obstetrics Flashcards
placenta accreta
placenta attaches to the myometrium
placenta increta
placenta invades into the myometrium
placenta percreta
placenta percolates through the perimetrium
what is the cut off for iron supplementation in the first trimester
<110g/L
what is the cut off for iron supplementation in the second/third trimester
<105g/L
what is the cut off for iron supplementation post partum
<100g/L
when are preg women screened for anaemia
the booking visit (often done at 8-10 weeks)
28 weeks
formal definition of pre-eclampsia
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement: e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
high RFs for pre-eclampsia
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
moderate RFs for pre-eclampsia
- first pregnancy
- 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
- family history of pre-eclampsia
- multiple pregnancy
what to do it 1+ high Rfs or 2+ mod Rfs for pre-eclampsia
take aspirin 75-150mg (low dose) daily from 12 weeks gestation until the birth
first line for pre-eclampsia
oral labetalol
nifedipine if asthma
delivery is definitive
who to admit for pre-eclampsia
≥ 160/110 mmHg
causes of PPH
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
RFs primary PPH
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
mx PPH
ABC approach
- two peripheral cannulae, 14 gauge
- lie the woman flat
- bloods including group and save
- commence warmed crystalloid infusion
mechanical
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output
medical
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
surgical:
- intrauterine balloon tamponade
- B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
when is a baby dx w foetal macrosomia
birth weight >4kg
PPH def
blood loss of > 500 ml after a vaginal delivery and may be primary (within 24 hrs) or secondary.
erb’s palsy arm position
adduction and internal rotation of the arm, with pronation of the forearm.
RFs of shoulder dystocia
fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal body mass index
diabetes mellitus
prolonged labour
mx shoulder dystocia
McRoberts’ manoeuvre (mums knees to abdo)- providing a posterior pelvic tilt
Pressure to anterior shoulder
Episiotomy
Rubins manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuvre
RFs 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)
how to screen for gestational diabetes
OGTT
if had it previously: OGTT asap after booking + at 24-28 wks if 1st test is normal
any other RFs: OGTT at 24-28 wks
diagnostic thresholds for gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
gest diabetes if the fasting plasma glucose level is < 7 mmol/l
trial of diet and exercise
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
gest diabetes mx if the fasting glucose level is >= 7 mmol/l
start insulin
how to induce labour if bishop score </= 6
vaginal prostaglandins or oral misoprostol
how to induce labour if bishop score > 6
amniotomy and an intravenous oxytocin infusion
main comp of induction of labour
Uterine hyperstimulation
first-line treatment for magnesium sulphate induced respiratory depression
Calcium gluconate
what vaccines is a woman offered at 16-32 wks preg
pertussis and influenza
1st degree tear
limited to the superficial perineal skin or vaginal mucosa only
2nd degree tear
extends to perineal MUSCLES + fascia, but anal sphincter is in tact
3rd degree tear (a)
<50% thickness of EXTERNAL ANAL sphincter is torn
3rd degree tear (b)
> 50% thickness of EXTERNAL ANAL sphincter is torn
3rd degree tear (c)
external + INTERNAL anal sphincters are torn
4th degree tear
perineal skin, muscle, anal sphincter + ANAL MUCOSA are torn
tx of vaginal tear
assess extent of the trauma
1. if minimal blood loss may not need anything
2. suture - experienced midwife
3 + 4. surgical repair by experienced clinician, sld take place in operating theatre under regional / general anaesthetic
Broad spec abx + laxatives
what is lochia
passing vaginal discharge containing blood, mucus + uterine tissue which can continue for 6 weeks after childbirth
chickenpox exposure in pregnancy
check for varicella antibodies if doubt about prev infection
<20 wks + not immune = varicella immunoglobulin asap
> 20 wks + not immune = VXIG/antivirals given 7-14 days after exposure
mx of chickenpox in preg
> 20 wks + rash within 24 hrs presentation = oral aciclovir 800mg 5x/day 7 days
risk to fetus if mum gets chickenpox in preg
Fetal varicella syndrome (FVS)
- skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Shingles in infancy
Severe neonatal varicella
what does the mum have greater risk of if she gets chickenpox in preg
5 times greater risk of pneumonitis
normal BP variations in preg
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 HTN in preg defined as
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
gestational HTN
Hypertension occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Resolves after birth
mx gestational HTN /pre-existing in preg
1 = oral labetalol
oral nifedipine (e.g. if asthmatic) and hydralazine
RFs for breech
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 more common in breech
cord prolapse
mx breech
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks = external cephalic version (ECV). Success rate = 60%. Offer from 36 weeks in nulliparous women and from 37 weeks in multiparous women
Still breech = c sec?
