obstetrics Flashcards
gravidity
Number of times a woman has been pregnant regardless of outcome
parity
Number of times a woman has given birth to a foetus (gestational age >/=24 weeks) regardless of whether the child was born alive or was stillborn
estimating gestation
Naegele’s rule: to the first day of the LMP add 1 year, subtract 3 months, add 7 days)
crown-rump length(CRL): measured by ultrasoundscan between 10+0 and 13+6
CV changes in pregnancy
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
resp changes in pregnancy
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
haem changes in pregnancy
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
urinary system changes in pregnancy
blood flow increases by 30%
GFR increases by 30-60%
salt and water reabsorption is increased by elevated sex steroid levels
urinary protein losses increase
trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose
biochem changes in pregnancy
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
liver changes in pregnancy
Unlike renal and uterine blood flow, hepatic blood flow doesn’t change
ALP raised 50%
Albumin levels fall
uterus development in pregnancy
100g → 1100g
hyperplasia → hypertrophy later
increase in cervical ectropion & discharge
Braxton-Hicks: non-painful ‘practice contractions’ late in pregnancy (>30 wks)
retroversion may lead to retention (12-16 wks), usually self corrects
baby blues features
typically seen 3-7 days following birth and is more common in primips, Mothers are characteristically anxious, tearful and irritable
baby blues mx
Reassurance and support, the health visitor has a key role
postnatal depression features
Most cases start within a month and typically peaks at 3 months, Features are similar to depression seen in other circumstances
mx postnatal depression
As with the baby blues reassurance and support are important. Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe
puerperal psychosis features
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)
mx puerperal psychosis
Admission to hospital is usually required, ideally in a Mother & Baby Unit
screening for postnatal depression
The Edinburgh Postnatal Depression Scale
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%
includes a question about self-harm
when is the booking apointment
<10w
what happens at the booking appoitnment
education, lifestyle, nutrition
BMI
BP
urine dip
FBC
blood groupo
antibodies and rhesus D
screenin for thalassaemia and sickle cell
offer screenin for HIV, hepB, syphilis
what happens at 11-14w appointment
USS: gestational age, multiple pregnancy
offer anaomaly screening
what happens at the 18-20w appointment
USS: anomalies, placental location
24w scan
measure symothysis-fundal height
monitor hoetal movements
when is the ogtt
24-28w
28w appointment
give rhesus negative anti d
recheck fbc, blood group and antibody levels
discuss birth plans
36w appoiintment
abdo palpation for breech
USS
discuss delivery options
when will a mother be induced
41w
what is done at all antenatal appointments
BP
urine dip
wellbeing
vitamins in pregnancy
400 microgams folic acid, 10 micrograms vit D for all women
vaccines in pregnancy
Whooping cough, influenza (live attenuated vaccines CI)
who needs higher doses of vitamins
Women at high risk of neural tube defects require a higher dose of folic acid (5mgin the first trimester, in particular those with certain medical conditions which include:
Epilepsy
Previous baby with neural tube defects
Obesity with BMI over 35
Diabetes (Type 1 and 2)
Sickle cell disease
Thalassemia
Malabsorption disorders (e.g. Crohn’s disease)
Those taking folate antagonist drugs (HIV anti-retroviral drugs, methotrexate, sulphonamides)
It should be taken ideally 3 months before pregnancy and up to the first 12 weeks.
Offer all women Vitamin D (10 mcg) per day to reduce the risk of rickets. Women with darker skin, those from any BAME group (Black/Asian/Caribbean) or with a BMI >30 should have a higher dose.
combined test
11- 13+6 , USS and bloods Screens for trisomy 13 (Pataus), trisomy 18 (Edwards), trisomy 21
features on combined test suggesting downs syndrome
Nuchal translucency (thickened >6mm), BHCG (high), Pregnancy associated plasma protein A PAPP-A (low)
triple test
15-20w. alpha-fetoprotein unconjugated oestriol , human chorionic gonadotrophin .
triple test suggesting downs syndrome
alpha-fetoprotein (low), unconjugated oestriol (low), human chorionic gonadotrophin (high).
