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Obstetrics Flashcards

1
Q

What is done at a booking visit?

A

Identify high risk women who need additional care
General information = diet, alcohol, smoking, folic acid, vitamin D, antenatal classes, pregnancy care pathway, maternity benefits, how baby develops
BP, urine dipstick, check BMI
Bloods = FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Screening = Hep B, syphilis, HIV
Urine culture = asymptomatic bacteriuria

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2
Q

When is the first scan done

A

10-13+6 wks

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3
Q

When is OGTT offered to those at high risk of GDM

A

24-28 wks
o Fasting >5.6mmol/l
o 2hrs >7.8mmol/l

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4
Q

When is anti-D prophylaxis given to rhesus neg

A

1st 28 wks
2nd 34 wks

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5
Q

Conditions which are screened for in pregnancy

A

Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down’s syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Syphilis

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6
Q

Down’s syndrome results on quad testing

A

Low alpha-fetoprotein
Low unconjugated oestriol
High Human chorionic gonadotrophin
High Inhibin A

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7
Q

Edward’s syndrome results on quad testing

A

Low AFP
Low unconjugated oestriol
Low HCG
Normal Inhibin A

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8
Q

Neural tube defects results on quad testing

A

High AFP
Normal unconjugated oestriol
Normal HCG
Normal Inhibin A

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9
Q

Findings on fetal anomaly scan

A
  • Anencephaly
  • Spina bifida
  • Gastroschisis
  • Exomphalos
  • Trisomies
  • Cleft lip
  • Bilateral renal agenesis
  • Diaphragmatic hernia
  • Serious cardiac abnormalities
  • Lethal skeletal dysplasia
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10
Q

Investigations for anaemia during pregnancy

A
  • Screening at booking clinic and 28 weeks gestation
  • Haemoglobinopathy screening for thalassaemia and sickle cell disease
  • Ferritin, B12, folate
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11
Q

Indications for oral iron therapy in pregnancy

A

o First trimester <110g/l
o Second/third trimester <105g/l
o Postpartum <100g/L

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12
Q

Management of anaemia in pregnancy

A
  • Iron deficiency  Ferrous sulphate 200mg 3xday
  • B12 deficiency
    o Test for pernicious anaemia = intrinsic factor antibodies
    o IM hydroxocobalamin injections
    o Oral cyanocobalamin tablets
  • Folate deficiency  Folic acid 5mg daily
  • Thalassaemia and sickle cell
    o Management with specialist haematologist
    o Folic acid 5mg
    o Close monitoring
    o Transfusions
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13
Q

Causes of folic acid deficiency in pregnancy

A
  • Phenytoin
  • Methotrexate
  • Pregnancy
  • Alcohol excess
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14
Q

High risk groups for folate deficiency

A
  • Either partner has NTD
  • Previous pregnancy affected by NTD
  • Family history of NTD
  • Woman taking antiepileptic drugs
  • Maternal coeliac disease
  • Maternal diabetes
  • Maternal thalassaemia
  • Obesity
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15
Q

Prevention of folic acid deficiency

A
  • All women take 400mcg until 12th week of pregnancy
  • Women at higher risk of conceiving child with NTD take 5mg folic acid from before conception until 12th week of pregnancy
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16
Q

Complications of folic acid deficiency

A
  • Macrocytic, megaloblastic anaemia
  • Neural tube defects
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17
Q

Risk factors for gestational diabetes

A
  • Previous gestational diabetes
  • Previous macrosomic baby (>/= 4.5kg)
  • BMI >30
  • Ethnic origin = black Caribbean, Middle Eastern and South Asian
  • FHx of diabetes
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18
Q

Presentation of gestational diabetes

A
  • Large for dates fetus
  • Polyhydramnios (increased amniotic fluid)
  • Glucose on urine dipstick
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19
Q

Management of gestational diabetes

A
  • Taught about self-monitoring of blood glucose
  • 4 weekly USS to measure fetal growth and amniotic fluid volume from 28-36 wks
  • If fasting glucose <7mmol/l
    o Diet and exercise 1-2 weeks
    o Then metformin then short-acting insulin
  • If fasting glucose >7mmol/l  Start insulin
  • Target glucose levels
    o Fasting 5.3
    o 1 hr after meals 7.8
    o 2 hrs after meals 6.4
  • OGTT 6 wks postpartum to ensure returned to normal
  • Medications stopped after delivery
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20
Q

Management of pre-existing diabetes in pregnancy

A
  • Weight loss for women BMI >27
  • Stop oral hypoglycaemic agents (apart from metformin and commence insulin)
  • Folic acid 5mg/day from pre-conception to 12wks
  • Detailed anomaly scan at 20 wks
  • Tight glycaemic control
  • Treat retinopathy
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21
Q

Complications for gestational diabetes

A
  • Large for dates fetus and macrosomia
  • Shoulder dystocia = McRoberts position
  • Type 2 DM after pregnancy
  • Neonatal hypoglycaemia
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22
Q

What is gestational hypertension

A
  • Pregnancy induced hypertension developing after 20 weeks gestation
  • BP returns to normal within 6 wks of delivery
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23
Q

Risk factors for gestational hypertension

A
  • Primigravidity
  • Young female (x3 risk)
  • Black (x2 risk)
  • Multifetal pregnancies
  • Hypertension
  • Renal disease
  • Collagen vascular disease
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24
Q

Management of gestational hypertension

A
  • Mild = 140/90-159/109
    o Check BP and proteinuria once or twice weekly
    o Start labetalol
    o Blood tests at presentation and weekly
  • Severe >160/110
    o Admit to hospital
    o Start labetalol
    o Measure BP every 15-30 mins until <160/110
    o Check for proteinuria daily
    o Discharge when BP <140/90
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25
Q

Management of pre-existing hypertension in pregnancy

A
  • Review medications in women with pre-existing HTN
  • ACEi and ARBs teratogenic
    o Switch to labetalol (CI in asthma)
    o 2nd line = nifedipine
    o 3rd methyldopa (CI. In depression)
  • Regular checking for proteinuria  If 1+ proteinuria arrange for 24hr urine collection
  • Placental growth factor-based testing between 20-35 wks
  • US 28-30 wks and 32-34 wks  Fetal growth, Amniotic fluid volume, Umbilical artery doppler
  • 2-4 weekly appointments if well controlled
  • Weekly if poorly controlled
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26
Q

What is pre-eclampsia

A

Gestational hypertension and organ damage after 20 weeks gestation

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27
Q

Risk factors for pre-eclampsia

A
  • High risk
    o Pre-existing hypertension
    o Previous gestational hypertension/pre-eclampsia
    o Existing condition = CKD, SLE, DM
  • Moderate risk
    o First pregnancy
    o Older than 40
    o More than 10 years since previous pregnancy
    o BMI >35
    o Family history of pre-eclampsia
    o Multiple pregnancy
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28
Q

Presentation of pre-eclampsia

A
  • Usually asymptomatic
  • Severe pre-eclampsia
    o Visual disturbances or blurriness
    o Headache
    o Papilloedema
    o RUQ/epigastric pain
    o N+V
    o Hyperreflexia/ankle clonus
    o Platelets <100, abnormal liver enzymes, HELLP syndrome
    o Oedema
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29
Q

