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
2
Q
When is the first scan done
A
10-13+6 wks
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
4
Q
When is anti-D prophylaxis given to rhesus neg
A
1st 28 wks
2nd 34 wks
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
6
Q
Down’s syndrome results on quad testing
A
Low alpha-fetoprotein
Low unconjugated oestriol
High Human chorionic gonadotrophin
High Inhibin A
7
Q
Edward’s syndrome results on quad testing
A
Low AFP
Low unconjugated oestriol
Low HCG
Normal Inhibin A
8
Q
Neural tube defects results on quad testing
A
High AFP
Normal unconjugated oestriol
Normal HCG
Normal Inhibin A
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
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
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
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
13
Q
Causes of folic acid deficiency in pregnancy
A
- Phenytoin
- Methotrexate
- Pregnancy
- Alcohol excess
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
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
16
Q
Complications of folic acid deficiency
A
- Macrocytic, megaloblastic anaemia
- Neural tube defects
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
18
Q
Presentation of gestational diabetes
A
- Large for dates fetus
- Polyhydramnios (increased amniotic fluid)
- Glucose on urine dipstick
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
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
21
Q
Complications for gestational diabetes
A
- Large for dates fetus and macrosomia
- Shoulder dystocia = McRoberts position
- Type 2 DM after pregnancy
- Neonatal hypoglycaemia
22
Q
What is gestational hypertension
A
- Pregnancy induced hypertension developing after 20 weeks gestation
- BP returns to normal within 6 wks of delivery
23
Q
Risk factors for gestational hypertension
A
- Primigravidity
- Young female (x3 risk)
- Black (x2 risk)
- Multifetal pregnancies
- Hypertension
- Renal disease
- Collagen vascular disease
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
25
Management of pre-existing hypertension in pregnancy
- 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
26
What is pre-eclampsia
Gestational hypertension and organ damage after 20 weeks gestation
27
Risk factors for pre-eclampsia
- 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
28
Presentation of pre-eclampsia
- 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
29
Diagnostic criteria for pre-eclampsia
- New onset Hypertension (>140/90 after 20wks pregnancy)
- Proteinuria >/= 0.3g /24hr
30
Investigations for pre-eclampsia
- 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
31
Prevention of pre-eclampsia
Aspirin prophylaxis if 1 high-risk factor or more than one moderate-risk factor from 12 wks gestation
32
Management of pre-eclampsia
- 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
33
Indications for delivery in pre-eclampsia
- 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
34
Maternal complications of pre-eclampsia
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
35
Fetal complications of pre-eclampsia
o Intrauterine growth restriction
o Preterm birth
o Placental abruption
o Hypoxia
36
Maternal risk of obesity in pregnancy
- Miscarriage
- VTE
- Gestational diabetes
- Pre-eclampsia
- Dysfunctional labour, induced labour
- PPH
- Wound infections
- C-section
37
Fetal risks of obesity in pregnancy
- Congenital anomaly
- Prematurity
- Macrosomia
- Stillbirth
- Increased risk of developing obesity and metabolic disorder in childhood
- Neonatal death
38
Management of obesity in pregnancy
- 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
39
Management of UTI in pregnancy
- 7 days Abx
o Nitrofurantoin (avoid in 3rd trimester neonatal haemolysis)
o Amoxicillin
o Cefalexin
- Avoid trimethoprim in 1st trimester folate antagonist
40
Complications of UTI in pregnancy
- Increase risk of preterm delivery
- Low birth weight
- Pre-eclampsia
41
Risk factors for VTE in pregnancy
- Smoking
- Parity >/= 3
- Age >35
- BMI >30
- Reduced mobility
- Multiple pregnancy
- Pre-eclampsia
- Gross varicose veins
- Immobility
- Family history of VTE
- Thrombophilia
- IVF pregnancy
42
Prophylaxis of VTE in pregnancy
- 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
43
Postpartum management of VTE
- 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)
44
Management of VTE in pregnancy
- 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
45
What is hyperemesis gravidarum
Extreme nausea and vomiting in pregnancy caused by raised bHCG levels
46
Associations of hyperemesis gravidarum
- Multiple pregnancies
- Trophoblastic disease
- Hyperthyroidism
- Nulliparity
- Obesity
47
Protective factor for hyperemesis gravidarum
Smoking
48
Presentation of hyperemesis gravidarum
- Most common between 8-12 wks and may persist up to 20wks
- N+V
- Dizziness
- Low BP (Hypovolaemia)
49
Diagnosis of hyperemesis gravidarum
- 5% pre-pregnancy weight loss + dehydration + electrolyte imbalance
- Pregnancy-Unique Quantification of Emesis score (severity)
50
Referral criteria for hyperemesis gravidarum
- 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
51
Management of hyperemesis gravidarum
- 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
52
Complications of hyperemesis gravidarum
- Wernicke’s encephalopathy
- Mallory-Weiss tear
- Central pontine myelinolysis
- Acute tubular necrosis
- Fetal: SGA, pre-term birth
53
What is large for gestational age
- EFW >90th centile
- Severe LGA >97th centile
- Birthweight more than 4.5kg
54
Causes of LGA
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Overdue
- Male baby
55