quadruples test
15-20w, alpha-fetoprotein ,unconjugated oestriol ), human chorionic gonadotrophin) and inhibin-A (high)
quadruple test suggesting down syndrome
alpha-fetoprotein (low), unconjugated oestriol (low), human chorionic gonadotrophin (high) and inhibin-A (high)
what to do if positive downs syndrome screening
Chorionic villous sampling (11-14 weeks)
Amniocentesis (15-20 weeks)
Non-invasive prenatal testing (private only)
key differentials for bleeding in early pregnancy
Miscarriage=
Ectopic pregnancy:
Molar pregnancy:
Antiphospholipid syndrome:
define miscarriage
loss of a pregnancy at less than 24 weeks’ gestation. Early miscarriages occur in the first trimester (<12-13 weeks) and are more common than late miscarriages, which occur at 13-24 weeks
ectopic pregnancy
any pregnancy which is implanted at a site outside of the uterine cavity
molar pregnancy
A molar pregnancy arises from anabnormalityin chromosomal number during fertilisation
antiphospholipid syndrome
An acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent foetal loss and thrombocytopenia.
ix for bleeding in early pregnancy
History and examination (abdo, bimanual, speculum)
TVUS=gold standard
Bloods: serum b-HCG, FBC, blood group and rhesus status, if pyrexial=triple swabs and CRP
Pregnancy test
In EPAU
If molar pregnancy need histological examination of products of conception
most common site ectopic
ampulla of fallopian tube
RF miscarriage
Maternal Age >30-35 (largely due to an increase in chromosomal abnormalities)
Previous miscarriage
Obesity
Chromosomal abnormalities (maternal or paternal)
Smoking
Uterine anomalies
Previous uterine surgery
Anti-phospholipid syndrome
Coagulopathies
RF ectopic
Previous ectopic pregnancy
Pelvic inflammatory disease (due to adhesion formation)
Endometriosis (adhesion formation)
Intrauterine device or intrauterine system
Progesterone oral contraceptive or implant (due to fallopian tube ciliary dysmotility)
Tubal ligation or occlusion
Pelvic surgery – especially tubal surgery (reversal of sterilisation)
Assisted reproduction i.e. embryo transfer in IVF
RF molar pregnancy
Maternal age <20 or >35
Previous gestational trophoblastic disease (this risk is not decreased by a change of partner)
Previous miscarriage
Use of the oral contraceptive pill
sx antiphospholipid syndrome
Coagulation disorder (isolated raised APTT)
Livedo reticularis
Obstetric complications
Thrombocytopenia (low platelets)
diagnosis antiphospholipid syndrome
Antibody testing needs to be positive on 2 occasions 12 weeks apart
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
partial molar pregnancy
where one ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes. This produces cells with 69 chromosomes (triploidy).
complete molar pregnancy
where one ovum without any chromosomes is fertilised by one sperm which duplicates, or (less commonly) two different sperm. This leads to 46 chromosomes of paternal origin alone.
These tumours are usually benign, but can become malignant – invading into the uterine myometrium, and disseminating around the body. These are known asinvasive moles.
sx ectopic pregnancy
pain-lower abdominal/pelvic pain, with or without vaginal bleeding. .
Shoulder tip pain– the irritation of the diaphragm by blood in the peritoneal cavity leads to referred shoulder tip pain.
Vaginal discharge– brown in colour, classically described as being akin to prune juice.
On examination, the patient may have localised
abdominal tenderness, with vaginal examination revealing cervical excitation and/or adnexal tenderness.
If the ectopic pregnancy has ruptured, the patient may also be
haemodynamically unstable(pallor, increased capillary refill time, tachycardia, hypotension), with signs of peritonitis (abdominal rebound tenderness and guarding). Vaginal examination may reveal fullness in the pouch of Douglas.
sx molar pregnancy
vaginal bleedingand abdominal pain early in pregnancy.
On examination, the uterus can be larger than expected for gestation, and of a soft, boggy consistency.
Hyperemesis– because there is an increased titre of B-hCG which is thought to be linked to nausea in pregnancy.
Hyperthyroidism –gestational thyrotoxicosis due to stimulation of the thyroid by high HCG levels.
Anaemia
Later in pregnancy, a ‘large for dates’ uterus may be noted on examination.
pregnancy of unknown location
Can’t be identified on ultrasound scan BUT β-HCG is positive
mx pregnancy unknown location
If the initialβ-HCGlevel is >1500 iUand there is no intrauterine pregnancy on transvaginal ultrasound, then this should be considered an ectopic pregnancy until proven otherwise, and a diagnostic laparoscopy should be offered.
If the initialβ-HCGlevel is <1500 iUand the patient is stable, a further blood test can be taken 48 hours later:
In a viable pregnancy, HCG level would be expected to double every 48 hours.
