Obstetrics Flashcards
What is the complication of maternal hypertension that is to be worried about?
Placental abruption
What are the risk factors of spontaneous abortion?
- Advanced maternal age (> 35 years)
- substance abuse
- TORCH infection
- Thyroid dysfunction
- Pre-existing hypercoagulable states (e.g., SLE, antiphospholipid syndrome
- Foetal risk factors - congenital anomalies, exposure to teratogenic drugs and trauma
Why is presence of foetal movement important?
Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero.
This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.
When do expectant mothers start to feel foetal movement?
The first onset of recognised fetal movements is known as quickening.
This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau.
Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation.
Towards the end of pregnancy, fetal movements should not reduce.
What is considered as reduced foetal movement?
There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.
What are the risk factors causing reduced foetal movement?
Posture - generally awareness being more prominent during lying down and less when sitting and standing
Distraction - women is distracted
Placental position - Anterior placenta position prior to 28wks may have lesser awareness
Medication - alcohol and sedative medications like opiates or benzodiazepines
Fetal position - Anterior fetal position - movement less noticable
Body habitus- Obese patients are less likely to feel prominent fetal movements
Amniotic fluid volume- Both oligohydramnios and polyhydramnios can cause reduction in fetal movement
Fetal size
Up to 29% of women presenting with RFM have a SGA fetus (small for gestation age)
What is the management if 28wk gestation woman presents with reduced foetal movement?
If past 28 weeks gestation:
- Initially, handheld Doppler should be used to confirm fetal heartbeat.
- If no fetal heartbeat detectable, immediate US should be offered.
- If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
- If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
What is the management if 26wk gestation woman presents with reduced foetal movement?
Between 24 and 28 weeks gestation:
a handheld Doppler should be used to confirm presence of fetal heartbeat.
What is the management if 18wk gestation woman presents with reduced foetal movement?
If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
What is the period before which foetal movements are to be noticed?
If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
What are the potential sensitising events for rhesus haemolytic disease? And how is it managed
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
- Termination of pregnancy or evacuation of retained products of conception (ERPC) after miscarriage
- Ectopic pregnancy - (if managed surgically, if managed medically with methotrexate anti-D is not required)
- Vaginal bleeding < 12wks or if heavy
- External cephalic version
- Invasive uterine procedure - amniocentesis or chorionic villus sampling (CVS)
- Intrauterine death
- Delivery - delivery of a Rh +ve infant, whether live or stillborn (Kleihauer test - to test maternal circulation within 2hrs of birth)
- Antepartum haemorrhage
When is the rhesus disease screened for during antenatal care?
Booking and 28 weeks
When is anti-D given to rhesus negative women?
Give anti-D at 28 wks after any bleeding or potentially sensitising event and after delivery if neonate is rhesus positive (28 week and 34 weeks)
How is severity of foetal anaemia in rh haemolytic disease assessed? How is it managed
Doppler of foetal middle cerebral artery
Transfuse if foetus anaemic, deliver if >36wks
How do babies with rhesus haemolytic disease present?
- Neonatal jaundice, anaemia and hepatosplenomegaly - less severe
- oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
- heart failure
- kernicterus
What tests are done in rhesus disease?
All babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
- An indirect Coombs is a screening test that is carried out at booking/28/34 weeks to establish if the mother already has Rh Abs present.
- The Kleihauer is used after a sensitising event to see if fetomaternal haemorrhage has occurred
- The direct Coombs is used to see if the baby has Rh Haemolytic Disease
Who are patients at high risk of developing preeclampsia and how are they managed?
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby
What is the normal fluctuation of BP observed in pregnancy?
Blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
After this time the blood pressure usually increases to pre-pregnancy levels by term
What is the criteria for HTN in pregnancy?
systolic > 140 mmHg or diastolic > 90 mmHg
OR
An increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
What is the criteria for pre-existing hypertension?
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
What is the criteria for gestational hypertension?
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) - > 140/90
No proteinuria, no oedema
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
What are the principal RFs for pre-eclampsia
Moderate risk:
- Nulliparity
- Previous preeclampsia
- Family history
- Multiple gestation (twins)
- Chromosomal anomalies or congenital structural anomalies
- Hydatidiform moles
- old maternal age - 40 years or older
- Pregnancy interval of more than 10 years
- Body mass index (BMI) of 35 kg/m² or more at first visit
High risk:
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
What are the features of severe pre-eclampsia?
hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++ (300mg in 24h / urine protein:creatinine ratio - 0.3 )
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
What are the blood investigation findings in pre-eclampsia?
FBC: Relative ↑ Hb due to haemoconcentration (due to oedema – more fluid stay in interstitial space!) , Thrombocytopenia, Anaemia (if haemolysis)
Coagulation - mildly prolonged PT and APTT
Biochemistry: ↑ Urate ↑ Urea & Creatinine Abnormal LFTs (↑ transaminases) ↑ Lactate dehydrogenase (LDH – a marker for haemolysis) ↑ Proteinuria (>300mg protein/24h)
How is mild-moderate preclampsia managed?
o Give antihypertensive if BP:
Systolic > 160
Diastolic > 110
o Regardless of other symptoms (eg: proteinuria etc!); gv treatment as long as BP is higher than the range!
- Labetalol
- Nifedipine
- Methyldopa
What are the causes of folic acid deficiency
phenytoin
methotrexate
pregnancy
alcohol excess
When is folic acid prescribed?
All women should take 400mcg of folic acid until the 12th week of pregnancy
Women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
Who are the high risk patients requiring folate supplements?
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
→ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
In normal pregnancy, what are the CVS changes observed?
- SV up 30%, HR up 15% & cardiac output up 40%
- systolic BP is unaltered
- diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
- enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
In normal pregnancy, what are the respiratory system changes observed?
- Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre)
- Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm
- BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable
In normal pregnancy, what are the haematological system changes observed?
- Maternal blood volume up 30%, mostly in 2nd half - red cells up 20% but plasma up 50% Hb falls
- Low grade increase in coagulant activity
- rise in fibrinogen and Factors VII, VIII, X
- fibrinolytic activity is decreased - returns to normal after delivery (placental suppression?)
- prepares the mother for placental delivery
- leads to increased risk of thromboembolism
- Platelet count falls
- WCC & ESR rise
In normal pregnancy, what are the urinary system changes observed?
- blood flow increase by 30% - thus decreased serum urea and creatinine
- GFR increases by 30-60%
- Salt and water reabsorption is increased by elevated sex steroid levels
- Urinary protein losses increase - threshold is 300 mg/24
In normal pregnancy, what are the biochemical system changes observed?
