, adnexal masss >35mm, visible HR and HCG >5000 IU/L
- Laparoscopic salpingectomy (removal of tube)
- Laparoscopic salpingotomy (cut in tube)
- Anti- Rd 500 IU
Molar Pregnancy (hydatiform)
gestational trophoblastic disease which grows as a mass characterised by swollen chorionic villi. Categorized as partial moles or complete moles
- complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form. Overgrowth of placental tissue
- partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time or 1 sperm cell (reduplicating DNA). The new cell now has three sets of chromosomes (it is a haploid cell 69XXY triploid). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form
- Complete hydatidiform moles have a higher risk of developing into choriocarcinoma (a malignant tumour of trophoblast) than partial moles.
Molar pregnancy signs/symptoms
o More severe morning sickness
o Vaginal bleeding: spotting/bleeding
o Increased enlargement of the uterus
o Abnormally high hCG
o Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
o Early onset pre-eclampsia
o Rare cases: shortness of breath due to embolization to the lungs or seizures (mets to brain)
Molar pregnancy Ix
USS: snowstorm appearance
T4, T3 and hCG
Molar pregnancy Mx
- Surgical evacuation of the uterus to remove the mole and products of conception need to be sent for histological examination to confirm a molar pregnancy.
- In higher gestation where fetus is present in partial mole medical management can be undertaken
- Patients should be referred to the gestational trophoblastic disease centre for management and follow up.
- The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.
Implantation bleeding
- Occurs when the fertilised egg implants in the endometrial lining
- Timing is about 10 days post ovulation
- Bleeding is light brownish and self-limiting
- Soon signs of pregnancy emerge e.g. breast tenderness and morning sickness
Chorionic haematoma
• Pooling of blood between endometrium and the embryo due to separation: sub chorionic
- Bleeding, cramping, threatened miscarriage
- Symptoms and course follow size and perpetuation
- Large haematomas may be source of infection, irritability (causing cramping) and miscarriage
- Usually self-limiting and resolve
- Reassurance important but surveillance should remain
Hyperemesis gravidarum (HG)
Nausea and vomiting are normal during early pregnancy. Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks.
• hCG is thought to be responsible. Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies due to the higher hCG levels. It also tends to be worse in the first pregnancy and overweight or obese women.
• Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy
Hyperemesis gravidarum (HG) signs/symptoms
o More than 5 % weight loss compared with before pregnancy
o Dehydration
o Electrolyte imbalance
• Ketosis and nutritional disturbance
• Weight loss, altered liver function
• Signs of malnutrition
• Emotional instability, anxiety. Severe cases can cause mental health issues e.g. depression
HG Mx
• Rehydration IVI, electrolyte replacement
Anti-emetic:
1st: Cyclizine, prochlorperazine
2nd: metoclopramide
• Thiamine supplement 50mg tds / pabrinex • NG feeding and TPN • Ranitidine and omeprazole: acid reflux • Prednisolone 40mg/day • Thromboprophylaxis TOP
Termination of Pregnancy documentation
• Certified on HSA1 form (“Certificate A”) - 2 doctors sign (green form): for A to E
• Two ‘emergency’ Clauses (F and G) - one doctor signs (HSA2)
• Clause C: An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
o The pregnant woman
o Existing children of the family
•Clause E: An abortion can be performed at any time during the pregnancy if (no gestational limit):
o Continuing the pregnancy is likely to risk the life of the woman
o Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
o There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
TOP Ix
Clinical
o Estimated by LMP +/- date of +ve UPT
o Palpable uterus (> 12 wks)
Ultrasound
o Abdominal or transvaginal (< 6wks)
Medical abortion
Mifepristone 200mg (blocks action of progesterone, halting the pregnancy and relaxing cervix)
Misoprostol 800mcg (prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions)
<12 weeks: self admister mife/miso at home
- 2nd dose misoprostol if >10 weeks
>12 weeks: inpatient - Repeated doses of PV misoprostol: 800mcg PV then 400mcg 3-hourly PV/PO/SL (up to 4)
if >10 weeks: anti D
VTE high risk: LMWH
Surgical Abortion Mx
misoprostol or osmotic dilators (soften and dilate cervix prior)
o < 14wks Electric vacuum aspiration (GA) Manual vacuum aspiration (up to 10wks; LA) o >14wks Dilatation and evacuation
After care for TOP
Preg test 2/3 weeks after abortion
Immediate provision of Long-Acting Reversible Contraception (LARC): post abortion sepsis
Hormonal methods
Infertility
• Infertility defined as inability to conceive after 12 months regular intercourse without contraception
Causes
• Sperm problems (30%)
• Ovulation problems (25%): oligomenorrhea and amenorrhea
• Tubal problems (15%)
• Uterine problems (10%)
• Unexplained (20%)
• 40% of infertile couples have a mix of male and female causes.