absolute CIs to ECV
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
CIs to VBAC
previous uterine rupture or classical caesarean scar (vertical)
- offered a caesarean section at 37 weeks or more
Cat 1 c sec
an immediate threat to the life of the mother or baby
delivery of the baby should occur within 30 minutes of making the decision
Cat 2 c sec
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
Cat 3 c sec
delivery is required, but mother and baby are stable
Cat 4 c sec
elective
some causes of folic acid deficiency
phenytoin
methotrexate
pregnancy
alcohol excess
Consequences of folic acid deficiency
macrocytic, megaloblastic anaemia
neural tube defects
how to take folic acid in preg
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk should take 5mg of folic acid from before conception until the 12th week of pregnancy
- either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a FHx of a NTD
- antiepileptic drugs, has coeliac disease, diabetes, or thalassaemia trait.
- BMI > 30
what is intrahepatic cholestasis of pregnancy / Obstetric Cholestasis
reduced outflow of bile acids from the liver
occurs in 1% of pregnant women
usually dev after 28 wks, the result of increased oestrogen and progesterone levels
more common in women of South Asian ethnicity
increased risk of stillbirth
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis presentation
3rd trim
Itching (pruritis) - particularly affecting the palms of the hands and soles of the feet.
Fatigue
Dark urine
Pale, greasy stools
Jaundice
No rash
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis ix
Abnormal LFTs - mainly ALT, AST and GGT
Raised bile acids
(It is normal for ALP to increase in pregnancy as it is produced by the placenta)
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis mx
Ursodeoxycholic acid
Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged
Monitor of LFTs is required during pregnancy (weekly) and after delivery (after at least ten days)
Planned delivery after 37 weeks
screening for down’s syndrome
the combined test
when
results
done between 11-13+6 wks
↑ HCG
↓ PAPP-A
thickened nuchal translucency
screening for down’s syndrome
the quadrapule test
when
results
offered between 15 - 20 weeks
↓ AFP
↓ oestriol
↑ hCG
↑ Inhibin A
quadrapule test in Edward’s syndrome
↓ AFP
↓ oestriol
↓ hCG
↔ Inhibin A
quadrapule test for neural tube defects
↑ AFP
↔ oestriol
↔ hCG
↔ Inhibin A
Results of combined or quadruple tests
Both the combined and quadruple tests return either a ‘lower chance’ or ‘higher chance’ result
‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
‘higher chance’: 1 in 150 chance or less e.g. 1 in 100
what to do when a woman has higher chance of down syndrome results
offered a second screening test (Non-invasive prenatal screening test-NIPT, high sensitivity + specificity) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)
Causes of an increased nuchal translucency
Down’s syndrome
congenital heart defects
abdominal wall defects
RFs for GBS infection
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
who gets intrapartum abx (IAP) for GBS prev
women who’ve had GBS detected in a prev preg should be informed that their risk is 50% + offered intrapartum abx prophylaxis OR testing in late pregnancy and then abx if still positive
women with a previous baby with early- or late-onset GBS disease
women in preterm labour regardless of their GBS status
women with a pyrexia during labour (>38ºC)
when would you swab for GBS
35-37 weeks or 3-5 weeks prior to the anticipated delivery date
abx for GBS proph
benzylpenicillin
when to refer to midwife-led breastfeeding clinic
If a breastfed baby loses > 10% of birth weight in the first week of life
indications for inductionof labour
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
maternal medical problems
- diabetic mother > 38 weeks
- pre-eclampsia
- obstetric cholestasis
intrauterine fetal death
what does the bishop score mean
a score of < 5 indicates that labour is unlikely to start without induction
a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
methods of induction
membrane sweep
- Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit
vaginal prostaglandin E2 (PGE2) - dinoprostone
oral prostaglandin E1 - misoprostol
maternal oxytocin infusion
amniotomy (‘breaking of waters’)
cervical ripening balloon
guidelines for what type of induction to use
if the Bishop score is ≤ 6
- vaginal prostaglandins or oral misoprostol
- mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
- amniotomy and an intravenous oxytocin infusion
comps of uterine hyperstimulation
intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
uterine rupture (rare)
tx uterine hyperstimulation
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
consider tocolysis
can you breastfeed with antiepileptics
yes
risks of prematurity
increased mortality depends on the gestation
respiratory distress syndrome
intraventricular haemorrhage
necrotizing enterocolitis
chronic lung disease, hypothermia, feeding problems, infection, jaundice
retinopathy of prematurity
hearing problems
prematurity def
birth before 37 weeks gestation
non-viable below 23 weeks gestation
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
Prophylaxis of Preterm Labour
Vaginal Progesterone -offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.