- Calcium requirements increase during pregnancy - especially during 3rd trimester + continues into lactation
calcium is transported actively across the placenta
- serum levels of calcium and phosphate actually fall (with fall in protein)
- ionised levels of calcium remain stable
- Gut absorption of calcium increases substantially - due to increased 1,25 dihydroxy vitamin D
In normal pregnancy, what are the hepatic system changes observed?
Unlike renal and uterine blood flow, hepatic blood flow doesn’t change
ALP raised 50%
Albumin levels fall
What are the main indications for C-section?
- Repeat CS
- Fetal compromise
- Failure to progress’ in labour
- Breech presentation
- HIV with high viral load or those not receiving anti-retroviral therapy
- Primary genital herpes in the third trimester (NB not a secondary attack)
- Placenta praevia major, i.e. grade 3 or 4
- Twin pregnancy where the first baby is breech
- Singleton breech at term but only after external cephalic version - has been offered or CI
What are the extended indications for C-section?
- placenta praevia grades 3/4
- pre-eclampsia
- post-maturity
- IUGR
- fetal distress in labour/prolapsed cord
- failure of labour to progress
- malpresentations: brow
- placental abruption: only if fetal distress; if dead deliver vaginally
- vaginal infection e.g. active herpes
- cervical cancer (disseminates cancer cells)
What are the intraoperative complications of CS?
- Uterine/ Uterocervical lacerations (5-10%)
- Blood loss >1L (7-9%)
- Bladder laceration (0.5-0.8%)
- Blood transfusion (2-3%)
- Hysterectomy (0.2%)
- Bowel lacerations (0.05%)
- Ureteral injury (0.03-0.09%)
What are the posteroperative complications of CS?
- Endometritis (5%)
- Wound infections (3-27%)
- Pulmoanry atelectasis
- Venous thromboembolism
- UTI
A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus.
What is the most diagnosis and appropriate management?
Retained products of conception
Can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected.
This lady needs and urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed. Sometimes a scan would be done before but with a history this clear, it is not necessary. It is also hard to pick up products on scan sometimes as they can be very small.
What are the long-term complications of C-sections?
- Uterine rupture (1:200 (0.5%) with spontaneous labour)
- Placenta praevia (47% ↑ of background risk)
- Placenta accreta
- Antepartum stillbirth (Risk x2 with previous CS)
When is VBAC recommended in pateints?
If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
Women with both previous CS & previous vaginal birth more likely to give birth vaginally
What are the risks associated with VBAC?
• Uterine rupture risk - spontanous onset of labour and if induction of labour - risk of uterine rupture increases
What are the indications of Crash CS/ emergency C-section? (within 30mins)
• Placental abruption with: Abnormal FHR or Uterine irritability • Cord prolapse • Scar rupture • Prolonged bradycardia • Scalp pH <7.20 Severe foetal distress
What are the indications of urgent C-section?
Failure to progress + Pathological CTG
Dystocia
What are the indications of scheduled C-section?
- Severe pre-eclampsia
- IUGR + Poor fetal function tests
- Failed induction of labour
What are the indications of elective C-section?
Performed after 39wks gestation to reduce the risk of neonatal lung immaturity
- Term singleton breech (If EVC CI/failed)
- Twin pregnancy with non-cephalic 1st twin
- Maternal HIV
- Primary genital herpes in 3rd trimester
- Placenta praevia
- Previous classical CS- vertical
What is the precaution to be taken for VBAC?
• EFM (Electronic fetal monitoring AKA continuous CTG):
o Recommended during labour (As FHR changes may be the earlist signs of scar rupture)
• Women should deliver in a unit whr there is immediate access to:
o CS
o On-site blood transfusion
What is the use of a bishop score?
The Bishop score is used to help assess the whether induction of labour will be required
What are the thresholds for bishop scores and what is the recommended management?
- a score of < 5 indicates that labour is unlikely to start without induction
- a score of > 9 indicates that labour will most likely commence spontaneously
What are the features of obstetric cholestatsis and how is it managed?
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth.
Features
- pruritus - may be intense - typical worse palms, soles and abdomen
- clinically detectable jaundice occurs in around 20% of patients
- raised bilirubin is seen in > 90% of cases
Management
- ursodeoxycholic acid - again widely used but evidence base not clear
- induction of labour at 37 weeks is common practice but may not be evidence based
- Weekly liver function tests
- vitamin K supplementation
What are the indications for IOL?
IOL is preferred where allowing the pregnancy to continue would expose the fetus and mother to risk greater than that of induction
- Prolonged pregnancy
- Suspected growth restrictioon
- prelabour term rupture of membranes
- Pre-eclampsia
- Uncontrolled HTN or diabetes
Foetal indications - suspected IUGR or compromise, antepartum haemorrhage, PROM
How is labour induced?
- Induction using intravaginal prostaglandin (PGE2) into posterior fornix = Stats labour or ripeness of cervix is improved to allow for amniotomy - if one dose does not increase cervical ripeness, another dose can be given 6h later provided there is no uterine activity.
- Amniotomy - breaking of waters(Artificial rutupre of membrane/ARM) + oxytocin (given once membranes have ruptured)
- membrane sweep - 30% will go into spontaneous labour in <7 days
What are the CI for IOL?
- Acute foetal compromise
- Abnormal lie
- Placenta praevia
- Pelvic obstruction - pelvic mass or pelvic deformity - cephalo-pelvic disproportion
Relative CI - one previous c-section increases scar rupture rate and prematurity
What are the complications that can develop from IOL?
- Labour may fail to start or take longer - inefficient uterine activity
- Risk of instrumental delivery is high
- Hyperstimulation is rare but causes foetal distress and uterine rupture
- Umbillical cord can prolapse at amniotomy
- PPH, intrapartum and postpartum infections
- Prematurity - may be iatrogenic or unintentional
Who is VBAC contraindicated in?
Vertical uterine scar
Multiple previous caesareans
After 2 c-sections, vaginal delivery not attempted
What is the definition of PROM?
Prelabour rupture of membranes (PROM) at term = Leakage of amniotic fluid in absence of uterine activity after 37 completed weeks of gestation
What are the diagnostic features of PROM?
Gush of clear fluid - followed by an uncontrollable intermittent trickle (constnt leaking)
Occasionally confused with urinary incontinence
US - finding of reduced liquor volume
What is avoided in PROM?