Infertility Ix
Body mass index (BMI)
• Chlamydia screening
• Semen analysis
• Rubella immunity
Serum progesterone on day 21 of the cycle
Anti-Mullerian hormone (related to inhibin and activin)
Thyroid function tests
If amenorrhoeic/cycle longer than 42days
o Serum LH and FSH on day 2 to 5 of the cycle
High FSH suggests poor ovarian reserve
High LH may suggest polycystic ovarian syndrome (PCOS).
Prolactin
Ultrasound pelvis and transvaginal
Hysterosalpingogram
• Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Hysteroscopy
Infertility Mx
Lifestyle
- Clomifene citrate (stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH)
- Alternatively: Letrozole (stimulate ovulation)
- Gonadotropins injections
- Laparoscopic Ovarian drilling
•Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Mx Tubal factors: Tubal cannulation during a hysterosalpingogram (proximal lesions), Laparoscopy to remove adhesions or endometriosis and In vitro fertilisation (IVF)
Mx Uterine: correct polyps, adhesions or structural abnormalities
Management of Sperm Problems
- Surgical sperm retrieval is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen.
- A needle and syringe is used to collect sperm directly from the epididymis through the scrotum.
- Surgical correction of an obstruction in the vas deferens may restore male fertility.
- Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. It is unclear whether this is any better than normal intercourse.
- Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm.
- Donor insemination with sperm from a donor is another option for male factor infertility.
IVF cycle
- Suppressing the natural menstrual cycle
- Ovarian stimulation
- Oocyte collection
- Insemination / intracytoplasmic sperm injection (ICSI)
- Embryo culture
- Embryo transfer
UTI pregnancy Mx
Non-pregnant Women:
• Urine culture should be sent if age>65 or haematuria is present
• Trimethoprim or nitrofurantoin for 3 days
Symptomatic Pregnant Women:
• Urine culture done
• Nitrofurantoin (1st and 2nd trimester), Trimethoprim 3rd trimester
Asymptomatic Pregnant Women:
• Urine culture should be done at 1st antenatal visit
• High risk of progressing to acute pyelonephritis
• Immediate course of Nitrofurantoin (avoid near term pregnancy), amoxicillin or cefalexin for 7 days should be started
• Urine culture after treatment, for test of cure.
Gravida (G) Primigravida Multigravida Para (P) Nulliparous Primiparous Multiparous
- Gravida (G) is the total number of pregnancies a woman has had
- Primigravida refers to a patient that is pregnant for the first time
- Multigravida refers to a patient that is pregnant for at least the second time
- Para (P) refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
- Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation
- Primiparous: patient that has given birth after 24 weeks gestation once before
- Multiparous: patient that has given birth after 24 weeks gestation two or more times
Trimesters
- The first trimester is from the start of pregnancy until 12 weeks gestation.
- The second trimester is from 13 weeks until 26 weeks gestation.
- The third trimester is from 27 weeks gestation until birth.
Additional milestones for antenatal care
- Anti-D injections in rhesus negative women (at 28 and 34 weeks)
- Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
- Serial growth scans are offered to women at increased risk of fetal growth restriction
Pregnancy lifestyle advice
Folic acid 400mcg from before pregnancy to 12 weeks
• Individuals with diabetes, on anti-epileptic medications and those with BMI>30, individuals with a previous pregnancy affected by a neural tube defect, or mothers who have a personal history or have a partner with a history of neural tube defect will need to take 5mg daily from 12 weeks.
• Take vitamin D supplement (10 mcg or 400 IU daily)
• only an extra 250-300 calories needed to support a pregnancy especially in the last trimester.