Diagnostic criteria for pre-eclampsia

A
  • New onset Hypertension (>140/90 after 20wks pregnancy)
  • Proteinuria >/= 0.3g /24hr
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30
Q

Investigations for pre-eclampsia

A
  • Scoring systems (fullPIERS or PREP-S)
  • Urinalysis to exclude differentials and confirm diagnosis
  • At diagnosis and every 2 wks
    o CTG
    o Foetal monitoring with US = fetal growth and amniotic fluid volume
    o Uterine artery doppler
  • Monitoring for organ dysfunction
    o Low Hb, low platelets
    o High urea, creatinine, urate, low urine output
    o Raised ALT and AST
    o Clotting
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31
Q

Prevention of pre-eclampsia

A

Aspirin prophylaxis if 1 high-risk factor or more than one moderate-risk factor from 12 wks gestation

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32
Q

Management of pre-eclampsia

A
  • Initial assessment
    o Arrange emergency secondary care assessment for ALL woman with suspected pre-eclampsia
    o BP >160/110 are likely to be admitted and observed
  • Anti-hypertensives
    1. Oral Labetolol
    2. Nifedipine
  • Palliate maternal condition to allow fetal maturation and cervical ripening
  • Only cure is delivery of baby
    o Mild = delivery by 37 wks
    o Moderate/severe = delivery at 34-36 wks with steroids given
    o IV magnesium sulphate = given during labour and 24 hours after to prevent seizures
    o Fluid restriction during labour
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33
Q

Indications for delivery in pre-eclampsia

A
  • Maternal
    o Gestational age 38 wks
    o Platelet count >100 000 cells/mm3
    o Progressive deterioration in liver and renal function
    o Suspected abruptio placentae
    o Persistent severe headaches, visual changes, nausea, epigastric pain or vomiting
  • Fetal
    o Severe fetal growth restriction
    o Non-reassuring fetal testing results
    o Oligohydramnios
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34
Q

Maternal complications of pre-eclampsia

A

o Eclampsia = generalised tonic clonic seizures, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata
o Cerebrovascular accident
o Haemolysis, elevated liver enzymes and low platelet count (HELLP syndrome)
o Disseminated intravascular coagulation (DIC)
o Liver failure
o Renal failure
o Pulmonary oedema

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35
Q

Fetal complications of pre-eclampsia

A

o Intrauterine growth restriction
o Preterm birth
o Placental abruption
o Hypoxia

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36
Q

Maternal risk of obesity in pregnancy

A
  • Miscarriage
  • VTE
  • Gestational diabetes
  • Pre-eclampsia
  • Dysfunctional labour, induced labour
  • PPH
  • Wound infections
  • C-section
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37
Q

Fetal risks of obesity in pregnancy

A
  • Congenital anomaly
  • Prematurity
  • Macrosomia
  • Stillbirth
  • Increased risk of developing obesity and metabolic disorder in childhood
  • Neonatal death
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38
Q

Management of obesity in pregnancy

A
  • Obese women should take 5mg folic acid rather than 400mcg
  • Do not advise to diet during pregnancy
  • Screened for gestational diabetes with OGTT at 24-28 wks
  • If BMI >35 = consultant-led obstetric unit
  • If BMI >40 = antenatal consultation with obstetric anaesthetist and plan made
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39
Q

Management of UTI in pregnancy

A
  • 7 days Abx
    o Nitrofurantoin (avoid in 3rd trimester  neonatal haemolysis)
    o Amoxicillin
    o Cefalexin
  • Avoid trimethoprim in 1st trimester  folate antagonist
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40
Q

Complications of UTI in pregnancy

A
  • Increase risk of preterm delivery
  • Low birth weight
  • Pre-eclampsia
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41
Q

Risk factors for VTE in pregnancy

A
  • Smoking
  • Parity >/= 3
  • Age >35
  • BMI >30
  • Reduced mobility
  • Multiple pregnancy
  • Pre-eclampsia
  • Gross varicose veins
  • Immobility
  • Family history of VTE
  • Thrombophilia
  • IVF pregnancy
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42
Q

Prophylaxis of VTE in pregnancy

A
  • LMWH = enoxaparin, dalteparin, tinzaparin
    o Prophylaxis at 28 wks in 3 RF
    o Prophylaxis from 12wks if 4+ RF
  • Intermittent pneumatic compressor
  • Anti-embolic compression stockings
  • Avoid DOACs and warfarin
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43
Q

Postpartum management of VTE

A
  • LMWH for 6 wks if previous VTE, Anyone who had antenatal LMWH, High risk thrombophilia, Low risk thrombophilia and FHx
  • LMWH at least 10 days if
    o C-section
    o BMI >40
    o Readmission/prolonged admission (>3 days)
    o Any surgical procedure
    o Medical comorbidities (cancer, HF, SLE, OBD, SCD)
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44
Q

Management of VTE in pregnancy

A
  • Suspected DVT  Compression duplex US undertaken where clinical suspicion of DVT
  • Suspected PE
    o ECG and CXR
    o Also with Sx of DVT, compression duplex US
    o Confirmed DVT = treat with LMWH first
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45
Q

What is hyperemesis gravidarum

A

Extreme nausea and vomiting in pregnancy caused by raised bHCG levels

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46
Q

Associations of hyperemesis gravidarum

A
  • Multiple pregnancies
  • Trophoblastic disease
  • Hyperthyroidism
  • Nulliparity
  • Obesity
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47
Q

Protective factor for hyperemesis gravidarum

A

Smoking

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48
Q

Presentation of hyperemesis gravidarum

A
  • Most common between 8-12 wks and may persist up to 20wks
  • N+V
  • Dizziness
  • Low BP (Hypovolaemia)
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49
Q

Diagnosis of hyperemesis gravidarum

A
  • 5% pre-pregnancy weight loss + dehydration + electrolyte imbalance
  • Pregnancy-Unique Quantification of Emesis score (severity)
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50
Q

Referral criteria for hyperemesis gravidarum

A
  • Continued N+V and unable to keep down liquids or oral antiemetics
  • Continued N+V with ketonuria and/or weight loss (>5% body weight) despite treatment with oral antiemetics
  • Confirmed/suspected comorbidity (unable to tolerate oral Abx for UTI)
  • Low threshold for admission if co-existing condition that may adversely affected by N+V
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51
Q

Management of hyperemesis gravidarum

A
  • Eat small and often
  • 1st line = antihistamines
    o Oral cyclizine or oral promethazine
    o Oral prochlorperazine (alternative)
  • 2nd line = ondansetron and metoclopramide
    o Metoclopramide only for 5 days (extrapyramidal S/E)
    o Ondansetron in 1st trimester increases risk of cleft lip/palate
  • Admission may be needed for IV hydration
    o If not tolerating oral fluids
    o >5% weight loss
    o Ketones on urine dip
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52
Q

Complications of hyperemesis gravidarum

A
  • Wernicke’s encephalopathy
  • Mallory-Weiss tear
  • Central pontine myelinolysis
  • Acute tubular necrosis
  • Fetal: SGA, pre-term birth
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53
Q

What is large for gestational age

A
  • EFW >90th centile
  • Severe LGA >97th centile
  • Birthweight more than 4.5kg
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54
Q