PV examination: If planning to use conservative management = Avoid digital examination because ↑ risk of: Chorioamnionitis Post-partum endometritis Neonatal infection
What is the diagnostic criteria for chorioaminonitis?
Maternal fever (≥38oc)
+ At least 2 of the following:
- Maternal leukocytosis (>15,000 cells/mm3)
- Maternal tachycardia (>100 bpm)
- Fetal tachycardia (>160bpm)
- Irritable uterus / Uterine tenderness
- Foul odor of amniotic fluid
And excluded:
Maternal URTI
Maternal UTI
What is the management of women in PROM without any CI ?
o Immediate induction
o /Expectant management (waiting for spontaenous labour - however increases risk of chorioamnionitis >24hrs) - presence of meconium or evidence of infection - immediate induction
What is the management of women in PROM with GBS?
- Immediate induction should be encouraged (↓ neonatal infection)
- Benzylpenicillin intrapartum for mothers
- Screen neonates soon after birth
What are the indications for elective C-section < 34 weeks?
- Pre-eclampsia
2. Severe intrauterine growth restriction
What are the risk factors for breech pregnancy?
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
What is the management of breech presentations?
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
What is the common complication of breech presentation?
Cord prolapse is more common in breech presentations
What are the absolute contraindications for ECV?
1. where caesarean delivery is required antepartum haemorrhage within the last 7 days 2. abnormal cardiotocography 3. major uterine anomaly 4. ruptured membranes 5. multiple pregnancy 6. Pre-eclampsia
When is ECV offered for breech presentation?
• Performed from:
o Nulliparous – 36wks
o Multiparous – 37wks
What are the sensitising events causing rhesus immunisation?
Child birth (main & most frequent) – usually maternal blood doesn’t mix with fetal blood until delivery!!! (So 1st pregnancy not affected) C-section Miscarriage Therapeutic abortion Amniocentesis Ectopic pregnancy Abdominal trauma External cephalic version
What is the definition of PPH?
Primary PPH - Blood loss of ≥ 500mL from genital tract occurring within 24h of delivery of baby
Secondary PPH = ‘Excessive’ blood loss occurring btwn 24h & 12wks after delivery of baby
What are the causes of primary PPH?
o Tone (90%) – Uterine atony
o Trauma (7%)– Genital tract trauma
o Thrombin – Coagulopathy
o Tissue – Retained products of conception
What are the causes of secondary PPH?
o Infection (often associated with retained products of conception Endometritis
o Rarely:
Gestational trophoblastic disease
Uterine arteriovenous malformation including a pseudo-aneurysm
What is the management of PPH?
ABCD
1st line (physical method)
- bimanual uterine massage
- empty bladder (catheter)
2nd line
- IV oxytocin / IV ergometrine (CI in hypertension)
- IM carboprost (CI in asthma)
3rd line (surgical)
- 1st option - intrauterine balloon tamponade
- B-Lynch suture
- ligation of the uterine arteries or internal iliac arteries
Last option
hysterectomy
What are the risk factors of primary PPH?
Previous PPH
Prolonged labour
Pre-eclampsia
↑ Maternal age
Polyhydramnios
Emergency CS
Placenta praevia
Placenta accreta
Macrosomnia
Ritodrine (A β2-adrenergic receptor agonist for tocolysis)
What are the risk factors of GBS infection?
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection
- maternal pyrexia e.g. secondary to chorioamnionitis
What are the causes of late onset sepsis in neonates?
Staphylococcus epidermidis and Staphylococcus aureus.
Is universal screening offered for GBS?
NOPE
Can GBS screen be requested by the mother?
NOPE
What is the mx of a preganant pt with previous history of GBS preganancy?
Women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%.
They should be offered maternal intravenous antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
When are women swabbed for GBS?
if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
Who is prophylactic antibiotics offered to? and what antibiotic is preferred?
maternal intravenous antibiotic prophylaxis should be offered to women:
- with a previous baby with early- or late-onset GBS disease
- in preterm labour regardless of their GBS status
- women with a pyrexia during labour (>38ºC)
3Ps- pyrexia, previous GBS and prolonged rupture of membrane
benzylpenicillin is the antibiotic of choice for GBS prophylaxis
What are the tests in the combined test? And when are they performed?
the combined test is now standard: (Down syndrome screening)
- nuchal translucency measurement
- serum B-HCG
- pregnancy associated plasma protein A
these tests should be done between 11 - 13+6 weeks
What are the triple and quadriple testing and when are they offered
They are offered if the combined test period is missed and offered between between 15 - 20 weeks
Triple test - alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
Quadriple test - alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
What are the levels detected in the combined test to diagnose down syndrome?
HI - High
High human chorionic gonadotrophin beta-subunit (-HCG)
Inhibin
Thickened nuchal transluency
How are epileptic patients managed during pregnancy?
folic acid 5mg once + lamotrigine/ carbamazepine
What are the risk factors for gestational diabetes?
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
When are women screened for diabetes?
- women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
- women with any of the other risk factors should be offered an OGTT at 24-28 weeks
What is the threshold value to diagnose gestational diabetes?
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
What is the management of gestational diabetes?
- Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
- If the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered - diet includes eating foods with a low glycaemic index
If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
If glucose targets still not met - add insulin + diet + exercise + metformin
- If the fasting plasma glucose level is > 7 mmol//l
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide - offered to anyone who cannot take metformin
What is the management of pre-existing diabetes during pregnancy?
- weight loss for women with BMI of > 27 kg/m^2
- stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- folic acid 5 mg/day from pre-conception to 12 weeks gestation
- detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
How long does lochia last? What is the diagnosis if vaginal discharge present beyond the period and how is it tested for?
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
Beyond 6 weeks - indication for US to test for retained products of conception
What is the criteria for oligohydroamnios ?
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
What are some of the causes of oligohydroamnios?
- premature rupture of membranes
- fetal renal problems e.g. renal agenesis
- intrauterine growth restriction
- post-term gestation
- pre-eclampsia
What is the score used to screen for postnatal depression? and what are the cutoffs?
Edinburgh Postnatal Depression Scale may be used to screen for depression:
- 10-item questionnaire, with a maximum score of 30
- score > 13 indicates a ‘depressive illness of varying severity’
What are the diagnostic features of baby blues? Mx?
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Mx: Reassurance and support, the health visitor has a key role
What are the diagnostic features of postnatal depression? Mx?