Avoid vitamin A supplements and eating liver or pate
Don’t drink alcohol
Don’t smoke
Avoid unpasteurised dairy or blue cheese
(
• risk of listeriosis)
• Avoid undercooked or raw poultry (risk of salmonella)
• Continue moderate exercise but avoid contact sports
• Sex is safe
• Flying increases the risk of venous thromboembolism (VTE)
• Place car seatbelts above and below the bump (not across it)
Alcohol in pregnancy
o Miscarriage
o Small for dates
o Preterm delivery
o Fetal alcohol syndrome: microcephaly, thin upper lip, smooth flat philtrum, short palpebral fissure, learning disability and behaviour disability
Management of substance abuse in antenatal care
- Consider methadone programme – to avoid chaotic lifestyle
- Child protection and social work referral
- Smear history – put measures in place to ensure the woman gets involved with a screening programme
- Breastfeeding education
- Labour plan regarding analgesia and labour ward delivery
- Early IV access
- Postnatal contraception plan
Booking clinic
10-12 weeks gestation
• A history will be taken including medical, surgical, drug, social and family history.
• Additional details such as date of the last menstrual period, whether the pregnancy was planned and ethnicity of parents [to identify risk factors for developing haemoglobinopathies like sickle cell anaemia or beta thalassemia].
• An obstetric history will also be taken including previous pregnancy, mode of delivery, previous miscarriages or terminations.
• Blood group, antibodies and rhesus D status
• Full blood count for anaemia
• Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
• Patients are also offered screening for infectious diseases, by testing antibodies for:
o HIV
o Hepatitis B
o Syphilis
Other: BMI, Urine (protein and bacteria), BP
Booking clinic risk assessment for additional appointments
o Rhesus negative (book anti-D prophylaxis)
o Gestational diabetes (book oral glucose tolerance test)
o Fetal growth restriction (book additional growth scans)
o Venous thromboembolism (provide prophylactic LMWH if high risk)
o Pre-eclampsia (provide aspirin if high risk)
Screening for fetal abnormality
18-20+6weeks gestation for conditions below and placenta site
- anencephaly, spina bifida, cleft lip, gastroschisis, exemphalos, congential cardiac
Downs syndrome screening
Combined test (11 and 13+6 weeks gestation)
• Ultrasound measures nuchal translucency
o A normal value for nuchal translucency is ≤ 3.5mm.
o Down’s syndrome > nuchal thickness 6mm
•Maternal blood tests:
o beta-HCG – a higher result indicates a greater risk
o Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk
Triple test (14-20 weeks gestation)
o Beta-HCG – a higher result indicates greater risk
o Alpha-fetoprotein (AFP) – a lower result indicates a greater risk
o Serum oestriol (female sex hormone) – a lower result indicates a greater risk
Quadruple test (15-16 weeks) - same as triple + A higher inhibin-A indicates a greater risk.
Definitive testing for downs syndrome
o Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 12-15 weeks). <2% risk of miscarriage
o Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample. Usually after 15 weeks <1% risk of miscarriage
Non-Invasive Prenatal Testing
- Cell free fetal DNA (cffDNA)
- The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA.
- These fragments can be analysed to detect conditions such as Down’s.
- NIPT is not a definitive test, but it does give a very good indication of whether the fetus is affected.
Rhesus Incompatibility
- Individuals who lack these antigens are termed rhesus negative while those who have the antigen are rhesus positive.
- Women that are rhesus-D positive do not need any additional treatment during pregnancy.
- blood from the baby will find a way into the mother’s bloodstream.
- When this happens, the baby’s red blood cells display the rhesus-D antigen.
- The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens.
- When mothers are first exposed to the rhesus antigen, they form IgM antibodies which are too big to cross the placenta and harm the current fetus. However, in future pregnancies when the mother is exposed to the same antigen from the fetus’ red blood cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus leading to haemolytic disease of the newborn.
- If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis).
- The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.
Rhesus Incompatibility Mx
IM anti-D injections to rhesus-D negative women.
Anti-D injections are given routinely on two occasions:
o 28 weeks gestation & 34 weeks
o Birth (if the baby’s blood group is found to be rhesus-positive)
sensitisation (give anti-D within 72 hours) may occur, such as:
o Placental abruption
o Any abdominal trauma (from road traffic accidents for example)
o Amniocentesis or chorionic villus sampling
o External cephalic version
o Intra-uterine surgery/transfusion
o Fetal death
o Vaginal bleeding from 12weeks
o Surgical management of miscarriage at <12 weeks
o Evacuation of retained products of conception and molar pregnancy
o Termination of pregnancy
o Ectopic pregnancy
o Delivery (if baby is rhesus-D positive)
Kleinhauer test
done at 20 weeks
- The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth.
- Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated
fetal anaemia
- There are other causes of fetal anaemia such as parvovirus and other congenital infection such as cytomegalovirus, syphilis, toxoplasmosis.
- In addition, haemoglobinopathies (thalassaemia, sickle cell), feto-maternal haemorrhage and monochorionic twin complications are other causes of fetal anaemia.
fetal anaemia Mx
fetal blood sampling and in utero transfusion via the umbilical vein under ultrasound guidance.
• When the anaemia is extremely severe, the fetus can experience heart failure and develop a condition called hydrops fetalis.
• Hydrops fetalis is a condition where there is abnormal accumulation of fluid in 2 or more compartments and manifests as ascites, pleural effusion, skin oedema, pericardial effusion
• Hydrops fetalis is a late and poor sign of feta anaemia and if untreated could result in death.
• If at more than 32 weeks, the fetus will be delivered for ex-utero transfusion.
Epilepsy and pregnancy
• Ideally, epilepsy should be controlled with a single lowest dose anti-epileptic drug before becoming pregnant.
o Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
o Sodium valproate is avoided as it causes neural tube defects and developmental delay (be careful with child bearing women)
o Phenytoin is avoided as it causes cleft lip and palate
Epilepsy – maternal/fetal risks
• Risks from maternal seizure o Maternal abdominal trauma – FMH (fetal maternal haemorrhage) o PPROM (premature rupture of membranes) o Preterm birth o Hypoxia/acidosis • Fetal risks o Major congenital malformations o Minor malformations o Adverse perinatal outcomes o Long-term developmental effects o Haemorrhagic disease of the newborn o Risk of childhood epilepsy
Maternal epilepsy Mx
- Left lateral tilt
- IV lorazepam / diazepam
- PR diazepam / buccal midazolam
- IV Phenytoin
- May need to expedite delivery by CS
- If no history of epilepsy - MgSO4
pregnancy drugs yes and no
• YES: o Steroids o Azathioprine o Sulfasalazine o Hydroxychloroquine o Aspirin o (Etanercept / Infliximab / Adalimumab) o (Rituximab) • NO: o NSAIDs (>32 weeks) o Cyclophosphamide o Methotrexate o Chlorambucil o Gold o Penicillamine o MMF o Leflunamide
Antiphospholipid syndrome
- An acquired thrombophilia with variable presentation and severity
- Antiphospholipid antibodies (aPL) - autoantibodies that react with the phospholipid component of the cell membrane
- Arterial / venous thrombosis
- Recurrent early pregnancy loss
- Late pregnancy loss - usually preceded by FGR
- Placental abruption
- Severe early onset pre-eclampsia (PET): before 32 weeks
- Severe early onset Fetal Growth Restriction (FGR)
Laboratory: X2 / >6 weeks apart
o IgM / IgG aCL (medium / high titre)
o LA
APS Mx
• No thrombosis / adverse pregnancy outcome
o Low dose aspirin (LDA), Maternal + Fetal Surveillance
• Previous thrombosis
o On warfarin Stop warfarin
o LDA + LMWH (treatment dose)
• Recurrent early pregnancy loss
o LDA + LMWH (prophylaxis dose)
• Late fetal loss / Severe PET / FGR
o LDA + LMWH (prophylaxis dose)
Teratogenic drugs:
ACE inhibitors/ARB Androgens Antiepileptics Cytotoxics Lithium Methotrexate Retinoids Warfarin
- ACE inhibitors/ARB Renal hypoplasia
- Androgens Virilisation of female foetus
- Antiepileptics Cardiac, facial, limb, neural tube defects
- Cytotoxics Multiple defects, abortion
- Lithium Cardiovascular defects
- Methotrexate Skeletal defects
- Retinoids Ear, cardiovascular, skeletal defects
- Warfarin Limb and facial defects
NSAIDs and pregnancy
- They work by blocking prostaglandins.
- Prostaglandins are important in maintaining the ductus arteriosus in the fetus and neonate.
- Prostaglandins also soften the cervix and stimulate uterine contractions at the time of delivery.
- NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis).
