Obstetrics Flashcards
What is Pre-eclampsia
Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.
Pre-eclampsia features a triad of:
- Hypertension
- Proteinuria
- Oedema
Pre-eclampsia is a significant cause of maternal and fetal morbidity and mortality. Without treatment, it can lead to
maternal organ damage, fetal growth restriction, seizures, early labour and in a small proportion, death.
What is Eclampsia
Eclampsia is when seizures occur as a result of pre-eclampsia.
Patho of Pre-eclampsia
When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.
Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.
When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
Risk Factors for Pre-Eclampsia
High-risk factors are:
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (e.g. systemic lupus erythematosus)
- Diabetes
- Chronic kidney disease
Moderate-risk factors are:
- Older than 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
Women are offered _____ from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors for pre-eclampsia
Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.
Pre-eclampsia has symptoms of the complications:
- Headache
- Visual disturbance or blurriness
- Nausea and vomiting
- Upper abdominal or epigastric pain (this is due to liver swelling)
- Oedema
- Reduced urine output
- Brisk reflexes
Diagnosis of Pre-eclampsia
The NICE guidelines (2019) advise a diagnosis can be made with a:
- Systolic blood pressure above 140 mmHg
- Diastolic blood pressure above 90 mmHg
PLUS any of:
- Proteinuria (1+ or more on urine dipstick)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
Proteinuria in pregnancy can be quantified using:
- Urine protein:creatinine ratio (above 30mg/mmol is significant)
- Urine albumin:creatinine ratio (above 8mg/mmol is significant)
NICE recommends using placental growth factor PlGF between __ and __ weeks gestation to rule-out pre-eclampsia.
NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia
All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with:
Blood pressure
Symptoms
Urine dipstick for proteinuria
When gestational hypertension (without proteinuria) is identified, the general management involves:
- Treating to aim for a blood pressure below 135/85 mmHg
- Admission for women with a blood pressure above 160/110 mmHg
- Urine dipstick testing at least weekly
- Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by serial growth scans
- PlGF testing on one occasion
When pre-eclampsia is diagnosed, the general management is similar to gestational HTN to gestational hypertension, except:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure is monitored closely (at least every 48 hours)
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
- Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Medical management of pre-eclampsia is with:
- Labetolol is first-line as an antihypertensive
- Nifedipine (modified-release) is commonly used second-line
- Methyldopa is used third-line (needs to be stopped within two days of birth)
- Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
- IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
- Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
What can be given o women having a premature birth to help mature the fetal lungs.
Corticosteroids
What happens if pre-eclampsia can not be controlled
Planned early birth
What is used to managed seizures in Eclampsia
. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.
complication of pre-eclampsia and eclampsia
HELLP
Haemolysis
Elevated Liver enzymes
Low Platelets
What is Gestational Diabetes
Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
What are common complications from gestational diabetes
The most significant immediate complication of gestational diabetes is a large for dates fetus and macrosomia.
This has implications for birth, mainly posing a risk of shoulder dystocia
. Longer-term, women are at higher risk of developing type 2 diabetes after pregnancy.
WHat should be the investigation for anyone with risk factors for gestational diabetes?
oral glucose tolerance test at 24 – 28 weeks gestation. Women with previous gestational diabetes also have an OGTT soon after the booking clinic.
RF for gestational Diabetes
The NICE guidelines (2015) list the risk factors that warrant testing for gestational diabetes:
- Previous gestational diabetes
- Previous macrosomic baby (≥ 4.5kg)
- BMI > 30
- Ethnic origin (black Caribbean, Middle Eastern and South Asian)
- Family history of diabetes (first-degree relative)
OGTT should be given to a pregant lady if:
Large for dates fetus
Polyhydramnios (increased amniotic fluid)
Glucose on urine dipstick
An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a ____glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
OGTT normal results for pregnant ladies
Normal results are:
- Fasting: < 5.6 mmol/l
- At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.
TOM TIP: It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.
Management for gestational diabetes
The initial management suggested by the NICE guidelines (2015) is:
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Gestational Diabetes
__________ (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.
Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.
Gestationa Diabetes
Women need to monitor their blood sugar levels several times a day. The NICE (2015) target levels are:
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
Before becoming pregnant, women with existing diabetes should aim for good glucose control. They should take__mg _____ ___ from preconception until 12 weeks gestation.
Before becoming pregnant, women with existing diabetes should aim for good glucose control. They should take 5mg folic acid from preconception until 12 weeks gestation.
_________ _______ should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ___________ to check for _______ ________. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.
Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.
A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A_____ and ____ ______ is titrated to blood sugar levels, according to the local protocol. This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes.
A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes.
Babies of mothers with diabetes are at risk of:
- Neonatal hypoglycaemia
- Polycythaemia (raised haemoglobin)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
Babies need close monitoring for ______ _______, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need __ _______ of nasogastric feeding.
Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.
If you remember two complications of gestational diabetes, remember ________ and ________ __________
If you remember two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia.
What is placenta praevia
Placenta praevia is where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. Praevia directly translates from Latin as “going before”.
The RCOG guidelines (2018) recommend the following definitions:
- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia is used only when the placenta is over the internal cervical os
What are three causes of antepartum haemorrhage?
signs?
placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality.
Causes of spotting or minor bleeding in pregnancy include cervical ectropion, infection and vaginal abrasions from intercourse or procedures
Placenta praevia is associated with increased morbidity and mortality for the mother and fetus. The risks include:
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
The RCOG guidelines (2018) recommend against using this grading system, as it is considered outdated. The two descriptions used are l____ ____ _______ a and _____ _______
The RCOG guidelines (2018) recommend against using this grading system, as it is considered outdated. The two descriptions used are low-lying placenta and placenta praevia.
The risk factors for placenta praevia are:
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
Presentation and Diagnosis of placenta praevia
The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.
Many women with placenta praevia are asymptomatic. It may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage). Bleeding usually occurs later in pregnancy (around or after 36 weeks).
For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), the RCOG guideline (2018) recommends a repeat __________ ______ ______ at:
- 32 weeks gestation
- 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), the RCOG guideline (2018) recommends a repeat transvaginal ultrasound scan at:
- 32 weeks gestation
- 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
Management for Placenta Praevia
Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.
Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).
Emergency caesarean section may be required with premature labour or antenatal bleeding.
The main complication of placenta praevia is haemorrhage before, during and after delivery. When this occurs, urgent management is required and may involve:
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
What is Placental Abruption
Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy.
The site of attachment can bleed extensively after the placenta separates.
Placental abruption is a significant cause of antepartum haemorrhage.
RF for Placental Abruption
The risk factors for placental abruption are:
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
The typical presentation of placental abruption is with:
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (antepartum haemorrhage)
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
The RCOG guideline (2011) defines the severity of antepartum haemorrhage as:
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
What is Concealed Abruption
Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.
Concealed abruption is opposed to revealed abruption, where the blood loss is observed via the vagina.
Placental abruption is an obstetric emergency. The urgency depends on the amount of placental separation, extent of bleeding, haemodynamic stability of the mother and condition of the fetus. It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding.
The initial steps with major or massive haemorrhage are:
- Urgent involvement of a senior obstetrician, midwife and anaesthetist
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
_________ can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.
Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.
There is an increased risk of _________ __________ after delivery in women with placental abruption. Active management of the third stage is recommended.
There is an increased risk of postpartum haemorrhage after delivery in women with placental abruption. Active management of the third stage is recommended.
Placental Abruption
Rhesus-D negative women require_____ ________ when bleeding occurs. A ________ ____ is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of _____ that is required.
Rhesus-D negative women require anti-D prophylaxis when bleeding occurs. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.
What is Placenta Accreta
Placenta accreta refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby. It is referred to as placenta accreta spectrum, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.
With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond. This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as a caesarean section or curettage procedure. The deep implantation makes it very difficult for the placenta to separate during delivery, leading to extensive bleeding (postpartum haemorrhage).
WHat are the three layers to the uterine wall
- Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels
- Myometrium, the middle layer that contains smooth muscle
- Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)
Usually the placenta attaches to the________. This allows the placenta to separate cleanly during the ____ ____ __ _____, after delivery of the baby.
Usually the placenta attaches to the endometrium. This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby.
Placenta Accreta can split further into three classes
- Superficial placenta accreta
- Placenta increta
- Placenta percreta
- Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
- Placenta increta is where the placenta attaches deeply into the myometrium
- Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
Risk Factors of Placenta Accreta
- Previous placenta accreta
- Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- Previous caesarean section
- Multigravida
- Increased maternal age
- Low-lying placenta or placenta praevia
Presentation
Placenta accreta
Placenta accreta does not typically cause any symptoms during pregnancy. It can present with bleeding (antepartum haemorrhage) in the third trimester.
It may be diagnosed on antenatal ultrasound scans, and particular attention is given to women with a previous placenta accreta or caesarean during scanning.
It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.
Management Placenta accreta
A specialist MDT should manage women with placenta accreta. Patients may require additional management at birth due to the risk of bleeding and difficulty separating the placenta. This may include:
- Complex uterine surgery
- Blood transfusions
- Intensive care for the mother
- Neonatal intensive care
Placenta accreta
Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery.
The options during caesarean are:
- Hysterectomy with the placenta remaining in the uterus (recommended)
- Uterus preserving surgery, with resection of part of the myometrium along with the placenta
- Expectant management, leaving the placenta in place to be reabsorbed over time
What is Cord prolapse
Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
RF for Cord Prolapse
The most significant risk factor for cord prolapse is when the fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique).