Cervical Cerclage - offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy)
“Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery
Rupture of membranes dx
speculum examination revealing pooling of amniotic fluid in the vagina
Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
tx premature rupture of membranes
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis
- erythromycin 250mg 4x daily for 10 days, or until labour is established if within ten days
Induction of labour may be offered from 34 weeks to initiate the onset of labour.
dx Preterm Labour with Intact Membranes
< 30 wks = clinical assessment is enough to offer mx of preterm labour
> 30 wks= a transvaginal ultrasound to assess cervical length. If < 15mm = mx.
OR
fetal fibronectin < 50 = not preterm labour
mc preterm labour
Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality (gets fetal lungs to dev)
- two doses of intramuscular betamethasone, 24 hours apart
IV magnesium sulphate: can be given before 34 weeks gestation within 24 hrs del and helps protect the baby’s brain
- monitor mums of mg tox
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
key signs of magnesium toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
what is placental abruption
when the placenta separates from the wall of the uterus during pregnancy
signif cause APH
RFs placental abruption
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
presentation placental abruption
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
severity levels of APH
Spotting: spots of blood noticed on underwear
Minor haemorrhage: < 50ml blood loss
Major haemorrhage: 50 – 1000ml blood loss
Massive haemorrhage: > 1000 ml blood loss, or signs of shock
what is a concealed abruption
where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated
tender + hard uterus
mx placental abruption
Fetus alive and < 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: observe closely, STEROIDS, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: deliver vaginally
Fetus dead
- induce vaginal delivery
causes of thyrotoxicosis in pregnancy
grave’s disease is most common
activation of the TSH receptor by HCG may also occur (transient gestational hyperthyroidism) HCG levels will fall in the second and third trimester
tx thyrotoxicosis in pregnancy
Propylthiouracil is used in the first trimester of pregnancy in place of carbimazole (as this may be assoc w risk of congenital abnormalities). At the beginning of the second trimester, the woman should be switched back to carbimazole (as propylthiouracil has risk of hepatic injury)
what is cord prolapse
when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after ROM
danger of fetal hypoxia
RF for cord prolapse
abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique)
when to suspect cord prolapse + dx
signs of fetal distress on CTG
dx by vaginal exam
speculum to confirm
mx cord prolapse
emergency c section
keep cord warm + wet whilst waiting, minimal handing
push presenting part up to prevent it from compressing the cord
px lie in LEFT LATERAL position (w pillow under hip) or KNEE-CHEST position (on all fours)
can use tocolytic meds
what abx to give after instrumental delivery
single dose of co-amoxiclav
indications for instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
risks of instrumental delivery to mother
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)
risks of instrumental delivery to baby
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
what is cephalohaematoma
a collection of blood between the skull and the periosteum
poss nerve injuries to mother after instrumental delivery
Femoral nerve -> weakness of knee extension, loss of patellar reflex, numbness of anterior thigh
Obturator nerve -> weakness of hip adduction + rotation, numbness of medial thigh
difference between complete + incomplete uterine rupture
incomplete - the uterine serosa (perimetrium) surrounding the uterus remains intact
complete - the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity
RFs uterine rupture
prev c section is the main one - scar is pt of weakness
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
presentation of uterine rupture
acutely unwell mother and abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
mx uterine rupture
Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
what is an amniotic fluid embolism
rare but severe condition where the amniotic fluid passes into the mothers blood causing an immune reaction -> systemic illness
usually occurs around labour + delivery
RFs amniotic fluid embolism
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
presentation amniotic fluid embolism
usually presents around the time of labour and delivery, can be postpartum. Similarly to sepsis, PE or anaphylaxis, with an acute onset of:
SOB
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
mx amniotic fluid embolism
emergency
ABCDE
Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.
