Obstetrics Flashcards
What are the 3 types postnatal depression?
- Baby blue: is seen in the majority of women in the first week after birth
- Postnatal depression: is seen in about 1 in 10 women, with a peak around ** 3 months after
- Puerperal psychosis: is seen in about one in a thousand women starting a few weeks after birth
What are the baby blues?
Baby blues affect more than 50% of women in the first week or so after birth (particularly in first time mothers)
What are the symptoms of the baby blues?
- Mood swings
- Low mood
- Anxiety
- Irritability
- Tearfulness
What causes baby blues?
- Hormonal changes
- Recovery from birth
- Fatigue and sleep deprivation
- The responsibility of caring for the neonate
- Establishing feeding
What is the classic triad of postnatal depression?
- Low mood
- Anhedonia (lack of pleasure in activities)
- Low energy
When do symptoms usually appear in postnatal depression?
Usually 3 months after birth and last for longer than 2 weeks
What is the treatment for postnatal depression?
Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
What is the screening tool for postnatal depression?
Edinburgh Postnatal Depression Scale
What is included in the Edinburgh Postnatal Depression Scale?
I have been able to laugh and see the funny side of things.
I have looked forward with enjoyment to things.
I have blamed myself unnecessarily when things went wrong.
I have been anxious or worried for no good reason.
I have felt scared or panicky for no very good reason.
Things have been getting on top of me.
I have been so unhappy that I have had difficulty sleeping.
I have felt sad or miserable.
I have been so unhappy that I have been crying.
The thought of harming myself has occurred to me.
The subject is asked to consider the feelings they have experienced in the past 7 days and all items must be answered by the mother alone without prompting.
What is puerperal psychosis?
It is a rare but severe illness that has an onset 2-3 weeks after delivery
What are the symptoms of puerperal psychosis?
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
What is the treatment of puerperal psychosis?
- Admission to the mother and baby unit
- Cognitive behavioural therapy
- Medications
- Electroconvulsive therapy (ECT)
What is the problem with SSRIs in pregnancy?
Can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome).
It presents in the first few days after birth with symptoms such as irritability and poor feeding.
What is an ectopic pregnancy?
Is when a pregnancy is is implanted outside the uterus, the most common site fallopian tube.
Can also occur at the entrance to the fallopian tube, ovary, cervix or abdomen
What are the risk factors for an ectopic pregnancy?
- Previous ectopic pregnancy
- Previous PID
- Previous surgery to the fallopian tubes
- Intrauterine devices
- Older age
- Smoking
What is the typical presentation of an ectopic presentation?
- Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations
- Always suspect with missed periods and lower abdominal pain
What are the classic features of an ectopic pregnancy?
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
What are some other symptoms of an ectopic pregnancy?
Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)
What are the ultrasound findings in an ectopic pregnancy?
- A gestational sac containing a yolk sac or foetal pole in the fallopian tube
- Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance).
A mass representing a tubal ectopic pregnancy moves separately to the ovary.
Features that may also indicate an ectopic pregnancy are:
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
What is a pregnancy of unknown location?
- When a women has a positive pregnancy test and there is no evidence of pregnancy on an ultrasound scan
How do you monitor a PUL?
- Track hCG over time (every 48 hours)
- In an intrauterine pregnancy hCG will double every 48 hours, it won’t in an miscarriage or ectopic pregnancy . Once levels are above 1500 should be able to see on USS
- A fall of more than 50% is likely to indicate a miscarriage
What is the management for women with a suspected ectopic pregnacy?
- They need to be referred to an early pregnancy assessment unit
All ectopic pregnancies need to be terminated: there are 3 options:
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy)
What is the criteria for expectant management?
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
What is the criteria for methotrexate use?
Same as expectant management apart from:
- HCG level must be <5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
Must be below 5000 but is mainly recommended less than 1500.
HcG needs to be monitored on days 4 and 7 after use and check levels are falling. Then re-assess if this has not occurred
How does methotrexate work and what are the side effects of it?
- It is highly teratogenic and is given as an intramuscular injection into a buttock
Common side effects include:
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis
What are the indications for surgical management of an ectopic pregnancy?
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
Is laparoscopic, it should be a salpingectomy removal of all the tube.
Salpingotomy is an alternative with women for risk factors of infertility
What is a miscarriage?
A spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks. Late miscarriage is between 12-24
What are some key definitions for miscarriage?
- Missed miscarriage: the foetus is no longer alive but no symptoms have occurred
- Threatened miscarriage: vaginal bleeding with a closed cervix and a foetus that is alive
- Inevitable miscarriage: vaginal bleeding with an open cervix
- Incomplete miscarriage: retained products of conception remain in the uterus after the miscarriage
- Complete miscarriage: a full miscarriage has occurred, and there are no products of conception left in the uterus
- Anembryonic pregnancy: a gestational sac is present but contains no embryo
What are the ultrasound findings that a sonographer looks for in an early pregnancy?
- When a foetal heartbeat is visible the pregnancy is considered viable: a foetal heartbeat is expected once crown-rump length is 7mm
- When there is no foetal heartbeat and CRL is less than 7mm scan repeated in 1 week
- A foetal pole is expected once the mean gestational sac is more than 25mm
- When there is a mean gestational sac diameter of 25mm without a foetal pole an anembryonic pregnancy is expected
What is the management for women with vaginal bleeding that are less than 6 weeks gestation?
- If there is no pain and no risk factors then use Expectant management
- A repeat urine pregnancy test is performed 7-10 days and if negative, a miscarriage can be confirmed
- When bleeding continues then do further investigation
What is the management for women with vaginal bleeding that are more than 6 weeks gestation?