- They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus.
- They can also delay labour.
Beta blockers and pregnancy
• Beta-blockers can cause:
o Fetal growth restriction
o Hypoglycaemia in the neonate
o Bradycardia in the neonate
ACE Inhibitors and Angiotensin II Receptor Blockers and pregnancy
block the renin-angiotensin system (ACE inhibitors and ARBs) can cross the placenta and enter the fetus.
• In the fetus, they mainly affect the kidneys, and reduce the production of urine (and therefore amniotic fluid).
• ACE inhibitors and ARBs, when used in pregnancy, can cause:
o Oligohydramnios (reduced amniotic fluid)
o Miscarriage or fetal death
o Hypocalvaria (incomplete formation of the skull bones)
o Renal failure in the neonate
o Hypotension in the neonate
o Renal hypoplasia
Opiates and pregnancy
neonatal abstinence syndrome (NAS).
Presents 3-72 hours
Lithium pregnancy
avoided in 1st trimester: linked with ebsteins anomaly (tricuspid valve is lower on right side of heart)
avoid: breastfeeding
Selective Serotonin Reuptake Inhibitors
o First-trimester use of paroxetine has a stronger link with congenital malformations
o Third-trimester use has a link with persistent pulmonary hypertension in the neonate
o Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management
Isotreinoin
• Isotretinoin is highly teratogenic, causing miscarriage and congenital defects.
Pre-eclampsia
new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).
• A pregnancy-specific multi-system disorder with unpredictable, variable and widespread manifestations
o Renal / Hepatic / Cardiovascular / Haematology / CNS / Placenta
Classic triad of hypertension, proteinuria and oedema
Pre-eclampsia pathophysiology
- When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.
- Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile.
- The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes).
- Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.
- When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia.
- Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta.
- This causes oxidative stress in the placenta (placental ischaemia), and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
Pre-eclampsia risk factors
• High-risk factors are: o Pre-existing hypertension o Previous hypertension in pregnancy o Existing autoimmune conditions (e.g. systemic lupus erythematosus) o Diabetes o Chronic kidney disease • Moderate-risk factors are: o Older than 40 o BMI > 35 o More than 10 years since previous pregnancy o Multiple pregnancy o First pregnancy o Family history of pre-eclampsia • Medical risk factors o Pre-existing renal disease o Pre-existing hypertension o Diabetes (pre-existing/gestational) o Connective tissue disease o Thrombophilias (congenital / acquired)
Pre-eclampsia signs/symptoms
o Hypertension, typically >170/100mmHg and proteinuria o Headache (cerebral oedema) o Visual disturbance or blurriness o Nausea and Vomiting o Papilloedema o Right upper quadrant/epigastric pain (liver swelling and hepatic capsule rupture) o Abdominal tenderness o Disorientation o Sudden onset oedema o Hyperreflexia, clonus o Reduced urine output o Platelets <100 x106 /L, abnormal liver enzymes or HELLP syndrome
Pre-eclampsia Dx
• BP: >140/90 (two occasions) or increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic compared to first trimester
• Urinalysis: Proteinuria (1+ or more on urine dipstick)
o Urine albumin: creatinine ratio (above 30mg/mmol is significant)
o Urine protein: creatinine ratio (above 8mg/mmol is significant
- Bloods: FBC, Platelets, U&Es, LFTs, coagulation screen, urate
- Cardiotocography: technical means of recording the fetal heartbeat and the uterine contractions during pregnanc
- Ultrasound – fetal assessment: Maternal uterine artery Doppler (20-24 weeks) – maybe be a notch
Pre-eclampsia Mx
Pre-existing HTN
- switch to labetalol, nifedipine or methyldopa
Pregnancy induced hypertension/Gestational pregnancy (if after 20 weeks gestation)
- Antihypertensives like labetalol, nifedipine, methyldopa, hydralazine
Pre-eclampsia (after 20 weeks gestation) including prophylaxis
- aspirin 150mg
- aspirin 75mg
- BP, symptoms and urine dipstick at each antenatal appointment
- 1st line: labetolol (no asthma)
- 2nd line: nifedipine
- 3rd line: Methyldopa (stopped within 2 days of birth and not in depression)
- IV hydralazine: critical care
- Doxazocin
- IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Planned birth
- IM steriods <34 weeks
Eclampsia
- refers to the seizures associated with pre-eclampsia.