Being in an abnormal lie provides space for the cord to prolapse below the presenting part. In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.
Diagnosis of Cord Prolapse
Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.
Management of Cord Proplase
Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby. Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm).
When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord.
________ medication (e.g. _______) can be used to minimise contractions whilst waiting for delivery by caesarean section.
Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.
What is Ectopic Pregnancy
Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
RF for Ectopic Pregnancy
Certain factors can increase the risk of ectopic pregnancy:
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
Ectopic Pregnancy Presentation
The classic features of an ectopic pregnancy include:
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
Ectopic pregnancy typically presents around _____ ______ gestation.
Ectopic pregnancy typically presents around 6 – 8 weeks gestation.
Ultrasound Findings of Ectopic pregancy
A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign”
Features that may also indicate an ectopic pregnancy are:
- An empty uterus
- Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
What is Pregnancy of Unknown Location
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
WHat is Pregnancy of Unknown Location
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
Serum _______ ______ __________ ____ can be tracked over time to help monitor a pregnancy of unknown location. The serum hGC level is repeated after ___ hours, to measure the change from baseline.
Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location. The serum hGC level is repeated after 48 hours, to measure the change from baseline.
There are three options for terminating an ectopic pregnancy:
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
How is methrotrexate give for ectopic pregnancy
IM injection
Ectopic pregnancy
Common side effects of methotrexate include:
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis (inflammation of the mouth)
Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management. This include those with:
- Pain
- Adnexal mass > 35mm
- Visible heartbeat
- HCG levels > 5000 IU / l
There are two options for surgical management of ectopic pregnancy:
Laparoscopic salpingectomy
Laparoscopic salpingotomy
What is Laparoscopic salpingectomy
Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
WHat is Laparoscopic salpingotomy
Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.
What are the definition of these miscarriage
Missed miscarriage –
Threatened miscarriage –
Inevitable miscarriage –
Incomplete miscarriage –
Complete miscarriage –
Anembryonic pregnancy –
Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy – a gestational sac is present but contains no embryo
What is Miscarriage
Miscarriage is the spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.
A ________ _______ _____ is the investigation of choice for diagnosing a miscarriage.
A transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage.
There are three key features that the sonographer looks for in an early pregnancy. These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy. These features are:
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heartbeat
When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is ____ or more.
When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.
Management of Miscarriage
Less Than 6 Weeks Gestation
Expectant management (do nothing and await a spontaneous miscarriage)
Management of Miscarriage
More Than 6 Weeks Gestation
There are three options for managing a miscarriage:
Expectant management (do nothing and await a spontaneous miscarriage)
Medical management (misoprostol)
Surgical managemen
Medical Management
More Than 6 Weeks Gestation
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.
The key side effects of misoprostol are:
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
There are two options for surgical management of a miscarriage:
- Manual vacuum aspiration under local anaesthetic as an outpatient
- Electric vacuum aspiration under general anaesthetic
WHat is given before surgical management for miscarriage to soften the cervix.
Prostaglandins (misoprostol)
What is Manual vacuum aspiration
Manual vacuum aspiration involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth (parous women).
What is Electric vacuum aspiration
Electric vacuum aspiration is the traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
There are two options for treating an incomplete miscarriage:
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
What is Evacuation of retained products of conception (ERPC)
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). A key complication is endometritis (infection of the endometrium) following the procedure.
What is Recurrent miscarriage
Recurrent miscarriage is classed as three or more consecutive miscarriages.
Causes Recurrent Miscarriage
- Idiopathic (particularly in older women)
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
- Chronic histiocytic intervillositis
- Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
What is Antiphospholipid Syndrome
Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:
Low dose aspirin
Low molecular weight heparin (LMWH)
Antiphospholipid syndrome can occur on its own, or secondary to an autoimmune condition such as ______ ____ ________
Antiphospholipid syndrome can occur on its own, or secondary to an autoimmune condition such as systemic lupus erythematosus
If you remember one cause of recurrent miscarriages, remember _________ _______ Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of ____ _____ _______.
If you remember one cause of recurrent miscarriages, remember antiphospholipid syndrome. Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of deep vein thrombosis.
Hereditary Thrombophilias
The key inherited thrombophilias to remember are:
- Factor V Leiden (most common)
- Factor II (prothrombin) gene mutation
- Protein S deficiency
Several uterine abnormalities can cause recurrent miscarriages:
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
What is Chronic Histiocytic Intervillositis
Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
Investigations for recurrent miscarriage
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of the products of conception from the third or future miscarriages
- Genetic testing on parents
What is Obstetric Cholestasis
Obstetric cholestasis is also known as intrahepatic cholestasis of pregnancy. Chole- relates to the bile and bile ducts. Stasis refers to inactivity. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby.