- Referral to an early pregnancy assessment service
- They will arrange an ultrasound scan which will confirm the location and viability of the pregnancy.
What is the management for an incomplete miscarriage?
- If less than <35mm then can offer expectant, medical or surgical
- If greater than 35mm then offer surgical management
What is medical management for a miscarriage?
Misoprostol which is a prostaglandin analogue which softens the cervix and stimulates uterine contractions
Can be a vaginal suppository or an oral dose
What are the side effects of misoprostol?
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What are the surgical options for to treat a miscarriage?
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.
What is the management for an incomplete miscarriage?
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).
What is a complication of ERPC?
Endometritis (infection of the endometrium)
What is needed to diagnose a delayed miscarriage?
- Diagnosed on transvaginal scan
- Requires visualisation of gestation sac, yolk sac and foetal pole, with a CRL of greater than 7mm and no foetal heart activity
- Need 2 sonographers to diagnose
What is the management of a delayed miscarriage?
- If CRL is less than 22mm then anything can be offered
- If CRL is less than 54mm then medical or surgical
- If CRL is greater than 54mm then medical treatment should be offered
What criteria can justify the decision to proceed with an abortion?
if continuing the pregnancy involves greater risk to the physical or mental health of:
The woman
Existing children of the family
It is a matter of clinical judgement and must be agreed by 2 separate doctors
What is a molar pregnancy?
- Type of gestational trophoblastic disease
- Complete mole caused by a single or two sperm fertilising an egg which has lost its DNA
- 2-4% risk of developing into a choriocarcinoma
- partial is when 2 sperm supply chromosomes but mother are also present
- Looks likes bunch of grapes
- Only treated with surgical management
When can an abortion be performed at anytime?
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What is the medical way to cause an abortion?
- Give Mifepristone (anti-progestogen)
- Give Misoprostol (prostaglandin analogue) 1 – 2 day later
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
What are some complications of having an abortion?
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
What are monozygotic twins?
Identical twins
What are dizygotic twins?
Non-identical twins
What are monoamniotic twins?
Single amniotic sac
What are diamniotic twins?
Two separate amniotic sacs
What are monochorionic and dichorionic twins?
Monochorionic: share a single placenta
Dichorionic: two separate placentas
What type of twins have the best outcomes?
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each foetus has their own nutrient supply.
How can you determine which type of twins are present on an ultrasound scan?
- Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
- Monochorionic diamniotic twins have a membrane between the twins with a T sign
- Monochorionic monoamniotic twins have no membrane between them
What is the lambda/twin peak sign?
The triangular appearance where the membrane between the twins meets the chorion
What is the t-sign?
Where the membrane between the twins abruptly meets the chorion giving a t-sign
What are some complications to the mother with a twin pregnancy?
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
What are the risk to the foetuses and neonates in twin pregnancies?
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
What is twin transfusion syndrome?
- It occurs when foetuses share a placenta it is when there is a connection between the blood supplies of the two foetuses
- One foetus may receive the majority of the blood from the placenta while the other one is starved of blood
- The recipient will become fluid overloaded with heart failure and polyhydramnios
- The donor has growth restriction, anaemia and oligohydramnios
What is the treatment for foetal transfusion syndrome?
Laser treatment may be used to destroy the connection between the two blood supplies
What is twin anaemia polycythaemia sequence?
One twin becomes anaemic and the other develops polycythaemia
What extra care is a women given with multiple pregnancies?
A specialist multiple pregnancy obstetric team manages women with a multiple pregnancy.
Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:
Booking clinic
20 weeks gestation
28 weeks gestation
They also have scans:
every 2 weeks for monochorionic twins
every 4 weeks for dichorionic twins
When is planned birth offered with twins?
- 32 and 33 weeks for uncomplicated monochorionic twins, monoamniotic twins (require a C-section)
- 36 weeks for uncomplicated monochorionic diamniotic twins
- 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
- Before 35 + 6 weeks for triplets
Corticosteroids are given to help mature the lungs
How would you deliver diamniotic twins?
Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks):
Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
Caesarean section may be required for the second baby after successful birth of the first baby
Elective caesarean is advised when the presenting twin is not cephalic presentation
What is gestational diabetes?
Diabetes caused by pregnancy due to decreased insulin sensitivity and resolves after birth
What are the implications of gestational diabetes?
- Can cause larger for dates foetus and macrosomia. This causes implications for birth causing a risk of shoulder dystocia.
- Women are also at higher risk of developing type 2 diabetes after pregnancy.
- Anyone with risk factors should be screened with an oral glucose tolerance test at 24-28 weeks
What are the risk factors for developing gestational diabetes?
- Previous gestational diabetes
- Previous macrosomic baby
- BMI above 30
- Ethnic origin
- Family history of diabetes
When would you screen for gestational diabetes?
- Risk factors
- Larger for date foetus
- Polyhydramnios
- Glucose on urine dipstick
What are the figures for gestational diabetes?
- Fasting above 5.6
- At 2 hours above 7.8
What is the management for gestational diabetes?
- They need four weekly ultrasound scans to monitor foetal growth and amniotic fluid from 28-36 weeks
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Glibenclamide is another option
How do you manage pre-existing diabetes in a pregnant women?
- They should take 5mg folic acid preconception
- Retinopathy screening should be performed shortly after booking and at 28 weeks gestation
- Advise a planned delivery between 37 and 38+ 6 weeks for women with pre-existing
How is type 1 diabetes managed during labour?
A **sliding-scale insulin regime*
- A dextrose and insulin infusion is titrated ti blood sugar levels. Also considered
How do you treat gestational diabetes after birth?