Causes of LGA

A
  • Constitutional
  • Maternal diabetes
  • Previous macrosomia
  • Maternal obesity or rapid weight gain
  • Overdue
  • Male baby
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55
Q

Investigations of LGA

A
  • USS = EFW and exclude polyhydramnios
  • OGTT = GDM
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56
Q

Management of LGA

A
  • Most women with LGA baby have successful vaginal delivery
  • No need to induce labour based on purely macrosomia
  • Reduce risk of shoulder dystocia
    o Consultant led unit
    o Experienced midwife or obstetrician delivery
    o Access to obs and theatre if required
    o Active management of 3rd stage
    o Early decision for c-section
    o Paed at birth
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57
Q

Maternal complications of LGA

A

o Shoulder dystocia = shoulder fails to deliver after head
o Failure to progress
o 3rd degree Perineal tears
o Instrumental delivery or caesarean
o PPH
o Uterine rupture

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58
Q

Fetal complications of LGA

A

o Birth injury = Erbs palsy (C5/6), clavicular fracture, fetal distress, hypoxia
o Neonatal hypoglycaemia
o Obesity in childhood and later life
o Type 2 diabetes in adulthood

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59
Q

What is small for gestational age

A
  • Infant with birth weight <10th centile for its gestational age
  • Severe = <3rd centile
  • Low birth weight <2500g
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60
Q

Major risk factors for SGA

A

o Maternal age >40
o Smoker >/11 day
o Previous SGA baby
o Maternal/paternal SGA
o Previous stillbirth
o Cocaine use
o Daily vigorous exercise
o Maternal disease
o Heavy bleeding
o Low pregnancy associated plasma protein

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61
Q

Minor risk factors for SGA

A

o Maternal age >=35
o Smoker 1-10/day
o Nulliparity
o BMI <20 or 25-34.9
o IVF singleton
o Previous pre-eclampsia
o Pregnancy interval <6 or >/= 60 months
o Low fruit intake pre-pregnancy
- Autoimmune disease
- Renal disease
- Diabetes
- Chronic hypertension

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62
Q

Presentation of SGA

A
  • Reduced amniotic fluid volume
  • Symmetrically small = constitutionally small
  • Asymmetrically small = placental insufficiency
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63
Q

Investigations of SGA

A
  • USS including HC and AC  USS biometrics (EFW and AC) plotted on customised centile chart
  • Ratio of head circumference and AC
    o Symmetrically small = constitutional cause
    o Asymmetrically small = placental insufficiency
  • Detailed fetal anatomical survey
  • Uterine artery doppler
  • Karyotyping
  • Screening for infections (congenital CMV, toxoplasmosis, syphilis, malaria)
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64
Q

Prevention of SGA

A
  • Modifiable RF managed = smoking cessation, optimising maternal disease
  • High risk pre-eclampsia = 75mg aspirin 16 weeks gestation until delivery
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65
Q

Management of SGA

A
  • Surveillance
    o UAD repeat every 14 days
    o If abnormal repeat more frequently or consider delivery
    o Symphysis fundal height
    o Middle cerebral artery doppler
    o Ductus venosus Doppler
    o CTG
    o Amniotic fluid volume
  • Delivery
    o <37 weeks if absent/reverse end-diastolic flow on doppler = C-section
    o By 37 weeks if abnormal UAD/MCA doppler = induction
    o At 37 weeks if normal UAD = induction
    o Give single course antenatal steroids if before 37 weeks
    o Continuous fetal heart monitoring required from onset of contractions
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66
Q

Antenatal complications of SGA

A

Fetal growth restriction, Stillbirth

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67
Q

Neonatal complications of SGA

A

o Birth asphyxia
o Meconium aspiration
o Hypothermia
o Hypo/hyperglycaemia
o Polycythaemia
o Retinopathy of prematurity
o Persistent pulmonary hypertension
o Necrotising enterocolitis

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68
Q

Long-term complications of SGA

A

o Cerebral palsy
o T2DM, obesity, HTN
o Precocious puberty
o Behaviour problems
o Depression
o Alzheimer’s disease
o Cancer = breast, ovarian, colon, lung and blood

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69
Q

What is polyhydramnios

A

Abnormally large level of amniotic fluid during pregnancy (above 95th centile for gestational age) = >2000ml

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70
Q

Causes of polyhydramnios

A
  • Idiopathic (50-60%)
  • Any condition that prevents fetus from swallowing
    o oesophageal atresia
    o CNS abnormalities
    o muscular dystrophies
    o congenital diaphragmatic hernia obstructing oesophagus
  • Duodenal atresia (double bubble sign on US)
  • Anaemia
  • Fetal hydrops
  • Twin-to-twin transfusion syndrome
  • Increased lung secretions
  • Genetic or chromosomal abnormalities
  • Maternal diabetes
  • Maternal ingestion of lithium
  • Macrosomia
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71
Q

Presentation of polyhydramnios

A

Maternal breathlessness

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72
Q

Investigations for polyhydramnios

A
  • Examination = Palpate uterus
  • US  Amniotic fluid index >24cm, Maximum pool depth
  • Doppler = detect fetal anaemia
  • Maternal glucose tolerance test
  • Karyotyping
  • TORCH screen
  • Maternal red cell antibodies (routinely at 28 wks)
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73
Q

Management of polyhydramnios

A
  • No intervention required in most
  • If symptoms severe, amnioreduction considered
  • Indomethacin
    o Enhance water retention and reduce fetal urine output
    o Associated with premature closure of ductus arteriosus
    o Not used beyond 32 wks
  • Baby examined before first feed by paediatrician if idiopathic
    o NG tube passed to ensure not tracheoesophageal fistula or oesophageal atresia
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74
Q

Complications of polyhydramnios

A
  • Increased perinatal mortality
  • Malpresentation
  • Cord prolapse
  • PPH
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75
Q

What is oligohydramnios

A

Low level of amniotic fluid during pregnancy (<5th centile for gestational age) = <200ml

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76
Q

Causes of oligohydramnios

A
  • Preterm prelabour rupture of membranes
  • Placental insufficiency
  • Renal agenesis (Potter’s syndrome)
  • Non-functioning fetal kidneys (bilateral multicystic dysplastic kidneys)
  • Obstructive uropathy
  • Genetic/chromosomal anomalies
  • Viral infections
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77
Q

Investigations of oligohydramnios

A
  • Symphysis fundal height
  • Speculum examination = pool of liquor in vagina (PPROM)
  • US
    o Amniotic fluid index = measuring max cord-free vertical pocket of fluid in 4 quadrants of uterus (<5cm)
    o Max pool depth = vertical measurement in any area
  • Karyotyping
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78
Q

Management of oligohydramnios

A
  • Treat underlying cause
  • Ruptured membrane (PPROM)
    o Labour likely to commence within 24-48 hrs in most pregnancies
    o If PROM and where labour doesn’t start, induction of labour considered around 34-36 wks
    o Course of steroids given to aid fetal lung development
    o Abx to reduce risk of ascending infection
  • Placental insufficiency = Babies likely to be delivered before 36-37 wks
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79
Q

Complications of oligohydramnios

A
  • Premature complications
  • Infection
  • Severe muscle contractions in fetus
  • Poor prognosis if in 2nd trimester
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80
Q