Obstetric Cholestasis is more common in?
women of South Asian ethnicity.
Bile acids are produced in the liver from the breakdown of _________
Bile acids are produced in the liver from the breakdown of cholesterol
Why do you get the classic symptom of itching with obstetic cholestasis
Bile acids flow from liver to the hepatic ducts, past the gallbladder and out of the bile duct to the intestines. In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in the classic symptoms of itching (pruritis)
Obstetric cholestasis is associated with an increased risk of
stillbirth
Presentation of Obstetric cholestasis
Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester.
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
- Fatigue
- Dark urine
- Pale, greasy stools
- Jaundice
Importantly, there is no rash associated with obstetric cholestasis. If a rash is present, an alternative diagnosis should be considered, such as _________ ________ _ __________ or _________ ______
mportantly, there is no rash associated with obstetric cholestasis. If a rash is present, an alternative diagnosis should be considered, such as polymorphic eruption of pregnancy or pemphigoid gestationis.
Differential Diagnosis for Obstetric cholestasis
Other causes of pruritus and deranged LFTs should be excluded, for example:
- Gallstones
- Acute fatty liver
- Autoimmune hepatitis
- Viral hepatitis
Investigations for Obstetric cholestasis
- Women presenting with pruritus should have liver function tests and bile acids checked.
- Obstetric cholestasis will cause:
- Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
- Raised bile acids
TRUE OR FALSE
It is normal for alkaline phosphatase (ALP) to increase in pregnancy.
TRUE
A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology.
Management for Obstetric Cholestasis
Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
- Emollients (i.e. calamine lotion) to soothe the skin
- Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged
Vitamin K is a __ ______ vitamin. Bile acids are important in the absorption of fat-soluble vitamins in the intestines. A lack of bile acids can lead to ________ __ _______
Vitamin K is a fat-soluble vitamin. Bile acids are important in the absorption of fat-soluble vitamins in the intestines. A lack of bile acids can lead to vitamin K deficiency.
Why is Vitamin K important
Vitamin K is an important part of the clotting system, and deficiency can lead to impaired clotting of blood.
Major PPH can be further sub-classified as:
Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood los
The severe form of nausea and vomiting in pregnancy is called
hyperemesis gravidarum
Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
- More than 5 % weight loss compared with before pregnancy
- Dehydration
- Electrolyte imbalance
Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are:
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide
Acid reflux in pregnancy
______ or _______ can be used if acid reflux is a problem.
Ranitidine or omeprazole can be used if acid reflux is a problem.
Nausea and Vomiting of Pregnancy
Mild cases can be managed with oral antiemetics at home. Admission should be considered when
- Unable to tolerate oral antiemetics or keep down any fluids
- More than 5 % weight loss compared with pre-pregnancy
- Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
- Other medical conditions need treating that required admission
Nausea and Vomiting of Pregnancy
Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
What is pelvic organ prolapse
Pelvic organ prolapse refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
What is Uterine Prolapse
Uterine prolapse is where the uterus itself descends into the vagina.
What is Vault Prolapse
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina
What is Rectocele
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.
What is Cystocele
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.
Risk Factors
Pelvic organ prolapse
Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Prolapse
Typical presenting symptoms are:
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down.
What is sim’s speculum
A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele.
Grades of Uterine Prolapse
The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system:
- Grade 0: Normal
- Grade 1: The lowest part is more than 1cm above the introitus
- Grade 2: The lowest part is within 1cm of the introitus (above or below)
- Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
- Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
There are three options for management for pelvic prolapse
Conservative management
Vaginal pessary
Surgery
Pelvic prolapse
Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management involves:
- Physiotherapy (pelvic floor exercises)
- Weight loss
- Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
- Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
- Vaginal oestrogen cream
What are Vaginal pessaries
Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems. There are many types of pessary:
- Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
- Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
- Cube pessaries are a cube shape
- Donut pessaries consist of a thick ring, similar to a doughnut
- Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
Pelvic prolapse management
Surgery
Surgery is the definitive option for treating a pelvic organ prolapse. It is essential to consider the risks and benefits of any operation for each individual, taking into account any co-morbidities. There are many methods for surgical correction of a prolapse, including hysterectomy. Surgery can be very successful in correcting the problem. Possible complications of pelvic organ prolapse surgery include:
Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex
What is Mesh repairs
Mesh repairs have been the subject of a lot of controversy over recent years. Mesh repairs involve inserting a plastic mesh to support the pelvic organs. After review, NICE recommend that mesh procedures should be avoided entirely.
Potential complications associated with mesh repairs are:
- Chronic pain
- Altered sensation
- Dyspareunia (painful sex) for the women or her partner
- Abnormal bleeding
- Urinary or bowel problems