In a miscarriage, HCG level would be expected to halve every 48 hours
Where the increase or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded and the patient should be managed accordingly.
mx miscarriage
if the patient is Rhesus negative and is greater than 12 weeks gestation, they requireanti-D prophylaxis
Conservative (Expectant)
Medical management: vaginal misoprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions.
Surgical management: manual vacuum aspiration with local anaesthetic if <12 weeks, or evacuation of retained products of conception (ERPC)
mx ectopiuc pregnancy
Medical: IM methotrexate. For patients who: arestable, well controlled pain and β-HCG levels <1500 iU/ml, unruptured, andno visible heartbeat
Surgical management: laparoscopic salpingectomy
Conservative management: serum B-hCGshould be monitored every 48 hrs, patient must be stable with a small and unruptured ectopic
mx molar pregnancy
surgery, may need chemo
mx antiphospholipid syndrome
LMWH in pregnancy
features threatened miscarriage
Mild bleeding +/- PainCervix closed
TVUSS: Viable pregnancy
features inevitable miscarriage:
Heavy bleeding, clots, painCervix open
TVUSS: Internal cervical os openedFetus can be viable or non-viable
features missed miscarriage
Asymptomatic or hx of threatened miscarriage, on-going discharge, small for dates uterus
TVUSS: No fetal heart pulsation in a fetus where crown rump length is >7mm*
features incomplete miscarriage
POC** partially expelled – Sx of missed miscarriage or bleeding/clots
TVUSS: Retained POC, with A/P endometrial diameter >15mm AND proof that were was a intrauterine pregnancy previously present (USS/clinically remove clots)
features complete miscarriage
Hx of bleeding, passing clots and POC and pain. Sx settling/settled now
TVUSS: No POC seen in uterus, with endometrium that is <15 mm diameter AND previous proof of intrauterine pregnancy i.e. scan
features of a septic miscarriage
Infected POC: fever, rigors, uterine tenderness, bleeding/discharge, pain
TVUSS: Leucocytosis, raised CRP + can be features of complete or incomplete miscarriage
differetnials for antepartum haemorrhage
placenta praevia
placental abruption
vasa praevia
placenta praevia
placenta lying across OS
placental abruption
placental prematurely separates
vasa praevia
When foetal vessels lie outside the protection of the umbilical cord or placenta
presentation plaental abruption
sudden onset severe continuous abdominal pain, +-Antepartum haemorrhage, can be concealed if cervical os remains closed, Maternal haemodynamic instability, Foetal distress on CTG, Woody abdomen on palpation
presentation vasa praevia
Antepartum haemorrhage, Visible pulsating foetal vessels on cervical exam, Immediate bleed and foetal distress following ROM
presentation placental praevia
Usually detected on 20w USS / presents 24w+ with painless PV bleeding or asymptomatic until labour.
mx placenta pravia
Corticosteroids from 32-36w
Planned CS 36-37w to reduce risk of spontaneous labour and massive haemorrhage.
If already bleeding (antepartum haemorrhage) emergency CS required
mx vasa pravia
Corticosteroids from 32w.
Planned CS 34-36w.
mx placental abruption
ABCDE, obstetric emergency so immediately involve consultant.
2 grey cannulas + bloods (FBC, U&Es, LFTs, coag). And Crossmatch 4 units of blood.
Fluid and blood resus
Monitor mother and foetus
Corticosteroids, Anti-D prophylaxis if rhesus –ve mother
Emergency CS
abortion act
In the UK, termination of pregnancy (TOP) is governed by the The Abortion Act of 1967. There are five ‘categories’ for requesting TOP:
A. that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.
B. that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
C. that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated D. that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
termination of pregnancy
Medical termination of pregnancy: Mifepristone, a progesterone antagonist, Followed by Misoprostol 48h later , a prostaglandin analogue.
Surgical termination of pregnancy: Suction termination, Dilatation and evacuation/curettage ‘D&C’
Choice loosely based of gestation
less than 9 weeks: medical management,
less than 13 weeks: surgical dilation and suction of uterine contents
more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
features polyhydramnios
uterus feels tense or large for dates, may be difficult to feel the foetal parts on palpation of the abdomen
cause of polyhydramnios
excessive production of amniotic fluid
insufficient removal of amniotic fluid.
