Obstetrics Flashcards
What is McRoberts manoeuvre?
Supine with hips fully flexed and abducted -> shoulder dystocia
What are the SSRI drugs of choice for breastfeeding women?
Sertraline or Paroxetine
How to manage reduced foetal movements?
- Handheld doppler
- US scan
Respiratory distress, hypoxia, and hypotension within 30 mins of delivery suggests what?
Amniotic fluid embolism
What is the management of PPH secondary to uterine atony?
Syntocin then ergometrine
Management of low lying placenta at 20 weeks?
Re-scan at 32 weeks
How to investigate suspected placenta praveia?
Transvaginal US
When is CVS done?
11 weeks to end of 13
When is amniocentesis done?
Week 15 onwards
How should suspected cases of rubella be managed?
Discussion with local health protection unit
What is involved in combined screening?
- Nuchal translucency
- bHCG
- PAPPA
What is the most common cause of PPH?
Placentra increta
What are risk factors for placental abruption?
increasing maternal age, multiparity and maternal trauma
An ultrasound is indicated after how many weeks of lochia?
6 weeks
When should aspirin be taken for pre-eclampsia?
12 weeks until delivery
What is wood screws manoeuvre?
Put the hand in the vagina and attempt to the foetus by 180 degrees
What should you monitor when you give magnesium sulfare for eclampsia?
- Reflexes and respiratory rate
What is a C/I to ECV for a transverse lie baby?
If the amniotic sac has ruptured
What is the medical management of miscarriage?
Vaginal misoprostol
Management of cord prolapse when it is past the level of the introitus?
Avoid handling and keep warm/moist to avoid vasospasm
Management of reduced foetal movements
- Handheld doppler
- If heartbeat, CTG
- If no heartbeat, US scan
First line investigation for preterm prelabour rupture of membranes?
Speculum exam to look for pooling of fluid in the posterior vaginal vault
Management of PE in pregnant women?
Treat with LMWH first then investigate
Management of woman with BP > 160/110
Admit for observation
When is the latest that women can travel via plane?
37 weeks for single pregnancy
32 weeks for twins
General malaise, anorexia, vomiting, jaundice in third trimester?
Acute fatty liver of pregnancy
What are the blood results for acute fatty liver of pregnancy?
- elevated liver enzymes
- prolonged PT
- raised bilirubin
What is the management of AFLP?
- Delivery of foetus
- Ongoing monitoring of LFTs
- Stabilise mother
A blighted ovum suggests what?
Ovum with no embryonic tissue -> missed miscarriage
What infection can occur following delivery of foetus?
Endometritis
Women with grade III/IV placenta praevia should be offered what?
Elective C-section at 37-38 weeks
APH definition
Bleeding from the genital tract after 24 weeks’ gestation.
Signs of placental abruption/shock but minimal bleeding?
Blood is retroplacental -> not escaping from the uterus
What would you expect to see on clotting studies after a major
abruption?
Afibrinogenemia as you get DIC which uses up clotting factors and fibrinogen
Which medication is used to suppress lactation when breastfeeding?
Cabergoline
BP >160/110
Admission to maternal unit for observation
Dizziness, electric shock sensations and anxiety
SSRI discontinuation syndrome
Bladder still palpable after urination
Urinary overflow incontinence
Management of pregnant woman with VTE history?
LMWH throughout pregnancy + 6 weeks after
What is an amniotic fluid embolism?
Where the amniotic fluid enters the maternal circulation causing PE like symptoms
What is the management of amniotic fluid embolism?
- ICU
- Oxygen and fluid resus
- CTG for foetal monitoring if before delivery
When does puerpueral psychosis often present?
Within 3-5 days of delivery
What is the probable cause of baby blues?
Change in hormone levels
How to check for mag sulph toxicity when given for eclampsia?
Reflexes
What are the components of bishop score?
Station
Consistency of cervix
Os position
Cervical dilatation
Effacement
Why is DVT more common in left leg than right in pregnancy women?
Gravid uterus puts greater pressure on the left iliac vein at the point it crosses the left iliac artery, slowing venous return to the heart.
What are the risks of obstetric cholestasis?
Premature delivery
Stillbirth
Sleep deprivation of mother
What are risk factors for cord prolapse?
- Polyhydramnios
- Prematurity
- Abnormal lie
- AROM
- Breech presentation
What can be helpful in cord prolapse?
Insert a urinary catheter and fill the bladder with saline
What are associated defects with anti-epileptics in pregnancy?
Orofacial
Neural tube
Congenital heart disease
Haemorrhagic disease of newborn
Primary herpes in third trimester?
Oral aciclovir 400mg tds until delivery
Suspected PE in someone with confirmed DVT?
Treat with LMWH first then scan
What should be prescribed for breastfeeding mothers who are omitting dairy from diet in suspected CMPI?
Calcium + Vit D
Management of asthma attack in pregnancy?
Admission - even if symptoms improve
Management of hypothyroidism in pregnancy?
Increase thyroxine by 25 and repeat TFT in 4 weeks
What is the biggest risk factor for cord prolapse?
Artificial ROM
Other include prematurity, multiparty, twin pregnancy
How should cord prolapse be managed?
- Push presenting part of foetus back into uterus to avoid compression
- If past level of Introits, do not handle and keep warm/moist to avoid vasospasm
What should be done in pregnant women treated for UTI?
Urine culture
serum bHCG levels >1,500 points
Think ectopic
Pre eclampsia symptoms?
- Headache
- Oedema
- Vision changes
- Epigastric/RUQ pain
- HTN
What is associated with pre eclampsia?
HELLP - Haemolysis, elevated LFTs, low platelets
What anatomical landmark is used to determine the station of the foetal head?
Ischial spines
Combined screening features?
- Done between 11 and end of 13 weeks
- Nuchal translucency, serum BHCG and PAPP-A
Quadruple test features?
- AFP, unconjugated oestriol, HCG, inhibin A
Management of abnormal results of combined/quadruple screening?
- Non-invasive prenatal testing
- Amniocentesis
- Chorionic villus sampling
What are are indications for expectant management of ectopic?
- Size <35mm
- Unruptured
- No symptoms
- No heartbeat
- HCG < 1000
- Closely monitor patients over 48 hours and recheck hCG
What are indications of surgical management of ectopic?
- Size >35mm
- Ruptured
- Pain
- Visible heartbeat
- HCG >5000
Management of chickenpox exposure in pregnant?
- Check VZV antibodies
- If not present, give oral Aciclovir from day 7-14 of exposure
Management of chickenpox in pregnancy?
- Specialist advice
- Give oral aciclovir if >20 weeks pregnant and presents within 24 hours of onset of rash
UTI in third trimester?
Treat with amoxicillin or cefalexin
Management of woman in early stages of labour with transverse lie?
Can do ECV if membranes have not ruptured
Placenta accreta vs increta vs percreta
Accreta - where the placenta adheres to the myometrium
Increta - where the placenta invades into the myometrium but not through
Percreta - where the placenta invades through the full thickness of the myometrium
Foetal anomalies which can result in death?
Termination of pregnancy can be at any point in pregnancy
Membrane sweep vs prostaglandin?
Membrane sweep is a labour adjunct not a method of induction
PPH management
- ABCDE
- Palpate fundus to stimulate contractions + catheterise
- IV Oxytocin
- IV/IM Ergometrine (C/I in HTN)
- Carboprost (C/I in asthma)
- Surgical: intrauterine balloon tamponade
Risk factors for cord prolapse?
- Breech/transverse lie
- Multiple pregnancy
- Polyhydramnios
- Multiparity
What is the process of rhesus disease?
- Rhesus negative mother has a rhesus positive foetus and produced anti-RH antibodies
- During next pregnancy, these cross the placenta and cause haemolysis of foetal RBC causing rhesus haemolytic disease of newborn
When does uterus normally return to pre pregnancy size?
4 weeks
What BMI should take higher dose of folic acid?
> 30
What drug can be given to improve the success of ECV?
Terbutaline
What swab can be done to confirm pre labour rupture of membranes?
Actim-PROM vaginal swab
Instrumental deliveries can increase the risk of what?
PPH
What is given prophylactically before a C-section?
Omeprazole
Perineal tears classification
First - limited to superficial skin
Second - Into perineal muscles but not affecting sphincters
3a - <50% of sphincter, 3b - >50% of sphincter
Fourth - Skin, muscle sphincters and anal mucousa torn
Bloods for pre eclampsia monitoring?
U+E,FBC,LFTs and bilirubin
Twice a week for mild, Thrice a week for severe
What is Sheehan’s syndrome?
Post partum pituitary necrosis due to blood loss and hypovolaemia shock immediately after delivery
Which nerve is blocked during instrumental delivery?
Pudendal
What are the components of the quadruple test?
- Serum oestriol
- hCG
- AFP
- inhibin-A
Most specific test for intrahepatic cholestasis of pregnancy?
Bile acids
lambda sign of US is a sign of what?
Dichorionic diamniotic twin pregnancy
Stages of labour
1 - Latent: 0-3cm dilation
1 - Active: 3cm-10cm dilation
2 - Full dilation to delivery of foetus
3 - Delivery of foetus to delivery of placenta
Antepartum haemorrhage definition?
bleeding from genital tract after 24w pregnancy, prior to delivery of fetus
Shock out of keeping with visible blood loss?
placental abruption
Shock in proportion to visible blood loss?
placenta praevia
Pain in placental abruption?
constant
uterus= tender and tense
Pain in placenta praevia?
no pain, uterus not tender
Lie and presentation in placental abruption vs praevia?
A= normal lie and presentation
P= may be abnormal
Fetal heart rate in placental abruption vs praevia?
A= absent or distressed
P= usually normal
Cx of placental abruption vs placenta praevia?
A= coagulation problems; beware pre-eclampsia, DIC, anuria
P= coagulation problems rare; small bleeds before large
What should not be done in suspected antepartum haemorrhage?
vaginal exam SHOULD NOT be done in primary care as if placenta praevia they may haemorrhage
Threatened miscarriage?
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
cervival os closed
threatened miscarriage
Missed (delayed) miscarriage?
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear
Pain is not usually a feature
cervical os is closed
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear
Pain is not usually a feature
cervical os is closed
missed (delayed miscarriage)
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
missed (delayed) miscarriage
‘blighted ovum’ or ‘anembryonic pregnancy’?
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen
Inevitable miscarriage?
heavy bleeding with clots and pain
cervical os is open
heavy bleeding with clots and pain
cervical os is open
inevitable miscarriage
Incomplete miscarriage?
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
incomplete miscarriage
Another name for spontaneous abortion?
miscarriage
What % of pregnancies in UK miscarry?
10-20%
80% occurring before 12 weeks gestation
What account for 50% of early miscarriages?
chromosomal abnormalities
RFs for miscarriage?
advanced maternal age, with women over 35 having a significantly higher risk
a history of previous miscarriages
previous large cervical cone biopsy
lifestyle factors= smoking,
alcohol, obesity
medical conditions= uncontrolled diabetes
thyroid disorders,
Recurrent miscarriage?
three or more consecutive losses, affects 1% of couples.
Understanding these epidemiological factors is crucial for early identification and management, providing better support and care for affected women.
3 types of miscarriage Mx?
- expectant Mx
- medical Mx
- surgical Mx
Expectant Mx for miscarriage?
‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
1st line for Mx of miscarriage?
expectant unless certain situations
What if expectant Mx of miscarriage is unsuccessful?
medical or surgical Mx needed
What situations are miscarriages best managed medically or surgically?
- increased risk of haemorrhage= late 1st tri; coagulopathies; unable to have blood trans
- previous adverse/traumatic experience of preg eg. stillbirth, miscarriage or antepartum haemorrhage
- evidence of infection
What if evidence of infection in miscarriage?
need medical or surgical Mx
Medical Mx of a missed miscarriage?
oral mifepristone then 48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed
Medical Mx of a missed miscarriage= what if gestational sac has already been passed?
just oral mifepristone not misoprostol
Medical Mx of a missed miscarriage= what if bleeding has not started within 48hrs of misoprostol Tx?
contact healthcare professional
Medical Mx of a missed miscarriage= 2 drugs?
oral mifepristone and 48hrs later misoprostol (oral, vaginal or sublingual)
Medical Mx of miscarriage= how does mifepristone work?
progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
Medical Mx of miscarriage= how does misoprostol work?
prostaglandin analogue, binds to myometrial cells → strong myometrial contractions → expulsion of products of conception
Medical Mx of incomplete miscarriage?
single dose of misoprostol (vaginal, oral or sublingual)
When should preg test be done after medical Mx of miscarriage?
at 3w
What else should be offered during medical Mx of miscarriage?
antiemetics and pain relief
Surgical management of miscarriage?
‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
- Surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’
2 main options for surgical Mx of miscarriage?
vacuum aspiration (suction curettage) or surgical management in theatre
Causes of recurrent miscarriage?
antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders; PCOS
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
How is miscarriage defined?
spontaneous loss of pregnancy before the fetus reaches viability. The term includes all pregnancy losses from the time of conception until 24 weeks of gestation.
How is recurrent miscarriage defined?
loss of three or more pregnancies before 24 weeks of gestation.
Miscarriage should be suspected if…
woman who is pregnant, or has symptoms of pregnancy (such as amenorrhoea or breast tenderness), presents with vaginal bleeding, with or without pain, in the first 24 weeks of pregnancy.
What to do if suspect miscarriage?
1) confirm pregnancy with urine test
2) history and exam, rule out ectopic
When to arrange immediate hospital admission for miscarriage?
signs of haemodynamic instability or significant concerns about the degree of bleeding or pain.
What should be arranged for women with a positive pregnancy test and one or more of the following:
- Abdominal pain and tenderness.