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Mx:
Reassurance and support
Cognitive behavioural therapy
+ SSRI (sertraline and paroxetine) - if severe
What are the diagnostic features of peurpural depression? Mx?
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Recurrence is high in subsequent pregnancies
Mx: Admission to hospital is usually required
What are the risk factors of placenta praevia?
- multiparity
- multiple pregnancy
- embryos are more likely to implant on a lower segment scar from previous caesarean section
What are the characteristic features of placenta praevia?
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
How is placenta praevia usually diagnosed?
- placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal - ultrasound as it improves the accuracy of placental localisation and is considered safe
What antibiotics are CI during breastfeeding?
ciprofloxacin
tetracycline
chloramphenicol
sulphonamides
What endocrine drugs are CI during breastfeeding?
Carbimazole
sulfonylureas
What psychaitric drugs are CI during breastfeeding?
lithium, benzodiazepines
clozapine
What cardiovascular drugs are CI during breastfeeding?
Aspirin
Amiodarone
What is the commonest maternal complication of PPROM?
Chorioamnitis
What is the management of PPROM?
- Admission
- Regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- Antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- Delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
You are assisting an obstetrics clinic. A couple attend who are 32 weeks pregnant. They had trouble conceiving naturally but were successful in their second round of IVF. It is their first baby. On their 18 week scan the sonographer was concerned about the location of the placenta and they have been rescanned today, confirming the finding. What is the most likely abnormality?
Placenta praevia
What is the criteria for foetal bradycardia on CTG and what are the causes?
Heart rate < 100 /min
Increased fetal vagal tone, maternal beta-blocker use
These are a reduction in fetal heart rate by 15 beats or more for at least 15 seconds. Decelerations are generally abnormal and should prompt senior review. In particular, late decelerations, which are slow to recover are indicative of fetal hypoxia.
What is the criteria for foetal tachycardia on CTG and what are the causes?
Heart rate > 160 /min
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions.
What is the criteria for reduced baseline variability on CTG and what are the causes?
< 5 beats / min
Prematurity, hypoxia
What is the criteria for early decelerations on CTG and what are the causes?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Cause: Usually an innocuous feature and indicates head compression
What is the criteria for late decelerations on CTG and what are the causes?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Cause: Indicates fetal distress e.g. asphyxia or placental insufficiency
What is the criteria for variable decelerations on CTG and what are the causes?
Independent of contractions
May indicate cord compression
How is nausea and vomiting controlled in pregnancy?
- natural remedies - ginger and acupuncture on the ‘p6’ point (by the wrist) are recommended by NICE
- Medications - antihistamines - promethazine is first line
How is vitamin D levels controlled in pregnancy?
All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy
Can mothers drink alcohol at different stages of pregnancy?
If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk
AKA - NADA
What is the management of a woman who has previously had a VTE ?
A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
What is the management of a woman who has an intermediate risk of VTE ?
A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin.
What are the risk factors for VTE and what is the mx?
These risk factors include: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
4 or more risk factors warrants - immediate treatment with LMWH continued until 6 weeks postnatal.
If a woman has 3 risk factors LMWH should be initiated from 28 weeks and continued until six weeks postnatal.
How is DVT that is diagnosed before delivery managed?
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
What are the features of foetal varicella syndrome?
Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
What are the complications of varicella zoster infection during pregnancy?
- shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
What is the management of chickenpox exposure in pregnancy?
- If there is any doubt about the mother previously having chickenpox maternal blood should be URGENTLY checked for varicella antibodies!!
- if the pregnant woman is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
What is the management of chickenpox in pregnancy?
- if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
- there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
- oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
What are signs of labour?
- regular and painful uterine contractions
- a show (shedding of mucous plug)
- rupture of the membranes (not always)
- shortening and dilation of the cervix
What are the 3 stages of labour?
Stage 1: from the onset of true labour to when the cervix is fully dilated
Stage 2: from full dilation to delivery of the fetus
Stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
What are the monitored at what intervals during labour?
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
Why not also give a Varicella zoster vaccination to protect against further exposure?
VZ Vaccine is an attenuated (live) vaccine, so there’s a tiny chance of causing infection. Very unlikely, but avoidable by not giving. I think that’s why.
What causes rubella?
Toga virus
What is the foetal risk with maternal rubella?
Congenital rubella syndorme
sensorineural deafness congenital cataracts congenital heart disease (e.g. patent ductus arteriosus) growth retardation hepatosplenomegaly purpuric skin lesions 'salt and pepper' chorioretinitis microphthalmia cerebral palsy
Hoe is rubella diagnosed?
- Suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
- IgM antibodies are raised in women recently exposed to the virus
- It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
How is rubella infection managed?
- Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
since 2016, rubella immunity is no longer routinely checked at the booking visit - If a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
- non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
A 28-year-old G4P3 woman presents with a lump in the breast, having ceased breastfeeding her youngest child one week prior. Her past medical history is significant for previous episodes of mastitis when breastfeeding her older children. On examination the lump is in the left breast at the three o’clock position, 4cm from the nipple. The lump is non-tender and the overlying skin seems unaffected. Her observations are as follows:
Heart rate: 88, resp rate: 12, blood pressure: 110/70mmHg, Oxygen saturation: 98%, Temperature: 37.4 Cº.
What is the likely diagnosis, and what is the most appropriate next step in investigation?
Galactocele and no investigations necessary
Most common benign breast lesion in lactating women
Frequently occurs during or after lactation - milk retention in the mammary glands
Typically - Painless, firm mass located in the sub areolar region
How do you differentiate breast abscess from galactocele?
Galactocele - Typically - Painless, firm mass located in the sub areolar region, no local or systemic signs of infection
Abscess - Typically painful, movable mass , Breast pain, erythema, and edema, Purulent discharge from the nipple of the affected breast
What is the most common cause of mastitis and what are the clinical features of complications of it?
Inflammation of the breast parenchyma caused mostly due to Staphylococcus Aureus
- Tender, firm, swollen, erythematous breast (generally unilateral)
- Pain during breastfeeding
- Reduced milk secretion
- Flu-like symptoms, malaise, fever, and chills
In some cases, reactive lymphadenopathy
Complication - breast abscess
How do you differentiate between fibroadenosis/ fibrocystic changes and fibroadenoma?