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
complications polyhyramnios
Maternal: respiratory compromise (increased pressure on the diaphragm), Increased risk UTIs due to increased pressure on the urinary system, Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks, Increased incidence of caesarean section delivery, Increased risk of amniotic fluid embolism (although this is rare)
Foetal: Pre-term labour and delivery, Premature rupture of membranes, Placental abruption, Malpresentation of the foetus (the foetus has more space to “move” within the uterus), Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)
mx polyhydramnios
Treatment includes management of any underlying causes (e.g. in maternal diabetes) and amnio-reduction in severe cases.
causes oligohydramnios
premature rupture of membranes
Potter sequence
bilateral renal agenesis + pulmonary hypoplasia
intrauterine growth restriction
post-term gestation
pre-eclampsia
pathophysiology rhesus disease
if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
in later pregnancies these can cross placenta and cause haemolysis in fetus
this can also occur in the first pregnancy due to leaks
mx rhesus disease
All mothers tested at booking
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) of a sensitizing event
If known rhesus negative mother given routinely at 28 and 34 weeks
if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
ix 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
affects of rhesus disease on fetus
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
treatment: transfusions, UV phototherapy
sensitising events requiring anti d
Antepartum haemorrhage
Placental abruption
Abdominal trauma
External cephalic version
Invasive uterine procedures such as amniocentesis and chorionic villus sampling
Rhesus positive blood transfusion to a rhesus negative woman
Intrauterine death, miscarriage or termination
Ectopic pregnancy
Delivery (normal, instrumental or caesarean section)
RF for VTE
PREGNANCY
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
VTE PROPHYLAXIS
previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal.
If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
gestational diabetes diagnosis
a fasting plasma glucose level of 5.6mmol/litre or aboveor
a 2‑hour plasma glucose level / glucose tolerance test of 7.8mmol/litre or above
who is screened for gestational diabetes
First degree relative with diabetes mellitus
At-risk ethnic group
BMI > 30
Previous large baby (>4.5kg) or stillbirth
Persistent glycosuria
Polyhydramnios
mx gestational diabetes
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered and if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started, if still not met add insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
mx pre existing dm
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
dizygotic
non-identical, develop from two separate ova that were fertilized at the same time)
monozygotic
identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic
Monoamniotic monozygotic twins are associated with:
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
predisposing factors for dizygotic twins
previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean
complications in multiple pregnancy
Antenatal complications: polyhydramnios, pregnancy induced hypertension, anaemia, antepartum haemorrhage
Fetal complications - perinatal mortality: (twins * 5, triplets * 10), prematurity (mean twins = 37 weeks, triplets = 33), light-for date babies, malformation (3, especially monozygotic)
Labour complications: PPH increased (2), malpresentation, cord prolapse, entanglement
mx multiple pregnancy
rest
ultrasound for diagnosis + monthly checks
additional iron + folate
more antenatal care (e.g. weekly > 30 weeks)
precautions at labour (e.g. 2 obstetricians present)
75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
risks of obesity in pregnancy
Maternal risks: miscarriage, venous thromboembolism, gestational diabetes, pre-eclampsia, dysfunctional labour, induced labour, postpartum haemorrhage, wound infections, higher caesarean section rate.
Fetal risks: congenital anomaly, prematurity, macrosomia, stillbirth, increased risk of developing obesity and metabolic disorders in childhood, neonatal death
mx obesity in pregnancy
obese women should take 5mg of folic acid, rather than 400mcg
all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit
if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made
features cmv in pregnancy
Symptoms: asx, mild flu-like illness, mononucleosis syndrome(fever, splenomegaly and impaired liver function
mx cmv in pregnancy
can’t tx-drugs teratogenic, can offer TOP
features gbs in pregnancy
asx, UTI, Chorioamnioitis, Endometritis–
mx gbs in pregnancy
Management: High dose intravenous penicillinsthroughout labour
mx uti in pregnancy
Nitrofurantoin (avoid at term) 100mg modified-release twice a day for 7 days if eGFR ≥45ml/minute
mx asx bacteruria
Offer an immediate antibioticprescription, then take into account urine culture and susceptibility results and previous antibiotic use and choose from: Nitrofurantoin (avoid at term), Amoxicillin (only if culture results available and susceptible), Cefalexin
mx chorioamnionitis in pregnancy
Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics
mx varicella zoster in pregnancy
Management: If not immune and<20w gestation=varicella zoster immunoglobulin (VZIG)within 10 days of the contact. If not immune and>20 weeks gestation=eitherVZIG, orAciclovirdays 7 to 14 following exposure. Aciclovir(800mg PO 5tds for patients presenting within 24 hours of rash onset and at >20 weeks gestation