Investigations of LGA
- USS = EFW and exclude polyhydramnios
- OGTT = GDM
56
Management of LGA
- 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
57
Maternal complications of LGA
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
58
Fetal complications of LGA
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
59
What is small for gestational age
- Infant with birth weight <10th centile for its gestational age
- Severe = <3rd centile
- Low birth weight <2500g
60
Major risk factors for SGA
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
61
Minor risk factors for SGA
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
62
Presentation of SGA
- Reduced amniotic fluid volume
- Symmetrically small = constitutionally small
- Asymmetrically small = placental insufficiency
63
Investigations of SGA
- 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)
64
Prevention of SGA
- Modifiable RF managed = smoking cessation, optimising maternal disease
- High risk pre-eclampsia = 75mg aspirin 16 weeks gestation until delivery
65
Management of SGA
- 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
66
Antenatal complications of SGA
Fetal growth restriction, Stillbirth
67
Neonatal complications of SGA
o Birth asphyxia
o Meconium aspiration
o Hypothermia
o Hypo/hyperglycaemia
o Polycythaemia
o Retinopathy of prematurity
o Persistent pulmonary hypertension
o Necrotising enterocolitis
68
Long-term complications of SGA
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
69
What is polyhydramnios
Abnormally large level of amniotic fluid during pregnancy (above 95th centile for gestational age) = >2000ml
70
Causes of polyhydramnios
- 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
71
Presentation of polyhydramnios
Maternal breathlessness
72
Investigations for polyhydramnios
- 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)
73
Management of polyhydramnios
- 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
74
Complications of polyhydramnios
- Increased perinatal mortality
- Malpresentation
- Cord prolapse
- PPH
75
What is oligohydramnios
Low level of amniotic fluid during pregnancy (<5th centile for gestational age) = <200ml
76
Causes of oligohydramnios
- 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
77
Investigations of oligohydramnios
- 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
78
Management of oligohydramnios
- 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
79
Complications of oligohydramnios
- Premature complications
- Infection
- Severe muscle contractions in fetus
- Poor prognosis if in 2nd trimester
80
Types of presentation
- 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
81
Risk factors for malpresentation
- Prematurity
- Multiple pregnancy
- Uterine abnormalities (fibroids, partial septate uterus)
- Fetal abnormalities
- Placenta praevia
- Primiparity
82
Management of malpresentation
- 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
Complications of external cephalic version
o Fetal distress
o Pre-PROM
o APH
o Placental abruption
o C-section in 24 hours
84
Risk factors for breech presentation
- Uterine malformations, fibroids
- Placenta praevia
- Polyhydramnios/oligohydramnios
- Fetal abnormality
- Prematurity
85
Management of breech presentation
- 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
Absolute contraindication to ECV
- Where caesarean delivery required
- APH within last 7 days
- Abnormal CTG
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
87
Complications of breech
Cord prolapse
88
Types of multiple pregnancies
- 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
Presentation of multiple pregnancies
- Lambda sign (twin peak sign) = triangular appearance indicating dichorionic twin pregnancy
- T sign = indicates monochorionic twin pregnancy
90
Antenatal management of multiple pregnancies
- 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
Delivery of multiple pregnancies
- 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
Maternal complications of multiple pregnancies
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- PPH
93
Fetal complications of multiple pregnancies
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
94
Risk factors for obstetric cholestasis
- Hep C
- Multiple pregnancy
- Previous obstetric cholestasis
- Gallstones
95
Presentation of obstetric cholestasis
- Generally presents in 3rd trimester
- Intense pruritus on palms, soles, abdo (Worse at night)
- Anorexia
- Malaise
- Epigastric discomfort
- Steatorrhoea
- Dark urine
96
LFTs in obstetric cholestasis
raised AST, ALT, bilirubin
97
Management of obstetric cholestasis
- Weekly monitoring of LFTs
- Ursodeoxycholic acid
- Vitamin K supplements
- Induction of labour at 37-38 weeks
98
Complications of obstetric cholestasis
- Premature birth and stillbirth
- Recurrence is high in subsequent pregnancies
99
What is reduced fetal movements
Less than 10 movements within 2hrs in pregnancies past 28 wks gestation
100
Risk factors for reduced fetal movements
- 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
Investigations of reduced fetal movements
- 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
Presentation of foetal alcohol spectrum disorder
- 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
Presentation of opioid use during pregnancy
* Structural abnormalities
* IUGR
* Neurodevelopmental abnormalities
* Respiratory depression in neonate
* SIDS
* Neonatal withdrawal syndrome
104
Presentation of stimulant drug use in pregnancy
* Structural abnormalities
* IUGR
* Early miscarriage/preterm labour/stillbirth
* Placental abruption
* SIDS
105
Presentation of smoking in pregnancy