- Women can stop their diabetes medications immediately after birth and will need follow up after 6 weeks
- Women should be wary of hypoglycaemia in postnatal period, insulin sensitivity will increase with birth and breastfeeding
What are the babies at risk of if their mother has had gestational diabetes?
- Neonatal hypoglycaemia- babies will need regular blood glucose checking
- Polycythaemia
- Jaundice
- Congenital heart disease
- Cardiomyopathy
What are the two major impacts of gestational diabetes on neonates?
two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia
Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.
Name 3 major things that women are at risk of during puerperium.
- Sepsis.
- Sever haemorrhage.
- Pre-eclampsia.
- VTE.
- Prolapse.
- Incontinence.
- Depression.
Give 3 risk factors for sepsis in pregnancy.
- Obesity.
- Anaemia.
- Diabetes.
- Amniocentesis/invasive procedures
.Impaired immunity/ immunosuppressant medication
What can cause sepsis in pregnancy?
- Endometritis.
- Skin infections.
- Pyelonephritis.
- Chorioamnionitis.
- Pneumonia.
Define sepsis. Define septic shock
Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting the functioning of the organs of the body
Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.
What are the two key causes of sepsis in pregnancy?
Chorioamnionitis
Urinary tract infections
What is chorioamnionitis?
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid.
E coli is most common
What are some key features of sepsis?
(3Ts white with sugar)
Temperature <36 or >38 degrees
Tachycardia -Heart rate > 90bpm (PN)
Tachypnoea - Respiratory rate > 20bpm
WCC >12 or <4 x 109/l
Hyperglycaemia >7.7mmol
Low blood pressure
Altered consciousness
Reduced urine output
What is the some of the management steps for dealing with maternal sepsis?
Bloods cultures
Urine output
Fluid Resuscitation
Antibiotics
Lactate
Oxygen
piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.
Name some obstetric conditions that obesity is a huge risk factor for
Pre-eclampsia
Sepsis
Shoulder Dystocia
Gestational diabetes
Name 3 reproductive disorders that are associated with obesity.
PCOS.
Miscarriage.
Infertility.
What are some causes of primary hypertension?
It has multifactorial aetiology
Genetic factors – can run in families 40%-60% have a genetic component
Foetal factors – low birth weight is associated with hypertension
Obesity
High alcohol Alcohol intake
Insulin intolerance
Lack of physical activity
Metabolic Syndrome X cluster of conditions, such as high insulin levels, glucose intolerance, low levels of HDLs, central obesity
What are some main causes of secondary hypertension?
○ Renal e.g. CKD
○ Endocrine e.g. Conn’s syndrome, acromegaly, Cushing’s syndrome
○ Coarctation of the aorta
○ Pre-eclampsia occurring during third trimester of pregnancy
Define chronic hypertension.
A patient with high BP which is diagnosed prior to pregnancy or before week 20 of pregnancy. Their high BP is not resolved postpartum.
Define gestational hypertension.
New high BP after 20w gestation and resolves after giving birth. There is no proteinuria or end organ damage
Key definitions hypertension in pregnancy
- Chronic hypertension: High blood pressure that exists before 20 weeks gestation
- Pregnancy induced hypertension: is hypertension that occurs after 20 weeks gestation without proteinuria
- Pre-eclampsia is pregnancy induced hypertension associated with organ damage notably proteinuria
- Eclampsia is when seizures occur as a result of pre-eclampsia
What is the classic triad of pre-eclampsia?
- Hypertension
- Proteinuria
- Oedema
How does normal blood flow between the placenta and endometrium?
- When a placenta grows into the endometrium it forms finger-like projections called chorionic villi these contain foetal blood vessels
- When invasion occurs the endometrium sends signals to spiral arteries in the area to reduce their vascular resistance, this causes them to breakdown and causes pools of blood called lacunae
- Maternal blood flows in and out of these lacunae through uterine veins and arteries (this occurs at 20 weeks)
What causes pre-eclampsia?
- When the process of forming lacunae is inadequate, women can develop pre-eclampsia
- It is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta.
- This causes oxidative stress in the placenta and the release of inflammatory chemical leading to systemic inflammation and impaired endothelial function in the blood vessels
What are the high risk factors for pre-eclampsia?
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (SLE)
- Diabetes
- Chronic kidney disease
What are the moderate risk factors for pre-eclampsia?
- Older than 40
- BMI above 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
What is the prophylaxis for pre-eclampsia and when is it given?
Aspirin women are offered from 12 weeks until birth if they have 1 high risk factor or more than 1 moderate risk factor
What are the symptoms of the complications of pre-eclampsia?
- Headache
- Visual disturbance or blurriness
- Nausea and vomiting
- Upper abdominal or epigastric pain (due to liver swelling)
- Oedema
- Reduced urine output
- Brisk reflexes (clonus)
How can you diagnose pre-eclampsia?
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
What is tested if a women is suspected to have pre-eclampsia?
Measure placental growth factor levels will be Low in pre-eclampsia
Measure between 20-35 weeks to rule out
What is the management for gestational hypertension?
Treating to aim for a blood pressure below 135/85 mmHg
Admission for women with a blood pressure above 160/110 mmHg
Urine dipstick testing at least weekly
Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
Monitoring foetal growth by serial growth scans
PlGF testing on one occasion
When is the management for pre-eclampsia?
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
Blood pressure is monitored closely (at least every 48 hours)
Urine dipstick testing is not routinely necessary (the diagnosis is already made)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
What is the medical management of pre-eclampsia?