Don’t vaccinate while pregnant
chlamydia in pregnancy
azithromycin and erythromycin
gonorrhoea in pregnancy
intramuscularceftriaxone 1g
syphilis in pregnancy
benpen
hsv in pregnancy
acquired in 1st/2nd trimester=oral aciclovir in standard doses (400 mg three times daily, usually for 5 days) then daily suppressive aciclovir 400 mg three times daily from 36 weeks of gestation, normal delivery. Acquired in 3rd trimester= standard acyclovir treatment then continue with daily suppressive aciclovir 400 mg three times daily until delivery by caesarean section. Recurrent HSV=daily suppressive aciclovir 400 mg three times daily should be considered from 36 weeks of gestation
trichomonas vaginalis in pregnancy
Metronidazole400-500mg twice daily for 5-7 days
BV in pregnancy
Metronidazole400-500mg twice daily for 5-7 days
candidiasis in pregnancy
more common in pregnancy, do not give oral antifungal, tx with intravaginal antifungal (e.g. clotrimazole) or topical antifungal
gestational htn
HTN starting after 20 weeks gestation NO proteinuria
pre-eclampsi
gestational HTN associated with organ damage (proteinuria)
eclampsia
seizures due to pre-eclampsia
HELLP syndrome
HTN, proteinuria, haemolysis, elevated liver enzymes and a low platelet count
DIC markers
low platelet count, elevated D-dimer concentration, decreased fibrinogen concentration, prolonged prothrombin time
sx pre-eclampsia
Headache, Visual disturbance or blurriness, N+V, Upper abdominal or epigastric pain, Oedema, Reduced urine output, Brisk reflexes, RUQ pain
diagnosing pre-eclampsia
Systolic blood pressure above 140 mmHg OR Diastolic blood pressure above 90 mmHg PLUS Proteinuria(1+ or more on urine dipstick) OR Organ dysfunction(e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) OR Placental dysfunction(e.g. fetal growth restriction or abnormal Doppler studies)
mx pre-eclampsia
Labetalol first line, nifedipine 2nd. If high risk then aspirin from 12w
complications pre-eclampsia
Eclampsia, HELLP, DIC
mx eclampsia
IV magnesium sulphate, treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
tx HELLp syndrome
Deliver baby
mx obstetric cholestasis
occurs after 24 weeks of pregnancy
treated with emollients or sedating antihistamines such as chlorphenamine or promethazine at night
Should aim for delivery at 37-38 weeks as it is associated with sponteanous fetal death and maternal haemorrhage
when to tx for iron deficiency anaemia
Cut offs for treatment: first trimester <110, 2nd/3rd <105, postpartum <100
hyperemersis gravidarum
refers topersistent and severe vomiting during pregnancy, whichleads to weight loss, dehydration and electrolyte imbalances
diagnosing hyperemesis gravidarum
prolonged and severe NVP with more than 5% pre-pregnancy weight loss, Dehydration, and Electrolyte imbalances.
It is thought to be due rapidly increasing levels ofbeta human chorionic gonadotrophin(hCG) hormone
RF hyperemsis gravidarum
First pregnancy, Previous history of hyperemesis gravidarum, Raised BMI, Multiple pregnancy, Hydatidiform mole
Pregnancy-Unique Quantification of Emesis(PUQE)
mx hyperemesis gravidarum
Mild: community with oral antiemetics, oral hydration, dietary advice and reassurance.
Moderate: ambulatory daycarefor IV fluids, parenteral antiemetics and thiamine.
Severe: inpatient management for antiemetic therapies are shown in the box below. A combination of therapies should be used if there is no response to a single therapy.
Other therapies: IV rehydration, H2 receptor antagonists,
Thiamine, Thromboprophylaxis
Antiemetics:
First line: Cyclizine, Prochlorperazine, Promethazine, Chlorpromazine
Second line: Metoclopramide (maximum 5 days due to risk of extrapyramidal side effects), Domperidone, Ondansetron
Third line: Hydrocortisone IV
features acute fatty liver of pregnancy
very rare but presents as:
Deranged liver function tests (acute liver failure)
Raised PT (disseminated intravascular coagulation) and low platelets
Vague symptoms such as abdo pain, nausea, malaise, mild jaundice
In the third trimester
mx acute fatty liver of pregnancy
delivery – delay can result in coma and death secondary to hepatic failure. Resolves spontaneously after delivery
mx epilepsy in pregnancy
If no fits for >2 years then stop medication
Need to take 5mg/day of folic acid (normal pregnancy is 400mcg/day) until the end of the first trimester
Vitamin K therapy is needed from 36 weeks If seizures occur during labour – give benzos to avoid hypoxia in mum/baby
Breastfeeding is important after delivery so that the baby can withdraw slowly (AED levels are small but lesser in breastmilk)
NICE says lamotrigine and levetiracetam are the safest in pregnancy
mx hypothyrodism in pregnancy
increase levothyroxine by 25 mcg as soon as pregnancy is confirmed despite a euthyroid state
mx postpartum thyroiditis
just need symptomatic relief – propranolol
preterm labour
onset of regular uterine contractions and cervical changes <37 weeks gestation
preterm birth
delivery of a baby >20 weeks but <37 weeks
Premature rupture of the membranes (PROM) –
rupture of membranes at least one hour before the onset of contractions, >/= 37w
Prolonged premature rupture of the membranes –
rupture of membranes >24hrs before onset of labour
Preterm premature rupture of the membranes (PPROM)
– rupture of membranes at least one hour before the onset of contractions <37 weeks gestation
risks PROM/PPROM
Chorioamnionitis– inflammation of the fetal membranes, due to infection. The risk increases the longer the membranes remain ruptured and baby undelivered.