- Pelvic tenderness.
- Cervical motion tenderness.
Immediate admission to an early pregnancy assessment unit (EPAU) or out-of-hours gynaecology service
Referral to EPAU or out-of-hours gynaecology service should be arranged (urgency depending on the clinical situation) for women with bleeding or other symptoms and signs of early pregnancy complications who have one or more of the following:
- Pain.
- A pregnancy of 6 weeks gestation or more.
- A pregnancy of uncertain gestation.
When should expectant Mx of miscarriage be used?
women with a pregnancy of less than 6 weeks’ gestation who are bleeding but not in pain, and who have no risk factors (such as previous ectopic pregnancy).
What should the pt be advised following expectant Mx of miscarriage?
- To return if bleeding continues or pain develops.
- To repeat a urine pregnancy test after 7–10 days and return if it is positive.
- That a negative pregnancy test means that the pregnancy has miscarried.
Diagnostic Ix to assess location and viability of a pregnancy?
transvaginal USS
Mx of recurrent miscarriage?
should be offered referral for investigation and management. If no cause is found, the prognosis for a successful future pregnancy is about 75%. However, the prognosis worsens with increasing maternal age and the number of previous miscarriages.
Miscarriage= when is anti-D prophylaxis offered?
to all rhesus-negative women who have had a surgical procedure to manage a miscarriage.
Miscarriage= when is anti-D prophylaxis NOT offered?
Receive solely medical management for an ectopic pregnancy or miscarriage.
Have a threatened miscarriage.
Have had a complete miscarriage.
Have a pregnancy of unknown location.
What Ix may be done following referral for recurrent miscarriage?
Testing for acquired thrombophilia, particularly for lupus anticoagulant and anticardiolipin antibodies, before pregnancy.
Cytogenetic analysis on pregnancy tissue of the third and subsequent first-trimester miscarriage(s).
Parental peripheral blood karyotyping (if testing of pregnancy tissue reports an unbalanced structural chromosomal abnormality or there is unsuccessful or no pregnancy tissue available for testing).
Assessment for congenital uterine anomalies.
TFTs and assessment for thyroid peroxidase (TPO) antibodies.
Lifestyle advice, including (as appropriate) maintaining a body mass index (BMI) between 19 kg/m2 and 25 kg/m2, smoking cessation, limiting alcohol consumption, and limiting caffeine to less than 200 mg/day.
Recurrent miscarriage= If antiphospholipid antibodies are found, treatment with what?
aspirin + heparin until at least 34 weeks of gestation will be considered in future pregnancies.
Recurrent miscarriage= what may be considered for women with moderate subclinical hypothyroidism (thyroid-stimulating hormone [TSH] more than 4 mIU/l) but is not routinely recommended for women with mild subclinical hypothyroidism (TSH more than 2.5 mIU/l) irrespective of TPO status?
Thyroxine supplementation
Regular TSH measurement from 7–9 weeks of gestation is recommended in cases with TPO and/or SCH.
Doses of the drugs used for medical Mx of miscarriage?
200 mg oral mifepristone and, 48 hours later, 800 micrograms of misoprostol (vaginal, oral, or sublingual) unless the gestational sac has already been passed.
When may a transabdominal ultrasound scan may be considered over a transvaginal USS (which is GOLD) in assessing location and viability of pregnancy?
For women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst.
If a transvaginal ultrasound scan is unacceptable to the woman.
‘Minor’ breastfeeding problems?
1) frequent feeding in a breastfed infant is not alone a sign of low milk supply
2) nipple pain: may be caused by a poor latch
3) blocked duct (‘milk bleb’): causes nipple pain when breastfeeding.
4) nipple candidiasis
5) mastitis
6) breast engorgement
7) Raynaud’s disease of nipple
Breastfeeding problems= advice for blocked duct (milk bleb)?
Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried.
Breastfeeding problems= Mx of nipple candidiasis?
miconazole cream for the mother and nystatin suspension for the baby
When to treat mastitis?
if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
Tx for mastitis?
1st line Abx= flucloxacillin 10-14d
breastfeeding/expressing should continue
What if mastitis is left untreated?
breast abscess may develop- needs incision and drainage
Breast engorgement?
cause of breast pain in breastfeeding women
When does Breast engorgement usually occur?
1st few days after infant born and usually affects both breasts
CP of Breast engorgement?
pain or discomfort is typically worse just before a feed
Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle.
Fever may be present but usually settles within 24 hours.
The breasts may appear red.
Cx of breast egorgement?
blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply
Mx for breast engorgement?
Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.
Breastfeeding problems= Raynaud’s disease of the nipple?
pain is often intermittent and present during and immediately after feeding.
Blanching of the nipple may be followed by cyanosis and/or erythema.
Nipple pain resolves when nipples return to normal colour
Breastfeeding problems= Raynaud’s disease of the nipple Mx?
minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking.
If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
Around 1 in 10 breastfed babies lose more than the ‘cut-off’ ?% threshold in the first week of life.
10%
Infant loses more than 10% weight in first week of life= what to do?
- consider breastfeeding problems
- examine baby for underlying problems
Infant loses more than 10% weight in first week of life= Mx?
‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
Recommend to breatsfeed for how long?
exclusive breastfeeding until an infant is at least 6 months of age, with the introduction of solid food around this time and continued breastfeeding up to 2 years of age or longer.
Benefits of breastfeeding to infant and mother?
Infant= reduction in the incidence and severity of infections, asthma, and atopic eczema.
Mother= reduced rates of breast and ovarian cancer, and reduced incidence of obesity.
Breastfeeding problems which may lead to a mother stopping breastfeeding include?
Breast pain.
Nipple pain.
Low milk supply (true and perceived).
Oversupply of milk.
Breastfeeding problems= arranging a paediatric referral for the infant when?
concerns about dehydration, faltering growth, infant development, or the presence of an anatomical abnormality such as ankyloglossia (tongue-tie) that may be affecting infant attachment and feeding.
Ankyloglossia?
tongue tie
Breastfeeding problems= Considering specialist referral for possible drug treatment if?
Raynaud’s disease of the nipple, or prolactin deficiency causing a low milk supply, is suspected, and other measures have not worked.
Is benign cyclical mastalgia?
common cause of breast pain in younger females
CP of cyclical mastalgia?
breast pain that varies in intensity according to phase of menstrual cycle
What is cyclical mastalgia not usually associated with?
point tenderness of the chest wall (more likely to be Tietze’s syndrome)
Underlying cause of cycylical mastalgia?
difficult to pinpoint, examination should focus on identifying focal lesions (such as cysts) that may be treated to provide symptomatic benefit.
Mx of cyclical mastalgia?
Women should be advised to wear a supportive bra
Conservative treatments include standard oral and topical analgesia
flaxseed oil and evening primrose oil are sometimes used but neither are recommended
Mx of cyclical mastalgia= what if pain has not responded to conservative measures after 3m and is affecting QOL or sleep?
consider referral
Hormonal agents such as bromocriptine and danazol may be more effective. However, many women discontinue these therapies due to adverse effects.
Clinical features which indicate a diagnosis of cyclical breast pain include pain that:
Usually starts during the luteal phase of the cycle (within 2 weeks before menses), increases until menstruation begins, and improves after menses.
Is dull, heavy, or aching in nature.
Is usually bilateral.
May be poorly localized and extend to the axilla.
Cause of cyclical breast pain?
not fully understood — it is thought that hormonal changes affecting the breast tissue are involved.
It affects up to two-thirds of women, with one in ten women having moderate-to-severe pain.
Mastitis?
inflammation of the breast tissue and is typically associated with breastfeeding, where it develops in around 1 in 10 women.
painful, tender, red hot breast
fever, and general malaise may be present
?mastitis
Mastitis CP?
painful, tender, red hot breast
fever, and general malaise may be present
1st line Mx of mastitis?
continue breastfeeding; analgesia and warm compressess
When to Tx mastitis?
if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
1st line Abx for mastitis?
oral flucloxacillin
for 10-14 day
Most common organism causing infective mastitis?
staph aureus
Mastitis= should breastfeeding/expressing continue during Abx Tx?
yes
What is mastitis?
painful inflammatory condition of the breast which may or may not be accompanied by infection. It is usually associated with lactation (‘lactational’ or ‘puerperal mastitis’), but it can also occur in non-lactating women (‘non-lactational mastitis’).
What is a breast abscess?
localized collection of pus within the breast. It is a severe complication of mastitis, although it may occur without apparent preceding mastitis.
Cx of mastitis?
breast abscess; sepsis; scarring; recurrent mastitis
Cause of mastitis?
In lactating women, milk stasis is usually the primary cause of mastitis.
The accumulated milk causes an inflammatory response which may or may not progress to infection.
Causes of mastitis in non-lactating women?
usually accompanied by infection, which can be categorized as either central/subareolar or peripheral.
1) Central/subareolar infection is usually secondary to periductal mastitis (a condition where the subareolar ducts are damaged and become infected).
2) Peripheral infection (less common) is associated with diabetes mellitus, rheumatoid arthritis, trauma, corticosteroid treatment, and granulomatous mastitis (a rare inflammatory disease of the breast), but often there is no obvious underlying cause.
Most common organisms associated with infective mastitis in non-lactating women?
S. aureus, enterococci, and anaerobic bacteria (such as Bacteroides and anaerobic streptococci).
Mastitis should be suspected if a woman has?
A painful breast.
Fever and/or general malaise.
A tender, red, swollen, and hard area of the breast, often in a wedge-shaped distribution.
Mastitis in lactating vs non-lactating women?
lactating= most common cause is milk stasis
non-lactating= more commonly accompanied by infection
It is not possible to distinguish clinically between infectious and non-infectious mastitis. However, infection is more likely if the woman has….
nipple fissure that is infected, or if in a lactating woman:
- Symptoms do not improve, or are worsening, after 12–24 hours despite effective milk removal.
- Bacterial culture in breast milk is positive.
A breast abscess should be suspected if the woman has?
- A history of recent mastitis.
- A painful, swollen lump in the breast, with redness, heat, and swelling of the overlying skin.
- Fever and/or general malaise.
What if suspect breast abscess?
woman should be referred urgently to a general surgeon for confirmation of the diagnosis and management.
Amniotic fluid embolism?
when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in signs and symptoms.
How common is amniotic fluid embolism?
Rare complication of pregnancy associated with a high mortality rate.Incidence 2/ 100,000 in the U.K .
RFs for amniotic fluid embolism?
cause not really known, may be immune mediated
- link between maternal age and induction of labour
What must happen for an amniotic fluid embolism to occur?
maternal circulation must be exposed to fetal cells/amniotic fluid
CP of amniotic fluid embolism?
Symptoms= chills, shivering, sweating, anxiety, coughing
Signs= cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia and MI
When do amniotic fluid embolisms occur?
most in labour, can also happen during c-section and after delivery in the immediate postpartum
During labour mother starts shivering, sweating, anxious, coughing and is hypotensive, tachy and cyanosis?
?amniotic fluid embolism
Diagnosis of amniotic fluid embolism?
clinical diagnosis of exclusion
Mx for amniotic fluid embolism?
critical care unit by MDT, Mx is mostly supportive
Breech presentation?
the caudal end of the fetus occupies the lower segment
How common is the breech presentation?
around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term
Frank breech?
most common presentation with the hips flexed and knees fully extended
Footling breech?
where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity
Types of breech presentation?
- frank breech (most common)
- footling breech (rare but more serious)
RFs for breech presentation?
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
What is more common in breech presentations?
cord prolapse
Mx of breech presentations if <36w?
many fetuses will turn spontaneously
Mx of breech presentation if still breech at 36w?
external cephalic version (ECV)- this has a success rate of around 60%.
ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
Breech presentation= when should ECV be offered?
36 weeks in nulliparous women and from 37 weeks in multiparous women
Mx of breech presentation if women doesn’t have ECV or if fails to turn the baby so is till breech after 36/37w?
planned caesarean section or vaginal delivery
‘Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.’
‘Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.’
Contraindications for ECV if baby is breech?
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
What does ECV for breech presentation stand for?
external cephalic version
2 types of c-section?
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus
Indications for c-section?
absolute cephalopelvic disproportion
placenta praevia grades 3/4
pre-eclampsia
post-maturity
IUGR
fetal distress in labour/prolapsed cord
failure of labour to progress
malpresentations: brow
placental abruption: only if fetal distress; if dead deliver vaginally
vaginal infection e.g. active herpes
cervical cancer (disseminates cancer cells)
How many categories for c-section are there?
4
Category 1 c-setion?
delivery of the baby should occur within 30 minutes of making the decision
an immediate threat to the life of the mother or baby
Indications for cat 1 c-section?
suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
(immediate threat to life of baby or mother)
Category 2 c-section?
delivery of the baby should occur within 75 minutes of making the decision
maternal or fetal compromise which is not immediately life-threatening
Category 3 c-section?
delivery is required, but mother and baby are stable
Category 4 c-section?
elective caesarean
Serious maternal risks of c-section?
emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to intensive care unit
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)
Serious risks to future pregnancies after c-section?
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
Frequent maternal risks of c-section?
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Frequent risks of baby in c-section?
lacerations, one to two babies in every 100
Name 2 Cx of c-section?
prolonged ileus
subfertility: due to postoperative adhesions
Vaginal birth after Caesarean (VBAC)?
planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
around 70-75% of women in this situation have a successful vaginal delivery
Vaginal birth after Caesarean (VBAC)= contraindications?
previous uterine rupture or classical caesarean scar
Chorioamnionitis= how common?
up to 5% of pregnancies
Chorioamnionitis?
infection of the placenta and the amniotic fluid
potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency.