Types of presentation

A
  • Lie – relationship between long axis of fetus and mother
  • Presentation – fetal part that first enters the maternal pelvis
  • Position – position of fetal head as it exists birth canal
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81
Q

Risk factors for malpresentation

A
  • Prematurity
  • Multiple pregnancy
  • Uterine abnormalities (fibroids, partial septate uterus)
  • Fetal abnormalities
  • Placenta praevia
  • Primiparity
82
Q

Management of malpresentation

A
  • Abnormal lie = External cephalic version (37 weeks or 36 if nulliparous)
    o Tocolytics (terbutaline)
    o Anti-D for rhesus negative women
  • Delivery method
    o Elective C-section
    o Attempt vaginal delivery
83
Q

Complications of external cephalic version

A

o Fetal distress
o Pre-PROM
o APH
o Placental abruption
o C-section in 24 hours

84
Q

Risk factors for breech presentation

A
  • Uterine malformations, fibroids
  • Placenta praevia
  • Polyhydramnios/oligohydramnios
  • Fetal abnormality
  • Prematurity
85
Q

Management of breech presentation

A
  • If <36 wks, many fetuses will turn spontaneously
  • If still breech at 36 wks = external cephalic version (ECV)
    o 36 wks = nulliparous women
    o 37 wks = multiparous women
  • If baby still breech then delivery options = planned caesarean section or vaginal delivery
86
Q

Absolute contraindication to ECV

A
  • Where caesarean delivery required
  • APH within last 7 days
  • Abnormal CTG
  • Major uterine anomaly
  • Ruptured membranes
  • Multiple pregnancy
87
Q

Complications of breech

A

Cord prolapse

88
Q

Types of multiple pregnancies

A
  • Monozygotic = identical twins (from a single zygote)
  • Dizygotic = non-identical (two different zygotes)
  • Monoamniotic = single amniotic sacs
  • Diamniotic = two separate amniotic sacs
  • Monochorionic = share single placenta
  • Dichorionic = two separate placentas
89
Q

Presentation of multiple pregnancies

A
  • Lambda sign (twin peak sign) = triangular appearance indicating dichorionic twin pregnancy
  • T sign = indicates monochorionic twin pregnancy
90
Q

Antenatal management of multiple pregnancies

A
  • Additional monitoring for anaemia with FBC Booking clinic, 20wks, 28wks
  • Additional USS to monitor fetal growth restriction, unequal growth and twin-twin transfusion syndrome
    o 2 weekly scans from 16 wks for mono
    o 4 weekly scans from 20 wks for di
  • Planned birth
    o 32 and 33+6 wks = uncomplicated monochorionic monoamniotic
    o 36 and 36+6 wks = uncomplicated monochorionic diamniotic
    o 37 and 37+6 wks = uncomplicated dichorionic diamniotic
    o Before 35+6 for triplets
  • Corticosteroids given before delivery = mature lungs
91
Q

Delivery of multiple pregnancies

A
  • Monoamniotic twins = elective c-section
  • Diamniotic twins
    o Vaginal delivery when first baby has cephalic presentation
    o C-section may be required for second baby after successful birth of first
    o Elective c-section advised when presenting twin is not cephalic
92
Q

Maternal complications of multiple pregnancies

A
  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • PPH
93
Q

Fetal complications of multiple pregnancies

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
94
Q

Risk factors for obstetric cholestasis

A
  • Hep C
  • Multiple pregnancy
  • Previous obstetric cholestasis
  • Gallstones
95
Q

Presentation of obstetric cholestasis

A
  • Generally presents in 3rd trimester
  • Intense pruritus on palms, soles, abdo (Worse at night)
  • Anorexia
  • Malaise
  • Epigastric discomfort
  • Steatorrhoea
  • Dark urine
96
Q

LFTs in obstetric cholestasis

A

raised AST, ALT, bilirubin

97
Q

Management of obstetric cholestasis

A
  • Weekly monitoring of LFTs
  • Ursodeoxycholic acid
  • Vitamin K supplements
  • Induction of labour at 37-38 weeks
98
Q

Complications of obstetric cholestasis

A
  • Premature birth and stillbirth
  • Recurrence is high in subsequent pregnancies
99
Q

What is reduced fetal movements

A

Less than 10 movements within 2hrs in pregnancies past 28 wks gestation

100
Q

Risk factors for reduced fetal movements

A
  • Posture
  • Distraction
  • Placental and fetal position = anterior placentas
  • Medication  Both alcohol and sedative medications (opiates or benzos)
  • Obesity
  • Both oligohydramnios and polyhydramnios
  • Fetal size = SGA fetus
101
Q

Investigations of reduced fetal movements

A
  • Maternal perception
  • If past 28 wks gestation
    o Handheld Doppler to confirm fetal heartbeat
    o No fetal heartbeat detectable, immediate US
    o If fetal heartbeat present, CTG used for at least 20 mins to monitor fetal heart rate
  • If between 24-28 wks Handheld doppler to confirm fetal heartbeat
  • If below 24 wks and fetal movements previously been felt  Handheld doppler
  • If fetal movements not yet been felt by 24 wks
  • onward referral made to maternal fetal medicine unit
102
Q

Presentation of foetal alcohol spectrum disorder

A
  • Microcepahly
  • Flat philtrum
  • Thin upper lip
  • Low set ears
  • IUGR  short stature in adulthodd
  • Developmental delay
  • Learning disability
  • Behavioural problems = hyperactivity, sleep, langiage delay
  • ASD and VSD
  • Hearing and visual impairment
103
Q

Presentation of opioid use during pregnancy

A
  • Structural abnormalities
  • IUGR
  • Neurodevelopmental abnormalities
  • Respiratory depression in neonate
  • SIDS
  • Neonatal withdrawal syndrome
104
Q

Presentation of stimulant drug use in pregnancy

A
  • Structural abnormalities
  • IUGR
  • Early miscarriage/preterm labour/stillbirth
  • Placental abruption
  • SIDS
105
Q

Presentation of smoking in pregnancy

A
  • Increased risk of miscarriage
  • Preterm labour
  • Stillbirth and IUGR
  • SIDS
106
Q

Risks of cocaine use in pregnancy

A
  • Maternal risks
    o Hypertension  pre-eclampsia
    o Placental abruption
  • Fetal risk
    o Prematurity
    o Neonatal abstinence syndrome
107
Q

Causes of antepartum haemorrhage

A
  • Painless
    o Placenta previa
    o Vasa previa
  • Painful
    o Placenta accrete/precreta
    o Placental abruption
    o Uterine abruption
108
Q

Classification of antepartum haemorrhage

A
  • Spotting = spot of blood noticed on underwear
  • Minor haemorrhage <50ml
  • Major haemorrhage 50-1000ml
  • Massive haemorrhage >1000ml or signs of shock
109
Q

What is placenta accreta

A

Placenta attaches to myometrium due to defective decidua basalis

110
Q

Classifications of placenta accreta

A
  • Placenta accrete = attach to myometrium
  • Placenta increta = invade into the myometrium
  • Placenta percreta = placenta implanted through wall into surroundings (perimetrium)
111
Q

Risk factors for placenta accreta

A
  • Previous uterine surgery
  • IVF
  • Previous c-section
  • Maternal age >35
  • Placenta praevia
112
Q