Oligohydramnios– this is particularly significant if the gestational age is less than 24 weeks, as it greatly increases the risk of lung hypoplasia. Neonatal death– due to complications associated with prematurity, sepsis and pulmonary hypoplasia. Placental abruption, Umbilical cord prolapse
RF prom and PPROM
Smoking (especially < 28 weeks gestation).Previous PROM/ pre-term delivery.
Vaginal bleeding during pregnancy.
Lower genital tract infection.
Invasive procedures e.g. amniocentesis.Polyhydramnios.
Multiple pregnancy.
Cervical insufficiency
mx PROM/PPROM >36w
Monitorfor signs of clinical chorioamnionitis.Clindamycin/penicillin during labour if GBS isolated.
Watch and waitfor 24 hours (60% of women go into labour naturally), or considerinduction of labour.
IOL and deliveryrecommended if greater than 24 hours (but women can wait up to 96 hours – beyond this is their choice after counselling)
mx PROM/PPROM 34-36w
Monitorfor signs of clinical chorioamnionitis, and advise patient to avoid sexual intercourse (canincrease risk of ascending infection).Prophylactic erythromycin250 mg QDS for 10 days.
Clindamycin/penicillin during labour if GBS isolated.
Corticosteroids if between 34 and 34+6 weeks gestation.
Magnesium sulphate is given to prevent cerebral palsy. Give if 23–32 weeks – single dose of 4g by slow IV injection
IOL and delivery recommended.
mx PROM/PPROM 24-36w
Monitorfor signs of clinical chorioamnionitis, andadvise patient to avoid sexual intercourse.Prophylactic Erythromycin250 mg QDS for 10 days.
Corticosteroids (as less than 34+6).
Aim expectant management until 34 weeks.
indications for IOL
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
pre-eclampsia
rhesus incompatibility
bishop score interpretation
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
bishop score
0: posterior cervix, firm cervix, effacement 0-30%, dilation <1cm, fetal station -3
1: intermediate cervix position and consistency, effacement 40-50%, dilation 1-2cm, station -2
2: anterior and soft cervix, effacement 60-70%, dilation 3-4cm, station -1/0
3: effacement 80%, dilation >5cm, station +1/2
methods IOL
membrane sweep: involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. 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): NICE state that vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it
maternal oxytocin infusion
amniotomy (‘breaking of waters’)
cervical ripening balloon: passed through the endocervical canal and gently inflated to dilate the cervix
complications IOL
Uterine hyperstimulation: prolonged and frequent uterine contractions. Management =removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
tocolysis with terbutaline
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
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
labour stage 1
from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
labour stage 2
from full dilation to delivery of the fetus
‘passive second stage’ refers to the 2nd stage but in the absence of pushing (normal)
active second stage’ refers to the active process of maternal pushing
lasts approximately 1 hours
labour stage 3
begins at delivery of the foetus and ends with delivery of the placenta and foetal membranes.
Generally, it lasts 30 minutes to an hour when allowed to occur naturally or 5-10 minutes with administration of oxytocin.
Active management of the third stage: routine use of uterotonic drugs, deferred clamping and cutting of the cord, controlled cord traction after signs of separation of the placenta.
passage of baby
- descent
- flexion (of head)
- internal rotation to oblique
- extension
- external rotation: aka restitution
CTG interpretation
Dr = define (maternal) risk, high risk = continuous CTG.
C = contractions (bottom trace, frequency not strength).
Bra = baseline rate:
>160 – maternal pyrexia, prematurity, chorioamnionitis, hypoxia.
