Obstetrics Flashcards
What are the two sphincters of the cervix?
Internal and external os
What are the two layers of the uterus?
Endometrium and myometrium
What are the different parts of the fallopian tube?
Ismuth, Ampulla, Infundibulum, Fimbrae
What is the opening of the fallopian tube called?
Proximal ostium
What are the three parts of the uterus?
Fundus
Body
Cervix
What is the blood supply to the uterus?
Uterine artery
What are the 3 components of he hip bone?
Ileum
Pubis
Ischium
Outline the Hypothalamic-pituitary-gonodal axis
Hypothalamus releases GnRH.
GnrH stimulates anterior pituitary to produce LH and FSH.
These stimulate the ovaries to release oestrogen and progesterone.
This has a negative feedback on the hypothalamus and pituitary.
Where is oestrogen released?
The follicles of the ovaries (theca granulosa cells)
What does oestrogen stimulate?
Promotes female secondary sexual characteristics:
- Breast tissue development
- Growth/ development of female sex organs at puberty
- Blood vessel development in uterus
- Development of endometrium
Where is progesterone produced normally?
Corpus luteum after ovulation
Where is progesterone produced during pregnancy?
By the placenta (from 10 weeks gestation)
What are the actions of progesterone?
Thickens and maintains endometrium
Thickens cervical mucus
Increases body temperature
At what age does puberty usually start in females?
8-14
Why do overweight children tend to start puberty earlier?
Aromatase is an enzyme found in adipose (fat) tissue that is important in the creation of oestrogen so overweight children have more of it.
What does puberty start with in females?
Development of breast buds, followed by pubic hair and then periods
What is the first episode of menstruation called?
Menarche
What scale is used to determine the stage of pubertal development?
Tanner stage
What are the two phases of the menstrual cycle?
Follicular phase and Luteal phase
What days of the cycle make up the follicular cycle?
1-14 (May be longer or shorter)
What days of the cycle make up the luteal phase?
14- 28 (ALWAYS 14 days before menstruation)
What are the four stages of development of ovarian follicles?
Primordial follicles
Primary follicles
Secondary follicles
Antral follicles
What is the name of the egg cells in the ovaries and what surrounds them?
Oocytes surrounded by granulosa cells
At what stage of development do follicles develop FSH receptors and therefore require stimulation to further develop?
At the secondary follicle stage
What is day 1 of the menstrual cycle?
First day of bleeding
What is day 14 of the menstrual cycle?
Ovulation
What happens during the follicular phase?
There is rising FSH, which causes development of follicles.
Follicles release oestrogen which begins to inhibit FHS, leading to one dominant follicle.
What happens during ovulation? (Stimulated by what hormones)
The increased oestrogen levels triggers a surge in LH, causing the follicle to release the ovum.
What happens during the luteal phase?
The follicle forms the corpus luteum which secretes progesterone.
What happens to the progesterone level during the luteal phase and what does this trigger?
Peaks 7 days after ovulation, then the falling progesterone level triggers menstruation.
When is the menstrual phase of the cycle?
Day 1~5
What are the different phases that the endometrium goes through during the menstrual cycle?
Menstrual phase (1-5) Proliferative phase (5-14) Secretory phase (14-28)
What happens to the endometrium during the menstrual phase?
Falling levels of progesterone cause shedding
What happens to the endometrium during the proliferative phase?
Rising oestrogen levels causes the endometrium to grow.
There is early development of glands/ spiral arterioles
Cervical mucus becomes thin/ watery to aid sperm entry
What happens to the endometrium during the secretory phase?
After ovulation, progesterone predominates and the endometrium begins to prepare for implantation.
There is development of complex glands and arterioles.
If fertilisation occurs, how is the corpus luteum maintained and what does this cause?
The syncytiotrophoblast of the embryo secretes hCG which maintains the corpus luteum and therefore the endometrium is maintained.
What is hCG?
Human chorionic gonadotrophin.
What are the 3 layers of primary follicles?
Primary oocyte in centre
Zona pellucida
Granulosa cells
What is the further layer that follicles develop and what does it consist of?
Theca folliculli:
Theca interna- secretes androgen hormones
Theca externa- made up of connective tissue
What does the secondary follicle develop to become an antral follicle?
Antrum- single large fluid fillled area/
What happens to the dominant follicle when there is a surge of LH?
The smooth muscle of the theca externa squeezes, causing the follicle to burst and the ovum to escape.
What happens to the ovum once it has escaped the follicle?
It is swept up by the fimbrae into the fallopian tubes.
What happens to the primary oocyte around the time of ovulation?
It undergoes meiosis, splitting into two haploid (23 chromosome) cells
What happens to the other 23 chromosomes when the primary oocyte splits?
They float off and become a polar body
The other is the secondary oocyte.
What does the released ovum consist of (layers)?
Secondary oocyte
First polar body
Zona pellucida
Corona radiata (made up of granulosa cells)
What happens when a sperm enters the vagina?
It travels up the uterus into the fallopian tube and attempts to penetrate the corona radiata and zona pellucida to fertilise the egg
Where does fertilisation occur?
Ampulla of the fallopian tube
How long does an unfertilised egg stay in the fallopian tube?
24 hours before it dies
How long is the fertilisation window each month and why?
6 days- ovulation is only one day but sperm can survive for up to five days in the female body
What is the name of the fertilised egg?
Zygote
What does the zygote rapidly turn into?
Morula (mass of cells)
What does the morula become?
Blastocyst
What does the blastocyst contain?
The embryoblast and blastocele (fluid filled cavity), surrounded by trophoblast (outer layer)
How many cells does the blastocyst consist of when it enters the uterus?
100-150
How long does it take for the blastocyst to reach the uterus after ovulation?
8-10 days
What happens during implantation?
The trophoblast (outer layer of blastocyst) undergoes adhesion to the stroma of endometrium.
What is the outer layer of the trophoblast called and what happens to it during implantation?
The syncytiotrophoblast.
It projects into the stroma and mixes with endometrial cells.
What is the decidua?
Cells of the endometrial stroma that specialise to provide nutrients to the trophoblast
What does the syncytiotrophoblast produce and why is this essential?
HCG which maintains the corpus luteum, allowing it to continue producing progesterone and oestrogen.
What happens to hCG levels during pregnancy?
They are high in early pregnancy, plateau at 10 weeks gestation then start to fall.
What are the functions of the placenta?
Respiration Nutrition Excretion Endocrine Immunity
What hormones does the placenta produce?
hCG
Oestrogen
Progesterone
What are the 3 stages of labour?
1= Onset of labour until 10cm dilated 2= from 10cm dilated to delivery 3= from delivery of baby to delivery of placenta
What happens in the first stage of labour?
Cervical dilation and effacement
The show
What is cervical effacement?
When the cervix gets thinner from front to back
What is the ‘show’ and when does it happen?
When the mucus plug in the cervix that prevents bacteria from entering the uterus during pregnancy falls out during the first stage of pregnancy.
What are the 3 phases of the first stage of labour?
Latent phase
Active phase
Transition phase
What happens in the latent phase of pregnancy?
There is 0cm to 3cm dilation of the cervix, at around 0.5cm per hour
There are irregular contractions
What happens in the active phase of labour?
From 3cm to 7cm dilation of the cervix, at around 1cm per hour with regular contractions/
What is the transition phase of labour?
From 7cm to 10cm dilation of the cervix at about 1cm per hour.
There are strong and regular contractions.
What is the second stage of labour?
From 10cm dilation of the cervix to the delivery of the baby
What does the success of the second stage of labour depend on?
The 3 P’s
What are the 3 P’s of labour?
Power
Passenger
Passage
What does power refer to?
The strength of the uterine contractions
What does passage refer to and what can hinder this part of labour?
The size and shape of the pelvis.
There may be anatomical problems, ovarian cysts, fibroids, broken bones e.t.c.
What are the 4 components of the ‘passenger’ portion of the 3 P’s?
Size
Attitude
Lie
Presentation
What is the attitude of the fetus?
The posture (e.g. how the back is rounded and how the head and limbs are flexed)
What is the lie of the fetus?
The position of the fetus in relation to the mothers spine /
What are the potential ways the fetus may lie?
Longitudinal lie
Transverse lie
Oblique lie
What does presentation refer to?
The part of the fetus closest to the cervix
What are the different types of presentation?
Cephalic (head) presentation
Shoulder presentation
Breech presentation
What are the different types of breech presentation?
Complete breech (hips and knees flexed) Frank breech (hips flexed, knees extended) Footling breech (foot hanging down)
What are the structures that allow a babies skull/ brain to grow?
Posterior and anterior fontanelle
Sutures
Where is the posterior fontanelle?
Between the occipital bone and two parietal bones
Where is the anterior fontanelle?
Between the two parietal bones and two frontal bones
Ideally, which part of the babies head should come out first?
The occiput (back of the head)
What can you feel for when doing a vaginal exam to work out the position of the baby? for delivery?
Fontanelles
Face
What are the 7 stages of labour?
Engagement Descent Flexion (though baby should be flexed through whole above process) Internal rotation Extension Restitution External rotation Lateral flezion (Expulsion)
What are the borders of the pelvic outlet?
Tipc of coccyx
Ischial tuberosity
Pubic arch
Which diameter is greater at the pelvic inlet?
The transverse diameter
Which diameter is greater at the pelvic outlet?
The Antero-posterior diameter
What causes the fetal head to rotate from the transverse to an anterior-posterior position ?
The pelvic floor muscles
What causes descent?
Uterine contractions
Amniotic fluid pressure
Abdominal muscle contraction
What is engagement?
When the largest diameter of the fetal head descends into the pelvis.
What is crowning?
When the widest part of the fetal head gets through the narrowest part of the pelvis, causing it to become visible at the vulva
What is restitution?
When the shoulders naturally align with the head
How is descent measured and in relation to what?
In centimetres from -5 to +5 in relation so the mothers ischial spines.
What is the third stage of labour?
The completed birth of the baby to the delivery of the placenta
What would prompt active management of the third stage?
Haemorrhage
More than a 60 minute delay in delivery
What does active management of the third stage involve?
Giving a dose of intramuscular oxytocin to help uterine contractions.
What are Braxton-Hicks contraction?
Occasional contractions of the uterus that do not indicate the onset of labour.
What are the different parts of the baby that can present first?
Occiput (Back of head) Mentum (chin) Sacrum Face Brow
Where do contractions start?
The fundus
What is SROM?
Spontaneous rupture of membranes
What is ARM?
Artificial rupture of membranes
What are the two membranes of the placenta?
The amnion and the chorion
What is the amnion?
The placental membrane that acts as a bag around the baby
What is the chorion?
The membranes around the placenta
What are some hollistic methods for labour pain management?
Water bath Aromatherapy Massage Hypnotherapy TENS machine
What is entonox?
Gas and air
What are non-invasive pain relief options for labour?
Entonox
Paracetamol
Codeine
What is miscarriage?
The spontaneous termination of pregnancy before 24 weeks?
When is early miscarriageE?
Before 12 weeks gestation
When is late miscarriage?
Between 12 and 24 weeks gestation
What is a missed miscarriage?
When the fetus is no longer alive but no symptoms have occured
What is threatened miscarriage?
Vaginal bleeding with a closed cervix and the fetus is still alive
What is inevitable miscarriage?
Vaginal bleeding with an open cervix
What is incomplete miscarriage?