* Increased risk of miscarriage
* Preterm labour
* Stillbirth and IUGR
* SIDS
106
Risks of cocaine use in pregnancy
* Maternal risks
o Hypertension pre-eclampsia
o Placental abruption
* Fetal risk
o Prematurity
o Neonatal abstinence syndrome
107
Causes of antepartum haemorrhage
- Painless
o Placenta previa
o Vasa previa
- Painful
o Placenta accrete/precreta
o Placental abruption
o Uterine abruption
108
Classification of antepartum haemorrhage
- Spotting = spot of blood noticed on underwear
- Minor haemorrhage <50ml
- Major haemorrhage 50-1000ml
- Massive haemorrhage >1000ml or signs of shock
109
What is placenta accreta
Placenta attaches to myometrium due to defective decidua basalis
110
Classifications of placenta accreta
- Placenta accrete = attach to myometrium
- Placenta increta = invade into the myometrium
- Placenta percreta = placenta implanted through wall into surroundings (perimetrium)
111
Risk factors for placenta accreta
- Previous uterine surgery
- IVF
- Previous c-section
- Maternal age >35
- Placenta praevia
112
Management of placenta accreta
- Antenatal steroids
- Planned C-section at 35-36+6 wks
113
What is placenta praevia
Placenta is implanted in lower uterine segment or over internal cervical os
114
Risk factors for placenta praevia
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (fibroids)
- Assisted reproduction (IVF)
- Multiparity
115
Grades of placenta praevia
- 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
Management of placenta praevia
- 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
Complications of placenta praevia
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
118
What is vasa praevia
Fetal vessels are within fetal membranes and below fetal presenting part (travel across the internal cervical os)
119
Risk factors for vasa praevia
- Low lying placenta
- IVF pregnancy
- Multiple pregnancy
120
Types of vasa praevia
- Type 1 = fetal vessels are exposed as velamentous umbilical cord
- Type 2 = fetal vessels are exposed as they travel to accessory placental lobe
121
Vaginal exam of vasa praevia
pulsating fetal vessels seen in membranes through dilated cervix
122
Management of vasa praevia
- Asymptomatic
o Give corticosteroids from 32 wks to mature fetal lungs
o Planned caesarean section (34-36 wks)
- Antepartum haemorrhage = Emergency c-section
123
Risk factors for placental abruption
- 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
Presentation of placental abruption
- Sudden onset severe continuous abdo pain
- Vaginal bleeding
- Shock = hypotension and tachycardia
- “Woody” abdomen on palpation (large haemorrhage)
125
Management of placental abruption
- 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
Complications of placental abruption
- Maternal Shock, DIC, Renal failure, PPH
- Fetal IUGR, Hypoxia, Death
127
Post-exposure prophylaxis for chickenpox
- 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
Management of chickenpox in pregnancy
- 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
Complications of chickenpox in pregnancy
- 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
What is cord prolapse
Umbilical cord descends below presenting part of fetus and through cervix into vagina after rupture of fetal membranes
131
Risk factors for cord prolapse
- 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
Management of cord prolapse
- 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
Risk factors for uterine rupture
- 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
Presentation of uterine rupture
- 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
Management of uterine rupture
- 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
Presentation of amniotic fluid embolism
- Anaphylaxis
- Sudden dyspnoea
- Hypoxia
- Hypotension
- Seizures
- Cardiac arrest
137
Active management of third stage of labour
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
Indications for CTG monitoring
- Sepsis
- Maternal tachycardia (>120)
- Significant meconium
- Pre-eclampsia (>160/110)
- Fresh antepartum haemorrhage
- Delay in labour
- Use of oxytocin
- Disproportionate maternal pain
139
Indications for induction
- 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
Bishop score
- 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
Methods of induction of labour
- Membrane sweep
- Vaginal prostaglandin E2
- Balloon catheter
- Artificial ROM and syntocin
142
Indications for an instrumental delivery
- Failure to progress
- Fetal distress
- Maternal exhaustion
- Control of head in various fetal positions
143
Risks to mother of instrumental delivery
- PPH
- Episiotomy
- Perineal tears
- Injury to anal sphincter
- Incontinence of bladder or bowel
- Nerve injury (obturator or femoral nerve)
144
Risks to baby with instrumental delivery
- 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
Indications for caesarean section
- 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
Categories of caesarean section
- 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
Serious maternal risks of caesarean
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
Serious risks to future pregancies with caesarean
o uterine rupture
o antepartum stillbirth
o placenta praevia and placenta accrete
149
Frequent risks with caesarean sections
- 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
Vaginal birth after caesarean
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
Causes of failure to progress in labour
- Large for gestational age
- Shoulder dystocia
- Malpresentation
- Obstructed labour
- Hypoactive uterus
- Cephalopelvic disproportion
152
Failure to progress in labour is considered when