- Labetalol is first-line as an antihypertensive
- Nifedipine (modified-release) is commonly used second-line
- Methyldopa is used third-line (needs to be stopped within two days of birth)
- Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
What is given during labour in women with pre-eclampsia?
- Iv magnesium sulphate to prevent seizures
- Fluid restriction to avoid fluid overload
What is the medical treatment of pre-eclampsia after birth?
- Enalapril (first-line)
- Nifedipine or amlodipine (first-line in black African or Caribbean patients)
- Labetalol or atenolol (third-line)
What is anaemia?
A low concentration of haemoglobin in the blood
When are women screened for anaemia in pregnancy?
- Booking clinic
- 28 weeks gestation
Why do women often develop anaemia in pregnancy?
- Plasma volume increases during pregnancy, this results in a reduction in the haemoglobin concentration
What are the normal Hb concentrations in pregnancy?
Booking bloods:
> 110 g/l
28 weeks gestation:
> 105 g/l
Post partum:
> 100 g/l
What are the risk factors for VTE in pregnancy?
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
When would VTE prophylaxis be recommended?
- 28 weeks if there are 3 risk factors
- First trimester if there are 4 or more risk factors
What is the prophylaxis of VTE in pregnant women?
- LMWH such as enoxaparin, dalteparin, tinzaparin
What are the symptoms of DVT?
Almost always unilateral
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf
- Oedema
- Colour changes to the leg
What are the investigations for a DVT?
- Doppler ultrasound
The wells score is not validated for pregnant women. D-dimers also not helpful as pregnancy raises it anyway
What are the symptoms of gonorrhoeae?
- 50% asymptomatic
- Malodorous, purulent discharge from the urethra, cervix, vagina 3-5 days after exposure
- Simultaneous urethral infection (70% to 90%)
- Infection of the pharynx (10% to 20%)
- Gonococcal conjunctivitis
- Polyarthritis
How do you test for Gonorrhoea?
Microscopy of gram stained smears of genital secretions looking for gram negative diplococci
Male - urethra
Female - endocervix
Rectum
What is the treatment of gonorrhoea?
- A single dose of IM ceftriaxone 1g if sensitives not known
- A single doe of oral ciprofloxacin 500mg if sensitives known
What prophylactic antibiotic do we give to women going into labour who have group B streptococcal colonisation, bacteriuria or infection during the current pregnancy, or a clinical diagnosis of chorioamnionitis
Women without chorioamnionitis
Use Benzylpenicillin.
Women with chorioamnionitis
Use Benzylpenicillin plus gentamicin plus metronidazole.
What are some consequences for mother and neonate of a chlamydia infection?
Mother-
Asymptomatic
Preterm labour
Chorioamnionitis
PID
Neonate-
Conjunctivitis
Pneumonia
What is the treatment for chlymydia?
1-week oral doxycycline (a tetracycline)
Pregnant – oral erythromycin (14 days) or oral azithromycin - (macrolides)
What bacteria causes syphilis?
T.Pallidum
What are the stages of syphilis?
Primary syphilis involves a painless ulcer called a chancre at the original site of infection
Secondary syphilis
Latent syphilis symptoms disappear and the patient becomes asymptomatic despite still being infected.
Tertiary syphilis
Neurosyphilis occurs if the infection involves the central nervous system
What are the symptoms of primary syphilis?
A painless genital ulcer will resolve after 3-8 weeks
What are the symptoms of secondary syphilis?
Typically starts after the chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
What is the management for syphillis?
- A single deep intramuscular dose of benzathine benzylpenicillin
What are the complications of syphilis to a newborn?
- Still birth
- Maculopapular rash
- Hepatosplenomegaly
- Cardiovascular anomalies
- Sensorineural deafness
What is bacterial vaginosis?
- It refers to an overgrowth of bacteria in the vagina specifically anaerobic bacteria
- It is not Sexually transmitted
What causes BV?
Loss of lactobacilli which produce lactic acid and keep the vaginal pH low
What bacteria can cause BV?
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
What are the risk factors for BV?
- Multiple sexual partners
- Excessive vaginal cleaning
- Recent antibiotics
- Smoking
- Copper coil
What is the presentation of BV?
Fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
What are the investigations for BV?
- ## Test vaginal pH anything above 4.5 is badcharcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
What cells are shown with BV?
Clue cells
What is treatment for BV?
Metronidazole
Or clindamycin but is less effective
What can’t you take with metronidazole?
Alcohol
What are the complications of BV?
It increases risk of STI
- Also can cause problems in pregnancy
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
What is trichomonas vaginalis ?
A type of parasite spread through sexual intercourse
What is the presentation of trichomonas vaginalis ?
-Vaginal discharge (frothy green which may have a fishy smell
- Itching
- Dysuria
- Balanitis
- Painful sex
50% of cases are asymptomatic
What is the sign of trichomonas vaginalis ?
Strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection
Also vaginal pH would be high like bacterial vaginosis
What is the treatment for trichomonas vaginalis ?
Metronidazole
What causes Trichomnoiasis? what type of pathogen is it?
Trichomonas vaginalis - its type of parasite classed as a protozoan, and is a single-celled organism with flagella
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
Define Puerperal
during or relating to the period of about six weeks after childbirth (known as the puerperium) during which the mother’s reproductive organs return to their original non-pregnant condition.
Name some common complications of puerperium
Endometritis
C - Section infection
Mastitis
Breast engorgement
Necrotising fasicitis
Psychiatric issues
Outline what Endometiris is and some risk factors for it.
infection of the endometrium that often
invades the underlying myometrium.