When the retained products of conception (RPOC) remain in the uterus after miscarriage
What is complete miscarriage?
When there are no products of conception left in the uterus
What is an anembryonic pregnancy?
When a gestational sac is present but contains no embryo
What is the investigation of choice for diagnosing a miscarriage?
Transvaginal ultrasound
What are the 3 key features that sonographers look for in early pregnancy, in order of development?
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heart beat
What is the fetal crown-rump length?
The baby is measured in cm from the crown (top of head) to the bottom of their buttocks (rump).
What is the fetal pole?
First direct imaging manifestation of the fetus- thickening of the yolk sac margin visible approx. 6 weeks after conception.
When would a fetal heartbeat be expected?
When the crown-rump length is >7mm
If the crown-rump length is <7mm without a fetal heartbeat, how soon is there a repeat scan?
After at least 1 week to ensure heart beat develops
If there is a crown-rump length of >7mm without a fetal heart beat, what happens?
There is a repeat scan a week later before confirming a non-viable pregnancy
When would a fetal pole be expected to be seen?
Once the mean gestational sac diameter is >25mm
What is the management of a miscarriage at <6 weeks gestation?
Expectant
What is expectant miscarriage management before 6 weeks gestation?
Awaiting the miscarriage without investigations of treatment.
A repeat pregnancy test is performed after 7-10 days to confirm miscarriage.
What do the NICE guidelines recommend for a woman at >6 weeks gestation and a positive pregnancy test?
Referral to an early pregnancy assessment service (EPAU)
What investigation is given to a woman at >6 weeks gestation and bleeding?
An ultrasound to confirm location and viability of pregnancy (and to exclude ectopic pregnancy)
What are the 3 options for managing a miscarriage?
Expectant
Medical
Surgical
When would expectant management be offered for miscarriage?
If <6 weeks gestation
If >6 weeks with no risk factors for heavy bleeding or infection
How long is given for expectant management before moving on to other measures?
1-2 weeks given to allow miscarriage to occur spontaneously.
How soon after pain/ bleeding settle from expectant miscarriage should a repeat pregnancy test be done to confirm?
3 weeks
What factors may indicate an incomplete miscarriage?
Persistent or worsening bleeding
What is the medical management of miscarriage?
Misoprostol
What is misoprostol/ its mechanism of action?
A prostaglandin analogue- binds to prostaglandin receptors and activated them
Why does misoprostol stimulate miscarriage?
It activates prostaglandins which soften the cervix and stimulate uterine contractions
How is misoprostol given?
Either as a vaginal suppository or an oral dose
What are the key side effects of misoprostol?
Heavier bleeding
Pain
Vomiting
Diarrhoea
What are the indications for surgical management of miscarriage?
Sepsis, heavy bleeding or haemodynamic instability, suspicion of gestational trophoblastic disease.
What are the two options for surgical management of miscarriage?
Manual vacuum aspiration
Electric vacuum aspiration
Is manual vacuum aspiration done under local or general anaesthetic?
Local anaesthetic applied to the cervix as an outpatient
Is electric vacuum aspiration done under local or general anaesthetic?
General
What is given before surgical management of miscarriage and why?
Misoprostol to soften the cervix
What happens during manual vacuum aspiration?
A syringe attached to a tube is inserted into the uterus, and the contents are manually aspirated.
What are the indications for manual instead of electric vacuum aspiration?
Women consents
Below 10 weeks gestation
(More appropriate for parous women- those who have previously given birth)
What happens during electric vacuum aspiration?
Under general anaesthetic, the cervix is gradually widened using dilators and the products of conception are removed through the cervix using an electric -powered vacuum
What is given to rhesus negative women having surgical management of pregancy?
Anti-rhesus D prophylaxis
What is the risk of incomplete miscarriage?
The retained products create a risk of infection
What are the two options for treating an incomplete miscarriage?
Medical management
Surgical management
What is the surgical management for incomplete miscarriage?
Evacuation of retained products of conception (ERPC)
What happens during Evacuation of retained products of conception (ERPC)?
Cervix is widened using dilators, retatined products are manually removed using vacuum aspiration and curettage (Scraping)
What is a key complication of evacuation of retained products of conception surgery?
Endometritis
What is classed as recurrent miscarriage?
Three or more consecutive miscarriages
What increases the risk of miscarriage?
Increased age
50% in women aged 40-45
What are the causes of miscarriage?
Idiopathic
Bleeding disorders (Antiphospholipid syndrome, Hereditary thrombophilias)
Uterine abnormalities
Genetic factors
Chronic diseases (diabetes, thyroid disease, SLE)
What is antiphospholipid syndrome?
A disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting (hyper-coagulable state)
What is given to pregnant ladies with antiphospholipid syndrome?
Low dose aspirin
LMWH
What is ectopic pregnancy?
When a pregnancy is implanted outside the uterus
Where is the most common site for an ectopic pregnancy?
The fallopian tube
What is the name of the entrance to the fallopian tube?
Cornual region
Where can an ectopic pregnancy occur?
Fallopian tube Cornual region Ovary Cervix Abdomen
What are the key risk factors for developing an ectopic pregnancy?
Previous ectopic pregnancy Previous PID Previous surgery to fallopian tubes IUD Older age Smoking
At what gestation does ectopic pregnancy usually present?
6-8 weeks
What are the key features of an ectopic pregnancy?
Missed period
Constant lower abdominal pain in right or left iliac fossa
Vaginal bleeding
Lower abdominal/ pelvic tenderness
Cervical motion tenderness (Pain in cervix during bimanual exam)
Dizziness/ syncope
Shoulder tip pain (peritonitis)
What are the 9 regions of the abdomen?
R hypochondriac, Epigastric, L Hypochondirac, R lumbar, umbilical, L lumb, R iliac, hypogastric, L iliac
Why might you get shoulder tip pain during ectopic pregnancy?
Bleeding in the peritoneal cavity can irritate the diaphragm and therefore phrenic nerve which causes referred pain.
What is the investigation of choice for diagnosing a miscarriage?
TVUS (Transvaginal ultrasound scan)
What may be seen in a TVUS during ectopic pregnancy?
Gestational sac containing yolk soc or fetal pole in fallopian tube
What is a blob sign?
When a mass containing an empty gestational sac is seen on TVUS
What is a PUL?
Pregnancy of unknown location
How is a PUL diagnosed?
When there is a positive pregnancy test and no evidence of pregnancy on ultrasound
How often are serum hCG levels repeated during PUL?
After 48 hours to measure change from baseline
What change in hCG should be seen in a normal pregnancy?
Should double every 48 hours
What produces hCG?
The developing syncytiotrophoblast
What may a rise of more than 63% hCG after 48 hours indicate?
A normal intrauterine pregnancy
Over what hCG level should a pregnancy be visible on ultrasound?
> 1500 IU/L
What may a rise of less than 63% hCG indicate?
An ectopic pregnancy
What is a fall of >50% of hCG likely to indicate?
A miscarriafe
What is the immediate management of any women with suspected ectopic pregnancy?
Pregnancy test
What needs to happen to women with pelvic pain and and a positive pregnancy test?
Need to be referred to an early pregnancy assessment unit or gynae service
What are the 3 management options for ectopic pregnancy?
All must be terminated:
Expectant
Medical
Surgical
What is the criteria for expectant management for ectopic pregnancy?
Ectopic must be unruptured Adnexal mass <35mm No visible heartbeat No significant pain HCG level <1500 Must be available for follow up
What followup must be given to women on expectant management for ectopic?
Close monitoring of hCG
What is the criteria for medical management for ectopic?
Same as expectant but HCG must be <5000 and confirmed absence of intrauterine pregnancy on ultrasound
What is the medical management for ectopic pregnancy?
Methotrexate
Why is methotrexate given to treat ectopic?
It is highly teratogenic.
How is methotrexate given?
As an IM injection to the buttock.
How long should women treated with methotrexate wait to try for another baby?
3 months
What are common side effects of methotrexate?
Vaginal bleeding
Nausea/ vomiting
Abdominal pain
Stomatitis
What is the criteria for surgical management to treat ectopic pregnancy?
Pain
Adnexal mass >35mm
Visible heartbeat
HCG levels >5000
What is the most likely treatment option for most ectopic pregnancies?
Surgical
What are the two options for surgical management of ectopic pregnancy?
Laparoscopic salpingectomy
Laparoscopic salpingotomy
What is laparoscopic salpingectomy?
Key hole surgery to remove fallopian tube and ectopic pregnancy.
Done under general anaesthetic
What is laparoscopic salpingotomy?
The removal of the ectopic from the fallopian tube, but re-closing the tube to keep it there.
Which is the first line surgical treatment for ectopic pregnancy and why?
Laparoscopic salpingectomy as there is higher success rate.
What are the adnexa?
Ovaries, fallopian tubes, and ligaments that hold the reproductive organs in place
What is a molar pregnancy?
When a tumour called a hydatidiform mole grows like a pregnancy
What are the two types of molar pregnancy?
Complete mole
Partial mole
What is a complete mole?
When two sperm cells fertilise an ovum that contains no genetic material. The sperm then combine genetic material and the cells start to divide and grow into a tumour (complete mole)
What is a partial mole?
When two sperm cells fertilise a normal ovum at the same time, so the new cell has 3 sets of chromosomes.
What features can differentiate between a normal pregnancy and a molar pregnancy?
More severe morning sickness Vaginal bleeding Increased enlargement of uterus Abnormally high hCG Thyrotoxicosis
Why may molar pregnancy cause thyrotoxicosis?
hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4
What investigation is done to diagnose molar pregnancy?
Pelvis USS which shows characteristic ‘snowstorm appearance’
What investigation confirms diagnosis of molar pregnancy?
Histology of mole after evacuation
What is the management of molar pregnancy?
Evacuation of the uterus to remove the mole.
Referral to the gestational trophoblastic disease centre for management and follow up.
Monitoring of hCG levels until they return to normal
Why may a patient with a molar pregnancy require systemic chemotherapy?
Because the mole can metastasise
About 1 in 10 people
What is the name of the legal framework for the termination of pregnancy?
1967 Abortion Act
What is the latest gestational age where abortion is legal?
24 weeks
What is the key criteria that must be used to justify an abortion?
Continuing the pregnancy involves greater risk to the physical or mental health of the woman, or existing children of the family
What criteria allows an abortion to be perfomed at any time during the pregnancy?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent ‘grave permenant injury’ to the physical or mental health of the woman
- There is ‘substational risk’ that the child would suffer physical or mental abnormalities
What are the legal requirements for abortion?
Two registered medical practitioners must sign to agree abortion is indicated.
Carried out by a registered medical practitioner in and NHS hospital/ approved premise
How can abortion services be accessed?
- Self-referral
- GP
- GUM
- Family planning clinic referral
When is medical abortion most appropriate?
Earlier in pregnancy
What does medical abortion involve?
Mifepristone
Misoprostol 2 days later
What is Mifepristone?
An anti-progesterone medication that blocks the action of progesterone, therefore halting the pregnancy and relaxing the cervix
What is Misoprostol?
A prostaglandin analogue, that binds to prostaglandin receptors and activates themm therefore softening the cervix and stimulating uterine contractions
What are the types of anaesthetic surgical abortion can be performed under?
Local
Local + sedation
General
What is given to patients prior to surgical abortion?