Chorioamnionitis is usuallly the result of what?
an ascending bacterial infection of the amniotic fluid / membranes / placenta
Major RF in chorioamnionitis?
preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens
Tx for chorioamnionitis?
Prompt delivery of the foetus (via cesarean section if necessary) and administration of IV Abx
episiotomy?
incision in the posterior wall of the vagina and perineum that is performed in the second stage of labour to facilitate the passage of the fetus.
Indications for a forceps delivery?
fetal distress in the second stage of labour
maternal distress in the second stage of labour
failure to progress in the second stage of labour
control of head in breech deliver
How many types of perineal tears?
4
First degree perineal tear?
superficial damage with no muscle involvement
First degree perineal tear Mx?
do not require any repair
Second degree perineal tear?
injury to the perineal muscle, but not involving the anal sphincter
Second degree perineal tear Mx?
suturing on the ward by a suitably experienced midwife or clinician
Third degree perineal tear?
injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
Third degree perineal tear Mx?
require repair in theatre by a suitably trained clinician
Fourth degree perineal tear?
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
Fourth degree perineal tear Mx?
require repair in theatre by a suitably trained clinician
Risk factors for perineal tears?
primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery
Puerperal pyrexia?
temperature of > 38ºC in the first 14 days following delivery
Causes of puerperal pyrexia?
endometritis: most common cause
UTI
wound infections (perineal tears + caesarean section)
mastitis
VTE
Mx of puerperal pyrexia?
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
Mx if suspect endometritis?
refer to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
Abx for endometritis?
clindamycin and gentamicin until afebrile for greater than 24 hours
Shoulder dystocia?
complication of vaginal cephalic delivery. It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered
cause of both maternal and fetal morbidity
Why does shoulder dystocia typically occur?
due to impaction of the anterior fetal shoulder on the maternal pubic symphysis
RFs for shoulder dystocia?
fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal body mass index
diabetes mellitus
prolonged labour
Mx of shoulder dystoica?
1) senior help as soon as identified
2) McRobert’s manoeuvre
3) episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.
Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.
What is NOT indicated in shoulder dystocia?
oxytocin
McRobert’s manoeuvre for shoulder dystocia?
flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
Cx of shoulder dystocia?
maternal:
- postpartum haemorrhage
- perineal tears
fetal:
- brachial plexus injury
- neonatal death
What is foetal lie?
refers to the long axis of the foetus relative to the longitudinal axis of the uterus.
3 types of foetal lie?
longitudinal lie (99.7% of foetuses at term)
transverse lie (<0.3% of foetuses at term)
oblique (<0.1% of foetuses at term)
Causes of Mx options of transverse lie and oblique lie are the…
same
oblique is easier to correct as foetus is closer to longitudinal lie
What foetal lie should the baby be in?
longitudinal
Transverse foetal lie?
abnormal foetal presentation whereby the foetal longitudinal axis lies perpendicular to the long axis of the uterus
this means the foetal head is on the lateral side of the pelvis and the buttocks are opposite
In transverse lie, the foetus can be either…
‘scapulo-anterior’ (most common) where the foetus faces towards the mother’s back or ‘scapulo-posterior’ where the foetus faces towards the mothers front.
Epidemiology of transverse foetal lie?
Early in gestation, transverse lie is very common. Most have moved to longitudinal lie by 32 weeks.
At term, one in 300 foetuses are in transverse lie.
RFs for transverse foetal lie?
Most commonly occurs in women who have had previous pregnancies
Fibroids and other pelvic tumours
Pregnant with twins or triplets
Prematurity
Polyhydramnios
Foetal abnormalities
Diagnosis of transverse foetal lie?
Abnormal foetal lie will be detected during routine antenatal appointments with a midwife during abdominal examination.
Abdominal examination: the head and buttocks are not palpable at each end of the uterus. The foetus can be felt to be lying directly across the uterus.
Ultrasound scan: allows direct visualisation of the foetal lie. Foetal heart rate is also auscultated to assess for distress.
Cx of transverse foetal lie?
Pre-term rupture membranes (PROM)
Cord-prolapse (20%)
If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK.
Mx of transverse foetal lie before 36w?
no management required. The patient should be informed that most foetuses will spontaneously move into longitudinal lie during pregnancy.
Mx of transverse foetal lie after 36w?
patient must have an appointment with the obstetric medical antenatal team to discuss management options:
- active Mx (ECV)
- elective c-section
Mx of transverse foetal lie after 36w= active Mx (ECV)?
perform external cephalic version (ECV) of the foetus. This can be performed late in pregnancy and even early labour if the membranes have not yet ruptured. ECV should be offered to all women who would like a vaginal delivery.
Success rate is around 50%
Mx of transverse foetal lie after 36w= active Mx (ECV) contraindications?
maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality.
Mx of transverse foetal lie after 36w= elective c-section?
management for women where the patient opts for caesarian section or ECV has been unsuccessful or is contraindicated.
Mx of transverse foetal lie after 36w= decision to perform c-section over ECV will be based on what?
perceived risks to the mother and foetus, the preference of the patient, the patient’s previous pregnancies and co-morbidities and the patient’s ability to access obstetric care rapidly.
Ventouse delivery?
using a small cup connected to a suction device that is attached to the babies head. By applying careful traction to the cup it can help ‘pull’ the baby out.
What should there be in order to do ventouse delivery?
The fetal head should be one-fifth or less palpable abdominally and the cervix fully dilated.
Contraindications for ventouse delivery?
< 34 weeks gestation
cephalopelvic disproportion
breech, face or brow presentation
Cx of ventouse delivery?
cephalhaematoma
retinal haemorrhages
maternal infection
What should be given following assisted vaginal delivery eg. ventouse delivery to reduce risk of maternal infection?
single dose IV co-amoxiclav
What is not always required for ventouse delivery?
episiotomy
cephalopelvic disproportion?
childbirth complication when baby can’t pass through the opening in pelvis.
There are many reasons it can occur, including a large baby or pelvic irregularities.
Hyperemesis gravidarum vs NVP (N&V of pregnancy)?
HG is the extreme form
Hyperemesis gravidarum is thought to be related to what?
raised beta hCG levels
When is hyperemesis gravidarum most common?
between 8-12w but may persist up to 20w
RFs for hyperemesis gravidarum ?
- increased beta hCG= multiple pregnancy, trohoblastic disease
- nulliparity
- obesity
- family or personal history of NVP
What is associated with a decreased incidence of hyperemesis gravidarum?
smoking
Admission criteria for hyperemesis gravidarum?
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
When to have a low threshold for admission in hyperemesis gravidarum?
if women has co-existing condition eg. DM that may be adversely affected by N&V
Triad to diagnose hyperemesis gravidarum?
1) 5% pre-pregnancy weight loss
2) dehydration
3) electrolyte imbalance
What can be used to classify the severity of nausea and vomiting of pregnancy/hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE) score
Mx for NVP/hyperemesis gravidarum?
- rest, avoid triggers eg. odours; plain food esp in morning; ginger; P6(wrist) acupressure
- 1st line meds and reassess after 24-73hrs
- 2nd line meds and reassess after 24hrs
- 3rd line meds= 40-50mg pred daily
- admission may be needed for IV hydration
IV hydration for hyperemesis gravidarum?
saline with potassium
1st line meds for N&V of pregnancy/hyperemesis gravidarum?
antihistamines= oral cyclizine or premethazine
phenothiazines: oral prochlorperazine or chlorpromazine
2st line meds for N&V of pregnancy/hyperemesis gravidarum?
oral ondansetron= increased risk of cleft lip/palate in 1st trimester so discuss risks with women
oral metoclopramide (no more than 5d) or domperidone (no more than 7d due to risk of cardiac adverse effects)
2st line meds for N&V of pregnancy/hyperemesis gravidarum= metoclopramide should not be used for more than…
5 days as can cause extrapyramidal side effects
2st line meds for N&V of pregnancy/hyperemesis gravidarum= ondansetron is associated with what if used in 1st trimester?
cleft lip/palate
Cx of hyperemesis gravidarum?
- dehydration, weight loss, electrolyte imbalances
- AKI
- Wernicke’s E
- oesophagitis, Mallory-Weiss tear
- VTE
- Fetal outcome= severe resulting in multiple admissions may be linked to small increase in preterm birth and low birth weight
When does NVP usually begin?
between 4–7th weeks, peaks between 9–16th weeks, and resolves by 16–20 weeks of pregnancy. Onset of symptoms after 11 weeks of gestation usually suggests an alternative cause of symptoms unrelated to pregnancy.
Hyperemesis gravidarum?
most severe spectrum of symptoms — nausea and/or vomiting which is severe enough to cause an inability to eat and drink normally, and strongly limits daily activities of living. Signs of dehydration contribute to the diagnosis.
Possible maternal complications of hyperemesis gravidarum?
weight loss, electrolyte imbalance, acute kidney injury, nutritional and vitamin deficiencies, gastro-oesophageal reflux disease, venous thromboembolism, and impact on psychosocial functioning.
Intrahepatic cholestasis of pregnancy aka?
obstetric cholestasis
How common is intrahepatic cholestasis of pregnancy?
1% of pregnancies
intrahepatic cholestasis of pregnancy is associated with what?
increased risk of premature birth
Features of intrahepatic cholestasis of pregnancy?
- pruritus= may be intense, worse palms, soles and abdo
- clinically detectable jaundice occurs in 20%
- raised bilirubin in >90%
Mx of intrahepatic cholestasis of pregnancy?
- induction of labor at 37-38w
- ursodeoxycholic acid
- vit K supplementation
Can intrahepatic cholestasis of pregnancy reoccur?
45-90% recurrence in subsequent pregnancies
Clinical features suggesting obstetric cholestasis (intrahepatic cholestasis of pregnancy) then do what?
Arrange same-day referral to a local maternity unit so that maternal serum bile acid concentrations and liver function, as well as fetal wellbeing can be assessed, and other causes of hepatic impairment can be ruled out.
Ix and monitoring for obstetric cholestasis?
confirmed obstetric cholestasis will be offered ongoing monitoring of serum bile acid levels/liver function tests (LFTs) and fetal wellbeing, usually via the maternity unit, until delivery.
If a woman has unexplained itch but bile acids and/or LFTs are normal, levels should be monitored weekly (usually by the obstetrics team) until the itch resolves. Seek specialist advice if the itch significantly worsens.
Symptomatic relief (itch) for obstetric cholestasis in primary care?
emollient to be used liberally and regularly. Menthol 0.5% or 1% in aqueous cream may also be helpful if an inert emollient does not improve itch
Consider offering a sedating antihistamine such as chlorphenamine or promethazine at night (off-label indication).
Sitting directly in front of a fan, soaking in a cool bath, and applying ice packs for short periods to affected areas.
Applying naturally cooling substances, such as aloe to affected areas before rinsing off in a shower.
Obstetric cholestasis= following delivery…
ensure that LFTs are carried out from 2 weeks postnatally (usually by the obstetrics team). If liver function:
- Has returned to normal, obstetric cholestasis can be confirmed as having resolved. Advise the woman that the condition has a 45–90% recurrence rate in future pregnancies.
- Is still abnormal, repeat the tests. If, after 8 weeks, the results are still abnormal, seek specialist advice from the obstetric team.
Ix that may be carried out for obstetric cholestasis?
Serum bile acids and liver function tests (LFTs).
Viral screening, for hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus.
Liver autoimmune screening for chronic active hepatitis and primary biliary cirrhosis (for example anti-smooth muscle and anti-mitochondrial antibodies).
Urine dipstick for proteinuria.
Blood pressure measurement.
Liver ultrasound.
Cardiotocography to assess fetal wellbeing.
Secondary care drug Tx for obstetric cholestasis symptomatic relief?
Ursodeoxycholic acid (sometimes with rifampicin as adjunct therapy).
Sedating antihistamines such as chlorphenamine or promethazine.
Vitamin K supplements.
When is intrahepatic cholestasis of pregnancy typically seen?
third trimester
pruritus, often in the palms and soles
no rash (although skin changes may be seen due to scratching)
raised bilirubin
intrahepatic cholestasis of pregnancy
Summarise Mx for intrahepatic cholestasis of pregnancy?
ursodeoxycholic acid is used for symptomatic relief
weekly liver function tests
women are typically induced at 37 weeks
Most common Cx of intrahepatic cholestasis of pregnancy?
stillbirth
Acute fatty liver of pregnancy?
rare complication which may occur in the third trimester or the period immediately following delivery
Features of acute fatty liver of pregnancy?
abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
Ix for acute fatty liver of pregnancy?
ALT is typically elevated e.g. 500 u/l
Mx of acute fatty liver of pregnancy?
support care
once stabilised delivery is the definitive management
What liver syndromes may be exacerbated during pregnancy?
Gilbert’s and Dubin-Johnson syndrome
What is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelets
Causes of jaundice in pregnancy?
- intrahepatic cholestasis of pregnancy
- acute fatty liver of pregnancy (rare)
- HELLP
- Gilbert’s, Dubin-Johnson syndrome, may be exacerbated during pregnancy
What is cardiotocography (CTG)?
records pressure changes in the uterus using internal or external pressure transducers
What does CTG stand for?
cardiotocography
Normal fetal heart rate?
varies between 100-160 /min
Cardiotocography= baseline bradycardia?
HR <100/min
Cardiotocography= baseline bradycardia causes?
Increased fetal vagal tone, maternal beta-blocker use
Cardiotocography= baseline tachycardia?
HR >160/min
Cardiotocography= baseline tachycardia causes?
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
Cardiotocography= loss of baseline variability?