Risk factors
Miscarriage (when fetal tissue is left behind)
C - Section
Prolonged rupture of membranes,
multiple vaginal examinations,
What is the common presentionation of endometritis? When does it most commonly occur?
Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding.
It occurs most commonly 5–10 days after delivery.
What is the treatment for post partum endometritis?
The first line is IV Clindamycin and Gentamicin.
What is Mastitis, and what is the most common cause of it?
This is a condition that refers to inflammation of the breast
– It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus
What are some signs and symptoms of mastitis, and what is the management of it?
Erythematous, tender, swollen area of breast
– Systemic upset with fevers, chills and fatigue
– 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied
– If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days
What is breast engorgement? When and why can it happen?
Caused by vascular
and lymphatic stasis
May occur on days 2–4 postpartum in women who are not nursing
or at any time if breastfeeding is interrupted.
Management conservatively with ice packs and painkillers
What causes Trichomnoiasis? what type of pathogen is it?
Trichomonas vaginalis - its type of parasite classed as a protozoan, and is a single-celled organism with flagella
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
What are some risks of UTIs in pregnancy?
- Can cause a preterm delivery
- Low birth weight
- Pre-eclampsia
What is asymptomatic bacteriuria?
- When there is bacteria present in urine without symptoms of infection
- This puts women at higher risk of developing UTIs such as LUTI or pyelonephritis
What should be done for women with asymptomatic bacteriuria?
- They should be routinely tested for it and then have urine samples sent to lab
- They should be treated, this would not be the case for non-pregnant people
What are the symptoms of a LUTI?
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Increased frequency of urination
- Urgency
- Incontinence
- Haematuria
What are the symptoms of pyelonephritis?
- Fever
- Loin, suprapubic or back pain
- Vomiting
- Loss of appetite
- Haematuria
- Renal angle tenderness
What are the causes of a UTIs?
- E. Coli is the most common
- Klebsiella pneumoniae (gram-negative anaerobic rod)
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans (fungal)
What is the management of a UTI in pregnancy?
- Nitrofurantoin (avoid in third trimester)
- Amoxicillin (only after sensitives are known)
- Cefalexin
Why do trimethoprim and nitrofurantoin need to be avoided in pregnancy?
Nitrofurantoin: needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).
Trimethoprim: needs to be avoided in the first trimester as it is works as a folate antagonist. It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.
Why is chickenpox (varicella zoster virus) dangerous in pregnancy?
- It can lead to pneumonitis, hepatitis or encephalitis in the mother
- Fetal varicella syndrome
- Severe neonatal varicella infection (if infection around birth)
How do you reduce the risks of VZV in pregnancy?
- If mother has had previous exposure she is safe
- If unsure then test varicella IgG levels
- If not got IgG then vaccinate
How do you manage a women who has been in exposure to VZV?
- If not immune then you can treat with IV varicella immunoglobulins as prophylaxis within 10 days of exposure
- If rash starts in pregnancy then can treat with oral Aciclovir within 24 hours if more than 20 weeks gestation
What is congenital varicella syndrome?
Occurs in 1% of cases of chickenpox in pregnancy features include:
- Fetal growth restriction
- Microcephaly, hydrocephalus and learning disability
- Scars and significant skin changes following the dermatomes
- Limb hypoplasia (underdeveloped limbs)
- Cataracts and inflammation in the eye (chorioretinitis)
Name some pathogens that can be transferred from mother to fetus?
Toxoplasma Gondii
Other -Parvovirus B19, VZV, Zika, Syphilis
Rubella
Cytomegalovirus, Chlamydia, Coxsackie Virus
Herpes Simplex 2, HIV, Hepatitis B
What is polyhydramnios?
- A term used to describe an abnormally high level of amniotic fluid during pregnancy
- It is when it is above the 95 percentile
- It causes over-distension of the uterus and can lead to preterm birth and other complications
What causes Polyhydramnios?
- Can be idiopathic in majority of cases
- Maternal diabetes
- Twin transfusion syndrome
What are the the signs and symptoms of Polyhydramnios?
- Large uterus
- Dyspnoea
- Premature labour
- Difficulty hearing/palpating Fetal heart
Should be expected if fundal height is significantly more that expected for gestational age
What is the treatment for Polyhydramnios?
- Antacids to relieve heartburn and nausea for the mother
- Nonsteroidal anti-inflammatory drugs (indomethacin) can decrease fetal urine production, but may cause premature closure of the fetal ductus arteriosus.
- Removal of fluid by amniocentesis is only transiently effective.
What is Oligohydramnios?
A term used to describe abnormally low level of amniotic fluid during pregnancy
- Less than 500ml at 32-36 weeks
What can cause Oligohydramnios??
- Low production of fetal urine
- Poor placental diffusion
- Leakage of amniotic fluid (main cause 50%)
What are some complications of Oligohydramnios?
- Abnormal lie and development
- Poor respiratory development
What are the 3 definitions needed to know for Malpresentations?
Lie- the relationship between the long axis of the fetus and the mother
Presentation- the fetal part that the first enters the maternal pelvis
Position- the position of the fetal head as it exits the birth canal
What are the different types of malpresentation you may see
Cephalic vertex presentation is the most common and is considered the safest
Other presentations include breech, shoulder, face and brow
What are the different types of abnormal lie you may see?
Longitudinal, transverse or oblique
How would you manage abnormal lie?
An External cephalic version is the manipulation of the fetus to a cephalic presentation through the maternal abdomen
If this fails then perform a C-section
What are the 3 main types of breach?
- Complete- this is where the the caudal end of the fetus is in the lower segment
- Frank: the most common where the buttocks occupy the lower segment
- Footling: this is where the foot is in the pelvis most dangerous
What is the management of a breach presentation?