Misoprostol, Mifepristone or osmotic dilators, to soften and dilate the cervix.
What are osmotic dilators?
Devices inserted into the cervix that gradually expand as they absorb fluid, opening the cervical canal
What are the two options for surgical abortion?
Cervical dilation and suction of uterus contents (<14 weeks)
Cervical dilation and evacuation with forceps (14-24 weeks)
What happens after abortion?
Women may have bleeding and cramps for up to 2 weeks after.
Pregnancy test performed after 3 weeks
Support, counselling and contraception advice is given.
What are the complications of abortion?
Bleeding Pain Infection Failure Damage to uterus, cervix and surrounding structures
How many weeks is trimester 1?
0-12
When is trimester 2?
12-26 weeks
When is trimester 3?
27-40 weeks
What is the mechanism of miscarriage?
If the implantation site is not well established, then the fetus does not burrow properly. This leads to a decrease in HCG which causes progesterone levels to fall. The low progesterone causes the endometrium to break down the the uterus contracts to let unwanted contents out.
In a normal pregnancy, what effect does HCG have on progesterone?
Positive effect, more HCG= More progesterone so endometrium doesn’t die and the egg can burrow
What are the two types of shock that can occur with miscarriage?
Hypovolaemic–> Excessive bleeding lowers the blood pressure
Vagal stimulation–> When the cervix is forcibly dilated, it causes vagal stimulation which decreases the blood pressure (parasympathetic nervous system)
Why is a previous surgery a danger to pregnancy?
As usually the endo-myometrial interface prevents the fetus burrowing into the myometrium. However, if this has a cut it can perforate through.
What does LMP refer to?
Last menstrual period
What is GA?
Gestational age
What is EDD?
Estimated date or delivery
What is gravida?
The total number of pregnancies including the current one
What does primigravida mean?
Patient that is pregnant for the first time
What does multigravida mean?
A patient is pregnant for at least the second time
What does para/ parity refer to?
Number of times a women has given birth after 24 weeks gestation, regardless of outome
What does nulliparous mean?
Patient has never given birth after 24 weeks gestation
What does primiparous mean?
A patient that has given birth after 24 weeks once before
What does multiparous mean?
A patient that has given birth after 24 weeks two or more times
What would be the gravida and para for a pregnant woman with three previous deliveries and one miscarriage?
G4P3+1
When do fetal movements typically start?
From around 20 weeks
When does booking clinic occur?
Before 10 weeks
What pregnancy milestone should happen between 10 and 13+6 weeks?
Dating scan
How is the gestational age calculated?
From the crown rump length
What milestone occurs at 16 weeks?
Antenatal appointment
What milestone happens between 18 and 20+6 weeks?
Anomaly scan
At what weeks are there further antenatal appointments?
25, 28, 31, 34, 36, 38, 40 +
What additional appointments may be necessary for pregnant women?
Additional for higher risk/ complicated pregnancies
Oral glucose tolerance test for those at risk of gestational diabetes
Anti-D injections in rhesus negative women (28 and 34 weeks)
USS at 32 weeks for those with placenta praevia
Serial growth scans for those increased risk of fetal growth restriction
What is measured from 24 weeks onwards?
Symphysis-fundal height
What is assessed from 36 weeks onwards?
Fetal presentation
What is measured to assess for pre-eclampsia?
Urine dipstick
Blood pressure
What 2 vaccines are offered to all pregnant women?
Whooping cough (from 16 weeks) Flu jab (in autumn/ winter months)
What supplements are recommended in pregnancy?
Folic acid
VItamin D
When should you take folic acid and why is important to take folic acid in normal pregnancy?
From before pregnancy to 12 weeks
It reduces risk of neural tube defects
What things should be avoided in pregnancy?
Vitamin A Liver or pate (high in vitamin A) Alcohol Smoking Unpasteurised dairy/ blue cheese Undercooked/ raw poultry
What are the risks of drinking alcohol in early pregnancy?
Miscarrige
Small for GA
Preterm delivery
Fetal alcohol syndrome
What are the key features of fetal alcohol syndrome?
Microcephaly (small head) Thin upper lip Smooth flat philtrum (groove between nose and upper lip) Short palpebral fissure (from one side of eye to another) Learnng disability Behavioural difficulties Hearing/ vision problems Cerebral palsy
What are the risks of smoking in pregnancy?
Fetal growth restriction Miscarriage Stillbirth Preterm labour/ delivery Placental abruption Pre-eclampsia Cleft lip/ palate SIDS
What is SIDS?
Sudden infant death syndrome
Up to what stage in pregnancy is it ok to fly?
37 weeks
32 in twin pregnancy
At what stage of pregnancy does booking clinic occur?
Before 10 weeks gestation
What topics should be covered in booking clinic?
Stages of pregnancy Lifestyle advice Supplements Plans for birth Screening tests Antenatal classes Breastfeeding classes Mental health
What bloods are taken at booking clinic?
Blood grouo
Antibodies
Rhesus D status
FBC for anaemia
Screening for thalassaemia and sickle cell disease (for those at higher risk)
Screening for infectious disease (HIV, Hep B, Syphillis)
What is done at booking clinic?
Educating woman on pregnancy topics Bloods Weight, Height & BMI Urine (protein & bacteria) Blood pressure Discuss FGM/ domestic violence Risk assessment for pregnancy complications
What conditions are women risk assessed for at booking clinic?
Rhesus negative Gestational diabetes Fetal growth restriction VTE Pre-eclampsia
Who is at more risk of have a baby with Down’s syndrome?
Older mothers
What are the different screening tests for Down’s syndrome?
Combined test
Triple test
Quadruple test
Which is the first line screening test for Down’s syndrome?
The combined test
At what stage is the combined test completed?
11-14 weeks
What does the combined test involve?
Combining results from ultrasound and maternal blood tests
What does the ultrasound measure in the combined test for Down’s?
Nuchal translucency
What is nuchal translucency and what thickness would indicate Down’s?
The thickness of the fluid filled space at the back of the neck
6mm
What maternal blood tests are included in the combined test and what results would indicate greater risk of Down’s?
Beta-HCG (higher result = higher risk)
Pregnancy- associated plasma protein- A (PAPPA)- Lower result = greater risk
When is the triple test for Down’s syndrome completed?
Between 14 and 20 weeks gestation
What does the triple test for Down’s involve?
Three maternal blood tests:
Beta-HCG
Alpha-fetoprotein
Serum oestriol
When would the quadruple test for Down’s be completed?
Between 14 and 20 weeks gestation
What does the quadruple test involve?
4 blood tests:
- Beta HCG
- Alpha-fetoprotein
- Serum oestriol
- Inhibin A
For each of the blood tests in the quadruple test, what result would indicate a higher risk?
- Beta HCG–> High
- AFP–> Low
- Serum oestriol–> Low
- Inhibin-A–> High
What risk score from the Down’s screening tests would trigger further action?
Risk of greater than 1 in 150
What is offered to the woman if there is a greater than 1 in 150 risk of Down’s?
Amniocentesis or
Chorionic villus sampling
What is Chorionic villus sampling?
Ultrasound-guided biopsy of the placental tissue in order to karyotype the fetal cells and confirm Down’s
What is amniocentesis?
Ultrasound-guided aspiration of amniotic fluid using a needle and syringe
When would chorionic villus sampling be used instead of amniocentesis?
Early in the pregnancy (before 15 weeks) when there is not enough amniotic fluid to safely take a sample
What is NIPT?
Non-invasive prenantal testing
What does NIPT involve?
Blood test from the mother, containing fragments of fetal DNA which can be analysed to detect chromosomal conditions.
What chronic conditions may be problematic in pregnancy?
Hypothyroidism
Hypertension
Epilepsy
RA
How is hypothyroidism managed in pregnancy?
Levothyroxine dose increased by 30-50% to provide enough to the developing fetus
What changes may need to happen to women with existing hypertension during pregnancy?
STOP:
- Ace inhibitors
- ARB’s
- Thiazide-like diuretics
What medications can be continued/ changed to to treat existing hypertension in pregnancy?
Labetalol
CCB’s
Alpha-blockers
What adverse effects may pregnancy cause to women with epilepsey?
Can worsen seizure control due to additional stress, lack of sleeps, hormonal changes and altered medication regimes
What epilepsey medication should be avoided in women of childbearing age due to its teratogenic effects?
Sodium valproate
Which anti-epileptics are safer in pregnancy?
Levetiracetam
Lamotrigine
Carbamazepine
What medication for RA should be avoided in pregnancy?
Methotrexate- teratogenic
What key drugs should be avoided in pregnancy?
NSAIDs Beta-blockers ACE inhibitors ARB's Opiates Warfarin Sodium Valproate Lithium SSRIs Isotretinoin
Why should NSAID’s be avoided in pregnancy?
They work by blocking prostoglandins (which are important in maintaining the ductus arteriosus in the fetus and neonate, and soften the cervix/ stimulate contractions in labour)
At which stage of pregnancy are NSAIDs particularly avoided and why?
Third trimester as they can cause premature closure of the ductus arteriosus and delay labour
Why are beta- blockers contraindicated in pregnancy?
They can cause FGR, hypoglycaemia and bradycardia in the neonate
Why are medications that block the RAAS system (ACE inhibitors/ ARB’s) contraindicated in pregnancy?
They can cross the placenta and enter the fetus, affecting the fetal kidneys and reducing the production of urine (and therefore amniotic fluid)
What are the complications of using ACE/ ARB’s in pregnancy?
Oligohydramnios
Hypocalvaria (incomplete formation of skull bones)
Miscarriage/ fetal death
Renal failure/ hypotension in neonate
Why are opiates contraindicated in pregnancy?
They can cause neonatal abstinence syndrome (NAS)- withdrawal symptoms in the neonate after birth
What is NAS and how does it present?
Neonatal abstinence syndrome
Presents 3-72 hours after birth with irritability, tachypnoea, fevers and poor feeding
Why is warfarin avoided in pregnancy?
It is teratogenic and can cross the placenta to cause fetal loss, congenital malformations or bleeding
Why is sodium valproate contraindicated in pregnancy?
It causes neural tube defects and developmental delay
Why is lithium contraindicated in pregnancy?
Linked to congenital cardiac abnormalities in the first trimester.
Can also enter the breast milk and be toxic to the infant
Why are SSRI’s contraindicated in pregnancy?
First trimester- linked with congenital heart defects
Third trimester- linked to persistent pulmonary hypertension in the neonate
Neonates can experience withdrawal symptoms
What is isotretinoin and why is it contraindicated in pregnancy?
A retinoid (related to vitamin A) used to treat severe acne, that is highly teratogenic and can cause miscarriage and congenital defects
What viruses are most risky to pregnant women?
Rubella Chickenpox Listeria Congenital Cytomegalovirus Congenital toxoplasmosis Parvovirus B19 Zika virus
What causes congenital rubella syndrome?
Maternal infection with the rubella virus during the first 20 weeks of pregnancy
Should women be given the MMR vaccine when pregnant if not already immune?
No- it is a live vaccine
Should be given after birth
What are the features of congenital rubella syndrome?
Congenital deafness
Congenital cataracts
Congenital heart disease
Learning disability
Why is Chickenpox dangerous in pregnancy?
It can lead to varicella syndrome or severe infection in the mother
What can be tested if the mother is unsure if she is immune to chickenpox?