- 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
Progression in labour influenced by
- Power = insufficient uterine contractions
- Passenger = macrosomia, malpresentation, malposition
- Passage = bony pelvis, fibroids, cephalopelvic disproportion
- Psyche = support and antenatal preparation for labour and delivery
154
Management of failure to progress
- 1st line = Amniotomy (artificial rupture of membranes)
- Changing positions
- Encouragement
- Analgesia
- 2nd line = Oxytocin infusion
- Episiotomy
- Instrumental delivery
- Caesarean section
155
What is premature labour
- 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
Management of PPROM
- Prophylactic Abx = Erythromycin 250mg x4 daily for 10 days
- Induction of labour = offered from 34 wks
157
Management of preterm labour with intact membranes
- 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
Risk factors for Group B strep
- Prematurity
- Prolonged rupture of membranes
- Previous sibling GBS infection
- Maternal pyrexia (secondary to chorioamnionitis)
159
Management of Group B strep
- Women with pyrexia during labour given benzylpenicillin
- Vancomycin if known severe penicillin allergy
- Erythromycin used with PPROM
160
Risk factors for shoulder dystocia
- Macrosomia
- Maternal DM
- Previous shoulder dystocia
- Post maturity
- Obesity
- Prolonged labour
161
Management of shoulder dystocia
- Call for help
- Episiotomy
- McRoberts position = hyperflexed at hips
- Suprapubic pressure
- Rotational manoeuvres
162
MAternal complications of shoulder dystocia
- Vaginal tear
- PPH
- PTSD
- Bladder/uterine rupture
163
Fetal complications of shoulder dystocia
- Hypoxia
- Cerebral palsy
- Brachial plexus injury
o Erbs palsy = C5/6
o Klumpke’s palsy = C8-T1
- Fractured humerus or clavicle
164
Management of postpartum thyroiditis
- Thyrotoxic phase Propranolol (Sx control)
- Hypothyroid phase Thyroxine
165
Classifications of postpartum haemorrhage
- Minor PPH = <1000ml blood loss
- Major moderate PPH = 1000-2000ml blood loss
- Major Severe PPH = >2000ml blood loss
166
Risk factors for PPH
- 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
Causes of PPH
- 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
Prevention of PPH
- 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
Emergency management of PPH
- 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
1st line bleeding management in PPH
o Uterine massage
o Catheterisation = bladder distention prevents uterus contractions
171
Medical management of PPH
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
Surgical management of PPH
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
Risk factors for perineal tears
* Primigravida
* Large babies
* Precipitant labour
* Shoulder dystocia
* Forceps delivery
174
Classification of perineal tears
* 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
Problems with breastfeeding
- 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
Medications safe in breastfeeding
- 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
Medications avoided in breastfeeding
- Antibiotics = ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Psychiatric drugs = lithium, benzodiazepines
- Aspirin
- Carbimazole
- Methotrexate
- Sulfonylureas
- Cytotoxic drugs
- Amiodarone
178
Risk factors for miscarriage
- 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
Risk factors for recurrent miscarriage
o Antiphospholipid syndrome
o Endocrine disorders (PCOS)
o Uterine abnormality
o Parental chromosomal abnormalities
o Smoking
180
Presentation of miscarriage
- 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
Types of miscarriage
- 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
Management of miscarriage
- 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
Risk factors for ectopic pregnancy
- 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
Common sites of ectopic pregnancy
Most common sites are ampulla and isthmus of fallopian tube
185
Presentation of ectopic pregnancy
- 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
Investigations for ectopic pregnancy
- 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
Conservative management of ectopic pregnancy
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
Medical management of ectopic pregnancy
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
Surgical management of ectopic pregnancy
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
Legal requirements for termination of pregnancy
- 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
Pre-abortion care
- 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
Medical abortion
- 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
Surgical abortion
- 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
Post-abortion care
- Urine pregnancy test performed 3-4 wks after abortion
- Contraception discussed and started where appropriate
- Support and counselling
195
What is a molar pregnancy
Gestational trophoblastic disease caused by overgrowth of placenta
196
Types of molar pregnancy
- 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
Risk factors for molar pregnancy
- Extremes of reproductive life (>40 and <15) = complete moles
- 2x higher in East Asia (Korea and Japan)
- Previous molar pregnancy
- Multiple pregnancy
- OCP
198
Presentation of molar pregnancy
- 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
Investigations of molar pregnancy
- 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
Management of molar pregnancy
- 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
Contraception after molar pregnancy
- 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