<110 – maternal beta-blockers, increased foetal vagal tone.
V = variability:
Reduced variability may be hypoxia, lactic acidosis, prematurity.
Baby may be sleeping so 40m of reduced variability acceptable.
A = accelerations (rise in baseline HR by 15 for ≥15s):
Reassuring as shows baby moving.
D – decelerations (fall in baseline HR by 15 for ≥15s):
Early = peak of contraction corresponds with trough of deceleration.
Often head compression from uterine contraction (normal).
Late = deceleration after contraction, suggest hypoxia.
Placental insufficiency, asphyxia.
Variable = vary in shape + timing, suggests cord compression.
O = overall assessment.
reasuring baseline CTG
110–160bppm
reasuring CTG variability
> 5bpm
reasuring CTG acceleration
present
reassuring VTG decelerations
early
instrumental delivery
Ventouse: less pain, lower success
Forceps: less fetal but more maternal complications
pre-requisites for performing an instrumental delivery are: Fully dilated, Ruptured membranes, Cephalic presentation, Defined fetal position, Fetal head at least at the level of the ischial spines, and no more than 1/5 palpable per abdomen, Empty bladder, Adequate pain relief, Adequate maternal pelvis
indications instrumental delivery
Maternal: Inadequate progress, Maternal exhaustion, medical conditions that mean active pushing or prolonged exertion should be limited e.g. intracranial pathologies, some maternal congenital heart diseases and severe hypertension
Fetal: fetal compromise, clinical concerns e.g. antepartum haemorrhage
absolute CI to instrumental delivery
Absolute: Unengaged fetal head in singleton pregnancies, Incompletely dilated cervix in singleton pregnancies, True cephalo-pelvic disproportion Breech and face presentations, and most brow presentations, Preterm gestation (<34 weeks) for ventouse, High likelihood of any fetal coagulation disorder for ventouse.
complications instrumental delivery
Fetal: Neonatal jaundiceScalp lacerations, Cephalhaematoma, Subgaleal haematoma, Facial bruising, Facial nerve damage, Skull fractures, Retinal haemorrhage
Maternal: vaginal tears3rd/4thdegree tears:, VTE, Incontinence, PPH, Shoulder dystocia, Infection
mx breech
Breech (most common type)– attempt ECV before labour, vaginal breech delivery or C-section
mx brow presentation
CS
mx face presentation
If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
If the chin is posterior (mento-posterior) then a C-section is necessary
mx shoulder presentation
CS
mx malposition
90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation andoperative vaginal deliverycan be attempted. Alternatively a C-section can be performed.
RF malposition
Prematurity
Multiple pregnancy
Uterine abnormalities (e.g fibroids, partial septate uterus)
Fetal abnormalities
Placenta praevia
Primiparity
when is ecv done
36-38w
complications ecv
: fetal distress, premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption.
CI ecv
APH, ruptured membranes, uterine abnormalities or aprevious C-section.
types of breech
Complete (flexed) breech(both legs are flexedat the hips and knees
Frank (extended) breech (both legs are flexed at the hip and extended at the knee - most common type of breech presentation),
Footling breech(one or both legs extended at the hip, so that the foot is the presenting part)
complicaytions of breech
cord prolapse(Fetal head entrapment
Premature rupture of membranes
Birth asphyxia – usually secondary to a delay in delivery.
Intracranial haemorrhage – as a result of rapid compression of the head during delivery.
primary pph
> 500 ml of blood per-vagina within 24 hours of delivery. It can be classified into two main types: Minor PPH – 500-1000ml of blood loss, Major PPH – >1000ml of blood loss
causes primary pph
Tone: uterine atony, which is the most common cause of primary post-partum haemorrhage, the uterus fails to contract adequately following delivery.
Tissue: retentionof placental tissue – which prevents the uterus from contracting.
Trauma: damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears).
Thrombin: Vascular–Placental abruption, hypertension, pre-eclampsia, Coagulopathies– von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.
mx uterine atony
A_E
Uterine Atony: Bimanual compression, syntocinon, Surgical measures (intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy)
mx retained placenta
Administer IV Oxytocin, manual removal of placenta withregional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.
secondary pph
excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum.
causes secondary pph
endometritis, Retained placental fragments or tissue, Abnormal involution of the placental site, Trophoblastic disease(very rare), A personal history of secondary PPH.
mx secondary pph
USS to rule out retained tissue
Antibiotics– usually a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole.
Gentamicin should be added to the above combination in cases of endomyometritis (tender uterus) or overt sepsis.