Most common benign lesion of the breast
Primarily in premenopausal women 20–50 years of age
Clinical features:
1. Premenstrual bilateral breast pain
2. Tender breast nodules
3. Clear or slightly milky nipple discharge
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
Fibroadenoma - benign breast tumor with fibrous and glandular tissue ( most common <35y)
Clinical features:
- mostly solitary
- well-defined
- non-tender
- rubbery
- mobile mass
Who are immediately qualified to be referred for 2 wk waits for breast lumps?
- Aged 30 and over and have an unexplained breast lump with or without pain or
- Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Who can be considered for referred for 2 wk waits for breast lumps?
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
- with skin changes that suggest breast cancer or
- aged 30 and over with an unexplained lump in the axilla
What is the referral pathway for 25y old woman who presents with painful breast lump?
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
Everybody with breast lump is referred only at different rates
How is breast cancer and pagets disease differentiated from benign breast conditions?
Breast cancer - Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
What are the features of fat necrosis of the breast and what causes it?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
How do you differentiate mammillary duct ectasia from fibroadenoma ?
Mamillary duct ectasia
More common in Perimenopausal women - 40-50y
- Firm, stable, painful mass under the nipple
- Unilateral greenish or bloody discharge
- If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Fibroadenoma - benign breast tumor with fibrous and glandular tissue ( most common <35y)
Clinical features:
- mostly solitary
- well-defined
- non-tender
- rubbery
- mobile mass
What is the most common benign cause of bloody nipple discharge and what are its features?
Intraductal/ Duct papilloma
If solitary - Large, central lesion
Palpable breast tumor close to or behind the nipple
If multiple lesions - Usually asymptomatic but may cause nipple discharge in rare cases
What are the causes of painless breast lumps?
- Fat necrosis
- Fibroadenoma
- Breast cancer
- Galactocele
What are the the causes of painful breast lumps?
- Fibrocystic changes/ fibroadenosis
- Breast abscess
- Mammillary duct ectasia
What are the management for patients with suspected DVT?
For patients with a suspected deep vein thrombosis (DVT):
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
the presence of a confirmed deep vein thrombosis (DVT) should be treated with therapeutic dose LMWH in the first instance.
What are the management for patients with suspected PE?
- ECG and chest x-ray should be performed in all patients
- In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue
- The decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
A 19-year-old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding. Her ultrasound scan confirms a viable intrauterine pregnancy. However, the high vaginal swab has isolated group B streptococcus (GBS). How should she be managed?
Intrapartum intravenous benzylpenicillin is required to reduce neonatal transmission. An alternative would be clindamycin. This applies to GBS isolated in vaginal swabs and urine. (GBS urinary tract infection in pregnancy requires appropriate antibiotics at the time also).
A 45-year-old woman presents at 10 weeks gestation for a routine check. She has a previous history of severe pre-eclampsia. Her BMI is 38 kg/m^2. Her blood pressure was 145/94 mmHg.
What treatment would you advise to reduce the risk of pre-eclampsia?
Several risk factors for pre-eclampsia: BMI > 35 kg/m^2, past obstetric history of pre-eclampsia and age > 40 years.
Women at high risk of pre-eclampsia are advised to take 75 mg of aspirin daily from 12 weeks until the birth of the baby according to the NICE guidelines.
Which UTI medication is CI during first trimester?
Trimethoprim is a folate antagonist and so is teratogenic in the first trimester of pregnancy. The BNF states that the manufacturers advise avoiding its use throughout pregnancy. NICE guidelines advise prescribing nitrofurantoin 50mg qds or 100mg modified release bd for seven days first line for pregnant women with a UTI. This should be avoided in women at full-term due to the risk of neonatal haemolysis.
What are the risk of smoking during pregnancy?
Increased risk of miscarriage Increased risk of pre-term labour Increased risk of stillbirth IUGR Increased risk of sudden unexpected death in infancy
What are the risk of alcohol during pregnancy?
Fetal alcohol syndrome (FAS)
- learning difficulties
- characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
- IUGR & postnatal restricted growth
Binge drinking is a major risk factor for FAS
What are the risk of cocaine during pregnancy?
Maternal risks
- hypertension in pregnancy including pre-eclampsia
- placental abruption
Fetal risk
- prematurity
- neonatal abstinence syndrome
What are the types of placenta accreta?
- accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis (75%)
- increta: chorionic villi invade into the myometrium
- percreta: chorionic villi invade through the perimetrium
What are the risk factors of placenta accreta?
o Prior uterine surgery (eg: CS, Myomectomy , Curettage & Evac)
o Repeated surgical termination of pregnancy
o Placenta praevia
How is placenta accreta diagnosed?
• Usually by US during 2nd / 3rd trimester
Women with placenta praevia / low-lying placenta (usually on anterior wall of uterus) overlying a uterine scar early in pregnancy:
o Should undergo follow-up imaging in 3rd trimester (Potential placenta accreta?)
o Should be taken care in tertiary centre (to have an interventional radiologist) – so can have put the ‘embolization’ cathter rdy before delivery
What is the management of placenta accreta?
• Minimal bleeding: Leave placenta in situ + close monitoring
• Heavy bleeding: Follow the steps of massive obstetric haemorrhage!
(Blood replacement / Tamponade test / Hysterectomy
A 42-year-old female has just delivered her second and final child at 41 weeks gestation. She has currently been in the third stage of labour for 64 minutes. She has so far lost 2800ml of blood. Her previous baby was delivered by elective caesarean-section. Her only past medical history is pelvic inflammatory disease.
Due to her risk factors, an antenatal ultrasound was performed and confirmed the underlying diagnosis. Unfortunately, the results of this scan had not been seen by the delivery team until now.
What is the most definitive treatment of the underlying problem?
The definitive management of such a patient is hysterectomy with the placenta left in-situ [1]. This is because the attempts to actively remove the placenta can cause significant haemorrhage.
How is shoulder dystocia associated with maternal and foetal morbidity?
Maternal morbidity:
o PPH
o Perineal tears
Fetal morbidity:
o Brachial plexus injury
o Neonatal death (Occasionally)
What are the risk factors of shoulder dystocia?
Fetal macrosomia
↑ Maternal BMI
DM
Prolonged labour
What is the management of shoulder dystocia?
1) Call for help!
2) McRoberts’ manoeuvre
3) Application of suprapubic pressure
Episiotomy does NOT relieve bony obstruction:
o Sometimes used to allow better for internal manoeuvres
What is an absolute CI in shoulder dystocia?