IgG levels for VZV (Varicella zoster virus)
What should happen if a woman is exposed to chickenpox in pregnancy?
- If unsure about immunity, test VZV IgG levels.
- If not immune, treat with IV varicella immunoglobulins
- If present with a rash, treat with oral aciclovir
What is listeria and which patients are more at risk?
A gram-positive bacteria that causes listeriosis. It is a lot more likely in pregnant women.
What are the risks of developing listeriosis in pregnancy?
High rate of miscarriage, fetal death or severe neonatal infection
How is listeria typically transmitted?
By unpasteurised dairy products, processed meats and contaminated foods (why women should avoid blue cheese)
What is CMV and how is it spread?
Congenital cytomegalovirus. Spread via infected saliva or urine of asymptomatic children/
What is the classic triad of features in congenital toxoplasmosis?
Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of eye)
What is parvovirus B19 more commonly known as?
Slapped cheek syndrome
or fifth disease/ erythema infectiosum
What are the complications of parvovirus B19 in pregnancy?
Miscarriage/ fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
What does rhesus refer to?
The various types of rhesus antigens on the surface of RBC’s
When someone is ‘rhesus-negative’, what does that refer to?
Whether the rhesus-D antigen is present on the red blood cell surface
Do rhesus positive or rhesus negative women need additional treatment during pregnancy?
Rhesus negative
Outline how a rhesus-negative mother may become sensitised during pregnancy:
If a woman who is rhesus-negative has a rhesus positive baby, the babys red blood cells may enter her blood stream and display the rhesus-D antigent. Her immune system will therefore develop antibodies to the foreign D antigen and become sensitised.
Why is becoming sensitised to rhesus-D antigens an issue for the mother?
During subsequent pregnancies, the mothers anti-D antibodies can cross the placenta and attach to the fetal red blood cells, causing haemolysis
What is haemolytic disease of the newborn?
When a sensitised mothers antibodies attack a rhesus-D positive fetus’s red blood cells.
What is the mainstay of management in rhesus disease?
Prevention of sensitisation
How is sensitisation prevented in rhesus-negative pregnant women?
IM anti-D injections
How do anti-D injections work?
It attaches to the rhesus-D antigens on fetal RBC’s in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system creating antibodies against them.
When are anti-D injections given?
Routinely at:
-28 weeks
-Birth (if the baby is found to be rhesus +ve)
At any time when sensitisation may occur:
-Antepartum haemorrhage
-Amniocentesis
-Abdominal trauma
What test is used to see how much fetal blood has passed into the mother’s blood?
Kleihauer Test
How is fetal size measured?
USS:
- Estimated fetal weight (EFW)
- Fetal abdominal circumference (AC_
At what percentile is a fetus defined as small for gestational age?
Below the 10th centile
What percentile classes as severe SGA?
Below the 3rd centile
What is defined as low birth weight?
Less than 2500g
What are the two causes of SGA?
Constitutionally small
Fetal growth restriction (FGR)
What is fetal growth restriction?
When the fetus is not growing as expected due to pathology reducing the amount of nutrients and oxygen being delivered
What are the two categories relating to the causes of FGR?
Placenta mediated growth restriction
Non-placenta mediated growth restriction
What are some causes of placenta mediated growth restriction?
Idiopathic Smoking Drugs Alcohol Pre-eclampsia Anaemia Malnutrition Infection Maternal health conditions
What are the causes of non-placenta mediated growth restriction?
Genetic abnormalities
Structural abnormality
Fetal infection
Errors of metabolism
What are signs of FGR other than on ultrasound?
- Oligohydramnios
- Abnormal Doppler studies
- Reduced fetal movements
- Abnormal CTG’s
What are the short term complications of FGR?
Fetal death/stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
What are the long term risks of growth restricted babies?
Cardiovascular disease
T2 diabetes
Obesity
Mood/ behavioural problems
What are the risk factors for SGA?
Previous SGA baby Obesity Smoking Diabetes Hypertension Pre-eclampsia Geriatric pregnancy Multiple pregnancy Low PAPPA Antepartum haemorrhage Antiphospholipid syndrome
At what point in pregnancy are women assessed for risk factors for SGA?
Booking clinic
How are women at low risk of SGA monitored?
Symphysis fundal height measured at every antenatal appointment from 24 weeks onwards and plotted on customised growth chart
What happens if the symphysis fundal height is found to be less than the 10th centile during pregnancy?
Women are booked for serial growth scans with umbilical artery doppler
Under what circumstances would women be booked for serial growth scans and umbilical doppler?
- If the fetus is found to be <10th centile
- If they have 3 minor risk factors
- If they have a major risk factor
- If there are issues with measuring the SFH (e.g. large fibroids/ BMI>35)
How are women at high risk or with confirmed SGA monitored?
Serial USS (usually every 4 weeks from 28 weeks) measuring;
- Estimated fetal weight + Abdominal circumference
- Umbilical arterial pulsality index
- Amniotic fluid volume
What is the management of SGA?
Identify those at risk Try to identify underlying cause Treat cause/ risk factors (e.g. give aspirin to those with pre-eclampsia, stop smoking) Serial growth scans Early delivery if growth is static
What investigations can be done to identigy the underlying cause of SGA?
BP and urine dipstick for pre-eclampsia Uterine artery doppler Fetal anatomy scan Karyotyping for chromosomal abnormalities Testing for infections
When would a baby be defined as large for gestational age?
If the weight is >4.5kg at birth
or the EFW is >90th centile
What is macrosomia?
Being large for gestational age
What are the causes of macrosomia?
Constitutional Gestational diabetes Previous macrosomia Maternal obesity/ rapid weight gain Overdue Male baby
What are the risk of LGA to the mother?
Shoulder dystocia Failure to progress Perineal tears Instrumental delivery/ C-section Postpartum haemorrhage Uterine rupture
What are the risks of LGA to the baby?
Birth injury (e.g Erbs palsy, clavicle fracture, fetal distress)
Neonatal hypoglycaemia
Obesity in later life
T2 diabetes in adulthood
What investigations are done for LGA babies?
Ultrasound to exclude polyhydramnios and estimate fetal weight
Oral glucose tolerance test for gestational diabetes
What are monozygotic twins?
Twins from a single zygote- identical
What are dizygotic twins?
From two different zygotes- Non-identical
What does monoamniotic mean?
There is a single amniotic sac
What does diamniotic mean?
There are two seperate amniotic sacs
What does monochorionic mean?
Twins share a single placenta
What is dichorionic?
When there are two seperate placentas
What type of twin pregnancy has the best outcome and why?
Diamniotic, dichorionic as each fetus has its own nutrient supply
How is multiple pregnancy usually diagnosed?
On booking ultrasound scan
How are diachorionic diamniotic twins diagnosed using ultrasound?
There is a membrane between the twins, with a lambda/ twin peak sign
How are monochorionic diamniotic twins diagnosed with ultrasound?
Membrane between twins with a T sign
What are the risks of a multiple pregnancy to the mother?
Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous pre-term birth Instrumental delivery/ C-section Postpartum haemorrhage
What are the risks of multiple pregnancy to the fetuses?
Miscarriage Stillbirth FGR Prematurity Twin-twin transfusion syndrome Congenital abnormalities
What is twin-twin transfusion syndrome?
When there is a connection between the blood supplies of the two fetuses, and one fetus (the recipient) recieves the majority of the blood from the shared placenta, starving the other (the donor)
What is the risk to the recipient in twin-twin transfusion syndrome?
Fluid overload
Heart failure
Polyhydramnio
What is the risk to the donor in twin-twin transfusion syndrome?
Growth restriction
Anaemia
Oligohydramnios
What additional monitoring do women with multiple pregnancies require?
Additional FBC’s to monitor for anaemia
Additional USS to monitor FGR, unequal growth and twin-twin transfusion syndrome
When is planned birth offered to mothers with multiple pregnancies?
Uncomplicated monochorionic, monoamniotic twins= 32-33+6 weeks
Uncomplicated monochorionic diamniotic twins= 36-36+6 weeks
Uncomplicated dichorionic diamniotic twins= 37-37+6 weeks
Triplets= before 35+6 weeks
Why is planned birth before certain dates essential for multiple pregnancy?
Waiting too long is associated with increased risk of fetal death
How must monoamniotic twins be delivered?
Elective C-section between 32 and 33+6 weeks
What are the risks of a UTI in pregnancy?
Increase risk of preterm delivery, low birth weight and pre-eclampsia
What is asymptomatic bacteriuria?
Bacteria present in urine without symptoms of infections
Why is asymptomatic bacteriuria a risk in pregnany?
Pregnant women are more at risk of developing lower UTI and pyelonephritis, and therefore at risk of preterm birth
When are pregnant women tested for asymptomatic bacteriuria?
At booking and routinely throughout pregnancy
What may be found in a midstream sample of someone who has a UTI?
Nitrites
Leukocyte esterase
What is the most accurate indication of a UTI?
Nitrites
What are the most common bacterial causes of UTI’s?
E.coli
Klebsiella pneumoniae
How are UTI’s managed in pregnancy?
7 days of antibiotics
What are the antibiotic options to treat UTI in pregnancy?
Nitrofurantoin
Amoxicillin
Cefalexin
At what stages of pregnancy are women screened for anaemia?
Booking clinic
28 weeks gestation
Why are women more prone to anaemia in pregnancy?
The plasma volume increases during pregnancy, resulting in a reduced haemoglobin concentration.
What are the normal ranges of haemoglobin in pregnancy?
Booking: >110g/L
28 weeks: >105
Post partum: >100
What screening are women offered at booking clinic to reduce the risk of anaemia?
Haemoglobinopathy screening: Screens for thalassaemia and sickle cell disease
How is anaemia managed in pregnancy?
Depends on cause: e.g.
- Iron replacement
- B12
- Folic acid
Why is VTE more common in pregnancy?
Pregnancy is a hyper-coagulable state
What are the key risk facotrs for VTE in pregnancy?
Smoking Parity>3 Age>35 BMI>30 Reduced/ immobility Multiple pregnancy Pre-eclampsia Gross varicose veins Family history of VTE Thrombophilia IVF
How many VTE risk factors are an indication for starting prophylaxis (in the first trimester and at 28 weeks?)
First trimester: 4 or more risk factors
28 weeks: three risk factors
Under which conditions would VTE prophylaxis be given no matter the number of risk factors?
Hospital admission Surgical procedues Previous VTE Cancer Arthritis High-risk thrombophilias Ovarian hyperstimulation syndrome
When do pregnant women have a risk assessment for VTE?
At their booking appointment and again after birth
What prophylaxis is used for pregnant women at increased risk of VTE?
LMWH (E.g. Dalteparin, enozaparin, tinzaparin)
How long is VTE phrophylaxis continued for?
From first trimester (very high risk) or 28 weeks (high risk) until 6 weeks postnatally.
At what point in pregnancy is VTE prophylaxis temporarily stopped?
During labour (started immediately after delivery)
What is pre-eclampsia?
New hypertension in pregnancy with end-organ dysfunction and proteinuria
At what point in pregnancy does pre-eclampsia usually start?
after 20 weeks gestation
Why does pre-eclampsia usually start after 20 weeks gestation?
This is when the spiral arteries of the placenta form abnormally, leading to high vascular resistance
What is the pre-eclampsia triad?
Hypertension
Proteinuria
Oedema
What is the difference between gestational hypertension and pre-eclampsia?