< 5 beats / min
Cardiotocography= loss of baseline variability causes?
prematurity, hypoxia
Cardiotocography= early deceleration?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Cardiotocography= early deceleration causes?
Usually an innocuous feature and indicates head compression
Cardiotocography= late deceleration?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Cardiotocography= late deceleration causes?
Indicates fetal distress e.g. asphyxia or placental insufficiency
Cardiotocography= variable decelerations?
HR independent of contractions
Cardiotocography= variable decelerations causes?
may indicate cord compression
Most common cause of early-onset severe infection in neonatal period?
group B strep
GBS?
group B strep
What % of mothers have group B strep (GBS) present in their bowel flora and may therefore be thought of as ‘carriers’?
20-40%
How may neonate get group b strep?
Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.
RFS for group B strep (GBS) infection?
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
Should pregnant women be offered group b strep screening?
no not routinely; maternal request is not an indication
What if women has had GBS (group B strep) detected in a previous pregnancy?
should be informed that their risk of maternal GBS carriage in this pregnancy is 50%.
They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
If women need swabs for group B strep (eg. GBS detected in previous pregnancy) then when should this be offered?
at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
When should intrapartum antibiotic prophylaxis (IAP) for group b strep be offered?
- GBS detected in previous pregnancy
- previous baby with early or late onset GBS disease
- all women in preterm labour regardless of GBS status
- women with a pyrexia during labour (>38ºC)
What Abx should be offered for intrapartum antibiotic prophylaxis (IAP) for group b strep if indicated?
benzylpenicillin
antibiotic of choice for GBS prophylaxis
benzylpenicillin
Induction of labour?
where labour is started artificially
around 20% pregnancies
Indications for induction of labour?
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
maternal medical problems:
- diabetic mother > 38 weeks
- pre-eclampsia
- obstetric cholestasis
intrauterine fetal death
Bishop score?
used to help assess whether indication of labour will be required
Bishop score= how is it calculated?
1) cervical position= posterior (0), intermediate (1), anterior (2)
2) cervical consistency= firm (0), intermediate (1), soft (2)
3) cervical effacement= 0-30% (0), 40-50% (1), 60-70% (2), 80% (3)
4) cervical dilation= <1cm (0), 1-2cm (1), 3-4cm (2), >5cm (3)
5) fetal station= -3 (0), -2 (1),
-1 or 0 (2), +1 or +2 (3)
numbers in brackets is the points
Bishop score <5?
labour unlikely to start without induction
Bishop score >=8?
cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
Mx if Bishop score is 6 or less?
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
Mx if Bishop score 7 or more?
amniotomy and an intravenous oxytocin infusion
Possible methods of induction of labour?
- membrane sweep
- vaginal prostaglandin E2 (PGE2) aka dinoprostone
- oral prostaglandin E1
aka misoprostol - maternal oxytocin infusion
- amniotomy (breaking of waters)
- cervical ripening balloon
Induction of labour= membrane sweep?
involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit
membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction
prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping
Prior to the formal induction of labour, women should be offered what?
vaginal exam for membrane sweeping
regarded as an adjunct rather than an actual method of induction
Induction of labour= vaginal prostaglandin E2 (PGE2)
also known as…
dinoprostone
Induction of labour= oral prostaglandin E1
also known as…
misoprostol
Induction of labour= cervical ripening balloon?
passed through the endocervical canal and gently inflated to dilate the cervix
Cx of induction of labour?
uterine hyperstimulation
Cx of induction of labour= uterine hyperstimulation?
prolonged and frequent uterine contractions - sometimes called tachysystole
Cx of induction of labour= uterine hyperstimulation- potential consequences?
intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
uterine rupture (rare)
Cx of induction of labour= uterine hyperstimulation- Mx?
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
consider tocolysis
Stages of labour?
stage 1
stage 2
stage 3
Stage 1 of labour definition?
from the onset of true labour to when the cervix is fully dilated
Stage 2 of labour definition?
from full dilation to delivery of the fetus
Stage 3 of labour definition?
from delivery of fetus to when the placenta and membranes have been completely delivered
Stage 1 of labour= in a primigravida this typically lasts how long?
10-16hrs
How many phases are in stage 1 of labour?
2
latent phase and active phase
Stage 1 of labour= latent phase?
0-3cm dilation, normally takes 6hrs
Stage 1 of labour= active phase?
3-10cm dilation, normally 1cm/hr
Stage 1 of labour= how long does the latent phase normally take (0-3cm dilation)?
6hrs
Stage 1 of labour= how long does the active phase usually take (3-10cm dilation)?
1cm/hr
Stage 1 of labour= 90% of babies are what presentation?
vertex
During labour, the head enters the pelvis in what position?
occipito-lateral position
During labour, the head normally delivers in what position?
occipito-anterior
Position of baby head in labour?
Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.
Stage 2 of labour= what is the ‘passive second stage’?
refers to the 2nd stage but in the absence of pushing (normal)
Stage 2 of labour= what is the ‘active second stage’?
refers to the active process of maternal pushing
Stage 2 of labour= is it more or less painful than the 1st?
less painful than the 1st (pushing masks pain)
Stage 2 of labour= how long does it normally last?
1hr
Stage 2 of labour= what if it lasts longer than 1hr (can be left longer if epidural)?
consider Ventouse extraction, forceps delivery or c-section
Stage 2 of labour= what may be required following crowning?
episiotomy
What is crowning in labour?
when baby’s head is visible in vaginal opening
Stage 2 of labour= associated with what?
transient fetal bradycardia
Stage 3 of labour= how long does it last?
5-15mins
Stage 3 of labour= includes?
active management begins with delivery of anterior shoulder (i.e. 2nd stage, crowning in multip) with injection of syntocinon
Brandt-Andrews method: elevate uterus to separate placenta
examine placenta, membrane, cord (normal = 1 vein, 2 arteries)
examine perineum
mean blood loss < 200ml
Stage 3 of labour= mean blood loss?
<200ml
Stage 3 of labour= placenta, membrane and cord includes what vessels?
1 vein, 2 arteries
Active Mx of the 3rd stage of labour consists of what?
use of uterotonics
clamping and cutting of the cord
controlled cord traction
Stage 3 of labour= active management begins with delivery of anterior shoulder (i.e. 2nd stage, crowning in multip) with…
injection of syntocinon
Stage 3 of labour= Brandt-Andrews method?
elevate uterus to separate placenta
Rate of progression of labour depends on what?
whether a woman is a primip or not:
primip: 1 cm per 2 hours
multip: 1 cm per hour
The process of labour is monitored using what?
partogram
When is progress of labour monitored?
started at 3cm dilation
Monitoring progress of labour? (4)
fetal heart auscultation (every 15 mins)
maternal observations:
- heart rate (every hour)
- BP and temperature (every 4 hours)
contractions (every 30 mins: frequency, strength, regularity)
PV exam (every 4 hours)
- cervical dilation
- presenting part
- descent of the fetal head relative to the ischial spines
Monitoring progress in labour= On the partogram there is an ????? line. Failure of the cervix to progressively dilate with time leads to the readings crossing to the right of the alert and action lines.
On the partogram there is an ‘alert’ and ‘action’ line. Failure of the cervix to progressively dilate with time leads to the readings crossing to the right of the alert and action lines.
Monitoring progress of labour= on the partogram- what if the alert line is crossed?
then usually an amniotomy (artificial rupture of the membranes) is performed with a repeat examination in 2 hours.
Monitoring progress of labour= on the partogram- what if the action line is crossed?
usually results in the care being escalated to obstetric-led care if the woman is currently under midwife-led care.
Monitoring progress of labour= on the partogram- what are the options if the action line is crossed?
artificial rupture of the membranes
oxytocin infusion= stimulates uterine contractions
Oxytocin infusion if failure to progress in labour?
stimulates uterine contractions
CTG should be monitored to ensure fetal wellbeing
an epidural is also sometimes offered at this point
started at a low rate and titrated up at intervals of around 30 minutes
the aim is for ‘adequate contractions’: at least 3-5 contractions per 10 minutes, each contraction lasts 40-60 seconds and the contractions feel strong
Adequate contractions?
at least 3-5 contractions per 10 minutes, each contraction lasts 40-60 seconds and the contractions feel strong
Post term pregnancy?
extended to or beyond 42w
Potential consequences/Cx of post-term pregnancy to neonate?
Reduced placental perfusion
Oligohydramnios
Potential consequences/Cx of post-term pregnancy to mother?
Increased rates of intervention including forceps and caesarean section
Increased rates of labour induction
What can be used to screen for depression postpartum?
Edinburgh Postnatal Depression Scale
Edinburgh Postnatal Depression Scale to screen for depression?
- 10-item questionnaire, with a maximum score of 30
- indicates how the mother has felt over the previous week
- score > 13 indicates a ‘depressive illness of varying severity’
- sensitivity and specificity > 90%
- includes a question about self-harm
Types of postpartum mental health problems?
baby blues
postnatal depression
puerperal psychosis
‘Baby-blues’ is seen in what % of women?
60-70%
When is ‘baby blues’ typically seen?
3-7d following birth and is mroe common in primips
Features of ‘baby blues’?
anxious, tearful and irritable
Mx of ‘baby blues’?
reassurance and support, the health visitor has a key role
Postnatal depression affects what % of pregnant women?
10%
Most cases of postnatal depression start when?
within a month and typically peak at 3m
Features of postnatal depression?
similar to depression seen in other circumstances
Mx of postnatal depression?
reassurance and support are important
CBT may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant
What antidepressant is best avoided for postpartum depression due to a long half-life?
fluoxetine
What % of pregnant women are affected by puerperal psychosis?
0.2%
Onset of puerperal psychosis?
onset usually within 2-3 weeks following birth
Features of puerperal psychosis?
severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Mx of puerperal psychosis?
Admission to hospital is usually required, ideally in a Mother & Baby Unit
There is around a 25-50% risk of recurrence following future pregnancies
List 6 causes of nipple discharge?
- physiological
- galactorrhoea
- hyperprolactinaemia
- mammary duct ectasia
- carcinoma
- intraductal papilloma
Nipple discharge= physiological?
during breast feeding
Nipple discharge= galactorrhoea?
Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated
Nipple discharge= hyperprolactinaemia?
Commonest type of pituitary tumour
Microadenomas <1cm in diameter
Macroadenomas >1cm in diameter
Pressure on optic chiasm may cause bitemporal hemianopia
Nipple discharge= mammary duct ectasia?
Dilatation breast ducts.
Most common in menopausal women
Discharge typically thick and green in colour
Most common in smokers
Nipple discharge= carcinoma?
Often blood stained
May be underlying mass or axillary lymphadenopathy
Nipple discharge= intraductal papilloma?
Commoner in younger patients
May cause blood stained discharge
There is usually no palpable lump
Assessment of pts with nipple discharge?
- examine breast & determine whether there is a mass lesion present
- all mass lesions should undergo Triple assessment
Reporting of investigations= Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code. What is the code?
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
Management of non malignant nipple discharge?
Exclude endocrine disease
Nipple cytology unhelpful
Smoking cessation advice for duct ectasia
For duct ectasia with severe symptoms, total duct excision may be warranted.
Alpha-fetoprotein (AFP) is a protein produced by what?
developing fetus
Causes of increased AFP?
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
Causes of decreased AFP?
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
Amniocentesis is a procedure used in what?
prenatal diagnosis
When may amniocentesis be offered?
after screening tests have indicated a high risk of fetal abnormality or in women considered to be at high risk, for example if > 35 years old.
How is amniocentesis performed?
Around 20 ml of fluid is removed by transabdominal needle under ultrasound guidance. Fetal cells present in the amniotic fluid are then studied to aid the diagnosis of a number of conditions.
When is amniocentesis usually performed?
between 15-20 weeks (typically 16 weeks)
Risk of fetal loss in amniocentesis?
0.5%
Karyotype results form amniocentesis typically take how long?
3w
How accurate is amniocentesis?
the karyotype may be wrong in 1/1000 cases due to maternal cells being present
What conditions may be diagnosed by amniocentesis?
neural tube defects (raised AFP levels in the amniotic fluid)
chromosomal disorders
inborn errors of metabolism
Postnatal depression is defined as
developing up to one year after birth.
If a woman being treated for depression becomes pregnant, the risks of maternal relapse should be considered before
stopping or switching antidepressant treatment
Antidepressants can be used while trying to conceive and at any stage of pregnancy if clinically indicated and should not be withheld on the basis of
pregnancy/planning a pregnancy
Antenatal care= when should folic acid be given and what does?
folic acid 400mcg before conception until 12 weeks
Certain women may require higher doses (women who take antiepileptics)
Why should folic acid be taken before conception until 12w?
reduce the risk of neural tube defects
Is iron supplements recommended for antenatal care?
not offered routinely
Should vit A be given in antenatal care?
NO
(intake above 700 micrograms) might be teratogenic. Liver is high in vitamin A so consumption should be avoided
Should vitamin D be recommended for antenatal care?
yes
‘women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement’.
Particular care should be taken with higher risk women (i.e. those with darker skin or who cover their skin for cultural reasons)
Antenatal care: advice when it comes to alcohol?
no alcohol at all
‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.’
Antenatal care: advice about smoking?
risks of smoking including low birthweight and preterm birth should be discussed
NRT may be used but women must have stopped smoking and risks/benefits need to be discussed
neither varenicline nor bupropion should be offered to pregnant or breastfeeding women
What stop smoking meds are allowed in pregnancy?