Management of placenta accreta

A
  • Antenatal steroids
  • Planned C-section at 35-36+6 wks
113
Q

What is placenta praevia

A

Placenta is implanted in lower uterine segment or over internal cervical os

114
Q

Risk factors for placenta praevia

A
  • Previous caesarean sections
  • Previous placenta praevia
  • Older maternal age
  • Maternal smoking
  • Structural uterine abnormalities (fibroids)
  • Assisted reproduction (IVF)
  • Multiparity
115
Q

Grades of placenta praevia

A
  • Minor (grade 1) = placenta is lower in uterus but not reaching internal cervical os (ICO)
  • Marginal (grade 2) = placenta is reaching but not covering ICO
  • Partial praevia (grade 3) = placenta is partially covering ICO
  • Complete (grade 4) = placenta completely covering ICO
116
Q

Management of placenta praevia

A
  • Repeat transvaginal USS at 32 wks and 36 wks
    o If still present at 32 weeks or grade I/II scan every 2 weeks
    o US at 36wks determine method of delivery
  • Corticosteroids (34-36 wks) = mature fetal lungs
  • Method of delivery
    o Planned caesarean delivery (37-38 wks)
    o Emergency c-section if goes into labour prior to elective c-section
    o Potential for vaginal delivery if >20mm from os
  • If bleeding admit and ABCDE to stabilse
    o Emergency c-section if not stablised or term reached or in labour
117
Q

Complications of placenta praevia

A
  • Antepartum haemorrhage
  • Emergency caesarean section
  • Emergency hysterectomy
  • Maternal anaemia and transfusions
  • Preterm birth and low birth weight
  • Stillbirth
118
Q

What is vasa praevia

A

Fetal vessels are within fetal membranes and below fetal presenting part (travel across the internal cervical os)

119
Q

Risk factors for vasa praevia

A
  • Low lying placenta
  • IVF pregnancy
  • Multiple pregnancy
120
Q

Types of vasa praevia

A
  • Type 1 = fetal vessels are exposed as velamentous umbilical cord
  • Type 2 = fetal vessels are exposed as they travel to accessory placental lobe
121
Q

Vaginal exam of vasa praevia

A

pulsating fetal vessels seen in membranes through dilated cervix

122
Q

Management of vasa praevia

A
  • Asymptomatic
    o Give corticosteroids from 32 wks to mature fetal lungs
    o Planned caesarean section (34-36 wks)
  • Antepartum haemorrhage = Emergency c-section
123
Q

Risk factors for placental abruption

A
  • Abruption previously
  • Blood pressure (Pre-eclampsia)
  • Ruptured membranes (premature or prolonged)
  • Uterine injury (trauma to abdomen = domestic violence)
  • Polyhydramnios
  • Twins/multiple gestation (multigravida, fetal growth restriction)
  • Infection in uterus (chorioamnionitis)
  • Older age
  • Narcotic use (Cocaine or amphetamine use, smoking)
124
Q

Presentation of placental abruption

A
  • Sudden onset severe continuous abdo pain
  • Vaginal bleeding
  • Shock = hypotension and tachycardia
  • “Woody” abdomen on palpation (large haemorrhage)
125
Q

Management of placental abruption

A
  • Urgent involvement of senior obstetrician, midwife, anaesthetist
    o ABCDE  2x grey cannula, Bloods (FBC, UE, coagulation studies), Crossmatch 4 units of blood
    o Fluid and blood resuscitation as required
    o CTG monitoring of fetus and close monitoring of mother
  • Antenatal steroids offered 24-34+6 weeks gestation = mature fetal lungs for preterm delivery
  • Rhesus D neg = anti-D prophylaxis
  • Fetus alive and <36 wks
    o Fetal distress = immediate caesarean
    o No fetal distress = observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
  • Fetus alive and >36 wks
    o Fetal distress = immediate caesarean
    o No fetal distress = vaginal delivery
  • Fetus dead  Induce vaginal delivery
126
Q

Complications of placental abruption

A
  • Maternal  Shock, DIC, Renal failure, PPH
  • Fetal  IUGR, Hypoxia, Death
127
Q

Post-exposure prophylaxis for chickenpox

A
  • If unsure about immunity test for varicella antibodies
  • If <20 weeks gestation and not immune
    o Varicella-zoster immunoglobulin (VZIG) ASAP
    o Effective up to 10 days post exposure
  • If >20 weeks gestation and not immune
    o Either VZIG or antivirals (acyclovir) given for 7-14 days post exposure
128
Q

Management of chickenpox in pregnancy

A
  • Chickenpox in pregnancy
  • Specialist advice sought
  • Increased risk of serious chickenpox infection and fetal varicella risk
  • Oral acyclovir given if >20 weeks and presents within 24 hrs of onset of rash
  • If <20 wks acyclovir considered with caution
129
Q

Complications of chickenpox in pregnancy

A
  • Maternal = pneumonitis
  • Fetus
    o Fetal varicella syndrome = skin scarring, eye defects, limb hypoplasia, microcephaly, learning disabilities
    o Shingles in infancy
    o Severe neonatal varicella
130
Q

What is cord prolapse

A

Umbilical cord descends below presenting part of fetus and through cervix into vagina after rupture of fetal membranes

131
Q

Risk factors for cord prolapse

A
  • Abnormal lie/presentation of fetus after 37 wks gestation (unstable, transverse, oblique)
  • Prematurity
  • Multiparity
  • Polyhydramnios
  • Twin/multiple pregnancy
  • Cephalopelvic disproportion
  • Artificial rupture of membranes
  • Premature ROM
  • Long cord
132
Q

Management of cord prolapse

A
  • OBSTETRIC EMERGENCY
  • Constant monitoring
  • Presenting part pushed upwards to prevent compression
  • If cord past level of introitus
    o Cord should be kept warm and wet = avoid vasospasm
    o Minimal handling whilst waiting for delivery
  • Woman go on all fours (left lateral position alternative)
  • Retrofilling bladder
    o 500-700ml of saline = elevates presenting part
  • Tocolytic mediation (terbutaline)
    o Minimise contractions whilst waiting for delivery
  • Emergency c-section
    o Normal vaginal delivery has high risk of cord compression and significant hypoxia to baby
    o Instrumental vaginal delivery possible if cervix fully dilated and head low
133
Q

Risk factors for uterine rupture

A
  • Previous c-section
  • Vaginal birth after caesarean
  • Previous uterine surgery
  • Increased BMI
  • High parity
  • Increased age
  • Induction of labour
  • Use of oxytocin to stimulate contractions
134
Q

Presentation of uterine rupture

A
  • Acutely unwell mother
  • Abnormal CTG
  • Abdominal pain
  • Vaginal bleeding
  • Ceasing of uterine contractions
  • Hypotension
  • Maternal tachycardia
  • Collapse = sudden maternal shock
  • Disappearance of presenting part from pelvis
135
Q

Management of uterine rupture

A
  • OBSTETRIC EMERGENCY
  • Resuscitation and transfusion may be required
  • Emergency c-section  Deliver baby, High flow O2 and IV fluids, Stop any bleeding, Repair or remove uterus
136
Q