Pre-eclampsia involves proteinuria
What is eclampsia?
When seizures occur as a result of pre-eclampsia
What causes pre-eclampsia?
High vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, causing the release of inflammatory chemicals which impair endothelial function in blood vessels
What are the HIGH risk factors for pre-eclampsia?
Previous pre-eclampsia Pre-existing hypertension Autoimmune conditions Diabetes CKD
What are the MODERATE risk factors for pre-eclampsia?
>40 BMI > 35 >10 years since previous pregnancy Multiple pregnancy First pregnancy Family history
What is offered as phrophylaxis against pre-eclampsia?
Aspirin from 12 weeks
How many pre-eclampsia risk factors negate prophylactic aspirin?
One high risk factor
>1 moderate risk factor
What are the symptoms of pre-eclampsia?
Headache Visual disturbance Nausea & vomiting Epigastric pain (due to liver swelling) Oedema Reduced urine output Brisk reflexes
How is pre-eclampsia diagnosed?
Systolic >140 OR diastolic >90 \+ ONE OF: -Proteinuria -Organ dysfunction -Placental dysfunction
How is proteinuria confirmed?
+1 or more on urine dipstick
Urine protein:creatinine ratio >30
Urine albumin:creatinine ratio >8
What investigations may indicate organ dysfunction?
Raised creatinine Raised liver enzymes Seizures Thrombocytopenia Haemolytic anaemia
What should be measured at least once during pregnancy in patients with suspected pre-eclampsia?
Placental growth factor (PlGF)–> Protein released by the placenta that stimulates the development of new blood vessels. Will be low in pre-eclampsia
How are pregnant women monitored for pre-eclampsia?
At every antenatal appointment, check:
- Blood pressure
- Symptoms
- Urine dipstick for proteinuria
How is gestational hypertension managed?
Aim for 135/85 Urine dipstick weekly Weekly bloods Serial growth scans PlGF testing
How is pre-eclampsia managed?
BP monitored every 48 hours
USS monitoring of fetus, amniotic fluid and dopplers every 2 weeks
Medical management
What is the first line medical management of pre-eclampsia?
Labetolol
What is the second line medical management of pre-eclampsia?
Nifedipine
What drug is given to pre-eclamptic patients during labour to prevent seizures?
IV magnesium sulphate
What may be necessary to have a safe birth in pre-eclampsia women?
Planned early birth
What is given to women having a premature birth to help mature the fetal lungs?
Corticosteroids
What is HELLP syndrome?
The combination of features that occur as a complication of pre-eclampsia and eclampsia
What does HELLP stand for?
Haemolysis
Elevated Liver enzymes
Low Platelets
What causes gestational diabetes?
Reduced insulin sensitivity during pregnancy
What are the biggest complications of gestational diabetes?
LGA Macrosomia (large newborn) Shoulder hystocia Developing T2 diabetes after pregnancy Neonatal hypoglycaemia
What are the risk factors for gestational diabetes?
Previous GD Previous macrosomic baby BMI >30 Ethnic origin Family history of diabetes
What is characterised as a macrosomic baby?
> 4.5kg
What test should be done on any pregnant lady with risk factors for gestational diabetes?
OGTT ( Oral Glucose Tolerance Test)
When is a GTT usually performed?
24-28 weeks
Why would an OGTT be done?
If there are risk factors for gestational diabetes
If there are features of gestational diabetes
What features may suggest gestational diabetes?
Large for dates fetus
Polyhydramnios
Glucose on urine dipstick
What is polyhydramnios?
Increased amniotic fluid
How is an OGTT performed?
Patient drinks 75g glucose drink in the morning (after fasting). Blood sugar level measured before the drink and 2 hours fter
What are normal results of an OGTT?
Fasting <5.6 mmol/L
2 hours: <7.8mmol/L
(REMEMBER 5,6,7,8)
What monitoring do women with gestational diabetes need?
Under joint diabetes and antenatal clinics
28-36 weeks: Four weekly USS to monitor fetal growth and amniotic fluid volume
What is the management for GD patients with fasting glucose <7?
Trial of diet & exercise for 1-2 weeks, followed by metformin, then insulin
What is the management for GD patients with fasting glucose >7?
Insulin +/- metformin
What is the management of GD patients with fasting glucose >6 with macrosomia/ other complications?
Insulin +/- metformin
What medication can be given to women who can’t have insulin/ metformin?
Glibenclamide (sulfonylurea)
What are the target blood sugar levels for women with gestational diabetes?
Fasting: 5.3
1 hour post meal: 7.8
2 hours post meal: 6.4
What is advised for pregnant women with pre-existing diabetes?
Retinopathy screening
Aim to maintain target insulin levels
Planned delivery between 37 and 38+6 weeks
How soon after birth can women with gestational diabetes stop their medication?
Immediately after birth (will need a follow up fasting glucose 6 weeks later)
What are babies of mother with diabetes at risk of?
Neonatal hypoglycaemia Polycythaemia Jaundice Congenital heart disease Cardiomyopathy
Why do babies need close monitoring for neonatal hypoglycaemia?
They become accustomed to a large supply of glucose during pregnancy so after birth may struggle to maintain their supply with oral feeding alone
What are the three main causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
Vasa previa
What are causes of spotting or minor bleeding in pregnancy?
Cervical ectropion
Infection
Vaginal abrasions
What is placenta preavia?
When the placenta is over the internal cervical os
What is a low-lying placenta?
When the placenta is within 20mm of the internal cervical os
What are the main risks of placenta praevia?
Antepartum haemorrhage Emergency C-section Emergency hysterectomy Anaemia Preterm birth/ Low birth weight Stillbirth
What are the different grades of placenta praevia?
1= Minor (placenta doesn't reach internal cervical os) 2= Marginal (Reaches but doesn't cover internal os) 3= Partial preavia (partially covers internal os) 4= Complete preavia (Completely covers internal cervical os)
What are the risk factors for placenta praevia?
Previous C--section Previous placenta praevia Older age Maternal smoking Structural uterine abnormalities (e.g. fibroids) IVF
When is placenta praevia usually diagnosed?
20 week anomaly scan
How does placenta praevia present?
Usually asymptomatic
May present with painless vaginal bleeding around 36 weeks
What happens if low-lying placenta/ placenta praevia is diagnosed early in pregnancy?
Repeat transvaginal USS at 32 and 36 weeks to guide delivery decisions
What is given to women with placenta praevia given the risk if pre-term delivery?
Corticosteroids
When is planned delivery considered for with placenta preavia and why?
36-37 weeks to reduce the risk of spontaneous bleeding and labour
What management is required with low-lying placenta/ placenta praevia?
Planned C-section
What is the management of antepartum haemorrhage?
Emergency C-section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy
What is vasa praevia?
When the fetal vessels are exposed (outside of umbilical cord or placenta) and lie over the internal cervical os.
What do the fetal vessels consist of?
Two umbilical arteries and single umbilical vein
Where should the fetal vessels be?
Should be in the umbilical cord inserting directly into the placenta
What does the umbilical cord contain that protects the fetal vessels?
Wharton’s jelly–> Layer of soft connective tissue
What are the two instances where the fetal vessels may be exposed (outside of the placenta or umbilical cord)?
- Velamentous umbilical cord
- When an accessory lobe of the placenta is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.
What is velamentous umbilical cord?
Where the umbilical cord inserts into the chorioamniotic (fetal) membranes, and the vessels travel unprotected through the membranes before joining the placenta
What is the risk of vasa praevia?
Exposed vessels are prone to bleeding, especially when membranes are ruptured during labour/birth. Can lead to fetal blood loss and death
What are the two types of vasa praevia?
Type 1: Fetal vessels are exposed as a velamentous umbilical cord
Type 2: Fetal vessels are exposed as they travel to an accessory placental lobe
What are the risk factors for vasa praevia?
Low lying placenta
IVF pregnancy
Multiple pregnancy
How is vasa preavia diagnosed?
USS
Antepartum haemorrhage (second or third trimester)
Vaginal examination during labour (pulsing vessels felt)
During labour with fetal distress and bleeding after rupture or membranes
How is vasa praevia managed in asymptomatic patients?
Corticosteroids from 32 weeks to mature fetal lungs
Elective C-section for 34-36 weeks
What is placental abruption?
When the placenta seperates from the wall of the uterus during pregnancy
What are the risk factors for placental abruption?
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma Multiple pregnancy FGR Multigravida Increased maternal age Smoking Cocaine/ amphetamine use
How does placental abruption usually present?
Sudden onset, continuous sever abdominal pain Vaginal bleeding (antepartum haemorrhage) Shock CTG abnormaliites (fetal distress)
What is the characteristic finding on examination of placental abruption?
‘woody’ abdomen (suggesting large haemorrhage)
What are the different severities of antepartum haemorrhage?
Spotting
Minor (<50mls)
Major (50-1000ml)
Massive (>1000ml/ signs of shock)
What is concealed abruption?
Where the cervical os remains closed and bleeding remains in the uterine cavity.
How is placental abruption diagnosed?
Clinical diagnosis based on presenation- no diagnostic test
What are the initial steps with major or massive haemorrhage?
- Urgent involvement of senior obstetrician, midwife & anaesthetist
- 2X grey cannula
- Bloods
- Crossmatch
- Fluid/ blood resuscitation
- CTG monitoring
- Mother monitoring
What is placenta accreta?
When the placenta implants deeper past the endometrium, making it difficult to seperate after delivery.
What are the 3 layers of the uterine wall?
Endometrium (Stroma, epithelia cells, blood vessels)
Myometrium (smooth muscle)
Perimetrium (serous membrane)
What does the placenta usually attach to?
The endometrium
Why may placenta accreta occur?
Due to a defect in the myometrium:
-Previous uterine surgery (e.g. prev C-section)
What are the 3 types of placenta accreta?
Superficial (implants on surface of myometrium)
Increta (Deep into myometrium)
Percreta (Invades past myometrium and perimetrium, reaching other organs)
What are the risk factors for placenta accreta?
Prev placenta accreta Prev endometrial curettage procedures (e.g. miscarriage/ abortion) Prev C-section Multigravida Increased maternal age Low-lying placenta/ placenta praevia
How may placenta accreta present?
Usually asymptomatic
May present with antepartum haemorrhage
May be diagnosed with USS
May be diagnosed at birth when it becomes difficult to deliver placenta
How is placenta accreta managed?
Planned delivery 35-36+6 weeks:
- Hysterectomy
- Uterus preserving surgery (remove placenta and part of endometrium)
- Expectant management (placenta can be reabsorbed over time)
What is acute fatty liver of pregnancy?
Rapid accumulation of fat in the hepatocytes in the third trimester of pregnancy, causing acute hepatitis
What causes acute fatty liver of pregnancy?
Impaired processing of fatty acids in the placenta due to a fetal genetic condition (LCHAD deficiency), causing them to enter into the maternal circulation and accumulate in the liver
How does acute fatty liver of pregnancy present?
Vague symptoms: General malaise/ fatigue N&V Jaundice Abdomial pain Anorexia Ascites
What investigation is done into acute fatty liver of pregnancy and what will this show?
LFT's= Elevated ALT and AST Raised bilirubin Raised WBC Deranged clotting Low platelets
What condition should you think of if there are elevated liver enzymes and low platelets in pregnancy?