If less than 36 weeks no action is required
If greater than 36 weeks :
- 1st line is ECV offered at 36 weeks for first time and 37 weeks for other
- Do not perform where there is an abnormal ccg or multiple pregnancies
- Offer elective C-section or vaginal breech delivery if unsuccessful
What is Cephalopelvic disproportion?
When the size of the pelvis can’t allow the fetus to pass through the birth canal
This mat be due to a small pelvis, a large fetus or unfavourable orientation
How do you treat Cephalopelvic disproportion ?
If fetus is too large than induction pre-term can be arranged, if not then will result in a C-section
What is a uterine rupture?
- Where the muscle layer of the uterus (myometrium) ruptures.
- This causes significant bleeding and the baby may be released from the uterus into the peritoneal cavity
What is the difference between a complete and incomplete rupture?
Incomplete the uterine serosa surrounding the uterus remains intact
In complete this ruptures along with the myometrium releasing the uterus into the peritoneal cavity
What are the risk factors for a Uterine rupture?
A previous C-section as the scar on the uterus becomes a point of weakness and may rupture with excessive pressure
It is extremely rare in first time mothers.
The risk factors to consider are:
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
What is the presentation of a uterine rupture?
- An acutely unwell mother with an abnormal CTG signs and symptoms include:
- Abdo pain
- Vaginal bleeding
- Ceasing of uterine contractions
- hypotension
- Tachycardia
What is the management of a uterine rupture?
Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
What is defined as a premature birth?
A baby before 37 weeks gestation earlier=worse outcomes
Babies are considered non-viable below 23 weeks and have 10% chance of survival
What are the WHO definitions of prematurity?
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
What can be given as prophylaxis for preterm labour?
Vaginal progesterone- it decreases the activity of the myometrium and prevents the cervix from remodelling and preparing for delivery
Offered to women around 16-24 weeks
What is cervical cerclage?
Involves putting a stich in the cervix to add support and keep it closed
What is the premature rupture of membranes?
When amniotic sac ruptures releasing fluid before 37 weeks
How is premature rupture of membranes dignosed?
Can be diagnosed by speculum examination
Tests can be performed when there is doubt:
Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid
Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1
What is the management of premature rupture of membranes?
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.
Induction of labour may be offered from 34 weeks to initiate the onset of labour.
What is Preterm Labour with Intact Membranes?
Where there is regular painful contractions and cervical dilation without rupture of the amniotic sac
How would you manage Preterm Labour with Intact Membranes?
Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour.
More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.
What is tocolysis?
Using medications to stop uterine contractions
nifedipine is used a CCB
Atosiban is an oxytocin receptor antagonist as an alternative
Why are antenatal steroids given?
Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.
An example regime would be two doses of intramuscular betamethasone, 24 hours apart.
Why is magnesium sulphate given to women with a pre-term labour?
It helps protect the fetal brain and reduces the risk and severity of cerebral palsy.
it is given 24 hours before delivery for mothers who are before 34 weeks gestation
What are the complications of giving magnesium?
Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
What is a cord prolapse?
When the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina after rupture of the foetal membranes
What are the dangers of a cord prolapse?
There is a significant danger of the presenting part compressing the cord resulting in foetal hypoxia
What are the risk factors for a cord prolapse?
When the fetus is in an abnormal lie after 37 weeks gestation as it provides space for the cord to prolapse below the presenting part
When should a cord prolapse be suspected and how is it diagnosed?
- When there are signs of foetal distress on a CTG
- Should be diagnosed by vaginal examination or speculum
What is the management of a cord prolapse?
Emergency C-section as a normal delivery has a high risk of cord compression and hypoxia to the baby
Pushing the cord back in is not recommended
What are the two main things used in a instrumental delivery?
Ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by instrumental delivery
What is recommended to be given after an instrumental delivery?
A single dose of co-amoxiclav to reduce the risk of maternal infection
What are some indications for an instrumental delivery?
Some key features are:
- Failure to progress
- Foetal distress
- Maternal exhaustion
- Control of the head
Increased need for instrumental when given an epidural
What can an instrumental delivery increase the risk of?
- Post partum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of bladder or bowel
- Nerve injury
What will damage to the femoral nerve and obturator nerve look like?
- Injury to the femoral nerve causes weakness of the knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg
- Obturator nerve causes weakness of hip adduction and rotation as well as numbness of the medial thig
What is an episiotomy?
cut in the area between the vagina and anus (perineum) during childbirth, to make the opening of the vagina a bit wider, allowing the baby to come through it more easily.
Sometimes a woman’s perineum may tear as their baby comes out. In some births, an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly.
Episiotomy is equivalent to a second-degree perineal laceration
What is the main complication for a baby following instrumental delivery
- Cephalohematoma with Ventouse
- Facial nerve palsy with forceps
Describe a first degree vaginal tear.
First degree - tear within vaginal mucosa only.
Describe a second degree vaginal tear.
Second degree - tear into sub-cutaneous tissue.
Describe a third degree vaginal tear.
Third degree - laceration extends into external anal sphincter.
Describe a fourth degree vaginal tear.
Fourth degree - laceration extends through external anal sphincter into rectal mucosa.
Give 3 risk factor’s for vaginal tears.
- Primigravida.
- Macrosomia and shoulder dystocia.
- Forceps delivery.
What are the main causes of obstructed labour?
a large or abnormally positioned baby - eg shoulder dystocia, or macrosomia
small pelvis - if a girl is a teenager/young, malnutrition or lack of vit D exposure
problems with the birth canal - FGM, tumors
What is shoulder dystocia?