NRT but risks and benefits need discussed
varenicline and bupropion should be offered to pregnant or breastfeeding women
Antenatal care: what foods to avoid due to food-acquired infections?
listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
salmonella: avoid raw or partially cooked eggs and meat, especially poultry
Antenatal care: advice about work?
inform women of their maternity rights and benefits
for the majority of women it is safe to continue working. Women should be asked whether they work. The Health and Safety Executive should be consulted if there are any concerns about possible occupational hazards during pregnancy
Antenatal care: advice about air travel during pregnancy?
women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel
women with
uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks
associated with increased risk of venous thromboembolism
wearing correctly fitted compression stockings is effective at reducing the risk
Up to what gestation are pregnant women allowed to fly?
women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel
women with
uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks
Antenatal care: advice about prescribed medicines?
avoid unless the benefits outweigh the risks
Antenatal care: advice about over the counter medicines?
should be used as little as possible during pregnancy
Antenatal care: advice about complimentary therapies?
‘Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy’
Antenatal care: advice about exercise in pregnancy?
women should be informed that beginning or continuing moderate exercise is not associated with adverse outcomes
certain activities should be avoided e,g, high-impact sports where there is a risk of abdominal trauma and scuba diving
Antenatal care: advice about sexual intercourse?
not known to be associated with any adverse outcomes
1st line options for nausea and vomiting in pregnancy?
natural remedies - ginger and acupuncture on the ‘p6’ point (by the wrist) are recommended by NICE
antihistamines should be used first-line= promethazine
All women should be informed at booking appointment about the importance for their own and their baby’s health of maintaining adequate….
D stores during pregnancy and whilst breastfeeding’
Vitamin D in antenatal care?
‘All pregnant and breastfeeding women should take a daily supplement containing 10micrograms of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy’
Vitamin D should be particularly recommended in who?
women at risk (e.g. Asian, obese, poor diet)
How many antenatal visits in womens 1st pregnancy if uncomplicated?
10
How many antenatal visits if not first pregnancy and it is uncomplicated?
7
Do women need to be seen by a consultant if they are pregnant?
not unless it is complicated
Antenatal care timetable= what is done at 8-12w (ideally <10w)?
Booking visit:
- general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
- BP, urine dipstick, check BMI
Booking bloods/urine:
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- hepatitis B, syphilis
- HIV test is offered to all women
- urine culture to detect asymptomatic bacteriuria
Antenatal care timetable= what is done at 10-13+6 weeks?
Early scan to confirm dates, exclude multiple pregnancy
Antenatal care timetable= what is done at 11-13+6 weeks?
Down’s syndrome screening including nuchal scan
Antenatal care timetable= what is done at 16 weeks?
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
Antenatal care timetable= what is done at 18-20+6 weeks?
Anomaly scan
Antenatal care timetable= what is done at 25 weeks (only if primip)?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Antenatal care timetable= what is done at 28 weeks?
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
Antenatal care timetable= what is done at 31 weeks (only if primip)?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Antenatal care timetable= what is done at 34 weeks?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Second dose of anti-D prophylaxis to rhesus negative women
Information on labour and birth plan
Antenatal care timetable= what is done at 36 weeks?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
Antenatal care timetable= what is done at 38 weeks?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Antenatal care timetable= what is done at 40 weeks (only if primip)?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Discussion about options for prolonged pregnancy
Antenatal care timetable= what is done at 41 weeks?
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
Discuss labour plans and possibility of induction
Antenatal care timetable= what is routine care?
BP, urine dipstick, symphysis-fundal height (SFH)
Antenatal care timetable= what is done at booking visit?
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Antenatal care timetable= what is done at the booking bloods and urine?
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
Antenatal care timetable= when is the booking visit and booking bloods/urine done?
8-12w (ideally <10w)
Antenatal care timetable= when is the early scan to confirm the dates and exclude multiple pregnancy?
10-13+6 weeks
Antenatal care timetable= when is the Down’s syndrome screening down incl. nuchal scan?
10-13+6w
Antenatal care timetable= when is Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron and
Routine care: BP and urine dipstick?
16w
Antenatal care timetable= when is the anomaly scan done?
18-20+6w
Antenatal care timetable= when do women get Routine care: BP, urine dipstick, symphysis-fundal height (SFH)?
16w (NO SFH)
25w (only if primip)
28w
31w (only if primip)
34w
36w
38w
40w
41w
Antenatal care timetable= if Hb <10.5g/dl consider iron; when?
28w
Antenatal care timetable= when is 1st dose of anti-D prophylaxis given to rhesus negative women?
28w
Antenatal care timetable= when is the 2nd dose of anti-D prophylaxis given to rhesus negative women?
34w
Antenatal care timetable= when is info on labour and birth plan given?
34w
Antenatal care timetable= when is presentation checked and ECV offered if indicated?
36w
Antenatal care timetable= when is info on breast feeding, vit K and baby blues given?
36w
Antenatal care timetable= when is discussion about options for prolonged pregnancy given?
40w (only if primip)
Antenatal care timetable= when is labour plans and possibility of induction discussed?
41w
Antenatal care timetable= when are does of anti-D prophylaxis given to rhesus negative women if indicated?
28 & 34w
evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’
What conditions are all pregnant women offered screening for?
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
What conditions should pregnant women offered screening for depending on the history?
Placenta praevia
Psychiatric illness
Sickle cell disease
Tay-Sachs disease
Thalassaemia
What conditions should not be screened for in pregnancy?
Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis
What is a biophysical profile?
antenatal ultrasound test which assesses:
- amniotic fluid volume
- fetal tone
- fetal activity
- fetal breathing movements
- reactivity of the heart
Standard test to screen for Down’s syndrome?
Combined test
Down’s syndrome screening= when should the combined test be done?
11-13+6w
Down’s syndrome screening= combined test includes what?
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
Down’s syndrome screening= combined test results that suggest Down’s?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Down’s syndrome screening= combined test results that suggest trisomy 18 (Edward syndrome) and 13 (Patau syndrome)?
HCG lower than in downs, ↓ PAPP-A, thickened nuchal translucency
Down’s syndrome screening= when is the quadruple test offered?
between 15 - 20 weeks
(so if book later in pregnancy)
Down’s syndrome screening= tests to screeen?
- combined test if between 11-13+6w (standard)
- quadruple if 15-20w (if book in late)
Down’s syndrome screening= what does the quadruple test include?
alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A
Down’s syndrome screening= quadruple test results that suggest Down’s syndrome?
AFP= ↓
Unconjugated oestriol= ↓
HCG= ↑
Inhibin A= ↑
Down’s syndrome screening= quadruple test results that suggest Edward’s syndrome?
AFP= ↓
Unconjugated oestriol= ↓
HCG= ↓
Inhibin A= ↔
Down’s syndrome screening= quadruple test results that suggest neural tube defects?
AFP= ↑
Unconjugated oestriol= ↔
HCG= ↔
Inhibin A= ↔
Quadruple test=
AFP= ↑
Unconjugated oestriol= ↔
HCG= ↔
Inhibin A= ↔
?neural tube defects
Quadruple test=
AFP= ↓
Unconjugated oestriol= ↓
HCG= ↓
Inhibin A= ↔
? Edwards syndrome
Quadruple test=
AFP= ↓
Unconjugated oestriol= ↓
HCG= ↑
Inhibin A= ↑
? downs syndrome
Combined test=
↑ HCG,
↓ PAPP-A,
thickened nuchal translucency
? downs
Combined test=
lower HCG,
↓ PAPP-A,
thickened nuchal translucency
?Edwards or patau
Down’s syndrome screening= both the combined tests and quadruple tests return what type of results?
either a ‘lower chance’ or ‘higher chance’ result
‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
‘higher chance’: 1 in 150 chance or less e.g. 1 in 100
Down’s syndrome screening= what if results from combined or quadruple test comes back as a ‘higher chance’?
offered second screening test (NIPT) or diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)
Down’s syndrome screening= what if results from combined or quadruple test comes back as a ‘higher chance’ - what is the preferred next choice?
NIPT
Given the non-invasive nature of and extremely high sensitivity and specificity
Down’s syndrome screening= NIPT?
analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation
What is folic acid converted to?
tetrahydrofolate (THF)
Good sources of folic acid?
green leafy vegetables
Function of folic acid?
THF (what folic acid is converted to) plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
Causes of folic acid deficiency?
phenytoin
methotrexate
pregnancy
alcohol excess
Consequences of folic acid deficiency?
macrocytic, megaloblastic anaemia
neural tube defects
Prevention of neural tube defects (NTD) during pregnancy?
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take how much folic acid?
5mg (normal recommended is 400mcg)
What women are considered high risk for NTD and are recommended to take 5mg folic acid instead of 400mcg?
either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
Gravidity (Gravida)?
number of pregnancies
Parity (Para)?
number of deliveries that have progressed to a viable gestational age (24w) regardless of the number of offspring per pregnancy
Gravida vs Para?
Gravida (G) refers to the number of times a woman has been pregnant, regardless of the outcome.
Para (P) refers to the number of pregnancies that have resulted in the birth of potentially viable offspring, where viability is defined by the local standards, typically around 24 weeks of gestation.
Gravida and Parity in the case of twins?
The pregnancy is counted as one gestational event, and the number of viable offspring (in this case, two from a single pregnancy) does not affect the Para count. Para is incremented by one for each pregnancy that results in a birth (or births), rather than by the number of babies born. Thus, a woman who gives birth to twins in her first pregnancy would be G1P1, not G1P2.
G3P2?
This notation indicates that a woman has been pregnant three times, and two of these pregnancies have resulted in the birth of viable offspring. The implication is that there was one pregnancy that did not result in a viable birth, which could be due to a miscarriage.
G2P1?
This denotes that a woman has been pregnant twice. Out of these, one pregnancy led to the birth of one or more viable offspring, while the other might have ended in a miscarriage or was a pregnancy not yet carried to term (if she’s currently pregnant).
G5P3?
This means the woman has been pregnant five times and has had three pregnancies that resulted in the birth of viable offspring. The remaining two pregnancies might have ended in miscarriages or were ectopic pregnancies, for example.
Pregnant women are screened for anaemia at:
the booking visit (often done at 8-10 weeks), and at
28 weeks
NICE use the following cut-offs to determine whether a woman should receive oral iron therapy?
First trimester= < 110 g/L
Second/third trimester= < 105 g/L
Postpartum= < 100 g/L
1st trimester weeks?
conception to 12w
2nd trimester weeks?
13-27w
3rd trimester weeks?
28-40w
Mx of anaemia in pregnancy?
oral ferrous sulfate or ferrous fumarate
treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
treatment should be continued for ??? after iron deficiency is corrected to…
3m
allow iron stores to be replenished
Physiological changes during pregnancy?
Progesterone, a potent muscle relaxant, is released from both the corpus luteum (first 8 weeks) and placenta (after 8 weeks). This has profound effects on the cardiovascular and gastrointestinal systems.
Pregnancy is a hypercoagulable state and also causes a physiological anaemia. These physiological changes underly many of the presenting symptoms of pregnancy.
Within the first trimester, pregnant women typically present with an onset of?
Amenorrhoea
Nausea
Vomiting
Breast enlargement and tenderness, veins may engorge and become prominent
Fatigue
Increased skin pigmentation (face, linea alba, areola)
Throughout pregnancy, women may suffer from the following?
Palpitations and syncope
Increased sweating
Urinary frequency (caused by the foetal head pressing on the bladder)
Back pain (commoner in the third trimester)
Breathlessness
Constipation and gastro-oesophageal reflux disease (caused by general stasis of the gastrointestinal tract)
Varicose veins and haemorrhoids (caused by increased venous distensibility)
Spider angiomas
Palmar erythema
Ankle oedema
Carpal tunnel syndrome
Leg cramps
Itchy rashes
Food cravings and aversions
The uterus will increase in size over the course of the pregnancy - and can be approximated by physical examination or measured by ultrasound. It is often compared to the size of fruit:
Between 6-8 weeks the uterus is the size of a small pear
Between 8-10 weeks the uterus is the size of an orange
Between 10-12 weeks the uterus is the size of a grapefruit
After the 12th week, the uterus should be palpable just above the pubic symphysis
After the 16th week, the uterus should be palpable between the pubic symphysis and the umbilicus.
Between the 20th and 24th week, the uterus should be palpable by the umbilicus.
By 36 weeks the uterus should be palpable just below the ribs.
After 36 weeks, this is lower as the head of the foetus descends towards the pelvis
Physical examination findings in pregnancy?
The cervix softens and may look bluish on examination
There may be signs pertaining to the symptoms as described above (e.g. pigmentation, peripheral oedema) that may be elicited on physical examination
Pregnancy can be confirmed by one of four tests?
Urine hCG (positive 9 days after fertilisation)
Serum hCG
Ultrasound of the foetus
Identification of foetal heart rate
Obese women, and their unborn children, are at an increased risk of a number of complications during pregnancy and labour. Obesity is usually defined as a body mass index (BMI)…
> = 30 kg/m² at the first antenatal visit.
Obesity in pregnancy= maternal risks?
miscarriage
venous thromboembolism
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
postpartum haemorrhage
wound infections
There is also a higher caesarean section rate.
Obesity in pregnancy= fetal risks?
congenital anomaly
prematurity
macrosomia
stillbirth
increased risk of developing obesity and metabolic disorders in childhood
neonatal death
Explain to women with a BMI of 30 or more at the booking appointment how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to
reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy
Mx of obesity in pregnancy?
obese women should take 5mg of folic acid, rather than 400mcg
all obese women (>=30 BMI) should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
if the BMI >= 35 kg/m²
women should give birth in a consultant-led obstetric unit
if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made
Women with uncomplicated pregnancies are usually managed by who?
in the community by a midwife
Routine antenatal care includes:
10 antenatal appointments for nulliparous women or 7 antenatal appointments for parous women.