what is placenta praevia
when the placenta is over the internal cervical os (so lower than presenting part of fetus)
Low-lying placenta
when the placenta is within 20mm of the internal cervical os
risks of having placenta praevia
Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
RFs for placenta praevia
Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
presentation placenta praevia
The 20-week anomaly scan is used to assess the position of the placenta and dx it
Most asx
May get painless vaginal bleeding in preg (usually after 36 wks)
what to do if placenta praevia dx early in preg (at 20 wk scan)
a repeat transvaginal ultrasound scan at:
32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
mx placenta praevia
Corticosteroids are given between 34 and 35 + 6 weeks gestation (due to risk of preterm del)
Consider planned del between 34-35+6 wks - c section
May use USS to guide procedure
Emergency caesarean section may be required with premature labour or antenatal bleeding.
what is vasa praevia
where the fetal vessels (2 umbilical arteries + an umbilical vein) are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os
what is a velamentous umbilical cord
where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta (usually wld insert directly into placenta from umbilical cord + always be protected)
two types of vasa praevia:
Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord
Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe
RFs vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
presentation + dx vasa praevia
may be dx by USS in preg
May present as APH
May detect by vaginal exam in labour - pulsating fetal vessels are seen in the membranes through the dilated cervix
May be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes
mx vasa praevia
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
If APH -> emergency caesarean section
After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.
causes of SGA
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR) - small due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta
causes of placenta mediated growth restriction
conditions that affect the transfer of nutrients across the placenta:
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
cause of non-placenta medicated growth restriction
pathology of the fetus, such as:
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
RFs SGA
Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother (over 35 years)
Multiple pregnancy
Low pregnancy‑associated plasma protein‑A (PAPPA)
Antepartum haemorrhage
Antiphospholipid syndrome
when is a baby large for gestational age (macrosomia)
when the weight of the newborn is more than 4.5kg at birth.
an estimated fetal weight above the 90th centile during preg
causes of macrosomia
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
ix for large for gestational age baby
Ultrasound to exclude polyhydramnios and estimate the fetal weight
Oral glucose tolerance test for gestational diabetes
threatened miscarriage
mild bleeding
fetus present
cervical os closed
inevitable miscarriage
heavy bleeding + pain
fetus present
cervical os open
complete miscarriage
all products of conception expelled, empty uterus
pain + bleeding
cervical os usually closed
missed miscarriage
uterus still contains fetal tissue - no longer alive
asx
cervical os closed
what counts as a miscarriage
> 7mm crown rump length + no cardiac activity
wld repeat scan after 1 wk to confirm
when to refer for lack of fetal movement
if none by 24 wks (usually 18-20)
ix for miscarriage
transvaginal USS
mx miscarriage < 6 wks
expectant mx
repeat preg test after 7-10 days
mx miscarriage > 6 wks
refer to EPAU if +ve preg test + bleeding
USS to confirm location + viability
- expectant mx offered 1st if no RFs for heavy bleeding/infection. 1–2 weeks to allow it to occur spontaneously. Preg test 3 wks after bleeding + pain settle.
- medical mx
MISOPROSTOL (prostaglandin analogue) vag or oral - surgical mx
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
monochorionic monoamniotic twins
share chorion, common amniotic cavity, single placenta
rare
splitting of zygote between 8-12 days after fertilisation
dichorionic diamniotic twins
2 placentas, 2 amniotic sacs
division between 0-4 days
have the best outcomes
monochorionic diamniotic twins
2 distinct amniotic cavities, shared chorion, shared placenta
division between 4-8 days
iteterotropic pregnancy
presence of both an intrauterine + ectopic
dizygotic twins
non-identical (from two different zygotes)
Monozygotic twins
identical twins (from a single zygote)
risks to mum with twins
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
risk to babies w twins
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
what is twin-twin transfusion syndrome
occurs when the fetuses share a placenta
one fetus may get majority of BS (other fetus is called the donor + is starved of blood)
the recipient can become fluid overloaded -> HF + polyhydramnios
the donor has growth restriction, anaemia and oligohydramnios
Twin anaemia polycythaemia sequence
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin)
extra antenatal care for teins
additional monitoring for anaemia, with a full blood count at:
Booking clinic
20 weeks gestation
28 weeks gestation
Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome:
2 weekly scans from 16 weeks for monochorionic twins
4 weekly scans from 20 weeks for dichorionic twins
planned birth in twins
32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
Before 35 + 6 weeks for triplets
Monoamniotic twins delivery
require elective caesarean section at between 32 and 33 + 6 weeks.