- If pre-eclampsia is not controlled, it can develop into eclampsia which is characterised by grand mal seizures.
- Associated with ischaemia/vasospasm
Eclampsia Mx
• Make patient safe and note time and length of seizure
• Give high flow oxygen
• Move patient into left lateral and open airway
• Monitor baby (only deliver when mum stabilised)
• IV Labetolol
• IV Hydralazine
• Beware hypotension – fetoplacental unit
• IV magnesium sulphate (Loading dose: 4g IV over 5 minutes) is used to manage seizures associated with pre-eclampsia.
o Maintenance dose: IV fusion 1g/h
o If further seizures administer 2g Mg SO4
o If persistent seizures consider diazepam 10mg IV
• Urgent delivery by fasted method usually caesarean section, unless fully dilated and deliverable by assisted vaginal delivery.
HELLP syndrome
• HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:
o Haemolysis
o Elevated Liver enzymes
o Low Platelets
VTE in pregnancy Ix
Doppler USS
- If iliac vein thrombosis - MRI venography
Chest x-ray & ECG
CT pulmonary angiogram
Ventilation-perfusion (VQ) scan
The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
VTE prophylaxis Mx
risk assessment at booking scan and birth
• Women at increased risk of VTE should receive prophylaxis with low molecular weight heparin (LMWH) unless contraindicated e.g. enoxaparin, dalteparin and tinzaparin.
• Prophylaxis is started as soon as possible in very high-risk patients and at 28 weeks in those at high risk.
• It is continued throughout the antenatal period and for six weeks postnatally.
• Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals)
• Mechanical prophylaxis may be considered in women with contraindications to LMWH. The options for mechanical prophylaxis are:
o Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
o Anti-embolic compression stockings
DVT pregnancy Mx
• Low molecular weight heparin (LMWH). E.g. enoxaparin, dalteparin and tinzaparin
• LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis.
• When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer).
• There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery.
- DOAC but not in breastfeeding or preg
o Warfarin (dose dependent: more than 5mg/day, need to convert to LMWH by 6 weeks)
PE Mx pregnancy
o Unfractionated heparin: rapid onset of action and dose adjustment can be performed if thrombolytic therapy is administered.
o Thrombolysis: may be considered for patients with life-threatening pulmonary embolism and haemodynamic compromise.
Intravenous UFH should be started promptly after thrombolysis and this can be converted to LMWH once stability is achieved.
o Surgical embolectomy
Stages of labour
1) onset of labour until 10cm cervical dilation
2) 10cm dilation to delivery of baby
3) delivery to deliver of placenta
Prostaglandins role?
Stimulate contraction (uterine) and ripen cervix
Prostaglandin E2
Braxton Hicks contractions
Occasional irregular contractions of the uterus
Not true and stay hydrated and relaxed
1st stage
Cervical dilation and effacement Show release (mucus plug)
1) latent phase: 0-3cm (0.5cm per hour) and irregular contractions
2) active phase: 3-10cm (1cm per hour) and strong regular contractions
2nd stage: three ps
Power:strength of contractions
- frequency: 3-4 in 10 mins, up to 45 seconds
Passenger: size of head, attitude (posture), lie (longitudinal vs transverse vs oblique) and presentation (cephalic, shoulder and breech)
Passage: shape of pelvis
Gynaecoid Pelvis: This is the most suitable female pelvic shape
Anthropoid pelvis: There is an oval shaped inlet with large anterio-posterior diameter and comparatively smaller transverse diameter
Android Pelvis: Android shaped pelvis has triangular or heart-shaped inlet and is narrower from the front. African-Caribbean women are more at risk of having an android shaped pelvis
Cardinal movements of labour
Engagement Descent: -5 (pelvic inlet) , 0 (ischial spines) and +5. Occiput transverse Flexion Internal rotation Extension Restitution and external rotation Expulsion
Large Gestational Age (large for dates fetus)
> 4.5kg
estimated fetal weight (EFW) above the 90th centile and AC is >97th centile is considered large for gestational age.
• Clinically, the symphyseal-fundal height will be more than 2cm for the gestational age.
causes of macrosomia
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Overdue
- Male baby
- Polyhydramnios: Excess amniotic fluid
- Multiple pregnancy
- Macrosomia secondary to gestational diabetes
- Occasionally - wrong dates in late bookers, vulnerable women or women who have recently moved from abroad.