2 ultrasound scans — a ‘dating scan’ (between 11+2 weeks and 14+1 weeks) and a ‘fetal anomaly scan’ (between 18+0 weeks and 20+6 weeks).
The risks, benefits, and limitations of NHS screening programmes in pregnancy (including infectious disease screening [HIV, syphilis, and hepatitis B], sickle cell and thalassaemia screening, and screening for fetal anomalies) should be discussed and the woman advised that they can
accept or decline any part of any of these.
Advice on staying healthy during pregnancy should be provided, including discussion on:
Immunization for flu, whooping cough, and other infections such as COVID-19.
Infections that can impact on the baby in pregnancy or during birth (such as group B streptococcus).
Reducing the risk of infections.
Safe use of medicines and health supplements.
Mental health.
Lifestyle including nutrition and diet, physical activity, smoking, alcohol consumption, and recreational drug use.
Sleep position after 28 weeks of pregnancy.
Travel including air travel.
Occupation.
Assessment for risk of gestational diabetes, pre-eclampsia, fetal growth restriction, venous thromboembolism, and female genital mutilation should be carried out. Including…
Blood pressure measurement and a urine dipstick test for proteinuria should be offered at each appointment.
Advice on the symptoms of pre-eclampsia and when to seek immediate medical help should be discussed with all pregnant women.
Antenatal care: From 25 weeks of pregnancy?
The symphysis–fundal height (to identify small- or large-for-gestational-age infants) should be measured and plotted.
The baby’s movements should be discussed and the woman advised to contact maternity services at any time of day or night if she has any concerns about her baby’s movements or notices reduced movements.
Antenatal care: At 28 weeks of pregnancy?
routine antenatal anti-D prophylaxis should be offered to rhesus-negative women
Antenatal care: From 36 weeks of pregnancy?
abdominal palpation should be offered to check the position of the baby – if breech presentation is suspected, an ultrasound scan should be arranged to determine position.
Antenatal care: From 38 weeks of pregnancy?
prolonged pregnancy and options on how to manage this should be discussed
Reassure the woman that varicose veins are common in pregnancy, are not harmful to the baby, and often improve considerably after pregnancy.
Consider treatment with
compression stockings; these may improve the symptoms but will not prevent varicose veins from emerging.
Advise pregnant women who have vaginal discharge that this is common during pregnancy, but if it is accompanied by symptoms such as itching, soreness, an unpleasant smell or pain on passing urine, there may be an infection that needs to be investigated and treated. How?
Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause.
If a sexually transmitted infection is suspected, offer the woman access to testing, treatment, and support. This service may be provided by general practice (where appropriate training and facilities exist), community sexual and reproductive health services, or a genito-urinary medicine (GUM) clinic.
For women with pregnancy-related pelvic girdle pain?
consider referral to physiotherapy services for exercise advice and/or a non-rigid lumbopelvic belt.
Pregnancy= haemorrhoids?
Offer the woman advice to minimize constipation and straining= increasing daily fibre and fluid intake and taking regular exercise can help relieve constipation
Advise the woman about perianal hygiene
No topical haemorrhoidal preparations are licensed for use during pregnancy and women wishing to use these products should be made aware of the lack of data regarding pregnancy outcomes.
Antigens on RBC?
ABO system
Rhesus system= D antigen
What % of mothers are rhesus negative (Rh -ve)?
15%
Why can it be bad if mother is rhesus -ve?
if a Rh -ve mother delivers a Rh +ve child, a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
in later pregnancies these can cross the placenta and cause haemolysis in fetus
this can also occur in the 1st pregnancy due to leaks
Prevention of harm to baby if mother is Rh-ve?
test for D antibodies in all Rh -ve mothers at booking
give anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks)
anti-D is prophylaxis - once sensitization has occurred it is irreversible
if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
What if mother is Rh -ve and an event occurs in 2/3rd trimester?
give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
Kleihauer test?
determines proportion of fetal RBCs present and so how much anti-D to give
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations?
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
Tests for all babies born to Rh -ve mothers?
mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
Affects to fetus in Rh -ve pregnancy?
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
treatment: transfusions, UV phototherapy
The symphysis-fundal height (SFH) is measured from where?
top of the pubic bone to the top of the uterus in centimetres
Symphysis-fundal height should match what?
the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
incidence of multiple pregnancies?
twins: 1/105
triplets: 1/10,000
Twins can be what?
dizygotic or monozygotic
80% are dizygotic
Dizygotic twins?
non-identical, develop from two separate ova that were fertilized at the same time
Monozygotic twins?
identical, develop from a single ovum which has divided to form two embryos
Monoamniotic monozygotic twins are associated with what?
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
Twin-to-twin transfusion syndrome (in monoamniotic monozygotic twins)?
recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
Predisposing factors for dizygotic twins?
previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean
Antenatal complications associated with twins?
polyhydramnios
pregnancy induced hypertension
anaemia
antepartum haemorrhage
Fetal Cx associated with twins?
perinatal mortality (twins * 5, triplets * 10)
prematurity (mean twins = 37 weeks, triplets = 33)
light-for date babies
malformation (*3, especially monozygotic)
Labour Cx associated with twins?
PPH increased
malpresentation
cord prolapse, entanglement
Mx for twin pregnancies?
rest
ultrasound for diagnosis + monthly checks
additional iron + folate
more antenatal care (e.g. weekly > 30 weeks)
precautions at labour (e.g. 2 obstetricians present)
75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
A nuchal scan is performed at what gestation?
11-13w
Causes of an increased nuchal translucency? (on 11-13w nuchal scan)?
Down’s syndrome
congenital heart defects
abdominal wall defects
Causes of hyperechogenic bowel (fetal bowel appears brighter than normal on USS)?
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
RFs for ovarian ca?
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations: early menarche, late menopause, nulliparity
Placental abruption?
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
How common is placental abruption?
1/200 pregnancies
Cause of placental abruption?
not known but associated factors:
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
Clinical features of placental abruption?
shock out of keeping with visible blood loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
Shock out of keeping with visible blood loss?
placental abruption (blood may be concealed if cervical os closed)
RFs for placental abruption (ABRUPTION)?
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Polyhydramnios?
presence of excessive amniotic fluid
When is polyhydramnios detected?
when a uterus is large for dates or it is difficult to feel the fetal parts on palpation
Causes of polyhydramnios?
multiple pregnancy
poorly controlled maternal diabetes mellitus
tracheo-oesophageal fistula
duodenal atresia, oesophageal atresia
anencephaly (due to impaired swallowing reflex)
chorioangioma of the placenta
rhesus haemolytic disease
Cx of polyhydramnios?
umbilical cord prolapse=
polyhydramnios may stop the fetus engaging with the pelvis leaving room for the umbilical cord to prolapse out of the uterus before the presenting part
placental abruption
prematurity
maternal Cx
Maternal Cx of polyhydramnios?
increased dyspnoea due to pressure on the diaphragm
increased risk of urinary tract infections
Reduced fetal movements can represent what?
fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero.
Reduced fetal movements may reflect a risk of what?
still birth
fetal growth restriction
placental insufficiency
The first onset of recognised fetal movements is known as?
quickening
When do the first onset of fetal movements (quickening) usually occur?
18-20w gestation and increase until 32w then the frequency of movement plateaus
When do the first onset of fetal movements (quickening) usually occur in multiparous women?
sooner, 16-18w
Towards the end of pregnancy, should fetal movements reduce?
NO
How is reduced fetal movements (RFM) defined?
RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.
but mothers will recognise a pattern to the movements and nature which is very variable so they will know
Fetal movements should be established by what gestation?
24w
if no movement after 24w worrying
RFs for reduced fetal movements?
- posture
- distraction
- placental position
- medication
- fetal position
- body habitus
- amniotic fluid volume
- fetal size
RFs for reduced fetal movements= posture?
positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
RFs for reduced fetal movements= distraction?
Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
RFs for reduced fetal movements= placental position?
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
RFs for reduced fetal movements= medication?
Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
RFs for reduced fetal movements= fetal position?
Anterior fetal position means movements are less noticeable
RFs for reduced fetal movements= body habitus?
Obese patients are less likely to feel prominent fetal movements
RFs for reduced fetal movements= amniotic fluid volume?
Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
RFs for reduced fetal movements= fetal size?
Up to 29% of women presenting with RFM have a SGA fetus
Ix for reduced fetal movements if past 28w?
Initially, handheld Doppler should be used to confirm fetal heartbeat.
If no fetal heartbeat detectable, immediate ultrasound should be offered.
If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.
Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
Ix for reduced fetal movements if 24-28w?
handheld Doppler should be used to confirm presence of fetal heartbeat
Ix for reduced fetal movements if <24w and movements have previously been felt?
handheld Doppler
If fetal movements have not yet been felt by ??? weeks, onward referral should be made to a maternal fetal medicine unit.
24w
If RFM are recurrent, further investigations are also required to consider?
structural or genetic fetal abnormalities
Prognosis of reduced fetal movements (RFM)?
Concern regarding absent or reduced fetal movements stems for the potential for this presentation to represent fetal distress or impending demise. Between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis.
However, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication.
Eclampsia?
development of seizures in association pre-eclampsia
What is used to prevent seizures in pts with severe pre-eclampsia and Tx seizures once they develop (eclampsia)?
magnesium sulphate
Eclampsia= Mx of seizure?
Magnesium sulphate
should be given once a decision to deliver has been made
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
Eclampsia= magnesium sulphate dose?
IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Eclampsia= how long to give magnesium sulphate?
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Eclampsia= what to monitor whilst giving magnesium sulphate?
urine output, reflexes, respiratory rate and oxygen saturations as
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
1st line Mx for magnesium sulphate induced resp depression (eg. whilst treating eclampsia)?
calcium gluconate
Other important aspects of treating severe pre-eclampsia/eclampsia (as well as magnesium sulphate) include?
fluid restriction to avoid the potentially serious consequences of fluid overload
Small for Gestational Age (SGA)?
statistical definition; no universally agreed percentile, although 10th percentile often used; i.e. 10% of normal babies will be below tenth percentile; can be applied antenatally or postnatally.
Intrauterine Growth Restriction (IUGR)?
clinical diagnosis indicating that a fetus is not achieving its growth potential due to pathological reasons
Small for Gestational Age (SGA) vs Intrauterine Growth Restriction (IUGR)?
SGA= statistical definition
IUGR= clinical diagnosis
IUGR is a subset of SGA, meaning all IUGR babies are SGA, but not all SGA babies have IUGR
Causes of SGA?
incorrect dating, constitutionally small (normal) or an abnormal fetus
can by symmetrical or asymmetrical
What is meant by symmetrical causes of SGA?
fetal head circumference & abdominal circumference are equally small
What is meant by asymmetrical causes of SGA?
abdominal circumference slows relative to increase in head circumference
Causes of SGA= symmetrical (60%)?
Idiopathic
race (white > black > Asian)
sex (boy > girl)
Chromosomal and congenital abnormalities
Toxins: alcohol (FAS), cigarettes, heroin
Infection: CMV, parvovirus, rubella, syphilis, toxoplasmosis
Malnutrition
Causes of SGA= asymmetrical (40%)?
Placental insufficiency
Pre-eclampsia
Toxins: smoking, heroin
Chromosomal and congenital abnormalities
Management - symmetrical SGA?
most represent lower limits of normal range (>95% idiopathic)
fortnightly ultrasound growth assessment to demonstrate normal growth rate
try to detect any pathological cause:
check maternal blood for infections
search fetus carefully with ultrasound for markers of chromosomal abnormality - if present karyotype baby by cordocentesis
What infections may cause symmetrical SGA?
CMV, parvovirus, rubella, syphilis, toxoplasmosis
Management - asymmetrical SGA?
fortnightly ultrasound growth assessment to demonstrate normal growth rate
biophysical profile
Doppler waveforms from umbilical circulation: look for absent end-diastolic flow
consider daily CTGs
if sub-optimal results then consider delivery
Infertility affects around…
1 in 7 couples
Around 84% of couples who have regular sex will conceive within
1 yr
92% in 2yrs
Causes of infertility?
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
Basic Ix for infertility?
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
When is serum progesterone measured when Ix for infertility?
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21
Ix for infertility= serum progesterone <16 nmol/l?
Repeat, if consistently low refer to specialist
Ix for infertility= serum progesterone 16-30 nmol/l?
repeat
Ix for infertility= serum progesterone >30nmol/l?
indicates ovulation
What serum progesterone levels indicates ovulation?
> 30 nmol/l
Infertility= key counselling points?
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Infertility= when should semen analysis be performed?
after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour
Infertility= normal semen analysis results? (many different ranges but based on NICE values)
volume > 1.5 ml
pH > 7.2
sperm concentration > 15 million / ml
morphology > 4% normal forms
motility > 32% progressive motility
vitality > 58% live spermatozoa
Over 80% of couples in the general population will conceive within 1 year if the woman is
aged under 40 years and they have regular (every 2–3 days) unprotected sexual intercourse.
leading causes of infertility
are factors in the man causing infertility (30% of couples), ovulatory disorders (25% of couples), tubal damage (20% of couples), and uterine or peritoneal disorders (10% of couples).
No identifiable cause is identified in about 25% of couples.
The presence of factors in both the man and the woman has been reported in about 40% of infertile couples.
RFs for infertility?
increasing age, smoking, obesity, occupational risks, excessive alcohol consumption, and the use of certain prescription, over-the-counter, and recreational drugs.
Referral criteria for infertility?
varies…
For women younger than 36 years with normal history, examination, and investigations in both partners, referral should usually be considered if the couple has not conceived after 1 year.
Earlier referral should be offered if the woman is 36 years or over or if there is a known clinical cause of infertility or a history of predisposing factors.