Oxytocin administration NOT indicated in shoulder dystocia
What are the stages in the 1st stage of labour?
o Latent phase - Period taken for cervix to completely efface + dilate up to 3cm (can last days/ weeks /hrs). Women may also experience painful uterine contractions
o Active phase: 3cm to full dilatation (10cm)- 1cm per hr
What are braxton hicks contractions?
Braxton Hicks contractions are mild, often irregular and non-progressive and may occur from 30wks (more common after 36wks)
Braxton Hicks contractions often confused with contractions in labour; contractions in labour are: o Painful o Gradual increase in: Frequency Amplitude Duration
What is defined as poor progress in 1st stage? And what are the causes
<2cm dilatation in 4h
Causes:
- Inefficient uterine activity - common in nul
- Malposition/ malpresentation / large baby
- Inadequate pelvis
What is the management of delayed progress in 1st stage of labour?
o Amniotomy (artificial rupture of membranes (ARM)): Reassess in 2hrs
o Aminotomy + oxytocin infusion: Reassess in 2hrs
This should always be considered in nulliparous women
o Lower segment CS: If there is fetal distress
If the woman has epidural + CTG reassuring how long do you wait before active pushing?
Allow 1h for passive descent before commencing active pushing; ensure:
Maintain good contractions
May commence oxytocin
What is delayed cord clamping?
Delaying clamping for 2-3min - higher haematocrit lvl in neonate
What is the definition of delay in second stage of labour?
- Nulliparous - delivery doesn’t start after 2hrs of active pushing
- Multiparous – delivery doesn’t start within 1hr of active pushing
How is delay in second stage managed in nulliparous women?
Suspect there is delay if delivery is not imminent after 1h of active pushing
If delay : VE and Amniotomy
If NOT delivered in 2h:
Reviewed by obstetrician to consider:
Instrumental delivery
/ CS
How is delay in second stage managed in multiparous women?
If delivery is NOT imminent after 1h of active pushing:
Reviewed by obstetrician to consider:
Instrumental delivery
/ CS
Delay in 2nd stage in multiparous woman, Always suspect:
Malposition
Disproportion
What is considered as delay of 3rd stage in labour?
placenta is not delivered within 30mins after baby delivered
When to intervene in 3rd stage?
Haemorrhage
Failure to deliver placenta within 1h
Maternal desire to shorten 3rd stage
What is the management of 3rd stage delay?
o Use of uterotonics - syntometrine / oxytocin
o Clamping & cutting of cords
o Controlled cord traction
What is the management to reduce risk of PPH in multiple preganacy?
If increased risk of PPH (eg: multiple pregnancy):
o Give oxytocin infusion prophylactically:
For 3-4h
Give 40U in 500mL saline
Why is cord prolapse a fear?
Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.
What are the risk factors for cord prolapse?
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station
How is cord prolapse managed?
- The presenting part of the fetus may be pushed back into the uterus to avoid compression.
- Tocolytics may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.
- The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low. If treated early, fetal mortality in cord prolapse is low.
- Incidence has been reduced by the increase in caesarian sections being used in breech presentations.
What is the cutoff period to diagnose gestational HTN and preeclampsia?
After 20 wks
before that is pre-existing HTN
A 28-year-old woman who is P1 G2 is 30 minutes post-partum of an uncomplicated delivery. She suddenly begins gasping for breath with a blood pressure of 83/65mmHg, heart rate of 120bpm and a respiratory rate of 33/min. She appears cyanosed. She becomes unresponsive. What is the most likely diagnosis?
Amniotic fluid embolism
What is amniotic fluid embolism and what are the symptoms?
Fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
How is amniotic fluid embolism diagnosed?
Diagnosis of exclusion
How is amniotic fluid embolism managed?
Predominantly supportive
What is the definition of antepartum haemorrhage?
Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus
How do you differentiate placenta praevia from placental abruption?
Placental abruption:
shock out of keeping with visible loss pain constant tender, tense uterus* normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria
Placenta praevia:
shock in proportion to visible loss no pain uterus not tender* lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large
What is CI in anterpartum haemorrhage?
vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
Placenta praevia
How can you use the bloody discharge to differentiate between vasa praevia, placenta praevia and abruption?
The bleeding associated with placenta praevia is painless and usually bright red.
Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red.
The pattern of previous bleeding also favours vasa praevia. Though vasa praevia can also present with painless vaginal bleeding other expected features would include fetal bradycardia and membrane rupture.
What is the difference between engagement and station?
Engagement - When the widest part of the baby enters the pelvic rim or inlet, so basically how far into the pelvis the baby has moved down.
Station is the term used to describe the head in relation to the ischial spine. The station is ‘0’ when the head is directly at the level of the ischial spines, if the station was describes as -2, it would be 2cm above the ischial spines, and it was +2 it would be 2cm below the ischial spine.
Engagement and station are essentially the same thing but described with relation to different points of reference. Engagement is an abdominal palpation finding, whereas station is a vaginal examination finding. Both relate to the descent of the baby’s head through the pelvis
What causes red degeneration and what are the typcial features?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy.
If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.
This usually presents with low-grade fever, pain and vomiting.
The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
How is a woman with moderate risk of venothromboembolism managed?
LMWH initiated from 28 weeks and continued until six weeks postnatal.
How is a woman with high risk of venothromboembolism managed?
Immediate LMWH continued until six weeks postnatal
How is a woman with previous Hx of venothromboembolism managed?
LMWH throughout pregnancy until 6 weeks postnatal
What are the 4 causes of PPH?
4T’s of PPH
- tone (i.e. uterine atonicity in this case)
- tissue
- trauma
- thrombin
How long can secondary PPH last and what are the common casues?
Occurs between 24 hours - 12 weeks
Due to retained placental tissue
Endometritis
What reduces the chances of shoulder dystocia in GDM?
Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes.
What are the causes of an increased nuchal transleucency?
- Down’s syndrome
- congenital heart defects
- abdominal wall defects
What are the causes of an hyperechogenic bowel?
- cystic fibrosis
- Down’s syndrome
- cytomegalovirus infection
Which hyperglycaemic medications can be used during breastfeeding?
Metformin
Which hyperglycaemic medications are CI during breastfeeding?
Sulfonylureas (gliclazide) should be avoided when breastfeeding due to theoretical risk of neonatal hypoglycaemia.
Exenatide, liraglutide, and sitagliptin should be avoided when breast feeding.
What does HELLP stand for?
haemolysis (H), elevated liver enzymes (EL) and low platelet count (LP)
What is the blood test results for interhepatic cholestasis of preganancy?
It will give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT. Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment.
