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