Macrosomia risks to mother
Polyhydramnios Labour dystocia o Shoulder dystocia o Failure to progress o Perineal tears o Instrumental delivery or caesarean o Postpartum haemorrhage o Uterine rupture (rare)
Macrosomia risks to baby
o Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
o Neonatal hypoglycaemia
o Obesity in childhood and later life
o Type 2 diabetes in adulthood
Signs/symptoms of polyhydramnios
- Abdominal discomfort
- Prelabour rupture of membranes
- Preterm labour
- Cord prolapse
- Large for dates
- Malpresentation
- Shiny, tense abdomen
- Inability to feel fetal parts
Investigations polyhydramnios
USS:o USS estimated fetal weight >90th centile, AC>97th Centile
o Amniotic Fluid Index (AFI >25cm)
o Deepest Pool >8cm
- Serology- toxoplasmosis, CMV, Parvovirus
- Antibody Screen: Rhesus positive/negative
- Oral glucose tolerance test for gestational diabetes
- Generic population based charts and customised growth charts (ethnicity, BMI, parity)
Large for dates Mx
• Exclude diabetes
• Most women with large for gestational age pregnancy will have a successful vaginal delivery.
• NICE guidelines (2008) advise against induction of labour only on the grounds of macrosomia.
• The main risk with a large for gestational age baby is shoulder dystocia. The risks at delivery can be reduced by:
o Delivery on a consultant lead unit
o Delivery by an experienced midwife or obstetrician
o Access to an obstetrician and theatre if required
o Active management of the third stage (delivery of the placenta)
o Early decision for caesarean section if required
o Paediatrician attending the birth
Polyhydramnios management
- Serial USS - growth, LV, presentation
* Induction of labour (IOL) by 40 weeks
Multiple pregnancy risk factors
- Assisted conception e.g. clomid, IVF
- Ethnicity – higher rates in those of African origin
- Geography – Europe 6-9/1000 deliveries, Nigeria 40-50/1000 deliveries, Japan and China 2/1000
- Family history on maternal side
- Increased maternal age
- Increased parity
- Tall women > short women
Types of multiple pregnancies
• Monozygotic: identical twins (from a single zygote): splitting of a single fertilised egg (30%)
• Dizygotic: non-identical (from two different zygotes): fertilisation of 2 ova by 2 sperm (70%)
• Monoamniotic: single amniotic sac
• Diamniotic: two separate amniotic sacs
• Monochorionic: share a single placenta
o depending on the time of splitting of the fertilised ovum can be either monochorionic monoamniotic, monochorionic diamniotic or conjoined twins.
• Dichorionic: two separate placentas: always DCDA (dichorionic diamniotic)
multiple pregnancies aetiology
- Day 0-3 after fertilisation: Dichorionic, diamniotic (DCDA): morula
- Day 4-7 after fertilisation: Monochorionic , diamniotic (MCDA): blastocyst
- Day 8-14 after fertilisation: Monochorionic , monoamniotic (MCMA): implanted blastocyst
- Day 15 after fertilisation onwards: Conjoined twins: formed embroyonic disc
Multiple pregnancies Ix
Booking scan: 11-13+6 - gestational age, number of placentas and aminiotic sacs
USS:
o Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
o Monochorionic diamniotic twins have a membrane between the twins, with a T sign
o Monochorionic monoamniotic twins have no membrane separating the twins
Multiple pregnancy signs/symptoms
- Exaggerated pregnancy symptoms e.g. excessive sickness/hyperemesis gravidarum
- High AFP (alpha fetoprotein)
- Large for dates uterus
- Multiple fetal poles
Multiple pregnancy risks
• Risks to the mother: o Anaemia o Hyperemesis gravidarum o Polyhydramnios o Hypertension/pre-eclampsia o Malpresentation o Spontaneous preterm birth o Instrumental delivery or caesarean o Postpartum haemorrhage/Antepartum haemorrhage – abruption and placenta praevia o Gestational diabetes • Risks to the fetuses and neonates: o Miscarriage o Stillbirth o Fetal growth restriction o Prematurity o Twin-twin transfusion syndrome: only in monochorionic pregnancies o Twin anaemia polycythaemia sequence o Congenital abnormalities o IUD (Single/Both) o Cerebral palsy – twins 8x higher, triplets 47x higher
Twin-Twin Transfusion Syndrome
fetuses share a placenta. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses
• When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood.