Presentation of amniotic fluid embolism

A
  • Anaphylaxis
  • Sudden dyspnoea
  • Hypoxia
  • Hypotension
  • Seizures
  • Cardiac arrest
137
Q

Active management of third stage of labour

A

o IM oxytocin to help uterus contract
o Careful traction to umbilical cord to guide placenta out of uterus and vagina
o Shortens 3rd stage and reduces risk of bleeding
o Can be associated with nausea and vomiting
o Offered to all women
o Initiated if haemorrhage or prolonged third stage (>60mins)
o Usually <30 mins

138
Q

Indications for CTG monitoring

A
  • Sepsis
  • Maternal tachycardia (>120)
  • Significant meconium
  • Pre-eclampsia (>160/110)
  • Fresh antepartum haemorrhage
  • Delay in labour
  • Use of oxytocin
  • Disproportionate maternal pain
139
Q

Indications for induction

A
  • Post maturity (T+10)
  • Pre-eclampsia
  • Diabetes mother >38 wks
  • Growth restriction
  • Reduced fetal movements
  • PPROM
  • Obstetric cholestasis (at 37 wks)
  • In utero death
140
Q

Bishop score

A
  • Fetal station
  • Cervical position
  • Cervical dilation
  • Cervical effacement
  • Cervical consistency
  • If <5 = unlikely to progress without induction
  • Score >8 = cervix ripe and ready for labour
141
Q

Methods of induction of labour

A
  • Membrane sweep
  • Vaginal prostaglandin E2
  • Balloon catheter
  • Artificial ROM and syntocin
142
Q

Indications for an instrumental delivery

A
  • Failure to progress
  • Fetal distress
  • Maternal exhaustion
  • Control of head in various fetal positions
143
Q

Risks to mother of instrumental delivery

A
  • PPH
  • Episiotomy
  • Perineal tears
  • Injury to anal sphincter
  • Incontinence of bladder or bowel
  • Nerve injury (obturator or femoral nerve)
144
Q

Risks to baby with instrumental delivery

A
  • Cephalohaematoma (Ventouse)
  • Facial nerve palsy (forceps)
  • Caput succedaneum
  • Subgaleal haemorrhage
  • Intracranial haemorrhage
  • Skull fracture
  • Spinal cord injury
  • Bruises on baby’s face
  • Fat necrosis  hardened lumps of fat on cheeks
145
Q

Indications for caesarean section

A
  • Absolute cephalopelvic disproportion
  • Placenta praevia grades ¾
  • Pre-eclampsia
  • Post-maturity
  • IUGR
  • Fetal distress in labour/prolapsed cord
  • Failure of labour to progress
  • Malpresentations: brow
  • Placental abruption: if fetal distress not dead
  • Vaginal infection = active herpes
  • Cervical cancer
146
Q

Categories of caesarean section

A
  • 1= Immediate threat to life of mother or baby
    o Suspected uterine rupture
    o Major placental abruption
    o Cord prolapse
    o Fetal hypoxia
    o Persistent fetal bradycardia
    o Delivery of baby within 30mins of making decision
  • 2 = Maternal or fetal compromise which is not immediately-life threatening
    o Delivery of baby within 75 mins
  • 3 = Mother and baby stable
    o Delivery required
  • 4 = Elective caesarean
147
Q

Serious maternal risks of caesarean

A

o Emergency hysterectomy
o Need for further surgery at later date (retained placental tissue)
o Admission to ICU
o Thromboembolic disease
o Bladder injury
o Ureteric injury
o Death

148
Q

Serious risks to future pregancies with caesarean

A

o uterine rupture
o antepartum stillbirth
o placenta praevia and placenta accrete

149
Q

Frequent risks with caesarean sections

A
  • Maternal
    o Persistent wound and abdominal discomfort in first few moths after surgery
    o Increased risk of repeat c-section when vaginal delivery attempted in subsequent pregnancies
    o Readmission to hospital
    o Haemorrhage
    o Infection = wound, endometritis, UTI
  • Fetal  Lacerations
150
Q

Vaginal birth after caesarean

A

o Planned VBAC is appropriate method of delivery for pregnant women at >37 wks with single previous caesarean delivery
o 70-75% women have successful VBAC
o Contraindications = previous uterine rupture, classical caesarean scar

151
Q

Causes of failure to progress in labour

A
  • Large for gestational age
  • Shoulder dystocia
  • Malpresentation
  • Obstructed labour
  • Hypoactive uterus
  • Cephalopelvic disproportion
152
Q

Failure to progress in labour is considered when

A
  • 1st stage
    o Less than 2cm of cervical dilatation in 4 hours
    o Slowing of progress in multiparous women
  • 2nd stage
    o Nulliparous women >2hrs
    o Multiparous women >1hr
  • 3rd stage
    o >30mins with active management
    o >60mins with physiological management
153
Q

Progression in labour influenced by

A
  • Power = insufficient uterine contractions
  • Passenger = macrosomia, malpresentation, malposition
  • Passage = bony pelvis, fibroids, cephalopelvic disproportion
  • Psyche = support and antenatal preparation for labour and delivery
154
Q

Management of failure to progress

A
  • 1st line = Amniotomy (artificial rupture of membranes)
  • Changing positions
  • Encouragement
  • Analgesia
  • 2nd line = Oxytocin infusion
  • Episiotomy
  • Instrumental delivery
  • Caesarean section
155
Q

What is premature labour

A
  • Rupture of membranes = amniotic sac ruptured
  • Spontaneous rupture of membranes = amniotic sac ruptured spontaneously
  • Prelabour rupture of membranes = amniotic sac ruptured before onset of labour
  • Prolonged rupture of membranes = amniotic sac ruptures >18hrs before delivery
  • Prematurity = birth before 37 wks
156
Q

Management of PPROM

A
  • Prophylactic Abx = Erythromycin 250mg x4 daily for 10 days
  • Induction of labour = offered from 34 wks
157
Q

Management of preterm labour with intact membranes

A
  • Fetal monitoring
  • Tocolysis with nifedipine = stop uterine contractions
    o Alternative = atosiban
    o Used between 24-33+6 wks
    o Allows time for further fetal development, administration of steroids or transfer to more specialist unit
  • Maternal corticosteroids = offered before 35 wks
    o Reduce respiratory distress syndrome
    o Used with suspected preterm labour of <36 wks
  • IV magnesium sulfate
    o given within 24hrs of delivery
    o Babies before 34 wks to protect baby’s brain
    o Reduces risk of cerebral palsy
    o Mother’s need close monitoring for magnesium toxicity for at least 4 hourly
    o Delayed cord clamping or cord milking = increase circulating blood volume and Hb in baby at birth
158
Q

Risk factors for Group B strep

A
  • Prematurity
  • Prolonged rupture of membranes
  • Previous sibling GBS infection
  • Maternal pyrexia (secondary to chorioamnionitis)
159
Q

Management of Group B strep

A
  • Women with pyrexia during labour given benzylpenicillin
  • Vancomycin if known severe penicillin allergy
  • Erythromycin used with PPROM
160
Q

Risk factors for shoulder dystocia

A
  • Macrosomia
  • Maternal DM
  • Previous shoulder dystocia
  • Post maturity
  • Obesity
  • Prolonged labour
161
Q