When the anterior shoulder of the baby becomes stuck behind the pubic synthesis of the the pelvis after the head has been delivered
Often caused by macrosomia
What is the turtle neck sign?
where the head is delivered but then retracts back into the vagina.
What are some manoeuvres that can be used to help with shoulder dystocia?
Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary.
McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.
Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.
Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
What are some complications of shoulder dystocia?
- Foetal hypoxia
- Brachial plexus injury and Erb’s palsy
- Perianal tears
- Postpartum haemorrhage
What is Placenta Accreta Spectrum?
Where the placenta implants deeper and past the endometrium making it difficult to separate the placenta after delivery of the baby
What are the 3 layers of the uterine wall?
Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels
Myometrium, the middle layer that contains smooth muscle
Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)
What happens during Placenta Accreta Spectrum?
- Placenta implants beyond the endometrium into the myometrium and beyond making it difficult to separate during labour and increasing the risk of post partum haemorrhage
What are the 3 different definitions for Placenta Accreta Spectrum?
Superficial placenta accreta: is where the placenta implants in the surface of the myometrium, but not beyond
Placenta increta: is where the placenta attaches deeply into the myometrium
Placenta percreta: is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
What are the risk factors for Placenta Accreta Spectrum?
Previous placenta accreta
Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
Previous caesarean section
Multigravida
Increased maternal age
Low-lying placenta or placenta praevia
What is the management of Placenta Accreta Spectrum?
- Ideally diagnosed antenatally by ultrasound and then MRI used to assess the depth
- The options during caesarean are:
Planned for C-section
Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time
What is placenta praevia?
When the placenta is attached in the lower portion of the uterus lower than the presenting part of the foetus
What is the difference between a low lying placenta and placenta praevia?
- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia is used only when the placenta is over the internal cervical os
What are the 3 causes of antepartum haemorrhage?
- Placenta praevia
- Placental abruption
- Vasa praevia
What is a placental abruption?
- Premature separation of the placenta from the uterine wall
- Concealed or revealed haemorrhage
- Woody-hard, tense uterus
- Fetal distress
- Maternal shock out of proportion to bleeding
What are the risks associated with placenta praevia?
- Antepartum haemorrhage
- Emergency C-section
- Hysterectomy
- Anaemia
- Preterm birth and low birth weight
- Still birth
What are the 4 grades of placenta praevia?
Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os
Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os
Partial praevia, or grade III – the placenta is partially covering the internal cervical os
Complete praevia, or grade IV – the placenta is completely covering the internal cervical os
What are the risk factors for placenta praevia?
Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
When is placenta praevia usually diagnosed?
At the 20 week scan
What is the management of placenta praevia?
Planned delivery around 36-37 weeks gestation
- Advise to present if pain/bleeding
- Advise against sexual intercourse
When women are diagnosed with placenta praevia early in pregnancy when is a repeat ultrasound suggested?
32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
What is vasa praevia?
Where foetal vessels are within the foetal membranes and travel across the internal cervical os
What do the foetal vessels consist of?
- Two umbilical arteries
- Umbilical vein
What are two instances when foetal vessels can be exposed outside the umbilical cord?
- Velamentous umbilical cord: is where the umbilical cord inserts into the chorioamniotic membranes and the foetal vessels travel unprotected through the membrane
- An accessory lobe of the placental is connected by foetal vessels that travel through the chorioamniotic membranes between the placental lobes
Why is vasa praevia dangerous?
- When the vessels pass across the internal cervical os. These exposed vessels are prone to bleeding particularly when the membrane are ruptured during labour
What are the two types of vasa praevia?
- Type I vasa praevia: the foetal vessels are exposed as a Velamentous umbilical cord
- Type II vasa praevia: the foetal vessels are exposed as they travel to an accessory placental lobe
What are the risk factors for vasa praevia?
- Low lying placenta
- IVF pregnancy
- Multiple pregnancy
What is the presentation of vasa praevia?
- No presentations but may be detected on an ultrasound. If it is detected then an C-section may be performed
- Can also present with antepartum haemorrhage with bleeding during second or third trimester of pregnancy
- It is very dangerous during labour when foetal distress and dark red bleeding occurs following rupture of the membranes
What is postpartum haemorrhage?
Refers to bleeding after delivery of the baby and placenta.
How much blood loss is required for a PPH to be diagnosed?
- 500ml after a vaginal delivery
- 1000ml after a caesarean section
What is a minor PPH and major PPH?
- Minor PPH is under 1000ml blood loss
- Major PPH over 1000ml blood loss
(moderate major= 1000-2000: Severe PPH 2000ml)
What is a primary and secondary PPH?
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth
What are the four causes of PPH?
Four Ts
T- Tone (uterine atony)
T- Trauma ( perineal tear)
T- Tissue (retained placenta)
T- Thrombin (bleeding disorder)
What are the risk factors for PPH?
- Previous PPH
- Multiple pregnancy
- Obesity
- Large baby
- Failure to progress in the second stage of labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Retained placenta
- Instrumental delivery
- General anaesthesia
- Episiotomy or perineal tear
What are the preventative measures?
- Treating anaemia
- Giving birth with an empty bladder ( a full bladder reduces uterine contraction)
- Active management of the third stage ( IM oxytocin)
- Intravenous tranexamic acid
What is the management for PPH?
- Resuscitation with an ABCDE approach
- Lie the woman flat, keep her warm and communicate with her and the partner
- Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen - Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
- Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
What are the mechanical options for PPH?
- Rubbing the uterus: through the abdomen to stimulates a uterine contraction
- Catheterisation (bladder distension prevents uterus contractions)
What are the medical treatments for PPH?