HELLP syndrome
Then acute fatty liver
How is acute fatty liver of pregnancy managed?
Prompt delivery of baby
What is obstetric cholestasis?
Reduced outflow of bile acids from the liver during pregnancy
At what point in pregnancy would obstetric cholestasis usually present?
After 28 weeks
What causes obstetric cholestasis?
Raised oestrogen and progesterone levels
What is the pathophysiology of obstetric cholestasis?
Bile acids are produced in the liver from the breakdown of cholesterol. These flow from the liver to the hepatic ducts, past the gallbladder and out of the bile duct into the intestines. In obstetric cholestasis the outflow of bile acids is reduced, causing them to build up in the blood.
How does obstetric cholestasis present?
Pruritis (palms of hands/ soles of feet) Fatigue Dark urine Pale, greasy stools Jaundice
What are the differential diagnosis for obstetric cholestasis?
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
How is obstetric cholestasis investigated?
LFT's (abnormal) Bile acids (raised)
Which liver enzyme is normally raised in pregnancy and why?
ALP, it is also produced by the placenta
How is obstetric cholestasis managed?
Ursodeoxycholic acid
Emollients (to soothe itching)
Antihistamines (to help sleeping)
Vitamin K (If clotting is deranged)
What are the main pregnancy-related skin changes?
Polymorphic eruption of pregnancy Atopic eruption of pregnancy Melasma Pyogenic granuloma Pemphigoid gestationis
What is polymorphic eruption of pregnancy?
Itchy rash that start in the third trimester, usually beginning in the abdomen and associated with stretch marks
What is polymorphic eruption of pregnancy characterised by?
Urticarial papules (raised itchy lumps) Wheals (raised itchy areas of skin) Plaques (larger inflamed areas of skin)
What is atopic eruption of pregnancy?
Eczema that flares up during pregnancy (may or may not be pre-existing)
When does atopic eruption of pregnancy usually present?
In the first or second trimester
What are the two types of atopic eruption of pregnancy?
E-type: Eczematous, inflamed itchy skin on insides of elbows, back of knees etc
P-type: Intense itchy papules on abdomen, back and limbs
What is melasma?
Increased pigmentation to patches of the face. (mask of pregnancy)
What is pyogenic granuloma?
Benign rapid growing tumour of the capillaries (discrete dark red lump)
What is pemphigoid gestationis?
Autimmune skin condition that occurs in pregnancy, causing large fluid filled blisters
When does nausea and vomiting start in pregnancy and when does it usually peak and resolve?
Starts in first trimester (4-7 weeks) and peaks around 8-12 weeks, Resolve by 16-20 weeks
What is hyperemesis gravidarum?
Severe form of nausea and vomiting in pregnancy
What causes N&V in pregnancy?
hCG
In what kind of pregnancies is N&V worse and why?
Molar pregnancies and multiple pregnancies due to high hCG levels
How is hyperemesis gravidarum classified?
Protracted (prolonged) N&V
>5% weight loss compared to pre-pregnancy
Dehydration
Electrolyte imbalance
How is the severity of hyperemesis gravidarum assessed?
PUQE score:
<7= mild
7-12= moderate
>12= severe
How is hyperemesis gravidarum managed?
Antiemetics
Ompeprazole to treat acid reflux
When would admission be condsidered for mild cases of hyperemesis gravidarum?
Unable to keep down fluids
>5% weight loss
Ketones present in urine
What is the treatment of moderate- severe cases of hyperemesis gravidarum?
Ambulatory care/ admission: IV/ IM antiemetics IV fluids Monitoring of U&E's Thiamine supplementation
What does the anterior pituitary gland do during normal pregnancy?
Produces more ACTH, prolactin and melanocyte stimulating hormone
What do higher ACTH levels in pregnancy cause?
Rise in steroid hormones (cortisol and aldosterone), leading to improvement in autoimmune conditions
What do increased prolactin levels in pregnancy cause?
Suppression of FSH and LH
What can increased melanocyte stimulating hormone cause in pregnancy?
Increased pigmentation of skin, leading to linea nigra and melasma
What happens to the thyroid hormones during pregnancy?
TSH stays normal
T3 and T4 levels rise
What happens to HCG levels during pregnancy?
They double roughly every 48 hours until 8-12 weeks when they plateau and then fall
What happens to progesterone levels during pregnancy?
They rise throughout pregnancy
What is the action of progesterone in pregnancy?
Maintains the pregnancy
Prevents contractions
Suppresses the mother’s immune reaction to fetal antigens
By how much does the uterus increase in size during pregnancy?
From 100g to 1.1kg
What changes happen to the uterus during pregnancy?
It increases in size
There hypertrophy of the myometrium and blood vessels
What may happen to the cervix during pregnancy?
There may be cervical ectropion and increased cervical discharge
What happens to the vagina during pregnancy?
Hypertrophy of the vaginal muscles and increased vaginal discharge
What happens to the cervix just before delivery?
Prostoglandins break down its collagen allowing it to dilate and efface
What cardiovascular changes occur during pregnancy?
Increased blood volume, plasma volume, cardiac output, stroke volume and heart rate
Decreased peripheral vascular resistance and blood pressure
What may happen in pregnancy due to increased peripheral vasodilation?
Flushing
Hot sweats
Varicose veins
What respiratory changes occur in pregnancy?
Increased tidal volume and respiratory rate to meet increasing oxygen demands
What renal changes occur in pregnancy?
Increased blood flow to the kidneys, GFR, aldosterone levels (leading to increased salt and water reabsorption and retention) and protein excretion
Dilation of the ureters and collecting system leading to hydronephrosis (kidney swelling)
What haematological changes occur during pregnancy?
- Increased RBC production, leading to higher iron, folate and B12 requirements
- Increased plasma volume (leading to lower concentration of RBC’s and therefore anaemia)
- Increased clotting factor production, leading to hyper-coagulable state
- Increased WCC
- Increased ALP
- Decreased platelets
What skin and hair changes may occur in pregnancy?
Increased skin pigmentation Stria gravidarum (stretch marks) Pruritus Spider naevi Palmer erythema
By how much does the total plasma volume increase in pregnancy?
30-50% (1-2L)
What are the management options for a breech pregnancy?
- External cephalic version (ECV): Putting pressure on the pregnant abdomen to turn the fetus to the cephalic position
- C-section
What is given to women before ECV?
Tocolysis to relax the uterus
Anti-D phrophylaxis if required
What is the definition of stillbirth?
Birth of a dead fetus after 24 weeks gestation
What is IUFD?
Intrauterine fetal death
How common in IUFD?
1 in 200 pregnancies
What are the causes of stillbirth?
50% Unexplained Pre-eclampsia Placntal abruption Vasa praevia Cord prolapse/ wrapped around neck Obstetric cholestasis Diabetes Thyroid disease Infections Genetic/ congenital abnormalities
What factors increase the risk of stillbirth?
Smoking Alcohol FGR/ SGA Increased maternal age Maternal obesity Twins Sleeping on back
How is stillbirth prevented?
Serial growth scans for those with fetal growth restriction
Aspirin for pre-eclampsia
Treat modifiable risk factors
What 3 key symptoms should always be asked about in pregnancy and should be reported immediately by women?
- Reduced fetal movement
- Abdominal pain
- Vaginal bleeding
How is IUFD diagnosed?
USS to visualise fetal heartbeat
What is the management of IUFD?
Vaginal birth= First line:
May be expectant or have induction of labour
Can do testing after to find out cause
What can be used to suppress lactation after stillbirth?
Dopamine agonists
What are the 4 T’s of reversible causes of adult cardiac arrest?
Thrombosis
Tension pneumothorax
Toxins
Tamponade
What are the 4 H’s of reversible causes of adult cardiac arrest?
Hypocia
Hypovolaemia
Hypothermia
Hyperkalaema/ glycaemia
What additional causes of cardiac arrest may be found in pregnancy?
Eclampsia
Intracranial haemorrhage
What are the 3 main causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
Pulmonary embolsim
Sepsis
Why might obstetric haemorrhage cause cardiac arrest?
It causes severe hypovolaemia
What are the causes of massive obstetric haemorrhage?
Ectopic pregnancy Placental abruption Placenta praevia Placenta accreta Uterine rupture
What is aortocaval compression?
When a woman lies on her back the the uterus compresses the inferior vena cava and aorta, reducing the cardiac output and leading to hypotension .
What is the solution to aortocaval compression?
Place the woman in the left lateral position to relieve the compression of the inferior vena cava
What is the difference between standard adult life support and doing it in pregnancy?
Use a 15 degree tilt to the left for CPR
Early intubation and supplementary oxygen
Agressive fluid rescucitation
Delivery of the baby after 4 minutes
When would an immediate C-section be performed in an unresponsive pregnant woman?
When there is no response after 4 minutes of CPR
What is ROM?
Rupture of membranes (amniotic sac rupture)
What is SROM?
Spontatneous rupture of membranes
What is ARM?
Artificial rupture of membranes
What is PROM?
Prelabour rupture of membranes (before onset of labour)
OR
Prolonged rupture of membranes (>18 hours before delivery)
What is P-PROM?
Preterm prelabour rupture of membranes (before 37 weeks)
What is classifies as premature labour?
Before 37 weeks gestation
What are the 3 classifications of prematurity?
Extreme preterm = <28 weeks
Very preterm= 28-32 weeks
Moderate-late preterm = 32-37 weeks
What are the prophylaxis options for preterm labour?
Vaginal progesterone
Cervical cerclage
What is cervical cerclage?
Putting a stitch in the cervix to add support and keep it closed/
How can rupture of membranes be diagnosed?
With speculum examination revealing pooling of amniotic fluid in the vagina
(can test for IGFBP-1 or PAMG-1 if unsure)
How is P-PROM managed?
Prophylactic antibiotics to prevent chorioamniotis
Induction of labour from 34 weeks
How does preterm labour with intact membranes present?
Regular painful contraction and cervical dilation without rupture of amniotic sac
What is the clinical assessment of preterm labous?
Speculum examination to assess for cervical dilation
>30 weeks can use TVUS to assess cervical length (<15mm)
What are the management options for preterm labour?
Fetal monitoring Tocolysis with nifedipine Maternal corticosteroids IV magnesium sulphate Delayed cord clamping
What is Tocolysis?
Using medications to stop uterine contractions
What is the action of Nifedipine?
Calcium channel blocker that suppresses labour
Why is the mother given steroids in preterm labour?
To help develop the fetal lungs and reduce respiratory distress syndrome
Why is magnesium sulfate given in preterm labour?
Helps protect fetal brain
What are the indications for induction of labour?
- When the due date is passed (41-42 gestation)
- PROM
- FGR
- Pre-eclampsia
- Obstetric cholestasis
- Existing diabtes
- IUFD
What score is used to determine whether to induce labour?
Bishops score
What are the 5 assessment criteria used in the Bishops score?
Fetal station Cervical position Cervical dilation Cervical effacement Cervical consistency
What does cervical effacement refer to?
The dilation and stretching of the cervix
What does fetal station refer to?
Where the presenting part is in the pelvis
What Bishops score would be a successful indication for induction?
8 or more
What may be required if there is a Bishops score of <8?
Cervical ripening
What are the options for the induction of labour?
Membrane sweep Vaginal prostaglandin E2 Cervical ripening balloon ARM Oral mifepristone
What is involved in a membrane sweep?