Management of shoulder dystocia

A
  • Call for help
  • Episiotomy
  • McRoberts position = hyperflexed at hips
  • Suprapubic pressure
  • Rotational manoeuvres
162
Q

MAternal complications of shoulder dystocia

A
  • Vaginal tear
  • PPH
  • PTSD
  • Bladder/uterine rupture
163
Q

Fetal complications of shoulder dystocia

A
  • Hypoxia
  • Cerebral palsy
  • Brachial plexus injury
    o Erbs palsy = C5/6
    o Klumpke’s palsy = C8-T1
  • Fractured humerus or clavicle
164
Q

Management of postpartum thyroiditis

A
  • Thyrotoxic phase  Propranolol (Sx control)
  • Hypothyroid phase  Thyroxine
165
Q

Classifications of postpartum haemorrhage

A
  • Minor PPH = <1000ml blood loss
  • Major moderate PPH = 1000-2000ml blood loss
  • Major Severe PPH = >2000ml blood loss
166
Q

Risk factors for PPH

A
  • Previous PPH
  • Prolonged third stage
  • Pre-eclampsia
  • Placenta accrete, praevia
  • Polyhydramnios
  • Placenta (retained)
  • Perineal tear (or episiotomy)
  • Pregnancy (multiple)
  • Obesity
  • Large baby
  • Failure to progress in second stage of labour
  • Instrumental delivery
  • General anaesthesia
  • Increased maternal age
167
Q

Causes of PPH

A
  • Tone (uterine atony)
  • Trauma (perineal tear)
  • Tissue (retained placenta)
  • Thrombin (bleeding disorder)
  • Secondary (24hrs to 12wks after deliver)
    o Retained products of conception
    o Infection (endometritis)
168
Q

Prevention of PPH

A
  • Treating anaemia during ANC
  • Give birth with empty bladder
  • Active management of third stage (IM oxytocin)
  • IV tranexamic acid used in c-section in higher-risk patients
169
Q

Emergency management of PPH

A
  • OBSTETRIC EMERGENCY
  • Resuscitation with ABCDE
  • Lie woman flat, keep warm and communicate with her and partner
  • Insert two large-bore cannulas
  • Bloods for FBC, U+E, clotting screen
  • Group and cross match 4 units
  • Warmed IV fluid and blood resuscitation as required
  • Oxygen
  • Fresh frozen plasma (clotting abnormalities or after 4 units blood)
  • In severe cases, activate major haemorrhage protocol
    o Rapid access to 4 units of crossmatched or O neg blood
170
Q

1st line bleeding management in PPH

A

o Uterine massage
o Catheterisation = bladder distention prevents uterus contractions

171
Q

Medical management of PPH

A

o IV/IM Oxytocin (slow injection followed by continuous infusion)
o IV/IM Ergometrine = stimulates smooth muscle contraction. Not in HTN
o IM Carboprost = stimulates uterine contraction. Caution in asthma
o SL Misoprostol = stimulates uterine contraction
o IV Tranexamic acid = reduces bleeding

172
Q

Surgical management of PPH

A

o Intrauterine balloon tamponade = press against bleeding
o B-Lynch suture = suture round uterus to compress it
o Uterine artery ligation = reduce blood flow
o Hysterectomy = last resort to save woman’s life

173
Q

Risk factors for perineal tears

A
  • Primigravida
  • Large babies
  • Precipitant labour
  • Shoulder dystocia
  • Forceps delivery
174
Q

Classification of perineal tears

A
  • First degree
    o Superficial damage with no muscle involvement
    o Do no require any repair
  • Second degree
    o Injury to perineal muscle, but not involving anal sphincter
    o Require suturing on ward by suitably experienced midwife or clinician
  • Third degree
    o Injury to perineum involving anal sphincter complex
    o Require repair in theatre by suitably trained clinician
  • Fourth degree
    o Injury to perineum involving anal sphincter complex and rectal mucosa
    o Require repair in theatre by suitably trained clinician
175
Q

Problems with breastfeeding

A
  • Minor
    o Nipple pain = poor latch
    o Blocked duct = nipple pain when breastfeeding  continue breastfeeding and try breast massage
    o Nipple candidiasis  Tx = miconazole cream for mother and nystatin suspension for baby
  • Major
    o Mastitis  flucloxacillin for 10-14 days and continue breastfeeding
    o Engorgement (breast pain, redness)  expression of milk
    o Raynaud’s disease of nipple (nipple pain, blanching)  minimise exposure to cold, heat packs following feed, avoid caffeine, stop smoking
    o Poor infant weight gain  expert review of feeding, monitor weight
  • Galactocele (recently stopping breastfeeding
    o Usually painless with no local or systemic signs of infection
    o No further investigation or management needed
176
Q

Medications safe in breastfeeding

A
  • Antibiotics = penicillins, cephalosporins, trimethoprim
  • Endocrine = glucocorticoids (high doses), levothyroxine
  • Epilepsy = sodium valproate, carbamazepine
  • Asthma = salbutamol, theophyllines
  • Psychiatric drugs = tricyclic antidepressants, antipsychotics (clozapine)
  • Hypertension = beta-lockers, hydralazine
  • Anticoagulants = warfarin, heparin
  • Digoxin
177
Q

Medications avoided in breastfeeding

A
  • Antibiotics = ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • Psychiatric drugs = lithium, benzodiazepines
  • Aspirin
  • Carbimazole
  • Methotrexate
  • Sulfonylureas
  • Cytotoxic drugs
  • Amiodarone
178
Q

Risk factors for miscarriage

A
  • Maternal age >30-35
  • Previous miscarriage
  • Obesity
  • Chromosomal abnormalities
  • Smoking, alcohol and illicit drugs
  • High caffeine intake
  • Infections and food poisoning
  • Uterine or cervical anomalies
  • Previous uterine surgery
  • Coagulopathies
  • Chronic conditions = thyroid problems, severe HTN, uncontrolled DM
  • Invasive prenatal tests
  • Medicines = ibuprofen, methotrexate, retinoids
179
Q

Risk factors for recurrent miscarriage

A

o Antiphospholipid syndrome
o Endocrine disorders (PCOS)
o Uterine abnormality
o Parental chromosomal abnormalities
o Smoking

180
Q

Presentation of miscarriage

A
  • Vaginal bleeding (clots or products of conception)
  • Suprapubic, cramping pain
  • Haemodynamic instability = pallor, tachycardia, tachyopnea, hypotension
  • Distended, tender abdo
  • Products of conception in cervical canal
  • Uterine tenderness
181
Q

Types of miscarriage

A
  • Threatened miscarriage
    o Painless vaginal bleeding occurring <24 wks (typically 6-9wks)
    o Viable pregnancy detected
    o Cervical os closed
  • Missed miscarriage
    o No symptoms of expulsion = pain or bleeding (may be light)
    o Pregnancy symptoms disappear
    o Cervical os closed
    o Gestational sac >25mm and no embryonic/fetal part can be seen = ‘blighted ovum’ or ‘anembryonic pregnancy’
  • Inevitable miscarriage
    o Heavy bleeding with clots and pain
    o Cervical os open
  • Incomplete miscarriage
    o Not all products of conception been expelled
    o Pain and vaginal bleeding
    o Cervical os open
  • Complete miscarriage
    o All products passed
    o Cervical os closed
    o Empty uterine cavity
  • Recurrent miscarriage
    o 3 or more consecutive miscarriages <24 wks
    o Most common cause antiphospholipid syndrome
    o Tx: LMWH and low dose aspirin
182
Q