Uterotonics– examples include syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1).
Surgical measuresshould be undertaken if there is excessive or continuing bleeding (irrespective of ultrasound findings). In continuing haemorrhage, insertion of a balloon catheter into the uterus may be effective.
presentation endometritis
fever/rigors, lower abdominal pain and tenderness or foul smelling lochia (the normal discharge from the uterus following childbirth), PPH
RF plaenta accreta spectrum
previous caesarean section
placenta praevia
placenta accreta
chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
placenta increta
chorionic villi invade into the myometrium
placenta percreta
chorionic villi invade through the perimetrium
mxplacenta accreta spectrum
CS
RF cord prolapse
Breech, unstable lie, artificial ROM, polyhydramnios, prem
sx cord prolapse
Non reassuring CTG, fetal bradycardia
mx cord prolapse
EMERGENCY: don not handle cord, manually elevate presenting part (or fill the maternal bladder with 500ml of normal saline), left lateral or knee-chest position, tocolysis (e.g. terbutaline) while waiting for CS, EMERGENCY CS
RF uterine rupture
Prev CS, prev uterine surgery, induction, obstruction of labour, multiple pregnancy, multiparity
features uterine rupture
Non-specific, abdo pain, hypovolaemic shock, foetal distress
mx uterine rupture
EMERGENCY – A-E assessment, CS
RF shoulder dystocia
Pre-labour: Previous shoulder dystocia, macrosomia, Diabetes, Maternal BMI > 30, Induction of labour
Intrapartum: Prolonged 1st stage of labour, Secondary arrest, Prolonged second stage of labour, Augmentation of labour with oxytocin, Assisted vaginal delivery
features shoulder dystocia
Difficulty in delivering fetal head, failure of restitution, ‘turtle neck’ sign
mx shoulder dystocia
Call for help, stop pusing, consider episiotomy
Maneuvers: FIRST LINE: McRoberts, suprapubic pressure. 2ND LINE: posterior arm, corkscrew (internal rotation)
comploications shoulder dystocia
Maternal – 3rd or 4th degree tears (3-4%), post-partum haemorrhage (11%).
Fetal – humerus or clavicle fracture, brachial plexus injury (2-16%), hypoxic brain injury.
umbilical cord prolapse
where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus
uterien rupture
a full-thickness disruption of the uterine muscle and overlying serosa. It typically occurs during labour, and can extend to affect the bladder or broad ligament.
shoulder dystocia
after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory
indications CS
absolute cephalopelvic disproportion
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)
types CS
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus
cat 1 CS
an immediate threat to the life of the mother or baby. examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia. delivery of the baby should occur within 30 minutes of making the decision
cat 2 CS
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 CS
delivery is required, but mother and baby are stable
cat 4 CS
elective
common complications after CS
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
contraception after delivery
Women become fertile 21 days after delivery
Progesterone-only methods and the copper coil are all safe immediately after delivery and during breastfeeding
Women who are not breastfeeding should wait 3 weeks to start combined hormonal contraception, those who are breastfeeding should wait 6 weeks
Lactational amenorrhoea is 98% effective for the first 6 months if the woman is fully breastfeeding and amenorrhoeic
Contraception is needed from 5 days of ectopic pregnancy management, miscarriage or abortion
infertility
failure to achieve a pregnancy after 12 months or more of regular unprotected sex (without contraception) between a man and a woman”
Primary infertility:when a couple has never been able to conceive
Secondary infertility:when a couple cannot get pregnant again, despite previously having been able to without any difficulty
when to refer for infertility
begin in primary care and involve performing tests on both the male (e.g. semen analysis) and female (e.g. female hormonal testing).
Referrals for specialist clinical assessment should be considered in couples who, despite having normal examination/investigation findings, are still unable to conceive after 1 year.
Earlier referral may be considered for women aged 36 years or over (refer after 6 months), or if there is a suspected underlying cause for infertility as suggested by history/examination e.g. previous pelvic inflammatory disease
ix infertility
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.<16=repeat and refer if stays low, 16-30=repeat, >30 indicates ovulation
fertility counselling
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
fertility tx
Medical treatment e.g. drugs to induce ovulation such as Clomifene
Surgical treatment e.g. tubal microsurgery in women with tubal damage
Assisted conception e.g. intrauterine insemination, in vitro fertilisation (IVF)
counselling before, during and after investigation and treatment – irrespective of the outcome.
ovarian hyperstimulation syndrome
complication seen in some forms of infertility treatment