Inserting a finer into the cervix to stimulate it and begin the process of labour
Within what time frame should labour begin if a membrane sweep is successful?
48 hours
How is vaginal prostaglandin E2 used to induce labour?
Progesterone gel, tablet or pessary inserted into the vagina to stimulate cervix and uterus
How does a cervical ripening balloon work?
Silicone balloon inserted into the cervix and gently inflated to dilate the cervix
What is amniotomy and how is it done?
Artificial rupture of membranes with an oxytocin infusion or puncturing with hook
When would AROM be used ?
When vaginal prostaglandins are contraindicated or if they have been tried and failed
What is used to induce labour where IUFD has occured?
Oral mifepristone (antiprogesterone) and misoprostol
How is induction of labour monitored?
CTG
Bishops score
What are the options when there are no/ slow progress after IOL?
Further vaginal prostoglandins ARM Oxytocin infusion CRB ELCS
What is the main complication of IOL with vaginal prostaglandins?
Uterine hyperstimulation causing fetal distress and compromise
What is the classification of uterine hyperstimulation?
Contractions lasting more than 2 minutes
More than 5 contractions every 10 minutes
What can uterine hyperstimulation lead to?
Fetal compromise (hypoxia, acidosis)
Emergency C-section
Uterine rupture
What is the management of uterine hyperstimulation?
Remove vaginal prostaglandins
Tocolysis with terbutaline
What is CTG and what is it used for?
Cardiotocography used to measure the fetal heart rate and contractions of the uterus
How is a CTG carried out?
One transducer placed above fetal heart to monitor heartbeat using Doppler ultrasound.
One placed near fundus of uterus, using USS to assess tension of uterine wall
What are the indications for continours CTG monitoring in labour?
Sepsis Maternal tachycardia Significant meconium Pre-eclampsia Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain
What are the 5 key features to look for on CTG?
Contractions (no. per 10 mins) Baseline fetal heart rate Variability in heart rate Accelerations Decelerations
What is the baseline rate on a normal CTG?
110-160
What is the variability in a normal CTG?
5-25 bpm
Should accelerations and decelerations be present in a normal CTG?
Accelerations should but not decelerations
What is the baseline rate and variability in a non-reassuring CTG?
BR= 100-109 OR 161-180 Variability= <5 for 30-50 mins OR >25 for 15-25 mins
What is the baseline rate and variability in an abnormal CTG?
BR= <100 OR >180 V= <5 in over 50 mins OR >25 for over 25 mins
Why are decelerations a concerning finding in a CTG?
The fetal heart rate drops in response to hypoxia
What are the 4 types of deceleration to be aware of?
Early
Late
Variable
Prolonged
What are early decelerations?
Gradual dips and recoveries in heart rate that correspond with uterine contractions (considered normal)
What causes early decelerations?
The uterus compressing the head of the fetus, stimulating the vagus nerve and slowing the heart rate
What are late decelerations?
Gradual falls in heart rate that starts after the uterine contraction has already begun
What causes late decelerations?
Hypoxia in the fetus
Excessive uterine contractions
Maternal hypotension
Maternal hypoxia
What are variable decelerations?
Abrupt decelerations that may be unrelated to uterine contractions
What causes variable decelerations?
Intermittent compression of the umbilical cord causing fetal hypoxia
What are prolonged decelerations?
Decelerations that last between 2 and 10 minutes with a drop of more than 15bpm from baseline
Which types of decelerations are reassuring?
No decelerations
Early decelerations
<90 minutes of variable decelerations
What kind of decelerations are always abnormal?
Prolonged decelerations
What are the 4 categories of CTG?
Normal
Suspicious (1 non-reassuring feature)
Pathological (2 non-reassuring features of 1 abnormal feature)
Need for urgent intervention (acute bradycardia, prolonged deceleration of >3 minutes)
What is the ‘rule of 3’ management for fetal bradycardia?
3 minutes= call for help
6 mins= move to theatre
9 mins= prepare for delivery
12 mins= deliver baby (before 15 mins)
What is a sinusoidal CTG?
A CTG with a pattern similar to a sine wave associated with fetal anaemia
What is the pneumonic for assessing the features of a CTG?
DR C BRaVADO: Define risk Contractions Baseline rate Variability Accelerations Deceleraions Overall impression
Where is oxytocin secreted from?
Posterior pituitary
What is the action of oxytocin in labour and delivery?
Stimulates ripening of cervix and contractions of uterus
also involved in lactation
When might oxytocin infusions be used?
To induce labour
To progress labour
To improve the frequency/ strength of uterine contractions
To prevent/ treat PPH
What is the action of Ergometrine and when might it be used in labour?
Stimulates smooth muscle contraction.
Used in the third stage of labour to deliver the placenta and postpartum to treat PPH
What three P’s influence progress in labour?
Power
Passenger
Passage
When is failure to progress classified in the first stage of labour?
<2cm dilation in 4 hours
Slowing of progress in multiparous women
What is used to measure a womans progress in the first stage of labour?
Partogram
What is recorded on a partogram?
Cervical dilation Descent of the fetal head Maternal pulse, BP, Temp, urine output Fetal HR Frequency of contractions Status of membranes Drugs/ fluids given
How often is cervical dilation measured?
4 hourly vaginal examination
How are uterine contractions measured?
Measured by number in 10 minutes (e.g. 2 in 10)
What is crossing the alert line on a partogram an indication for?
Amniotomy
Repeat exam in 2 hours
What is classified as a delay in the second stage of labour?
When the active stage lasts over :
2 hours in nulliparous women
1 hour in multiparous women
What does power refer to in the 3 P’s?
The strength of the uterine contractions
What can be given if there are weak uterine contractions?
Oxytocin infusion to stimulate the uterus
What 4 things does passenger refer to in the 3 P’s?
- Size
- Attitude
- Lie
- Presentation
What does attitude refer to in terms of the fetus?
The posture (e.g. how the back is rounded and how the head/ limbs are flexed)
What the are potential ways the fetus may lie?
Longitudinal lie
Transverse lie
Oblique lie
What does presentation refer to?
The part of the fetus closest to the cervix
What are the different presentation options?
Cephalic
Shoulder
Breech (complete, frank, footling)
What does passage refer to in the 3 P’s?
The size and shape of the pelvis
What is classified as a delay in the third stage of labour?
> 30 min delay in delivery of placenta with active management
>60 min delay with physiological management
What is the active management of delay in placental delivery?
Intramuscular oxytocin
Controlled cord traction
What are the main options for treating failure to progress?
Amniotomy
Oxytocin infusion
Instrumental delivery
C-section
What are the different pain relief options in labour?
Simple analgesia (paracetamol + codeine) Entonox IM Pethidine/ DIamorphine IV Remifentanil (patient controlled) Epidural
What is entonox?
Gas and air (50% nitrous oxide, 50% oxygen) for short term pain relief
What does an epidural involve?
Inserting a catheter into the epidural space in the lower back and infusing local anaesthetics
What is cord prolapse?
When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina after rupture of membranes
What is the main risk of cord prolapse?
That the presenting part will compress the cord, resulting in fetal hypoxia
What is the main risk factor for cord prolapse?
When the fetus is in an abnormal lie after 37 weeks gestation
How is cord prolapse diagnosed?
Signs of distress on CTG
Vaginal examination
How is cord prolapse managed?
Emergency C-section
Can push presenting part away from cord to prevent compression
What is shoulder dystocia?
When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered
What causes shoulder dystocia?
Macrosomia secondary to gestational diabetes
Is shoulder dystocia an obstectric emergency?
Yes
How does shoulder dystocia present?
Difficulty delivering the head and obstruction in delivery the shoulders.
Failure of restitution (head will remain facing downwards instead of turning sideways)
What are the different management options for shoulder dystocia?
Episiotomy McRoberts manoeuvre Pressure to anterior shoulder Rubins manoeuvre Wood's screw manoeuvre Zavanelli manoeuvre
What is episiotomy?
Incising the area between the vagina and anus (not the perineal body) to create a larger space for delivery
What is McRoberts manoeuvre?
Hyperflexion of the mother at the hip to create a posterior pelvic tilt so the pubic symphysis moves out of the way
What are the key complications of shoulder dystocia?
Fetal hypoxia
Brachial plexus injury (Erbs palsy)
Perineal tears
PPH
What is instrumental delivery?
Vaginal delivery assisted by either ventouse suction cup or forceps
What should be given to the mother after an instrumental delivery?
Co-amoxiclav to reduce risk of infection
What are the indications for instrumental delivery?
Failure to progress Fetal distress Maternal exhaustion Control of the head in certain fetal positions Epidural
What are the risks of instrumental delivery to the mother?
PPH Episiotomy Perineal tears Injury to anal sphincter Incontinence of bladder/ bowel Nerve injury
What are the key risks of instrumental delivery to the baby?
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
What is a ventuose?
A suction cup that goes on the baby’s head that, along with traction to the cord, helps pull the baby out of the vagina
What maternal nerves may be affected in instrumental delivery?
Femoral nerve
Obturator nerve
When are perineal tears more common?
First births Large babies (>4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries
What are the 4 degrees of perineal tear?
First-degree- limited to the frenulum of the labia minora
Second degree- includes the perineal muscles
Third degree- Includes the anal sphincter
Fourth degree- Includes rectal mucosa
How can third-degree tears be further classified?
3A= <50% external anal sphincter affected 3B= >50% external anal sphincter affected 3C= External and internal anal sphincter affected
How are perineal tears treated?
If larger than first degree, will need sutures or surgical repair
Antibiotics given
Laxatives and physiotherapy
What are the short term complications of a perineal tear?
Pain
Infection
Bleeding
Wound breakdown
What are lasting complications of perineal tears?
Urinary incontinence Anal incontinence/ altered bowel habit Fistula Sexual dysfunction/ dyspareunia Psychological
What blood classifies a PPH?
> 500ml after vaginal delivery
>1000ml after C-section
What is a minor PPH?
<1000ml blood loss
What is a major PPH?
> 1000ml blood loss
What is a severe PPH?
> 2000ml blood loss
What is primary PPH?
Bleeding within 24 hours of birth
What is secondary PPH?
Bleeding from 24 hours to 12 weeks after birth
What are the 4T’s that cause PPH?
Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder
What are the risk factors for PPH?
Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in second stage Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental deliery General anaesthetic Epiostomy/ perineal tear
What preventative measures can reduce the risk of PPH?
Treating anaemia
Emptying bladder before birth
Active management of third stage
IV TXA during C-section in high risk patients
How is PPH managed?
ABCDE Comfort/ warmth 2 large bore cannulas Bloods (FBC, U&E, clotting screen) Group & Cross match Warmed IV fluid and blood resuscitation Oxygen Frozen plasma if there are clotting abnormalities
What are 3 categories of treatment option to stop the bleeding in PPH?
Mechanical
Medical
Surgical
What are the mechanical treatment options to stop PPH?
Rubbing the uterus through the abdomen to stimulate uterine contraction
Catheterisation to prevent bladder from stopping contractions
What are the medical treatment options to stop PPH?
Oxytocin
Ergometrine (stimulates smooth muscle contraction)
Carboprost (stimulates uterine contraction)
Misoprostol (stimulates uterine contraction)
TXA (antifibrinolytic)
What are the surgical treatment options to stop PPH?