Management of miscarriage

A
  • Expectant
    o 7-14 days = wait for miscarriage to complete spontaneously
    o Not suitable if increased risk of haemorrhage (late 1st trimester, coagulopathies) or evidence of infection
  • Medical
    o Vaginal or oral misoprostol = stimulate expulsion of conception
  • Surgical
    o Manual vacuum aspiration under local anaesthetic
    o Anti D to all rhesus negative women
183
Q

Risk factors for ectopic pregnancy

A
  • Previous ectopic pregnancy
  • PID
  • Endometriosis
  • IUD/IUS
  • Progesterone OCP or implant
  • Tubal ligation or occlusion
  • Pelvic surgery (tubal surgery)
  • Assisted reproduction (IVF)
  • Smoking
  • Multiple sexual partners
  • Infertility
  • Age <18 at first sexual intercourse
  • Ethnicity = black
  • Age >35 at first presentation
184
Q

Common sites of ectopic pregnancy

A

Most common sites are ampulla and isthmus of fallopian tube

185
Q

Presentation of ectopic pregnancy

A
  • 6-8 wks of amenorrhoea (missed period)
  • Lower abdo/pelvic pain
    o Constant and may be unilateral
    o Shoulder tip pain (peritoneal bleeding)
  • Vaginal bleeding
    o Less than normal period
    o Dark brown colour
  • Dizziness, fainting or syncope
  • Breast tenderness
  • Cervical excitation (Chandelier sign)
  • Adnexal tenderness
  • Haemodynamically unstable (ruptured ectopic)
  • Signs of peritonitis
  • Fullness in pouch of Douglas
186
Q

Investigations for ectopic pregnancy

A
  • Haemodynamically stable/unstable
  • Pregnancy test = urine BHCG
    o Repeat in 48 hrs = if doubling it’s intrauterine, if rising not doubling it’s ectopic, if falls by half or more it’s miscarriage
  • Transvaginal USS
    o If pregnancy not found but BHCG positive (>1500) then pregnancy of unknown location (PUL)
    o Free peritoneal fluid = intraperitoneal blood
    o Complex/homogenous adnexal mass
    o Adnexal gestation sac with/out fetal pole or heart beat
    o “Tubal ring” or bagel or blob sign
187
Q

Conservative management of ectopic pregnancy

A

o Watchful waiting of stable patient (unlikely to rupture)
o <35mm in size, <1000 BhCG
o Asymptomatic
o No fetal heartbeat
o Serum BHCG monitored every 48 hours to ensure falling by at least 50% of level until <5

188
Q

Medical management of ectopic pregnancy

A

o IM methotrexate
o Serum BHCG monitored regularly to ensure BHCG decline by >15% in day 4-5
o Repeat dose if not falling
o For stable patient with well controlled/no pain and BHCG <1500 and unruptured without visible heartbeat

189
Q

Surgical management of ectopic pregnancy

A

o Laparoscopic salpingectomy
o Salpingotomy = if fertility compromised or previous surgery
o Patients in pain, serum BHCG >5000, adnexal mass >34mm and fetal heartbeat visible
o Can be ruptured

190
Q

Legal requirements for termination of pregnancy

A
  • 1990 Human fertilisation and Embryology Act
  • Abortion up to 24 wks
    o If continuing pregnancy involves greater risk to physical or mental health of woman or existing children of family
  • Abortion at any time during pregnancy
    o Continuing pregnancy is likely to risk life of woman
    o Terminating pregnancy will prevent ‘grave permanent injury’ to physical or mental health of woman
    o Substantial risk that child would suffer physical or mental abnormalities making it seriously handicapped
  • Requirements
    o 2 registered medical practitioners must sign to agree abortion is indicated
    o Must be carried out by registered medical practitioner in NHS hospital or approved premise
191
Q

Pre-abortion care

A
  • Self-referral or refer from GP, GUM of family planning clinic to abortion services
  • Counselling and information to help decision making from trained practitioner
  • Informed consent given
192
Q

Medical abortion

A
  • Usually earlier in pregnancy (<9 wks)
  • Mifepristone  Anti-progestogen
    o Halting pregnancy and relaxing cervix
  • Misoprostol (1-2 days after)  Prostaglandin analogue
    o Softens cervix and stimulate uterine contractions
    o From 10wks gestation, additional doses every 3 hrs required until expulsion
  • Anti-D prophylaxis  Rhesus negative women with gestational age >10wks
193
Q

Surgical abortion

A
  • Anaesthetic  local / local + sedation / general
  • Medications used for cervical priming  Misoprostol, Mifepristone, Osmotic dilators
  • Surgical options
    o Cervical dilatation and suction of contents of uterus (<14wks)
    o Cervical dilatation and evacuation using forceps (14-24 wks)
  • Anti-D prophylaxis for rhesus negative women
194
Q

Post-abortion care

A
  • Urine pregnancy test performed 3-4 wks after abortion
  • Contraception discussed and started where appropriate
  • Support and counselling
195
Q

What is a molar pregnancy

A

Gestational trophoblastic disease caused by overgrowth of placenta

196
Q

Types of molar pregnancy

A
  • Complete mole (46 chromosome)  Empty ovum was fertilised by 2 sperm, No evidence of fetal tissue
  • Partial mole (69 chromosomes)  Egg was simultaneously fertilised by 2 sperm, Fetus may be present
  • Choriocarcinoma  Malignancy of trophoblastic cells of placenta
197
Q

Risk factors for molar pregnancy

A
  • Extremes of reproductive life (>40 and <15) = complete moles
  • 2x higher in East Asia (Korea and Japan)
  • Previous molar pregnancy
  • Multiple pregnancy
  • OCP
198
Q

Presentation of molar pregnancy

A
  • Irregular first trimester vaginal bleeding
  • Uterus large for dates
  • Abdominal pain
  • Vaginal passage of vesicles containing products of conception
  • Hypertension
  • Exaggerated pregnancy symptoms  Hyperemesis, Hyperthyroidism, Early pre-eclampsia
199
Q

Investigations of molar pregnancy

A
  • Serum hCG  Excessively high with complete moles but may be normal for partial moles
  • US
    o Complete = snowstorm appearance of mixed echogenicity, large theca lutein cysts
    o Partial = viable fetus with early growth restriction or structural abnormalities
  • Histological examination of products of conception (confirm diagnosis)
200
Q

Management of molar pregnancy

A
  • Complete
    o Surgical evacuation (dilation and suction)
    o Oxytocin may be required to reduce risk of haemorrhage
  • Partial  Surgical evacuation preferable unless size of fetal parts requires medical evacuation
  • Anti-D prophylaxis post-evacuation if mother is Rhesus negative
  • Chemotherapy for persistent gestational trophoblastic disease
    o If serum beta-hCG at 56 days raised
  • Specialist follow up for molar pregnancy
201
Q

Contraception after molar pregnancy

A
  • Women advised not to conceive until hCG level normal for 6m
    o Barrier contraception used
    o COCP and HRT safe after hCG levels returned to normal

Finals (23 decks)

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