Initial investigations in women for infertility?
mid-luteal phase progesterone (in all women to confirm ovulation), serum gonadotrophins (in women with irregular menstrual cycles), thyroid function tests (in women with symptoms of thyroid disease), prolactin measurement (in women with an ovulatory disorder, galactorrhoea, or a suspected pituitary tumour), and screening for chlamydia.
Initial investigations in men for infertility?
semen analysis and screening for chlamydia.
Fertility treatment falls into 3 main types?
Medical treatment to restore fertility, for example, the use of drugs (such as clomifene) to induce ovulation.
Surgical treatment to restore fertility, for example, laparoscopy for ablation of endometriosis and surgical correction of epididymal blockage in men with obstructive azoospermia.
Assisted reproduction techniques (any treatment that deals with means of conception other than vaginal intercourse), for example, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection.
Ovarian hyperstimulation syndrome (OHSS)?
is a potentially life-threatening complication of superovulation.
Cx of assisted conception
CP of Ovarian hyperstimulation syndrome (OHSS)?
Mild — abdominal bloating and mild abdominal pain.
Moderate — nausea and vomiting and increased abdominal discomfort.
Severe — oliguria, generalized oedema, abdominal pain and/or distension (caused by enlarged ovaries and acute ascites), and hydrothorax (occasionally).
Critical — oligo/anuria, tense ascites or large hydrothorax, thromboembolism, and acute respiratory distress syndrome.
What if women presents with S&S of Ovarian hyperstimulation syndrome (OHSS)?
Consider alternative diagnoses, such as complications of an ovarian cyst (torsion, haemorrhage), pelvic infection or abscess, intra-abdominal haemorrhage, ectopic pregnancy, bowel perforation, or appendicitis.
If OHSS is suspected, seek urgent advice from the specialist unit. The severity of OHSS can worsen over time, and even initially mild presentations should be kept under review.
complications that may occur after assisted conception include?
Ovarian hyperstimulation syndrome (OHSS)
Ectopic pregnancy
Pelvic infection
Multiple pregnancy
What medical Tx may be offered for infertility?
Clomifene (an anti-oestrogen drug) is an effective treatment for anovulation and may be used in selected women.
Gonadotrophins may be offered to women with clomifene-resistant anovulatory infertility. They are also effective in improving fertility in men with hypogonadotropic hypogonadism.
Pulsatile gonadotrophin-releasing hormone and dopamine agonists are other treatments that induce ovulation. Dopamine agonists can be considered for women with ovulatory disorders secondary to hyperprolactinaemia.
Surgical Tx to restore fertility?
Tubal microsurgery in women with mild tubal disease — tubal catheterization or cannulation improves the chance of pregnancy in women with proximal tubal obstruction.
Surgical ablation, or resection of endometriosis plus laparoscopic adhesiolysis in women with endometriosis.
Surgical correction of epididymal blockage in men with obstructive azoospermia — this is likely to restore patency of the duct and improve fertility.
Assisted reproduction techniques (any treatment that deals with means of conception other than vaginal intercourse) includes?
- Intrauterine insemination (IUI)
- In vitro fertilisation
- Intracytoplasmic sperm injection (ICSI)
- Donor insemination
- Oocyte donation
Assisted reproduction techniques= Intrauterine insemination (IUI)?
in this process, which is timed to coincide with ovulation, sperm is placed in the woman’s uterus using a fine plastic tube. Low doses of ovary-stimulating hormones (oral anti-oestrogens or gonadotrophins) might be given (stimulated IUI) to maximize pregnancy rates.
Assisted reproduction techniques= In vitro fertilization (IVF)?
involves retrieval of one or more ova combined with sperm and incubated for 2–3 days; the resultant embryo is then injected into the uterus via the cervix. This method is suitable for women who have blocked fallopian tubes, men with a minor degree of subfertility, and couples who have been diagnosed with unexplained infertility or have been unsuccessful with other techniques (such as ovulation induction or IUI).
Assisted reproduction techniques= Intracytoplasmic sperm injection (ICSI)?
involves injecting an individual sperm directly into the ovum to bypass natural barriers that prevent fertilization. The embryo is then transferred into the uterus. This method is suitable when the man has a very low sperm count or problems maintaining an erection and ejaculation (such as diabetes or spinal cord injury).
Assisted reproduction techniques= Donor insemination?
involves insemination of sperm, from a donor, into a woman via her vagina into the cervical canal or into the uterus itself (IUI). This method is considered when the man has no (or very few) sperm on testicular biopsy or surgical extraction, has had a vasectomy and reversal has failed or not been tried, or has an infectious disease (such as HIV), or where there is a high risk of transmitting a genetic disorder to the offspring. It is also considered in couples where there is no male partner.
Assisted reproduction techniques= Oocyte donation?
involves stimulation of the donor’s ovaries and collection of ova. The donated ova are then fertilized by the recipient’s partner’s sperm. After 2–3 days, the embryos are transferred to the uterus of the recipient via the cervix after hormonal preparation of the endometrium. This method is considered for women with ovarian failure (premature or after radiotherapy or chemotherapy); those with bilateral oophorectomy; those with gonadal dysgenesis, including Turner’s syndrome; and when the risk of transmitting a genetic disorder is high. It is also used in certain cases of IVF failure. Couples who have had successful IVF or ICSI may decide to donate their spare embryos to help other infertile couples (embryo donation).
On the ectocervix there is?
transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal
Ectocervix= Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in?
larger area of columnar epithelium being present on the ectocervix
Cervical ectropion?
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
Cervical ectropion may result in what features?
vaginal discharge
post-coital bleeding
Cervical ectropion Tx?
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
Features suggesting milk oversupply?
Suboptimal infant positioning and attachment= may not remove milk efficiently so suckles a lot, stimulating the breast to produce excessive milk.
Breastfeeding pattern:
- Moving the infant too early to the second breast before they have finished feeding from the first breast.
- Overstimulation due to excessive expression (by hand or pump) between breastfeeds.
The mother may describe:
- Breast fullness and possible engorgement or blocked ducts.
- A painful, forceful milk let-down reflex.
- Milk leakage and/or milk spraying from the opposite breast when feeding.
The infant may:
- Choke and splutter when let-down occurs.
- Clamp down on the nipple or pull off the breast during feeds.
- Have colic, or frequent explosive loose stools.
- Faltering growth if unable to feed adequately.
Features of low milk supply?
True maternal low milk supply is unusual, and there may be a subjective maternal perception of insufficient milk supply, if other causes have been excluded or are unlikely.
Insufficient access to the breast:
- Suggested by short or infrequent feeds, and/or no night feeds.
- Use of a dummy; or giving supplementary feeds other than breast milk may also contribute.
- Maternal depression, stress, and/or anxiety may result in a reduced response to infant feeding cues and a reduced frequency of feeds, which leads to reduced stimulation of milk production.
Suboptimal infant positioning and attachment:
- Suggested by nipple pain/trauma; frequent feeding more than every 2 hours; no long intervals between feeds; feeding for less than five minutes or longer than 40 minutes duration.
- The infant may be generally unsettled, have faltering growth, or show signs of dehydration.
Maternal prolactin deficiency:
- Causes of true low milk supply due to maternal prolactin deficiency may include drugs, thyroid disorders, retained placenta, alcohol use, and eating disorders.
Maternal anatomical conditions such as hypoplastic breasts causing a lack of glandular tissue, or a history of breast surgery.
What may cause itch in pregnancy?
pre-existing condition or a condition specific to pregnancy. The most common pregnancy-related causes of itch are:
- Obstetric cholestasis (also known as ‘intrahepatic cholestasis of pregnancy’) — which does not present with a rash.
- Polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis — all of which present with a rash.
Obstetric cholestasis is the main cause of itch without a rash in pregnancy. Features?
The itch (often severe) usually starts abruptly in the third trimester, is often more noticeable on the soles and palms but can occur anywhere on the body, and may be worse at night.
Obstetric cholestasis generally poses no risk to the pregnant woman. Although it is associated with an increased risk of stillbirth, for most women this appears to be only slightly raised above background rates with specialist management. Symptoms in the woman usually resolve spontaneously after delivery.
Any woman with suspected obstetric cholestasis should be referred to obstetrics for same-day investigation.
Itch in pregnancy= Polymorphic eruption of pregnancy usually occurs in the third trimester. It usually only affects the first pregnancy, and is more likely in women with a multiple pregnancy. Other features?
The rash is intensely itchy, and consists of pruritic urticarial papules that coalesce into plaques. Typically, it starts on the abdomen, but the umbilicus is usually spared. It may later develop into widespread non-urticated erythema, with eczematous lesions and vesicles.
It poses no serious risk to the woman or baby; symptoms last 4–6 weeks on average, and usually resolve immediately following delivery.
Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.
Itch in pregnancy= Atopic eruption of pregnancy commonly presents in the first trimester. It is more likely in women with a personal or family history of atopic eczema. Other features?
The rash is itchy and consists of eczematous, papular lesions.
Although it poses no serious risk to the woman, the child may be at increased risk of developing atopic eczema.
Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.
Itch in pregnancy= Pemphigoid gestationis is very rare. Features?
An intense itch often precedes the rash, which initially presents with erythematous urticarial papules and plaques on the abdomen (and nearly always the umbilicus), but may spread to cover the entire body and progress to form tense blisters.
The woman is likely to have exacerbations and remissions throughout pregnancy. It is associated with preterm birth and of the infant being small for gestational age. Pemphigoid gestationis spontaneously regresses after delivery. There is an approximately 10% chance of mild and transient skin lesions in the neonate.
Referral should be made to obstetrics for additional antenatal surveillance, and dermatology for treatment with topical or systemic corticosteroids.
Haemolytic disease of the newborn?
cause of haemolysis (red blood cells breaking down) and jaundice in the neonate. It is caused by incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus. The rhesus antigens on the red blood cells vary between individual. This is different to the ABO blood group system.
Within the rhesus group there are many different types of what?
antigens that can be present or absent depending on the persons blood type. The most important antigen within the rhesus blood group system is the rhesus D antigen.
When a woman that is rhesus D negative (does not have the rhesus D antigen) becomes pregnant, we have to consider the possibility that her child will be…
rhesus D positve (has the rhesus D antigen). It is likely at some point in the pregnancy the blood from the baby will find a way into her bloodstream. When this happens, the baby’s red blood cells display the rhesus D antigen. The mother’s immune system will recognise this rhesus D antigen as foreign and produce antibodies to the rhesus D antigen. The mother has then become sensitised to rhesus D antigens.
Usually, this sensitisation process does not cause problems during the first pregnancy (unless the sensitisation happens early on, such as during antepartum haemorrhage). But can during subsequent pregnancies.
Rhesus -ve mother has a Rhesus +ve baby so the mother has produced antibodies to the babies rhesus D antigen. Mother has now become sensitised to rhesus D antigens. Usually, this sensitisation process does not cause problems during the first pregnancy (unless the sensitisation happens early on, such as during antepartum haemorrhage). During subsequent pregnancies what happens?
the mother’s anti-D antibodies can cross the placenta into the fetus. If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack their own red blood cells. This leads to haemolysis, causing anaemia and high bilirubin levels. This leads to a condition called haemolytic disease of the newborn.
Differential diagnosis for bleeding in 1st trimester?
miscarriage
ectopic pregnancy=
the most ‘important’ cause as missed ectopics can be potentially life-threatening
implantation bleeding=
a diagnosis of exclusion
miscellaneous conditions=
- cervical ectropion
- vaginitis
- trauma
- polyps
Mx of bleeding >=6w gestation (or unknown)?
If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and the woman has bleeding she should be referred to an early pregnancy assessment service.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
Mx if bleeding <6w gestation?
ectopic pregnancy?
If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
- to return if bleeding continues or pain develops
- to repeat a urine pregnancy test after 7-10 days and to return if it is positive
- a negative pregnancy test means that the pregnancy has miscarried
Features of complete hydatidiform mole?
vaginal bleeding
uterus size greater than expected for gestational age
abnormally high serum hCG
ultrasound: ‘snow storm’ appearance of mixed echogenicity
Features of complete hydatidiform mole on USS?
‘snow storm’ appearance of mixed echogenicity
Causes of Delayed puberty with short stature?
Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome
Causes of Delayed puberty with normal stature?
polycystic ovarian syndrome
androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome
Endometrial hyperplasia?
an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types of endometrial hyperplasia?
simple
complex
simple atypical
complex atypical
Features of endometrial hyperplasia?
abnormal vaginal bleeding eg. intermenstrual
Mx of endometrial hyperplasia?
simple endometrial hyperplasia without atypia= high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
atypia= hysterectomy is usually advised
RF for endometrial hyperplasia?
tamoxifen
Uterine fibroids are sensitive to oestrogen and can therefore
grow during pregnancy
Fibroid degeneration?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.
Fibroid degeneration presents with what?
low-grade fever, pain and vomiting
Mx of fibroid degeneration?
conservatively with rest and analgesia and should resolve within 4-7 days.
Common long term complications of vaginal hysterectomy with antero-posterior repair include?
enterocoele and vaginal vault prolapse
What Cx may occur acutely following hysterectomy but not usually a chronic Cx?
urinary retention
The initial imaging modality for suspected ovarian cysts/tumours is ultrasound. The report will usually report that the cyst is either:
simple: unilocular, more likely to be physiological or benign
complex: multilocular, more likely to be malignant
Mx of ovarian enlargement (cyst/tumour)?
depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Ovarian enlargement (cyst/tumour) in premenopausal women?
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Ovarian enlargement (cyst/tumour) in postmenopausal women?
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
Ovarian hyperstimulation syndrome (OHSS) definition?
complication seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment
Ovarian hyperstimulation syndrome (OHSS) likely to be seen with what?
Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS
RCOG classification of Ovarian hyperstimulation syndrome (OHSS)= mild?
- Abdominal pain
- Abdominal bloating
RCOG classification of Ovarian hyperstimulation syndrome (OHSS)= moderate?
- As for mild
- Nausea and vomiting
- Ultrasound evidence of ascites
RCOG classification of Ovarian hyperstimulation syndrome (OHSS)= severe?
- As for moderate
- Clinical evidence of ascites
- Oliguria
- Haematocrit > 45%
- Hypoproteinaemia
RCOG classification of Ovarian hyperstimulation syndrome (OHSS)= critical?
- As for severe
- Thromboembolism
- Acute respiratory distress syndrome
- Anuria
- Tense ascites
Minor symptoms of pregnancy may include:
nausea/vomiting
tiredness
musculoskeletal pains
Antepartum haemorrhage is defined as bleeding after…
24w
Causes of bleeding in 1st trimester?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
Causes of bleeding in 2nd trimester?
Spontaneous abortion
Hydatidiform mole
Placental abruption
Causes of bleeding in 3rd trimester?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
Bleeding in pregnancy- alongside pregnancy related causes, conditions such as what should be excluded?
STI and cervical polyps
Bleeding in miscarriage?
Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.
Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.
Complete miscarriage - little bleeding
Bleeding in ectopic pregnancy?
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Bleeding in hydatidiform mole?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Bleeding in placental abruption?
Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed
*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
Bleeding in placental praevia?
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
Bleeding in vasa praevia?
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
Epilepsy in pregnancy?
The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus. All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.
Epilepsy in pregnancy= drugs?
aim for monotherapy
there is no indication to monitor antiepileptic drug levels
sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
Breast feeding in pt with epilepsy?
Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates
It is advised that pregnant women taking phenytoin are given what in the last month of pregnancy to prevent clotting disorders in the newborn?
vitamin K
Sodium valproate in pregnancy?
The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.
The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.
Galactocele generally occurs in women who?
have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast.
Galactocele vs abscess?
galactocele can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
Gestational thrombocytopenia ?
relatively common condition of pregnancy that results from a combination of dilution, decreased production and increased destruction of platelets. The latter is thought to be due to the increased work of the maternal spleen leading to mild sequestration.
Immune thrombocytopenia (ITP)?
autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.
Differentiating between ITP and gestational thrombocytopenia is difficult and often relies on a careful…
history
Gestational thrombocytopenia vs immune thrombocytopenia (ITP) ?
Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign. If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids and a diagnosis of ITP assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation.
Gestational thrombocytopenia vs immune thrombocytopenia (ITP) = is neonate affected?
Gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta. Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia.
What does HELLP stand for?
Hemolysis, Elevated Liver enzymes, and a Low Platelet count
What is HELLP syndrome?
It is a serious condition that can develop in the late stages of pregnancy. Whilst there is significant overlap with severe pre-eclampsia in terms of the features some patients present with no prior history so many specialists consider it a separate entity in its own right.
What % of pts with severe preeclampsia will go on to develop HELLP?
10-20%
Features of HELLP syndrome?
nausea & vomiting
right upper quadrant pain
lethargy
Ix for HELLP syndrome?
bloods: Hemolysis, Elevated Liver enzymes, and a Low Platelet
bloods: Hemolysis, Elevated Liver enzymes, and a Low Platelet
HELLP syndrome
Tx of HELLP syndrome?
delivery of baby
Who are offered hep B screening in pregnancy?
all pregnant women
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive what?
a complete course of vaccination + hepatitis B immunoglobulin
there is little evidence to suggest caesarean section reduces vertical transmission rates in what?
hep B
Can hep B be transmitted via breastfeeding?
NO
The aim of treating HIV positive women during pregnancy is to….
minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.
Factors what reduce vertical transmission (from 25-30% to 2%) of HIV in pregnancy?
- maternal antiretroviral therapy
- mode of delivery (caesarean section)
- neonatal antiretroviral therapy
- infant feeding (bottle feeding)
Is HIV screened for in pregnancy?
yes
Antiretroviral meds in pregnancy if HIV?
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
HIV in pregnancy= mode of delivery?
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
HIV in pregnancy= when can vaginal delivery be offered?
if viral load is less than 50 copies/ml at 36 weeks
HIV in pregnancy= what should be started 4hrs before c-section?
a zidovudine infusion
HIV in pregnancy= neonatal antiretroviral therapy?
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
Can women with HIV breastfeed?
NO
Human chorionic gonadotropin (hCG)?
hormone first produced by the embryo and later by the placental trophoblast. Its main role is to prevent the disintegration of the corpus luteum
How do hCG levels change in pregnancy?
hCG levels double approximately every 48 hours in the first few weeks of pregnancy. Levels peak at around 8-10 weeks gestation. Measurement of hCG levels form the basis of many pregnancy testing kits
Lochia?
the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
oligohydramnios?
reduced amniotic fluid
Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
Causes of oligohydramnios?
premature rupture of membranes
Potter sequence = bilateral renal agenesis + pulmonary hypoplasia
intrauterine growth restriction
post-term gestation
pre-eclampsia
Placenta accreta?
the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage.
RFs for placenta accreta?
previous c-section
placenta praevia
There are 3 types of placenta accreta, depending on what?
the degree of invasion
3 types of placenta accreta?
accreta
increta
percreta
Definition of placenta accreta?
chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
Definition of placenta increta?
chorionic villi invade into the myometrium
Definition of placenta percreta?
chorionic villi invade through the perimetrium
Way to remember placenta accreta, increta and percreta?
alphabetical order - more invasion
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium
Placenta praevia?
describes a placenta lying wholly or partly in the lower uterine segment
Placenta praevia= how common?
5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only
0.5%, therefore most placentas rise away from the cervix
Placenta praevia= associated factors?
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
Placenta praevia= clinical features?
shock in proportion to visible loss
NO pain
uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large
Shock in proportion to visible blood loss?
placenta praevia
Is placenta praevia painful?
NO
Is placental abruption painful?
YES
Diagnosis of placenta praevia?
digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal
ultrasound as it improves the accuracy of placental localisation and is considered safe
Grading of placenta praevia?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
Placental praevia= Mx if low-lying placenta at the 20-week scan?
rescan at 32 weeks
no need to limit activity or intercourse unless they bleed
Placental praevia= Mx if still present at 32 weeks and grade I/II?
scan every 2w
3 stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Postpartum thyroiditis= what are found in 90% pts?
thyroid peroxidase antibodies
Postpartym thyroiditis= Mx?
thyrotoxic phase=
- propranolol for symptom control
- not usually treated with anti-thyroid drugs as the thyroid is not overactive.
hypothyroid phase=
- usually treated with thyroxine
Postpartym thyroiditis= are anti-thyroid drugs used?
not normally as thyroid is not overactive
Postpartym thyroiditis= hypothyroid phase?
Mx- thyroxine usually used
Pregnancy= For patients with a suspected deep vein thrombosis (DVT)?
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
Pregnancy= for pts with suspected PE?
ECG and chest x-ray should be performed in all patients
In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue
the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
CTPA in pregnancy?
slightly increases the lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation
V/Q scanning in pregnancy?
V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA (1/50,000 versus less than 1/1,000,000)
Can you use D-dimer in pregnancy if suspected DVT or PE?
limited use as it is often raised in pregnancy
Physiological changes in pregnancy= cardiovascular system?
SV up 30%, HR up 15% & cardiac output up 40%
systolic BP is unaltered
diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
Physiological changes in pregnancy= BP?
systolic BP is unaltered
diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
Physiological changes in pregnancy= why may pregnant women get ankle oedema, supine hypotension or varicose veins?
enlarged uterus may interfere with venous return
Physiological changes in pregnancy= respiratory system?
Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre)
Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm
BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable
Physiological changes in pregnancy= blood?
Maternal blood volume up 30%, mostly in 2nd half= red cells up 20% but plasma up 50% → Hb falls
Low grade increase in coagulant activity
rise in fibrinogen and Factors VII, VIII, X
fibrinolytic activity is decreased - returns to normal after delivery (placental suppression?)
prepares the mother for placental delivery
leads to increased risk of thromboembolism
Platelet count falls
WCC & ESR rise
Physiological changes in pregnancy= urinary system?
blood flow increases by 30%
GFR increases by 30-60%
salt and water reabsorption is increased by elevated sex steroid levels
urinary protein losses increase
trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose
Physiological changes in pregnancy= cause of trace glycosuria?
common due to the increased GFR and reduction in tubular reabsorption of filtered glucose
Physiological changes in pregnancy= biochemical changes?
calcium requirements increase during pregnancy
especially during 3rd trimester + continues into lactation
calcium is transported actively across the placenta
serum levels of calcium and phosphate actually fall (with fall in protein)
ionised levels of calcium remain stable
Gut absorption of calcium increases substantially - due to increased 1,25 dihydroxy vitamin D
Physiological changes in pregnancy= liver?
Unlike renal and uterine blood flow, hepatic blood flow doesn’t change
ALP raised 50%
Albumin levels fall
Physiological changes in pregnancy= uterus?
100g → 1100g
hyperplasia → hypertrophy later
increase in cervical ectropion & discharge
Braxton-Hicks: non-painful ‘practice contractions’ late in pregnancy (>30 wks)
retroversion may lead to retention (12-16 wks), usually self corrects
Risk of smoking in pregnancy?
Increased risk of miscarriage (increased risk of around 47%)
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
Risk of alcohol in pregnancy?
Fetal alcohol syndrome (FAS):
- learning difficulties
- characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
- IUGR & postnatal restricted growth
Binge drinking is a major risk factor for FAS
Fetal alcohol syndrome (FAS)?
- learning difficulties
- characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
- IUGR & postnatal restricted growth
smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
fetal alcohol syndrome
Risk of cannabis in pregnancy?
Similar to smoking risks due to tobacco content
Risk of cocaine in pregnancy?
Maternal risks:
- hypertension in pregnancy including pre-eclampsia
- placental abruption
Fetal risk:
- prematurity
- neonatal abstinence syndrome
Risk of heroin in pregnancy?
Risk of neonatal abstinence syndrome
Risks of prematurity?
- increased mortality depends on the gestation
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease, hypothermia, feeding problems, infection, jaundice
- retinopathy of prematurity
- hearing problems
Retinopathy of prematurity?
- important cause of visual impairment in babies born before 32 weeks gestation
- the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
- screening is done in at-risk groups
Preterm prelabour rupture of the membranes (PPROM)= how common?
around 2% of pregnancies but is associated with around 40% of preterm deliveries
Cx of Preterm prelabour rupture of the membranes (PPROM)?
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
Confirming Preterm prelabour rupture of the membranes (PPROM)?
- sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
- if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1
- ultrasound may also be useful to show oligohydramnios
PPROM= if pooling of fluid is not observed NICE recommend testing the fluid for…
placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1
Mx of Preterm prelabour rupture of the membranes (PPROM)?
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
Mx of Preterm prelabour rupture of the membranes (PPROM)= regular monitoring why?
to ensure chorioamnionitis is not developing
Mx of Preterm prelabour rupture of the membranes (PPROM)= what Abx should be given?
oral erythromycin for 10 days
Mx of Preterm prelabour rupture of the membranes (PPROM)= why are antenatal corticosteroids given?
to reduce risk of respiratory distress syndrome
Mx of Preterm prelabour rupture of the membranes (PPROM)= when should delivery be considered?
34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
Rheumatoid arthritis (RA) typically develops in women of
reproductive age so issues surrounding conception are commonly encountered
Rheumatoid arthritis and pregnancy= patients with early or poorly controlled RA should be advised to?
defer conception until disease more stable
Rheumatoid arthritis and pregnancy= RA symptoms in pregnancy?
tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery
Rheumatoid arthritis and pregnancy= is methotrexate safe in pregnancy?
NO
Rheumatoid arthritis and pregnancy= when should methotrexate be stopped?
men and women at least 6m before conception
Rheumatoid arthritis and pregnancy= is leflunomide safe in pregnancy?
no
Rheumatoid arthritis and pregnancy= are sulfasalazine and hydroxychloroquine safe in pregnancy?
yes
Rheumatoid arthritis and pregnancy= TNF-a blockers?
studies looking at pregnancy outcomes in patients treated with TNF-α blockers do not show any significant increase in adverse outcomes. It should be noted however that many of the patients included in the study stopped taking TNF-α blockers when they found out they were pregnant
Rheumatoid arthritis and pregnancy= corticosteroids?
low-dose corticosteroids may be used in pregnancy to control symptoms
Rheumatoid arthritis and pregnancy= NSAIDs?
may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
Rheumatoid arthritis and pregnancy= why should patients be referred to an obstetric anaesthetist?
due to the risk of atlanto-axial subluxation
Rubella?
also known as German measles, is a viral infection caused by the togavirus. Following the introduction of the MMR vaccine it is now rare.
What if rubella is contracted during pregnancy?
there is a risk of congenital rubella syndrome
Rubella and pregnancy= incubation period and how long infectious?
incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
Rubella and pregnancy= risk?
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
Rubella and pregnancy= features of congenital rubella syndrome?
sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
‘salt and pepper’ chorioretinitis
microphthalmia
cerebral palsy
Rubella and pregnancy= diagnosis?
suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
Rubella and pregnancy= diagnosis- what is it very important to check?
parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
it is very difficult to distinguish rubella from parvovirus B19 clinically
Rubella and pregnancy= Mx?
suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
since 2016, rubella immunity is no longer routinely checked at the booking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
Can MMR be given to pregnant women?
NO