How do you differentiate interhepatic cholestatsis of pregnancy from biliary colic
Both have cholestatic LFTs,
however biliary colic causes pain
How do you differentiate interhepatic cholestatsis of pregnancy from acute fatty liver disease of the pregnancy
Acute fatty liver of pregnancy also occurs in the third term of pregnancy but a hepatic picture would be expected on LFTs, with a rise in ALT/AST greater than that of ALP, a raised white cell count and potential clotting abnormalities. This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy.
A 32-year-old pregnant lady is found to be anaemic 20 weeks gestation. A full blood count shows:
Serum Hb 104 g/L (115-160)
MCV 104 fL (80-100)
A blood film shows hypersegmented neutrophils. She has a past medical history of coeliac disease. What is the most likely cause of the anaemia?
Folate deficiency anaemia
Hypersegmented neutrophils - Failure of bone marrow stem cells to make DNA due to B12 or folate deficiency so the nucleus is made up of large clumps of dense chromatin
A Cardiotocogram (CTG) is performed on a 34-year-old female at 40 weeks gestation who has attended labour ward in spontaneous labour. The CTG shows a fetal heart rate of 150bpm. There is good variability in fetal heart rate, and it is a low risk pregnancy. The midwife rings you concerned that there are late decelerations present on the CTG trace. Which is the most appropriate next step in management?
Foetal blood sampling - to assess for fetal hypoxia and acidosis
A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is fetal acidosis.
What is twin to twin transfusion syndrome and when is it screened for?
Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic twin pregnancies. The two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the ‘donor’ receives a lesser share of the placenta’s blood flow than the other twin, the ‘recipient’. This is due to abnormalities in the network of placental blood vessels. The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems. In severe cases, TTTS can be fatal for one or both fetuses.
TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition.
What are the causes of low AFP?
- Down’s syndrome
- Trisomy 18
- Maternal diabetes mellitus
What are the causes of high AFP?
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
What is the contraindication for using epidural anaesthesia during labour
Coagulopathy
What are the foetal complications of post-term pregnancy?
Reduced placental perfusion
Oligohydramnios
What are the maternal complications of post-term pregnancy?
Increased rates of intervention including forceps and caesarean section
Increased rates of labour induction
A 32-year-old women para 1+0 is 37+1 weeks pregnant and is being monitored and treated for pre-eclampsia. Her current treatment is with labetalol and her blood pressure has been well controlled. She attends the antenatal clinic complaining of a severe headache, one episode of vomiting, and blurred vision. Her blood pressure is currently 156/100 mmHg. On examination she has papilloedema. She is admitted to hospital. What is the appropriate management?
IV Magnesium sulphate and plan immediate delivery
What are the risk of prematurity?
- increased mortality depends on gestation
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease, hypothermia, feeding problems, infection, jaundice
- retinopathy of newborn, hearing problems
When are women screened for anaemia?
- Booking visit
2. 28 weeks
A 34-year-old primiparous woman is 33+6 weeks pregnant. During a recent antenatal visit she had a blood pressure of 152/101 mmHg. She reports some swelling of her hands and feet but no other symptoms. Urinalysis is negative for protein. She has a past history of asthma for which she uses a salbutamol inhaler PRN and depression but she stopped her antidepressant medication when she became pregnant. What is the best management?
Oral nifedipine (Asthma B-blockers CI)
What is the normal pubic symphysis height expected and how is it managed if it is reduced?
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
If woman is small for dates - important to perform an ultrasound to confirm whether or not the foetus is small for gestational age.
What are the characteristic features of hydatidiform mole?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
What are the associations with placental abruption?
proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age
What is the biggest risk factor for cord prolapse?
Artificial amniotomy
How do you treat mastitis?
The first-line antibiotic is flucloxacillin for 10-14 days
Breastfeeding or expressing should continue during treatment.
what is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop?
Magnesium sulphate
How long does magnesium sulphate need to be given?
Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
What are the important side effects of magnesium sulphate and how can it be treated?
urine output, reflexes, respiratory rate and oxygen
saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
What manoeuvre can improve the efficiency of the mcroberts manouevre?
Suprapubic pressure
Which presentation has the greatest mortality and morbidity
Footling presentations are a rare but the most risky form of breech- there is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency.
What can you use in eclampsia if magensium sulphate does not control the seizures completely?
if it fails to terminate the seizure, a benzodiazepine (such as midazolam) can be considered.
How does rheumatoid arthritis change during pregnancy?
RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery
What do rheumatoid arthritis patients need to do while trying to conceive?
Both men and women need to stop taking methotrexate for 6mth while trying to concieve (leflunomide also CI)
What are the safe rheumatoid drugs during pregancny?
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
Low dose corticosteroids - to control symptoms
What is the side effect of NSAIDS during pregnancy?
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
What is the risk in rheumatoid arthritis pts who are pregnant
patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
What is the management for women who have had hep B or those who had hep B during preganancy?
- Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
- hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
- C-section does not necessarily reduce the chances of vertical transmission
What are the risk factors of transverse foetal lie?
- Most commonly occurs in women who have had previous pregnancies
- Fibroids and other pelvic tumours
- Pregnant with twins or triplets
- Prematurity
- Polyhydramnios
- Foetal abnormalities
How is a transverse lie managed?
<36 wks - nothing , will correct by itself
> 36 wks - if membranes not broken, perform external cephalic version (ECV) of the foetus [CI include maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality.]
If ECV CI or unsuccessful - Elective CS
How does acute fatty liver disease present in pregnancy?
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Features
- abdominal pain
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre-eclampsia
Clinically, acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea) whereas cholestasis of pregnancy is characterised by severe pruritis.
What reduced the risk of stillbirth in obstetric cholestasis?
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is recommended at 37-38 weeks gestation
A 30-year-old female presents in the emergency department. She is anxious that her waters broke this morning and describes a sudden ‘gush’ which soaked her trousers.
She is 30 weeks gestation and has had an uncomplicated pregnancy so far.
What is the most appropriate investigation to perform initially?
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
How do you manage a woman who is found to have a low lying placenta during the 16-20wk scan?
If low-lying placenta at 16-20 week scan:
- rescan at 34 weeks
- no need to limit activity or intercourse unless they bleed
- if still present at 34 weeks and grade I/II then scan every 2 weeks
- if high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed
How do you manage placenta praevia with bleeding?
- admit
- treat shock
- cross match blood
- final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery
How does IOL help in preeclampsia?