what is oligohydramnios
reduced amniotic fluid
less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile
causes of oligohydramnios
premature rupture of membranes
Potter sequence
- bilateral renal agenesis + pulmonary hypoplasia
intrauterine growth restriction
post-term gestation
pre-eclampsia
causes of polyhydramnios
Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
Rhesus Incompatibility in Pregnancy
when a rhesus -ve mother has rhesus +ve baby, when baby’s blood find a way into the mothers it will be seen as foreign causing her immune system to react + produce antibodies = sensitisation
not a prob in 1st preg but will be in next as the mothers anti-D antibodies can attack another rhesus +ve preg -> haemolytic disease
all mothers tested for rhesus status + anti-D antibodies at booking
what are sensitisation events
those which carry risk of foetal blood crossing the placenta into maternal circulation + triggering the antibody formation
APH
signif abdo trauma
ectopic preg
miscarriage
termination
intrauterine death
ECV
invasive uterine procedures e.g. chorionic villus sampling/amniocentesis
delivery of fetus
when to give anti-D prophylaxis
sensitisation events (within 72 hrs)
routinely given at 28 wks + at birth in rhesus -ve women
what is the kleihauer Test
checks how much fetal blood has passed into the mother’s blood during a sensitisation event
used after any sensitising event past 20 wks, to assess whether further doses of anti-D is required
features of complete hydatidiform mole
vaginal bleeding
uterus size greater than expected for gestational age
abnormally high serum hCG
ultrasound: ‘snow storm’ appearance of mixed echogenicity
- no fetal parts present
what is a complete hydatidiform mole
formation from a single sperm and an empty egg with no genetic material. The sperm replicates to provide a normal number of chromosomes, which are all paternal in origin. There is no foetal tissue present, only a proliferation of swollen chorionic villi.
what is a partial hydatidiform mole
Formed from two sperm and a normal egg. Both paternal and maternal genetic material are present, and there is variable evidence of foetal parts.
tx hydatidiform mole
suction curettage
Bimonthly serum and urine hCG testing until levels are normal.
In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance.
In a complete mole, monthly repeat hCG samples are sent for at least 6 months.
dx criteria for hyperemesis gravidarum
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
RFs hyperemesis gravidarum
increased levels of beta-hCG
- multiple pregnancies
- trophoblastic disease
nulliparity
obesity
family or personal history of NVP
(smoking assoc w decreased incidence)
tx hyperemesis gravidarum
- rest and avoid triggers e.g. odours
- bland, plain food, particularly in the morning
ginger - P6 (wrist) acupressure
first-line medications:
- antihistamines: oral CYCLIZINE or PROMETHAZNE
- phenothiazines: oral prochlorperazine or chlorpromazine
second-line medications
- oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate (discuss w the pregnant woman)
- oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects (so do not use > 5 days)
admission may be needed for IV hydration
- normal saline with added potassium is used to rehydrate
Referral criteria for nausea and vomiting in pregnancy
Continued N&V and is unable to keep down liquids or oral antiemetics
Continued N&V with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (e.g. she is unable to tolerate oral antibiotics for a urinary tract infection)
+ lower threshold if coexisting condition e.g. DM that may be adversely affected by N&V
when can you have IUS/IUD after birth
within 48 hours of childbirth or after 4 weeks
when do you require contraception after birth
after 21 days
POP after birth + breastfeeding?
anytime (after day 21 use additional contraception for the first 2 days)
also fine when breastfeeding
COCP after birth + breastfeeding?
CI (UKMEC 4) if breastfeeding < 6 wks pp
UKMEC 2 - if breastfeeding 6 wks - 6 mths pp
CI first 21 days due to increased VTE risk pp
After day 21 need additional contraception first 7 days
how effective is lactational amenorrhoea method (LAM) for contra + how to do it
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
risk of inter-pregnancy interval of less than 12 months between childbirth and conceiving again
increased risk of preterm birth, low birth weight and small for gestational age babies.