Intrauterine balloon tamponade
B-lynch suture
Uterine artery ligation
Hysterectomy
What causes secondary PPH ?
Retained products of conception or infection
What investigations can be done into secondary PPH?
USS
Endocervical or high vaginal swabs for infection
After what gestation would an elective c-section usually be performed?
39 weeks
What anaestetic is used for an elective C-section?
Spinal anaesthtic
What are the indications for an elective C-section?
Previous caesarean Previous perineal tear Placenta praevia Vasa praevia Breech Multiple pregnancy Uncontrolled HIV Cervical cancer
What are the 4 categories of emergency c-section?
1: Immediate threat to mother or babies life
2: Not imminent threat to life, but required urgently due to compromised mother or baby
3: Delivery required but mother and baby are stable
4: elective c-section
What should the delivery time be in a category 1 emergency c-section?
30 minutes
What should the delivery time be in a category 2 emergency c-section?
75 minutes
What are the layers of the abdomen that need to be dissected during a c-section?
Skin Subcutaneous tissue Fascia/ rectus sheath Rectus abdominis muscles Peritoneum Vesicouterine peritoneum (and bladder) Uterus Amniotic sac
What happens during the c-section?
Straight incision in abdomen
Blunt dissection to seperate remaining layers
Deliver baby by hand
Close uterus using two layers of sutures
What is the difference between an epidural and spinal anaesthetic?
Epidural involves putting a catheter into epidural space to receive continuous or periodic dose of anaesthesia
Spinal block is a single shot of anaesthesia into dural sac that lasts 1-2 hours.
What are the risks of spinal anaesthetic?
Takes longer than general Allergic reaction Hypotension Headache Urinary retention Nerve damage Haematoma
What measures are taken to reduce the risks of having a c-section?
H2 receptor agonists/ PPI’s before procedure
Prophylactic antibiotics
Oxytocin during procedure
VTE prophylaxis
Why are H2 receptor agonists of PPI’s given before a C-section?
To reduce the risk of aspiration pneumonitis caused by acid reflux and aspiration during the prolonged period lying flat
Why is oxytocin given during a c-section?
To reduce the risk of PPH
What is the success rate of vaginal birth after c-section?
75%
What are the contraindications of having a vaginal birth after a previous c-section?
Previous uterine rupture
Vertical incision
Normal contraindications fo vaginal delivery
What are the two key causes of sepsis in pregnancy?
Chorioamnionitis
UTI
What is chorioamnionitis?
Infection of the chorioamniotic membranes (membranes that surround fetus) and amniotic fluid
What system is used to monitor maternity inpatients?
MEOWS: Maternity early obstetric warning system
What are the non-specific signs of sepsis to look out for?
Fever Tachycardia Raised RR Reduced oxygen sats Low BP Altered consciousness Reduced urine output Raised WCC Evidence of fetal compromise on CTG
What are additional signs that might be seen in chorioamnionitis?
Abdominal pain
Uterine tenderness
Vaginal discharge
What additional signs might be seen in a UTI?
Dysuria Urinary frequency Suprapubic pain/ discomfort Pyelonephritis Vomiting
How would you investigate suspected maternal sepsis?
Blood tests Urine dipstick High vaginal swab Sputum culture Wound swab Lumbar puncture?
What blood tests would be performed to investigate suspected sepsis?
FBC (WCC, Neutrophils) U&E's LFT's CRP Clotting Blood cultures Blood gas (lactate)
How is sepsis managed?
Sepsis 6: Tests: 1. Blood lactate 2. Blood cultures 3. Urine output
Treatments:
- Oxygen
- Empirical broad-spectrum antibiotics
- IV fluids
What is amniotic fluid embolisation?
When the amniotic fluid passes into the mother’s blood
Why is amniotic fluid passing back to the mother a concern?
The amniotic fluid contains fetal tissue, so causes an immune reaction in the mother (mortality of 20%)
What are the main risk factors for amniotic fluid embolus?
Increasing maternal age
Induction of labour
C-section
Multiple pregnancy
How does amniotic fluid embolisation present?
Similarly to sepsis, PE or anaphylaxis:
- SOB
- Hypoxia
- Hypotension
- Coagulopathy
- Haemorrhage
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
When does amniotic fluid embolisation usually present?
Around time of labour and delivery (can be post partum)
How is amniotic fluid embolisation managed?
Supportive
ABCDE
What is uterine rupture?
A complication of labour where the myometrium ruptures
What is an incomplete uterine rupture?
When the uterine serosa (perimetrium) surrounding the uterus remains intact
What is a complete uterine rupture?
When the serosa ruptures along the myometrium, and the contents of the uterus are released into the peritonel cavity
What are the main risk factors for uterine rupture?
*Previous C-section (due to weakness at scar) VBAC Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions
How does uterine rupture present?
Acutely unwell mother Abnormal CTG Abdominal pain Vaginal bleeding Ceasing of contractions Hypotension Tachycardia Collapse
How is uterine rupture managed?
Resuscitation and transfusion
Emergency C-section
Repair or remove uterus
(Obstetric emergency with high morbidity and mortality)
What is uterine inversion?
Where the fundus of the uterus drops down through the uterine cavity and cervix during birth, turning the uterus inside out (very rare)
What is the introitus?
The opening of the vagina
What is incomplete uterine inversion?
When the fundus descends inside the uterus/ vagina but not as far as the introitus
What is complete uterine inversion?
When the uterus descends through the vagina to the introitus
What can cause uterine inversion?
Pulling too hard on the umbilical cord during active management of the third stage of labour
How does uterine inversion typically present?
With PPH, maternal shock or collapse
What are the management options for treating uterine inversion?
Johnson manoeuvre (pushing it back up) Hydrostatic methods (filling vagina with fluids to inflate uterus) Surgery
What will happen to the woman in the days after delivery?
Routine midwife-led care:
- Analgesia if required
- Help establishing breast/ bottle feeding
- VTE risk assessment
- PPH/ sepsis/ BP monitoring
- Anti-D if necessary
- Monitoring if had any surgery/ complications
- Routine baby check
What will be discussed in routine midwife led postnatal follow up appointments?
General wellbeing Mood/ depression Bleeding/ menstruation Urinary incontinence/ pelvic floor exercises Scar healing Contraception Breastfeeding Vaccines
How many weeks postpartum is a routine postnatal check performed?
6 weeks
What is lochia?
The mix of blood, endometrial tissue and mucus that comes out of the vagina in the period following birth
Why does a woman have vaginal bleeding after birth?
As the endometrium breaks down then returns to normal
How long after birth should bleeding settle?
6 weeks
Why may breastfeeding cause more bleeding?
It releases oxytocin which causes to uterus to contract
What is lactational amenorrhoea?
When women who are breastfeeding don’t have a return to normal menstruation for around 6 months after birth
How long after birth should women who are bottle feeding expect a menstrual period?
3 weeks onwards
How long after birth does fertility return?
21 days
What contraception should be given to women who are breastfeeding?
Lactational amenorrhoea is effective
POP or implant
What contraception should be avoided after birth?
COCP
When after birth can a copper coil or IUD be inserted?
Either within 48 hours or after 4 weeks
What is endometritis?
Inflammation of the endometrium
When is endometritis more common and why?
Postpartum as bacteria from the vagina may travel upwards during delivery
*Especially after C-section
How does endometritis present?
Foul smelling discharge or lochia Bleeding that gets heavier Lower abdominal/ pelvic pain Fever Sepsis
How is endometritis diagnosed?
Vaginal swabs
Urine culture/ sensitivities
USS may be used to rule out RPOC
How is endometritis managed?
May need sepsis 6
Oral antibiotics
What is RPOC?
Retained products of conception
What is the main risk factor for RPOC?
Placenta accreta
How may RPOC present?
Vaginal bleeding
Abnormal discharge
Lower abdominal/ pelvic pain
Fever
How is RPOC diagnosed?
USS
How is RPOC managed?
Surgical removal (ERCP- Evacuation of retained products of conception): Dilation and curettage
What haemoglobin level is defined as postpartum anaemia?
<100 g/L
Under what circumstances would a FBC be taken the fay after delivery?
PPH >500ml
C-section
Antenatal anaemia
Symptoms of anaemia
How can postpartum anaemia be treated?
Oral iron
Iron infusion
Blood infusion
When is an iron infusion contraindicated?
If there is active infection
What are the three levels on the spectrum of postnatal mental illness?
Baby blues
Postnatal depression
Puerperal psychosis
How long does the baby blues last and what percentage of women does it affect?
50% in the first week after birth
How many women are affected by postnatal depression and how long after birth does it peak?
1 in 10
Peaks around 3 months after birth
How common is puerperal psychosis and how long after birth does it usually start?
1 in 1000 women
Starts a few weeks after birth
What may be the causes of baby blues?
Significant hormonal changes Recovery from birth Fatigue/ sleep deprivation New responsibility Establishing feeding
What triad is seen in postnatal depression?
Low mood
Anhedonia
Low energy
What is anhedonia?
Lack of pleasure in activities
How is postnatal depression treated?
Mild- support and self-help
Moderate- SSRI’s, CBT
Severe- specialist psychiatry services
What screening tool is used to assess postnatal depression?
Edinburgh Postnatal Depression Scale
What symptoms are experiened in puerperal psychosis?
Delusions Hallucinations Depression Mania Confusion Thought disorder
How is puerperal psychosis managed?
Admission to mother & baby unit
CBT
Medications
Electroconvulsive therapy
What is mastitis?
Inflammation of breast tissue
What is the main cause of mastitis?
Obstruction in the ducts and accumulation of milk when breast feeding
Can also be caused by infection
How does mastitis present?
Unilateral breast pain/ tenderness Erythema Local warmth and inflammation Nipple discharge Fever
How is mastitis managed when breast feeding is the cause?
Conservative: Continued breastfeeding, expressing milk, breast massage, simple analgesia, heat packs
How is mastitis managed if infection is the cause or conservative is not effective?
Antibiotics: Flucloxacillin = 1st line
When might candida of the nipple occur?
After a course of antibiotics
What can canidida of the nipple lead to?
Recurrent mastitis due to the cracked skin that can create an entrance for infection
How might candida of the nipple present?
Bilateral sore nipple
Nipple tenderness/ itching
Cracked, flaky or shiny areola
Symptoms in baby (white patches, nappy rash)
How is candida of the nipple treated?
Topical Miconazole after each feed on the mother
Miconazole gel for the baby
What is postpartum thyroiditis?
Condition where there are changes to the thyroid function within 12 months of delivery
What are the 3 typical stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroid
- Gradual return to normal
How is postpartum thyroiditis managed?
TFT's 6-8 weeks after delivery Symptomatic control (Propanolol) Levothyroxine for hypothyroidism
What is Sheehan’s syndrome?
Complication of PPh where the drop in circulating volume leads to avascular necrosis of the pituitary gland
What gland does Sheehan’s syndrome affect?
The anterior pituitary
Where does the anterior pituitary get its blood supply from and why does this make it more susceptible to avascular necrosis?
Hypothalamo-hypophyseal portal system that is susceptible to rapid drops in blood pressure
What does Sheehan’s cause and therefore how does it present?
Lack of hormones produced by the pituitary:
- Reduced lactation
- Amenorrhoea
- Adrenal insufficiency/ adrenal crisis
- Hypothyroidism
How is Sheehan’s syndrome managed?
Replacement of missing hormones