• This causes the donor twin to have a decreased blood volume which affects growth and development and leading to decreased urine output, anaemia and oligohydramnios
• Recipient twin increases leading to increased urinary output and polyhydramnios, polycythaemia and eventually heart failure.
• Treatment involves fetoscopic laser ablation recommended before 26weeks which can lead to twin anaemia-polycythaemia sequence
• If after 26weeks, amnioreduction/septostomy is recommended with aim to deliver at 34-36weeks (but may require preterm delivery).
Twin Anaemia Polycythaemia Sequence
- Fetoscopic laser ablation for TTS can lead to twin-anaemia-polycythaemia sequence (TAPS) which is unequal blood counts caused by joining of a few small caliber artery-to-vein vessel anastomoses.
- Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute.
- One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
Multiple pregnancies Mx
• Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:
o Booking clinic, 20 weeks and 28 weeks gestation
• Additional ultrasound scans: fetal growth restriction, unequal growth and twin-twin transfusion syndrome:
o 2 weekly scans from 16 weeks for monochorionic twins
• Anomaly scan is done at 18-20 weeks.
o 4 weekly scans from 20 weeks for dichorionic twins
o Deep Vertical Pool, bladder & Umbilical Artery Doppler (UAPI), EFW
• Women are given iron and folic acid supplementation, low-dose aspirin (12 weeks) to try to prevent hypertensive disorders.
• Corticosteroids are given before delivery to help mature the lungs.
Multiple pregnancies delivery
• Monoamniotic twins: 32 and 33 + 6 weeks
elective caesarean section: due to the higher risk for cord entanglement
• Diamniotic twins: 37 and 37 + 6 weeks
o 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins with steroids
• Triplets or more – 35 +6 weeks Caesarean section
• Vaginal delivery is possible when the first baby has a cephalic presentation (head first) Caesarean section may be required for the second baby after successful birth of the first baby
• Conjoined Twins: MDT, Specialised centres
Multiple pregnancies labour Mx
- Epidural analgesia because can be used to facilitate operative delivery
- Fetal monitoring: USS & FSE
- Syntocinon after twin 1 to maintain contractions and aid delivery
- USS to confirm presentation
- Intertwin delivery time aimed for <30min
- Risk of PPH- active 3rd stage
Gestational diabetes
diabetes triggered by pregnancy
carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy
• It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
• The most significant immediate complication of gestational diabetes is a large for dates fetus and macrosomia.
women are at higher risk of developing type 2 diabetes after pregnancy
• Anyone with risk factors should be screened with an oral glucose tolerance test at 24 – 28 weeks gestation.
• Women with previous gestational diabetes also have an OGTT soon after the booking clinic.
Gestational diabetes - pathology
• Pregnancy is a diabetogenic state due to the influence of placental hormones which lead to a relative insulin deficiency/resistance e.g. Human placental lactogen, cortisol
• The consequences include:
o Overgrowth of insulin sensitive tissues and macrosomia
o Shoulder dystocia and vaginal trauma, increased risks and need for assisted delivery via forceps or caesarean section (CS)
o Hypoxaemic state in utero - higher risk of stillbirth
o Short term metabolic complications – fetal hypoglycaemia post-delivery
o Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes + cardiovascular disease
Gestational diabetes risk factors
- 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)
- Polyhydramnios
- Glycosuria (1+ on >1 occasion or >= 2+ on one occasion
Gestational diabetes OGTT normal values
• Normal results are (NICE)
o Fasting: < 5.6 mmol/l
o At 2 hours: < 7.8 mmol/l
• Normal results (SIGN)
o Fasting < 5.1 mmol/l
o 2 hour < 8.5 mmol/l
Gestational diabetes Mx
- Education
- four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation
Mx
o Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
o Fasting glucose above 7 mmol/l: start insulin ± metformin
o Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
- Glibenclamide (sulfonylurea) if they decline insulin
The NICE (2015) target levels are: o Fasting: 3.5-5.5 mmol/l o 1 hour post-meal: 7.8 mmol/l o 2 hours post-meal: 6.4 mmol/l o Avoiding levels of 4 mmol/l or below