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine ( intravenous or intramuscular0 stimulates smooth muscle contraction
- Carboprost (intramuscular): is a prostaglandin analogue and stimulates uterine contraction
- Misoprostol (sublingual): is also a prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (intravenous): is an antifibrinolytic that reduces bleeding
What is Rhesus incompatibility?
- When a women that is rhesus-D negative becomes pregnant we have to consider the possibility that her child will be rhesus positive
- It is likely at some point in the pregnancy that the blood from the baby will find a way into the mothers blood.
- This means that the mother will produce antibodies against the Rhesus D antibodies. The mother has then become sensitised to Rhesus-D antigens
When does the sensitisation to Rhesus D become a problem in pregnancy?
- When during a second pregnancy these antibodies can cross the placenta into the foetus and attack the red blood cells.
- This will cause the destruction of the red blood cells causing haemolytic disease of the newborn
What is the management of rhesus disease of the newborn?
- This involves giving intramuscular anti-D injections to rhesus-D negative women
- It attaches itself to the rhesus- D antigens on the foetal red blood cells in the mothers circulation and destroys them preventing them from becoming sensitised to them
When are Anti-D injections given?
28 weeks gestation
Birth (if the baby’s blood group is found to be rhesus-positive)
What is the kleihauer test?
The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth
What are the different stages of labour?
- Latent phase: contractions that are irregular, mucoid plug, cervix is beginning to dilate and can last 2-3 days
- First phase: Stronger uterine contractions, cervix is continuing to dilate up to 10cm
- Second phase: From full dilation to the birth of the fetus
- Third phase: from the birth of the fetus to the expulsion of the placenta
What are the different hormones in labour?
- Oxytocin: a surge in the oxytocin levels at the onset of labour will contract the uterus
- Prostaglandins: to aid with cervical ripening
- Oestrogen: surges at the onset of labour to inhibit progesterone to prepare the smooth muscles for labour
What are the key dates during pregnancy?
Before 10 weeks: Booking clinic
Offer a baseline assessment and plan the pregnancy
Between 10 and 13 + 6: Dating scan
An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified
16 weeks: Antenatal appointment
Discuss results and plan future appointments
Between 18 and 20 + 6: Anomaly scan
An ultrasound to identify any anomalies, such as heart conditions
What are the booking bloods for pregnancy?
A set of booking bloods are taken for:
Blood group, antibodies and rhesus D status
Full blood count for anaemia
Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
HIV
Hepatitis B
Syphilis
Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onward
What are the initial tests done to screen for down syndrome?
Nuchal translucency, beta hCG, PAPPA
What is the triple test for down syndrome and when is it done?
The triple test is performed between 14 and 20 weeks gestation. It only involves maternal blood tests:
Beta-HCG – a higher result indicates greater risk
Alpha-fetoprotein (AFP) – a lower result indicates a greater risk
Serum oestriol (female sex hormone) – a lower result indicates a greater risk
When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling.
How do you provide a sperm sample to test for fertility?
Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery
What are some factors that affect semen and sperm quality?
Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine
What are the normal values for sperm and semen?
Semen volume (more than 1.5ml)
Semen pH (greater than 7.2)
Concentration of sperm (more than 15 million per ml)
Total number of sperm (more than 39 million per sample)
Motility of sperm (more than 40% of sperm are mobile)
Vitality of sperm (more than 58% of sperm are active)
Percentage of normal sperm (more than 4%)
What are some pre-testicular causes of male infertility?
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
What are some testicular causes of infertility?
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
What are some genetic/congenital causes of male infertility?
Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)
What are some post-testicular causes of infertility?
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
What are the 3 stages of labour?
The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
The second stage is from 10cm cervical dilatation to delivery of the baby.
The third stage is from delivery of the baby to delivery of the placenta.
What are the 3 factors that affect the second stage of labour?
Power, passenger and passage
What are the 4 factors of the fetus that impact it’s delivery (passenger)?
Size: of the head
Attitude: the posture of the fetus
Lie: The position of the fetus in relation to the mother
Presentation: the part of the fetus closest to the cervix
What are the 7 cardinal movements of labour?
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution
Expulsion
What is measured in the descent phase?
Obstetricians describe the position of the baby’s head in relation to the mother’s ischial spines during the descent phase. Descent is measured in centimetres, from:
-5: when the baby is high up at around the pelvic inlet
0: when the head is at the ischial spines (this is when the head is “engaged”)
+5: when the fetal head has descended further out
What is bishop scoring?
Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)
A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.
What is CVS and amniocentesis?
Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
What event happens before 10 weeks into a pregnancy?
Booking scan
What scan happens between 10-13+6 weeks?
Dating scan
An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified
What happens at 16 weeks into pregnancy?
Antenatal appointment
Discuss results and plan future appointments
What happens between 18 and 20+6 weeks?
Anomaly scan
What are anti-D injections given in rhesus negative women?
28 and 34 weeks
When is an ultrasound for placenta praveia repeated?
32 weeks
What vaccines are offered to pregnant women?
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
When is thew combined down syndrome test performed and what does it include?
between 11 and 14 weeks
- Ultrasound for nuchal translucency (thicker than 6mm means higher risk)
- beta-HCG (higher means higher risk)
- PAPPA (low means higher risk)
When is the triple test performed and what does it include for down syndrome?
The triple test is performed between 14 and 20 weeks gestation. It only involves maternal blood tests:
Beta-HCG – a higher result indicates greater risk
Alpha-fetoprotein (AFP) – a lower result indicates a greater risk
Serum oestriol (female sex hormone) – a lower result indicates a greater risk