In induced labour, epidural anaesthesia should help to reduce BP
what is the diagnostic criteria for postpartum thyroiditis?
Postpartum thyroiditis can be definitively diagnosed based on three criteria:
1) Patient is within 12 months of giving birth
2) Clinical manifestations are suggestive of hypothyroidism
3) Thyroid function tests support diagnosis
How is postpartum thyroiditis managed?
- Thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive. Propranolol is typically used for symptom control
- The hypothyroid phase is usually treated with thyroxine
Why is obstetric cholestasis worrying?
There is an increased risk of premature birth and stillbirth.
Mnemonic for drugs CI in pregnancy?
L - Lithium A - Aspirin M - Methotrexate B - Benzodiazepines A - Amiodarone S - Sulphonylureas T - Tetracycline 4'Cs - Carbimazole, Ciprofloxacin, Chloramphenicol, Cytotoxics
What is the triad seen in vasa praevia? And how is it different from placenta praevia?
rupture of membranes followed by painless vaginal bleeding and fetal bradycardia
Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant. The two conditions may be difficult to distinguish in acute clinical situations, but for examination purposes a preceding rupture of membranes will usually be emphasis
What are the three types of gestational trophoblastic disease?
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma
What is the pathophysiology of complete hydatiform mole?
Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
What are the clinical features of hydatiform mole?
- bleeding in first or early second trimester
- exaggerated symptoms of pregnancy e.g. hyperemesis and uterus large for dates
- very high serum levels of human chorionic gonadotropin (hCG)
- hypertension and hyperthyroidism* may be seen (hcG can mimic TSH)
What is the first line investigation in suspected molar pregnancy? and what are the finding?
US - the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as ‘snow-storm’ appearance)
What is the management of molar pregancy?
- urgent referral to specialist centre - evacuation of the uterus is performed
- effective contraception is recommended to avoid pregnancy in the next 12 months
What is the pathophysiology of partial mole?
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.
What is the most appropriate management for prophylaxis of Rhesus sensitisation?
One dose of Anti-D immunoglobulin followed by a Kleihauer test
A Kleihauer test is a test for Foeta maternal haemorrhage which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.
What is the targeted therapeutic BP for use of antihypertensives in gestational hypertension
NICE recommends that blood pressure is targeted at systolic < 150 mmHg and diastolic 80-100 mmHg.
A 36-year-old multiparous patient has an uncomplicated delivery at 39 weeks gestation. One hour following delivery, the patient develops severe post partum haemorrhage which is acutely managed in the labour ward. Seven weeks later, the patient presents with difficulty breastfeeding due to a lack of milk production. Which of the following conditions is most likely to explain this history?
Sheehan syndrome - pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism
The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery.
When does vaginal bleeding lead to sensitisation?
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
What medication is used to supress lactation if required
Cabergoline
Why is eating chicken liver contraindicated during pregnancy?
Liver should be avoided in pregnancy as it contains high levels of vitamin A, a teratogen.
When is magnesium sulphate treatment stopped in preeclampsia?
24hrs after last seizure
What are the factors that reduce vertical transmission of HIV?
- maternal antiretroviral therapy
- mode of delivery (caesarean section)
- neonatal antiretroviral therapy
- infant feeding (bottle feeding)
What is the management of women with HIV during pregnancy?
- Antiretroviral therapy - All pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
- Mode of delivery - Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
A zidovudine infusion should be started four hours before beginning the caesarean section (Intrapartum)
- Neonatal antiretroviral therapy - zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
Women should be advised not to breastfeed
What are the causes of puerperal pyrexia?
endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
what is the management of puerperal pyrexia?
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
What are the classifications for perineal tear?
first degree: superficial damage with no muscle involvement
second degree: injury to the perineal muscle, but not involving the anal sphincter
third degree: injury to perineum involving the anal sphincter complex
fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
A 28-year-old Indian woman, who is 18 weeks pregnant, presents with increasing shortness of breath, chest pain and coughing clear sputum. She is apyrexial, blood pressure is 140/80 mmHg, heart rate 130 bpm and saturations 94% on 15L oxygen. On examination there is a mid diastolic murmur, there are bibasal crepitations and mild pedal oedema. She suddenly deteriorates and has a respiratory arrest. Her chest x-ray shows a whiteout of both of her lungs.
Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women. Mitral stenosis is becoming less common in the UK population, however should be considered in women from countries were there is a higher incidence of rheumatic heart disease. Mitral stenosis causes a mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients are at risk of atrial fibrillation (up to 40%), which can also contribute to rapid decompensation. Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty is the treatment of choice.
A 28-year-old woman, who is 30 weeks pregnant, presents with sudden onset chest pain associated with loss of consciousness. Her blood pressure is 170/90 mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is apyrexial. On examination there is an early diastolic murmur, occasional bibasal creptitations and mild peal oedema. An ECG shows ST elevation in leads II, III and aVF.
Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan’s, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.
A 28-year-old woman, who is 18 weeks pregnant, presents with sudden chest pain. Her blood pressure is 150/70 mmHg, saturations are 92% on 15L oxygen and her heart rate is 130 bpm. There are no murmurs and her chest is clear. There is signs of thrombophlebitis in the left leg.
Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism
When are women checked for anaemia and alloantibodies?
Booking - 8 - 12 weeks
Second time - 28 weeks
What is the management of a woman in PPROM?
- Admission
- Regular observations to ensure chorioamnionitis is not developing
- Oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome - Delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
What is the management of miscarriage?
Expectant management - waiting 7-14 days
Criteria for medical/surgical management:
- Increased risk of bleeding (late first trimester/ coagulopathies)
- Previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- Evidence of infection
Medical management -
- Vaginal misopristol (DO not give mifepristone!)
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief
Surgical management -
- ‘Undergoing a surgical procedure under local or general anaesthetic’
- The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
What are the indications for using CTG during labour?
- Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
- Severe hypertension 160/110 mmHg or above
- Oxytocin use
- The presence of significant meconium
fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014
How do you treat chlamydia infection in pregnancy?
Give erythromycin as doxycycline is CI
What is the grading of placenta praevia?
If low-lying placenta at 16-20 week scan
- Rescan at 34 weeks
- No need to limit activity or intercourse unless they bleed
- If still present at 34 weeks and grade I/II then scan every 2 weeks
- If high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed
How is placenta praevia managed?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV - placenta completely covers the internal os
How is acute placenta praevia managed?
- Admit
- Treat shock
- Cross match blood
- Final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery
