Obstetrics Flashcards
What is an ectopic pregnancy?
Implantation of a fertilised ovum outside the uterus
typical history of ectopic pregnancy
explain too
6-8 wk hx amenorrhoea present with lower abdo pain and later vaginal bleed
lower abdo pain:
- tubal spasm
- 1st sx
- constant unilateral (right or left iliac fossa)
vaginal bleed:
- less than normal period
- dark brown
hx of recent amenorhoea
- 6-8 weeks
- if longer - inevitable abortion?
peritoneal bleeding: shoulder tip pain and pain on defecation/urination
dizziness
fainting
syncope
sx of pregnancy poss like breast tenderness
what would you find in an examination in ectopic pregnancy?
abdo tenderness
cervical excitation
adnexal mass: dont examine for it though theres a risk of rupturing pregnancy.
do pelvic exam for cervical excitation.
in a pregnancy of unknown location what serum bhcg level points towards a diagnosis?
over 1500
risk factors of ectopic pregnancy
damage to tubes like through pelvic inflammatory disease, surgery
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF
smoking
intrauterine devices - coils
pathophysiology of ectopic pregnancy
how can it end up? 3 ways
which 2 are dangerous
and its side effect
97% tubal - most in ampulla. more dangerous in isthmus.
3% in ovary,cervix or peritoneum
trophoblast invades tubal wall, produce bleeding - dislodge the embryo poss
mc - absorption or abortion
tubal abortion - move to abdo cavity - can cause internal bleeding
tubal absorption - tube dont rupture, blood and embryo shed or converted into tubal mole and absorbed
tubal rupture - internal bleed
ix for ectopic pregnancy
transvaginal uss
pregnancy test - positive
poss see gestational sac - yolk sac or fetal pole.
sometime non specific mass. (blob/bagel/tubal ring sign)
how would you manage ectopic pregnancy
if hcg is 1500 or less - methotrexate im to the buttock. (teratogenic) - dont get pregnant for 3 months.
if hcg is over 5000, visible fetal heartbeat, pain, can be ruptured, size is over 35mm : surgical management - salpingectomy 1st line (if not risk for infertility) or salpingotomy ( if infertility risk like 1 tube damage already)
if they do salpingotomy theyll prob still need methotrexate and/or salpingectomy
hcg levels and associated pregnancy
repeat after 48 hrs
rise of over 63% after 47 hrs = intrauterine pregnancy. pregnancy should be visible after its more than 1500.
rise of less than 63% could be ectopic.
fall of more than 50% is miscarriage. do urine pregnancy test after 2 weeks to confirm.
common side effects to methotrexate
vaginal bleeding
n+v
abdo pain
stomatitis - inflammation of mouth
what prophylaxis is given to surgical mx of ectopic pregancy pts?
anti-rhesus d prophylaxis
what is miscarriage?
early
late
spontaneous termination of pregnancy
before 12 weeks gestation.
12-24 weeks
definitions in miscarriage
missed
threatened
inevitable
incomplete
complete
anembryonic
missed - fetus not alive - no sx - dead fetus in gestiational sac before 20 weeks. light bleed vaginal poss.
threatened - vaginal bleed. closed cervix. alive fetus painless
inevitable - heavy vaginal bleed clots and pain . open cervix.
incomplete: retained conception products - still in uterus post miscarriag.
complete: full miscarriage. no products.
anembryonic - gestational sac no embryo
how would you investigate for miscarriage?
3 features sonographer looks for in early pregnancy
transvaginal uss
mean gestational sac diameter
fetal pole and crown rump length
fetal heartbeat
talk to me about viability of pregnancy with regards to 3 features
when is fetal heartbeat expected?
when do you expect fetal pole
fetal heartbeat visible = viable pregnancy.
heartbeat expected when crown rump length 7mm or more.
if crown rump less than 7 and no heartbeat, repeat 1 week later to see heartbeat - if not its non viable.
fetal pole expect once mean gestational sac diameter is 25mm or more. if its this without fetal pole repeat after 1 week before confirming anembryonic pregnancy.
How would you manage miscarriage?
less than 6 weeks with bleeding but no pain or comps: expectant management.
repeat urine pregnancy test after 7-10 days, to confirm.
if more than 6 weeks:
uss. - confirm location and viability.
expectant
medical - misoprostol
surgical
explain expectant management in miscarriage
first line without rf for heavy bleeding or infection.
repeat urine pregnancy - 3 weeks after bleeding and pain settle.
risk factors for miscarriage
advanced maternal age, over 35
hx of previous miscarriage
previous large cervical cone biopsy
lifestyle: smoking, alcohol, obesity
meds: uncontrolled diabetes, thyroid
chromosomal abnormalities: 50% of early miscarriages.
medical management for miscarriage
missed miscarriage:
oral mifepristone - progesterone receptor antagonist - weakens attachement to endometrial wall and causes cervical softening and dilation and induces uterine contractions.
48 hrs later: misoprostol - vaginal oral or sublingual - unless gestational sac already passded.
prostaglandin analogue - binds to myometrial cels - strong myometrial contractions - expulsion of products of conception.
incomplete:
- single dose of misoprostol
antiemetics and pain relief
pregnancy test at 3 weeks
surgical management for miscarriage
vaccuum aspiration - suction curettage - local anaesthetic
surgery: general - evacuation of retained products of conception - electric vacuum.
key side effects of misoprostol
heavier bleeding
pain
vomiting
diarhoea
key complication of electrical vaccum of retained products of conception
endometritis - infection of endometrium after procedure
recurrent miscarriage defined as?
causes
3 or more consecutive spontaneous abortions.
antiphospholipid syndrome
hereditary thrombophilia
endo : poorly controlled dm/thyroid. pcos
sle
uterine abnormality: uterine septum
parental chromosomal abnormality
chronic histiocytic intervillositis
smoking
how does antiphospholipid syndrome related to miscarriage and what is it?
what hx should i be thinking?
how to reduce risk?
disorder of antiphospholipid antibodies - blood prone to clotting.
hypercoagulable state.
thrombosis.
can occur evai or secondary to sle.
reduce risk by :
low dose aspirin
LMWH
hx of reccurent miscarriages.
pmh of dvt.
key inherited thrombophilias to remember
factor v leider - mc
factor 2 prothrombin gene mutation
protein s deficiency
name some uterine abnormalities that can cause recurrent miscarriage
uterine septum
unicornuate uterus - single horned uterus
bicornuate uterus - heart shaped
didelphic - double
cervical insuffiency
fibroids
What is Chronic Histiocytic Intervillositis?
ix
mx
rare cause of recurrent miscarriage.
2nd trimester.
lead to intrauterine growth restriction and intrauterine death.
test for antiphospholipid , hereditary thrombophilias, pelvic uss, genetic testing product of conception from 3rd or future miscarriages, genetic test parents.
placental histology: infiltrates of mononuclear cells in intervillous spaces
mx: vaginal progesterone pessary in early pregnancy.
laws for abortion
1967 abortion act.
1990 human fertilisation and embryology act - 28 weeks to 24 weeks.
before 24 weeks if:
- involves greater risk to physical or mental health of the women or existing children in family.
in what scenario can an abortion happen regardless of gestation?
continue puts pt at risk in her life
grave permanent injury to physical/mental health risk to woman
substantial risk that the child would be physical or mental anormal ie handicapped
legal requirements for abortion
2 registeered med practioners might sign to agree.
carried out by registered med practioners in nhs or approved place.
when should anti-d prophylaxis be given in abortion pt?
all women who are rhesus d negative and having abortion after 10 weeks gestation
medical abortion management -
mifepristone - antiprogestone - then 48 hrs later misoprostol to stimulate contractions.
mimic miscarriage.
do pregnancy test 2 weeks after to confirm end. - should detect hcg too. MULTI LEVEL PREGNANCY TEST
surgical abortion - management
manual vaccum aspiration
electric vacuum aspiration
dilatation and evacuation
cervical priming with misoprostol +/- mifepristone
local anesthesia
after surgical abortion you can put intrauterine contraceptive.
after what time do medical abortions become less common
what factors would be considered?
upto what time are they done at home?
after 9 weeks.
likelihood of woman seeing products of conception pass.
before 10 weeks medical abortions done at home
complications of abortion
bleeding
pain
infection
failure of abortion - pregnancy continues
damage to cervix uterus or other structures
types of multiple pregnancy
monozygotic : identical twins - from single zygote
dizygotic: non-identical - 2 different zygotes
monoamniotic - single amniotic sac
diamniotic : 2 separate amniotic sacs
monochorionic : share single placenta
dichorionic: 2 separate placentas
best outcome for multiple pregnancy is which type
diamniotic dichorionic twin pregnancy
because each fetus has own nutrient supply
how would you diagnose multiple pregnancy
uss - gestational age, number of placentas, amniotic sacs - risk of downs
dichorionic diamniotic - have membrane between the twins - with lambda sign or twin peak sign
monochorionic diamniotic - membrane between twins with t sign
monochorionic monoamniotic - no membrane seperating twins
multiple pregnancy
what is lambda sign
what is t sign
lambda: triangle appearance when membrane between twins meets the chorion. - indicates dichorionic twin pregnancy (SEPERATE PLACENTAS)
t sign - membrane between twins abruptly meets chorion. - indicated monochorionic twin pregnancy - SINGLE PLACENTA
complications of multiple pregnancies
to mother
to fetuses/neonates
mother-
anaemia
polyhydramnios
htn (pregnancy induceD)
malpresentation
spontaneous
preterm birth
instrumental delivery or caesarean
PPH
antepartum haemorhage
fetus:
- miscarriage, stillbirth, prematurity, fetal growth restriction, twin-twin transfusion, twin anaemia polycythemia sequence, congenital abnormality
briefly explain twin twin transfusion syndrome
tx
fetuses share placenta.
connection in blood supply.
one gets most blood other starved.
if most: hf and polyhydramnios.
if less: growth restriction, anaemia, oligohydramnios.
tx: laser tx - destroy connection between 2 blood supplies.
briefly explain twin anaemia polycythaemia sequence
one anaemic
other polycythemia
antenatal care - scanning
for women with multiple pregnancy
additional monitoring for anaemia with fbc at
booking clinic
20 weeks
28 weeks
additional uss - fetal growth restriciton, unequal growth, twin twin tranfusion:
2 weekly scans from 16 weeks for monochorionic
4 weekly scans from 20 weeks for dichorionic
additional iron and folate
when would you offer planned birth for multiple pregnancy pt
why not wait beyond these dates
what drug given and why?
32 and 33 + 6 for uncomp mono mono
36 and 36+^ for uncomplicated mono diamnio
37 and 37+6 for uncomp di di
before 35 + 6 for triplets
risk of fetal deahth.
corticosteroids given before delivery to mature lungs
delivery for multiple pregnancy
monoamnio require elective caesaren section between 32 and 33+6
diamnio - aim between 37 and 37+6
vaginal if : 1st if cephalic
c section for seconda poss
electic c - when presenting twin not cephalic
potential labour complications for multiple pregnancy
pph increased * 2
malpresentation
cord prolapse, entanglement
predisosing factors for dizygotic twins
previous twins
fhx
increased maternal age
multigravida
induced ovulation/ivf
afro caribean
monoamnio monozygotic twins associated with what?
increased spontaneous miscarriage, perinatal mortality rate
increase malformation
intrauterine growth restriction, prematurity.
twin to twin transfusion
what is obesity in pregnancy defined as?
bmi over or equal to 30 at first antenatal visit.
maternal risks for obesity in pregnancy
miscarriage
vte
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
pph
wound infections
high c section rate
fetal risks of obesity in pregnancy
congenital anomaly
prematurity
macrosomia (baby excessive weight)
stillbirth
increased risk of developing obesity and met disorders in childhood
neonatal death
how should obesity in pregnancy be managed?.
not by dieting.
5mg of folic acid rather than 400mcg
screen for gestational diabetes with ogtt at 24-28 weeks
if bmi 35 or more - give birth in consultant led obs
im 40 or more - have antenatal consultation with obs anaesthetist
What is gestational diabetes?
cause
diabetes triggered by pregnancy
caused by reduced insulin sensitivity during pregnancy and resolves after birth.
complication of gestational diabetes
large for dates fetus
macrosomia
birth implication: shoulder dystocia.
longer term - women at higher risk of gettin t2dm after pregnancy.
women at risk factor of gestational diabetes, what to do?
screen with ogtt at 24-28 weeks gestation.
women with previous gestational diabetes also have ogtt soon after booking clinic.
OGTT:
75g drink morning empty stomach. measure glucose before drink and2 hrours after
fasting : under 5.6 mmol/l
2 hours: under 7.8
risk factors for gestational diabetes
previous
previous macrosomic baby (4.5kg or more)
bmi over 30
ethnic - black carrib, middle east, south asian
fhx of diabetes - first degree relativce
what features would suggest gestational diabetes
large for dates fetus
polyhydramnios
glucose on urine dipstick
how would you manage gestational diabetes?
if the women declines metformin then what?
4 weekly uss scans - monitor fetal growth and amniotic fluid vol from 28-36 weeks.
initial mx:
- fasting bg under 7 : trial diet and exercise for 1-2 weeks - then metformin, then insulin
fasting over 7 - insulin +/- metformin
fasting over 6 and macrosomia (other other comps_ - insulin+/- metformin
if women declineS:
glibenclamine (sulfonylurea)
advice for women with gestational diabetes
monitoring?
monitor bg several times a day
fasting :5.3
1 hr post meal : 7.8
2 hrs post meal: 6.4
avoiding levels of 4 or less
pt with pre-existing diabetes , pregnancy advise
5mg folic acid from preconception until 12 weeks .
aim for same target insulin levels. - stop anything other than metformin and insulin.
RETINOPATHY SCREENING - after booking and 28 weeks.
planned delivery - 37-38.+6 if preexisting
if gestational: upto 40+6
what is a sliding scale insulin regime
consider during labour for t1dm woman.
dextrose and insulin infusion titrated to blood sugar level.s.
if poorly controlled blood sugars with gestational or normal diabetes.
babies of mothers with diabetes are at risk of what?
neonatal hypoglycaemia
polycythemia
jaundice
congenital heart disease
cardiomyopathy
mother with gestational or preexisting diabets
how to manage baby post natal/
maintain bg above 2 mmol/l if falls below
iv dextrose of nasogastric feeding.
hypertension risk factor for what
cardiovascular disease like ihd and stroke
normal bp
between 90/60 and 140/90
clinical reading over or equal to 140/90 or 24 hr bp average reading 135/85
types of htn
essential - no single disease causing it - 95% pts
secondary - range of conditions causing
secondary causes of htn
renal: glomerulonephritis, chronic pyelonephritis, adult polcystic kidney disease, renal artery stenosis
endocrine: primary hyperaldosteronism, phaeochromocytoma, cushings syndrome, liddles syndrome, congenital adrenal hyperplasia (11 beta hydroxylase def) , acromegaly
others: glucocorticoids, naids, pregnancy, coarctation of aorta, combined coc pill
if htn very high like over 200 120 what sx
headaches
visual disturbance
seizures
white coat effect?
pt bp rises in clinical etting.
24 hr bp better
how to check for end organ damage in htn pt?
fundoscopy: hypertensive retinopathy
urine dip: renal disease, cause or consquence of htn
ecg: lv hypertrophy or ihd
ix for htn
24 hr bp - if not then automated sphygmomanometer
u and e - dip
hab1c
lipids - hyperlipidemia
ecg
types of med mx of htn
acei - inhibit conversion angiotensin 1 to 2 - 1st line in younger patients under 55. less effective in afro carribean. avoid in pregnant. renal function check 2-3 weeks after, renal risk worsening function if renovascular disease. - anything - pril
calcium channel blocker - block voltage gated calcium channnels relax vascular smooth muscle and force of myocardial contraction - 1st line tx in older over 55
thiazide like diuretic - inhibit sodium absorption at beginning of distal convulted tubule - although diuretic, thiazides have vry weak diuretic action
angiotension 2 receptor blockers - block angiotensin 2 effects at AT1 receptor - used when pts not tolerate acei due to cough - anything end in “sartan”
side effect of calcium channel blockers
flushing
ankle sweling
headache
side effect of thiazide type diuretics
hyponatremia
hypokalemia
dehydration
side effect of angiotensin 2 receptor blockers
hyperkalemia
side effect of acei
cough
angioedema
hyperkalemia
drug therapy stepwise approach for htn
if under 55 or t2dm : a+c and a+d
acei
acei + ccb or acei+ diuretic
acei + ccb + diuretic
if k less or equal to 4.5 - add low dose spironolactone
if more - alpha/beta blocker
if bp not controlled on 4 drusg - specialist review
if over 55 + no t2dm or afro + no t2dm : (c+a) c+d
ccb
acei+ccb or acei+diuretic
rest is the same
what is isolated systolic hypertension and how would you treat?
benefit of treating
elderly - over 70
treated it reduced both strokes and ihd.
1st line: thiazides.
now its recommended to tx in same way as general htn.
hypokalaemia with hypertension
4 causes
cushings syndrome
conn’s syndrome - primary hyperaldosteronism
liddle’s syndrome
11-beta hydroxylase deficiency.
what anti ulcer drug can cause hypokalaemia associated with hypertension
carbenoxolone
liquorice excess
hypokalaemia without hypertension causes
diuretics
gi loss - diarhoea, vomiting
renal tubular acidosis - type 1 and 2
bartter’s syndrome
gitelman syndrome
3 stages of hypertension
stage 1 : clinic bp = or over 140/90 mmHg and abpm daytime av or hbpm average bp = or over 135/85
stage 2 : 160/100 and 150/95
severe: over 180 systolic or diastolic over 120 - both clinic
diagnosing htn -
if difference in readings between arms is more than 20 mmHg what to do ?
if it remains what to do ?
cause of unequal bp ? what to do in this case?
repeat.
record higher reading.
supravalvular aortic stenosis.
listen to heart sounds.
if 2nd reading during consultation: if 1st is over 140 90 then take lower reading.
what to do if bp is over 180 120
admit if:
- signs of retinal haemorrhage or papilloedema or life threatening sx like acute confusion, signs of hf or aki
refer if phaeochromocytoma suspected (labile or postural htn , headache, palpitations, pallor, diaphoresis)
if none: ix for end organ damage - bloods urine acr ecg
- if idenitified start antihypertensive without abpm/hbpm.
- if not repeat clinic bp within 7 days
how to do abpm
how to do hbpm
2 measurements per hr during person usual waking hours
average val of 14 measurements
2 consecutive measurements, 1 min apart , seating pt.
- record twice daily, morning and evening.
4 days min - ideally 7 days.
discard 1st day and average the rest
how to tx htn based on abpm/hbpm
stage 1 : over 135/85
- treat if under 80 and target organ damage, cv disease, renal disease, diabetes or 10 yr cv risk 10% or more.
give for under 60 with stage 1 and estimated risk cv 10 yr below 10%
over 150/95 - stage 2: give drugs regardless of age.
what do i need to know about bp in normal pregnancy in the 1st trimester/
usualy falls esp the diastolic
continues to fall until 20-24 weeks.
then it increases to pre-pregnancy levels by term
women at high risk of developing pre-eclampsia should take what and when?
aspirin 75mg od from 12 weeks until birth of baby.
hypertension in pregnancy defined as?
systolic over 140 diastolic over 90
or increase above booking reading of over 30 sys or 15 dias
differentiating
pre-existing htn
pregnancy-induced hypertension(gestational htn)
pre-eclampsia
pre:
- hx of htn over 140/90 before 20 weeks gestation
- no proteinuria, no oedema
pregnancy -induced htn(gestational):
- htn in second half of pregnancy after 20 weeks
- no proteinuria no oedema.
- 5-7% of pregnancies.
- resolves after birth(1 months afteR). increased risk of future pre-eclampsia or htn later in life.
pre-eclampsia;
- pregnancy induced htn in association with proteinuria (>0.3g/24 hrs)
- oedema poss
- 5% pregnancies
if a women takes acei-i or angiotensin II receptor blocker for pre-existing htn what to do?
stop immediately
give alternative antihypertensive like labetalol whilst waiting for specialist
how would you manage pregnancy htn
oral labetalol - 1st line
oral nifedipine (if asthmatic) and hydralazine
what is idiopathic intracranial htn
risk factors
young overweight females htn
obesity
female
pregnant
drugs: coc, steroids, tetracyclines, retinoids(isotretinoin, tretinoin), vit A, lithium
features of idiopathic intracranial hypertension
headache
blurred vision
papilloedema
enlarged blind spot
sixth nerve palsy
how would you manage idiopathic intracranial htn
weight loss. - semaglitide or topiramate.
carbonic anhydrase inhibitor: acetazolamide
repeat lp : short term but not long term
surgery: optic nerve sheath decompression and fenestration to prevent damage to optic nerve.
lumboperitoneal or ventriculoperitoneal shunt to reduce icp.
lifestyle advice in htn mx
low salt diet - less than 6g a day, ideally 3.
less caffeine
stop smoking
less alcohol
balanced diet in fruit and veg
excercise
lose weight
bp targets
over 80
under 80
clinic bp
abpm/hbpm
clinic bp:
14090
150 90
abpm/hbpm
135 85
14585
What is pre-eclampsia?
triad
acc definition
high bp in pregnancy - poss precursor to women getting eclampsia and other comps.
triad :
- new-onset htn
-proteinuria
-oedema
new onset bp over 140 90 after 20 weeks of pregnancy and 1 or more of:
- proteinuria
- other organ involvement: renal insufficiency (creatinine over 90umol/L), liver, neurological, haematological, uteroplacental dysfunction
potential consquences of pre-eclampsia?
eclampsia: neuro comps like altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
fetal comps: intrauterine growth retardation, prematurity
liver involvement: elevated transaminases
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
features of severe pre-eclampsia
htn - over 160/110 and proteinuria
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count under 100 *10^6/l - abnormal liver enzymes of HELLP syndrome
low placental growth factor TEST
high risk factors of pre-eclampsia
moderate risk factors of pre-eclampsia
hypertensive disease in previous pregnancy
ckd
autoimmune: sle or antiphospholipid
t1dm,t2dm
chronic htn
1st pregnancy
40 or more
pregnancy interval of 10 yrs or more
bmi of 35 or more at 1st visit
fhx of pre-eclampsia
multiple pregnancy
how would you manage pre-eclampsia
initial assessment
further mx
emergency secondary case assessment
if over 160 110 - admit and observe
oral labetalol - 1st line - nifedipine if asthmatic ) - and hydralazine
what is eclampsia?
development of seizures in association with pre-eclampsia.
see after 20 weeks gestation
pregnancy induced htn
proteinuria
how to treat eclampsia?
when to give?
magnesium sulphate - prevent seizures in pts with severe pre-eclampsia and treat them once they develop.
give once a decision to delivery has been made.
- iv bolus of 4g over 5-10 mins followed by infusion of 1g/hr
- urine output, reflex, RR, ox sats: MONITOR
during tx: resp depression can happen - give calcium gluconate 1st line.
continue for 24 hrs after last seizure or delivery - 40% seizures occur post-partum.
fluid restriction avoid potentially serious consquences of fluid overload
how would you treat respitatory depression whcih is magnesium sulphate induced
eclampsia tx
calcium gluconate: 1st line
iv options for tx for hypertensive emergency
sodium nitroprusside
labetalol
glyceryl trinitrate
nicardipine.
why does pre-eclampsia happen?
spiral arteries of placenta form abnormally
pre-eclampsia sx
headache
visual disturbance/blurriness
n+v
oedema
upper abdo or epigastric pain - due to liver swelling
oedema
reduced urine output
brisk reflexes
in pre-eclampsia how would you check for
organ dysfunction
placental dysfunction
how is proteinuria quantified?
raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, haemolytic anaemia
fetal growth restriciton, abnormal dopplers
urine protein: creatinine ratio (above 30 mg/mmol )
urine albumin: creatinine ratio : over 8mg/mmol
What is HELLP syndrome?
when does it happen
features
triad
ix
tx
Haemolysis
Elevated liver enzymes
Low platelets
later stageof pregnancy.
10-20% of pts with severe pre-eclampsia will get this
features:
- n+v
- ruq pain
-lethargy
ix:
bloods: haemolysis, elevated liver enzymes, low platelet
tx: delivery of baby
What is group B streptococcus?
mc cause of what?
found where?
risk factors
mc cause of early-onset severe infection in neonatal period.
bowel flora or mother.
infants exposed during labour
prematurity
prolonged rupture of membranes
previous sibling gbs infection
maternal pyrexia - secondary to chorioamnionitis
How would you manage Group B streptococcus?
screening should not to be offered to all women.
if gbs in previous pregnancy: risk is 50%. give intrapartum abx prophylaxis or testing in late pregnancy and then abx if still positive
if women have swabs for gbs give at 35-37 weeks for 3-5 weeks before anticipated delivery date.
iv prophylaxis to women with previous baby with early or late onset gbs disease.
iv prophylaxis - women in preterm labour regardless of gbs status.
women with pyrexia (over 38) should be given it.
benzylpenicillin : abx of choice.
women with previous vte history and is pregnant what to do ?
women at intermediate risk of vte due to hospitalisation, surgery, comorbidity, thrombophilia, what to do?
low molecular weight heparin throughout the antenatal period
antenatal prophylactic, lmwh
rf for pregnant women getting vte
rules for when to tx and how to ?
age over 35
bmi over 30
parity over 3
smoker
gross varicose veins
current pre-eclampsia
immobility
fhx of unprovoked vte
low risk thrombophilia
multiple pregnancy
ivf
4 or more : immediate tx : lmwh for until 6 weeks postnatal.
3 rf lmwh initiated from 28 weeks and continue until 6 weeks postnatal.
if dvt diagnosed shortly before dilvery, continue anticoag for at least 3 months.
what drugs to avoid for vte in pregnancy
direct oral anticoagulant
warfarin
what medications put you at higher risk of vte?
coc pill: 3rd gen
hrt: higher risk is oestrogen+progestogen preps compared to just oestrogen
raloxifene and tamoxifen
antipsychotics - esp olanzapine
underlying conditions that can predispose to vte
malignancy
hf
behcets
polycythemia
nephrotic syndrome
sickle cell
homocystinuria
hyperviscosity syndrome
paroxysmal nocturnal haemoglobinuria
antiphospholipid syndrome
thrombophilia: activated protein c resistance, protein c and s deficiency
general rf for vte
age
obesity
fhx
pregnancy - esp puerperium
immobility
hospitalisation
aenaesthesia
central venous cathertr: femoral more than subclavian
types of vte prophylaxis
mechanical
pharmacological
mechanical:
- anti-embolism compresion stockings - thigh or knee height
- intermittent pneumatic compression device
pharma:
- fondaparinux sodium - subcut
- lmwh: enoxaparin - reduced doses used in pts with severe renal impairement
-unfractionated heparin - alternative to lwmh in pts with ckd
advice for vte pre-surgical pts
post-surgery
women stop taking coc pill/hrt 4 weeks before surgery.
after :
- try to mobilise pt asap after surgery
-ensure hydrated
elective hip pt - prophylaxis
lmwh for 10 days followed by aspirin (75 or 150mg) for further 28 days
or lmwh for 28 days with anit-embolism stockings until discharge
or
rivaroxaban
elective knee surgery pt -prophylaxis
aspirin 75/150mg for 14 days.
or
lmwh for 14 days combined with anti-embolism stockings until discharge
or
rivaroxaban
fragility fractures of pelvis, hip and proximal femur
vte prophylaxis for a month if risk of vte outweights risk of bleeding.
lmwh - 6-12 hrs after surgery or
fondaparinux sodium - 6 hrs after surgery.
how would you diagnose vte in pregnancy?
doppler uss - dvt
repeat negative uss on day 3 and 7 in pts with high index of suspicion for dvt.
women with suspected PE: cxr, ecg
definitive:
- CT pulmonary angiogram - iv contrast.
- Ventilation Perfusion scan - radioactive isotopes and gamma camera to compare ventilation with perfusion of lungs.
ctpa if abnormal cxr
ctpa - carries higher risk of breast cancer for mother.
vq : higher risk of childhood cancer for fetus
What is puerperal pyrexia?
causes?
mx
temp of over 38 degrees in 1st 14 days after delivery
causes:
-uti
-mastitis
-vte
-wound infections (perineal tears+c section)
- endometritis: MC
mx:
- if endometritis suspected: iv abx (clindamycin and gentamicin until afebrile for over 24hrs)
What is varicella zoster virus (vzv)
chicken pox as primary infection.
shingles when the dormant virus reactivates in the dorsal root ganglion.
in pregnancy: risk of both mother and fetus - fetal varicella syndrome)
chicken pox spread
infectivity
incubation period
respiratory route
caught from someone with shingles
infectivity = 4 days before rash, until 5 days after rash first appeared.
incubation = 10-21 days
clinical features of chicken pox
fever initially
more severe in older children/adults
itching ,rash starting on head/trunk before spreading, initially macular then papular then vesicular
systemic upset : mild
management of chicken pox
stay cool trim nails
calamine lotion
no school: 1-2 days before rash until lesions dry and crusted over (5 days after rash onset)
immunocompromised pts and newborns with peripartum exposure should get varicella zoster immunoglobulin (VZIG). if you get chickenpox then iv aciclovir.
complications of chicken pox
pneumonia
encephalitis (Cerebellar involvement poss)
disseminated haemorrhagic chickenpox
conjunctival lesions
arthritis, nephritis, pancreatitis.
The virus lays dormant in sensory dorsal root ganglion cells, and later reactivate as Shingles or Ramsay Hunt Syndrome
chicken pox is a risk factor for?
group a streptococcal soft tissue infections like necrotizing fasciitis.
nsaids can increase the risk.
mx of chicken pox in pregnancy
increased risk of what in pregnancy
oral aciclovir if women 20 weeks or more and presents within 24 hours of rash.
if woman under 20 weeks : consider aciclovir.
mx of chicken pox exposure in pregnancy
check maternal blood for varicella antibodies.
varicella zoster immunoglobulin VZIG.
oral aciclovir - 1st choice for PEP at any stage.
antivirals day 7-14 after exposure.
what is fetal varicella syndrome?
skin scarring
eye defects (microphthalmia)
limb hypoplasia
microcephaly
ld
What measurements are used on uss to assess fetal size?
estimated fetal weight
fetal abdominal circumference
risk of what 5 times greater from chicken pox exposure in pregnancy
pneumonitis
risks to fetus chickenpox exposure in pregnancy
shingles in infancy : 1-2% risk if maternal exposure in 2nd/3rd trimester
severe neonatal varicella: if mother gets rash 5 days before and 2 days after birth.
criteria for post exposure prophylaxis for chickenpox in pregnancy
what to give if criteria met?
significant exposure to CP/Herpes zoster
clinical condition that increases risk of severe varicella :
- immunosuppresed
-neonates
-pregnant women
- long term steroids, methotrexate and other immunosuppressants.
no antibodies to varicella virus. - never delay past 7 days after initial contact.
give varicella -zoster immunoglobulin - VZIG
What is varicella zoster and shingles?
two types of vaccines
VZ is the herpes virus that causes chickenpox.
shingles - acute unilateral painful blistering rash caused by reactivation of it.
- vaccine that stops you from getting primary varicella infection - CP
- vaccine that reduces the incidence of herpes zoster (shingles) caused by reactivation of VZV.
when is a fetus determined to be small for gestational age?
what weight defines low birth weight?
<10th centile
<3rd centile = severe SGA
<2500g = low birth weight
what information is used to plot a growth chart?
mother’s
- ethnic group
-weight
-height
-parity
What are causes of SGA
constitutionally small - normal for family to be small, growing appropriately on growth chart.
fetal growth restriction - pathology causing nutrient or oxygen delivery reduction.
What are some placenta mediated causes of FGR?
pre eclampsia
maternal smoking and alcohol
anaemia
infection
malnutrition
maternal health problems
what are some signs of FGR
reduced amniotic fluid volume
abnormal doppler studies
reduced fetal movements
abnormal CTGS
complications of FGR
fetal death/stillbirth
birth asphyxia
neonatal hypoglycaemia and hypothermia
increased risk of:
- cvd
-t2dm
-obesity
-mood/behavioural problems
What is polyhydramnios?
excessive amount of amniotic fluid
amniotic fluid index (AFI) >25 cm
or
single deepest pocket over 8cm
causes of polyhydramnios
maternal - dm , multiple pregnancy
fetal
- congenital abnormalities (anencephaly, GI tract obstruction (oesophageal atresia), fetal anaemia, infections
idiopathic half the time
how does polyhydramnios present
rapid uterine growth
maternal discomfort
dyspnoea
abdo pain
peripheral oedema
may have reduced fetal movement due to excess fluid
how does polyhydramnios investigated?
USS (measure AFI or Single deepest pocket)
Consider detailed anatomy scan and screen for gestational diabetes
Doppler for fetal anaemia for some reason
How is polyhyramnios treated?
treat underlying cause + amnioreduction if extremely severe
complications of polyhydramnios
preterm labour
preterm labour rupture of membrane
malpresentations
umbilical cord prolapse
PPH
placental abruption
What is oligohydramnios and what are some of its causes?
reduced amniotic fluid
premature rupture of membranes
fetal renal abnormalities (agenesis, dysplasia, obstruction)
post term gestation
fetal growth restriction
pre-eclampsia
post term pregnancy
What can oligohydramnios cause?
Potter sequence (Reduced development of fetal lungs and bilateral renal hypoplasia)
Flattened facial features (wide set eyes, flat nose, receding chin, low set ears - caused by compression)
Clubbed feet and limb abnormalities
Wrinkly skin
How is oligohydramnios diagnosed?
Ultrasound during second trimester
Usually advanced at diagnosis, and often results in stillbirth, or respiratory problems (pulmonary hypoplasia) so severe they’ll cause death.
Affects boys more
How is oligohydramnios managed?
If before term, monitoring with serial fetal testing. Therapeutic amniofusion may be used.
Delivery between 36-38 weeks
oligohydramnios in terms of how much amniotic fluid
less than 500ml at 32-36 weeks and amniotic fluid index of <5th percentile
What is gestational age? What do G and P refer to? What are the trimesters and when do foetal movements start
Gestational age is calculated from last menstrual period. EDD is 40 weeks gestation.
Gravida - number of pregnancies
Para/parity - number of deliveries after 24 weeks
First trimester - up to 12 weeks
Second trimester - 13-26 weeks
Third trimester - >27 weeks
Foetal movements start at 20 weeks
Hormonal changes in normal pregnancy
(Anterior pituitary hormones, TSH, HCG, Progesterone, Oestrogen)
Also give role of progesterone, and how does HCG rise
Anterior pituitary produces more prolactin, ACTH and melanocyte stimulating hormone.
Prolactin suppresses FSH and LH
ACTH increases cortisol and aldosterone (improvement in autoimmune conditions, increased susceptibility to diabetes)
MSH causes pigmentation of skin
TSH stays normal but T3/T4 rise
HCG rises, doubling every 48 hours until they plateau 8-12 weeks then gradually fall
Progesterone rises throughout pregnancy, maintaining pregnancy, preventing contractions and suppressing immunity to foetus. Corpus luteum produces for first 10 weeks, then placenta.
Oestrogen rises throughout, produced by placenta
What is post partum haemorrhage and what volumes of blood is it characterised by
Blood loss of >500ml after vaginal delivery, or >1000ml after C section. Can be primary or secondary
Causes of primary post partum haemorrhage
Within 24 hours.
4 Ts
- Tone (uterine atony - most common)
- Trauma (e.g. perineal tear)
- Tissue (retained placenta)
- Thrombin (Clotting/bleeding disorders)
rf for primary PPH
Previous PPH
Prolonged labour
Pre-eclampsia
Polyhydramnios
Emergency C Section
Macrosomia
Increased maternal age
preventative measures for PPH
Treating antenatal anaemia
Giving birth with empty bladder
Active management of third stage (IM oxytocin)
IV tranexamic acid during C section in third stage in high risk patients.
Mx of PPH (general , not necessarily addressing bleeding)
Medical emergency
Resuscitation with ABCDE
Lie flat, keep her warm.
Insert 2 14 gauge cannulae
Take bloods with group and save
Commence warmed crystalloid
Oxygen and blood transfusions.
Activate major haemorrhage protocol!
Mx to stop bleeding PPH
Mechanical: Palpate and rub uterine fundus to stimulate contractions. Catheterisation (bladder distension prevents uterine contraction)
Medical:
- IV Oxytocin, slow injection then infusion
- Ergometrine IV or IM (unless HTN) - Stimulates smooth muscle contraction
- Tranexamic acid (antifibrinolytic - prevents bleeding)
- Carboprost IM (unless asthmatic) - Prostaglandin analogue, stimulates uterine contraction
- Misoprostol
Surgical:
- Intrauterine balloon tamponade (Bakri)
- B-Lynch suture (suture around uterus to compress)
- Uterine artery litigation
What is secondary PPH, how is it investigated and treated?
Bleeding from 24 hours to 12 weeks post partum.
Usually due to Retained Products of Conception (RPOC) or infection e.g. endometritis.
USS and/or endocervical or high vaginal swabs
Treated with surgery or Abx
When does labour normally occur and what are its stages?
between 37 and 42 weeks
1 - Onset of labour (true contractions) until 10cm cervical dilatation
2 - 10cm cervical dilatation to delivery of the baby
3 - From delivery of baby to delivery of placenta
what happens during the first stage of labour
Cervical dilatation and effacement (thinning). The “show” (mucus plug that normally prevents bacteria from entering uterus) is passed, falling out and creating space for baby to pass through.
What are the 3 phases of the first stage of labour
Latent - 0 to 3cm dilatation. ~0.5cm/hour with irregular contractions
Active - 3 to 7cm dilatation. ~1cm/hour with regular contractions
Transition phase - 7 to 10cm dilatation. ~1cm per hour with regular strong contractions.
If a woman feels irregular, non labour contractions during pregnancy, what are these called and when do they normally happen?
Braxton-Hicks contractions.
Irregular uterus contractions usually during second or third trimester. Not true contractions, no indication of labour. Non progressive and irregular.
Staying hydrated and relaxing can help.
Give 4 signs of labour
Show (cervical mucus plug)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
What prostaglandin can be used to induce labour
Prostaglandin E2 (dinoprostone)
What is the second stage of labour and how long should it last
From 10cm until delivery of baby
Passive 2nd stage - Delivery without pushing (normal)
Active - Active process of maternal pushing
It is less painful than stage 1 and should last 1 hour. If longer, consider Ventouse, forceps or C section.
What factors most dictate success of second stage
3 Ps
Power - Strength of uterine contractions
Passage - Size and shape of passageway and pelvis
Passenger (4 descriptive qualities of fetus)
- Size (especially head
- Attitude: Posture (how back is rounded, how head and limbs are flexed)
- Lie: Position of child in relation to mother’s body
- Presentation: Part of fetus closest to cervix
Explain the 4 descriptive qualities of the fetus in second stage, giving best and worst presentations.
And how should head position be
Size: Normal or small head. Macrosomia can cause difficulty passing through birth canal, causing complications like shoulder dystocia.
Attitude (posture): Well flexed head, rounded back and tucked in limbs best for delivery.
Lie (childs long axis compared to mother’s): Longitudinal best - fetus head or buttocks down, lining up wiht mother. Transverse not compatible with vaginal delivery needs C section.
Presentation (part of fetus closest to cervix): Cephalic (head first) best. Breech (legs first) or shoulder presentation may need c section.
Head position being occiptoanterior is best.
How should contractions occur in normal labour, how often should they occur and how long should they last?
Regular, strong contractions - every 2-3 mins and lasting 60-90 seconds.
Weak, infrequent or uncoordinated contractions bad, may need oxytocin or c section
How should pelvis be ideally shaped in labour?
Gynaecoid - round and spacious
worst: android - narrow and heart shaped
What is the 3rd stage of labour, what are the benefits of an active 3rd stage
Completed baby birth to placental delivery
Physiological - Maternal effort without medication or cord traction
Active management - IM Oxytocin and careful traction to umbilical cord help deliver placenta.
Active shortens 3rd stage and reduces risk of bleeding. Haemorrhage or >60min delay should prompt active management.
What are the 7 cardinal movements of labour
Engagement - Babys head enters pelvis
Descent - Downward movement through birth canal
Flexion - Babys head flexes, allowing smallest head diameter to present
Internal rotation - Babys head rotates to align with pelvis
Extension - As head passses under pubic bnoe, it extends up
External rotation (Restitution) - Baby’s head rotates back to align with shoulders
Expulsion - Shoulders and body delivered
How does the head of the baby enter and exit the pelvis
Enters occipito-lateral
Exits occipito-anterior
DEFINE
Prelabour rupture of membranes
Preterm prelabour rupture of membranes
Prolonged rupture of membranes
Prelabour - Amniotic sac ruptures before onset of labour
Preterm prelabour - Prior to labour and before 37 weeks
Prolonged - Rupture more than 18 hours before delivery
Define prematurity
Birth <37 weeks gestation. More premature = worse outcomes.
Non viable before 23 weeks.
Under 28 weeks: Extreme preterm
28-32: Very preterm
32-37: moderate preterm
What prophylaxis can be given for preterm labour?
Vaginal progesterone. Offered to all women with cervical length of <25cm between 16 and 24 weeks gestation
Cervical cerclage. - Stitching cervix to keep it closed. Offered between 16-24 weeks with <25cm cervical length if previous premature birth or cervical trauma.
If there is cervical dilatation between 16 and 28 weeks, without rupture of membranes, what can be done?
“Rescue” Cervical cerclage (stitching cervix to keep it closed)
How can preterm prelabour rupture of the membranes be diagnosed
Sterile speculum examination showing pooling of amniotic fluid in the posterior vaginal vault.
If negative, test fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein 1
How should prelabour preterm rupture of membranes be managed
Prophylactic erythromycin 250mg 4xdaily for 10 days - prevent chorioamnionitis.
Antenatal corticosteroids to reduce risk of respiratory distress syndrome
How does preterm labour with intact membranes present
Regular painful contractions and cervical dilation without rupture of amniotic sac
How is preterm labour with intact membranes diagnosed?
Less than 30 weeks, clinical diagnosis with speculum examination to assess cervical dilatation
> 30 weeks, Transvaginal ultrasound to assess cervical length. If <15mm, preterm labour management. If >15mm, unlikely to be preterm labour.
Fetal fibronectin is an alternative test: found in vagina during labour
Mx of preterm labour
Tocolysis with nifedipine - stop uterine contractions between 24 and 34 weeks. Short term measure (<48 hours). Atosiban (oxytocin receptor blocker) is an alternative
Maternal corticosteroids (IM Betamethasone, 2 doses 24 hours apart) - reduce neonatal morbidity and mortality
Magnesium Sulfate IV to mother - helps protect fetal brain during premature delivery, reducing risk and severity of cerebral palsy.
What are signs of magnesium sulfate toxicity?
how is it treated?
Reduced resp rate
Reduced blood pressure
Absent reflexes
Treated with Calcium gluconate
Why is treatment with methotrexate incompatible with another pregnancy. Give possible side effects of use
Methotrexate is given IM, and is teratogenic. Halts pregnancy and causes spontaneous termination.
Should not get pregnant for 3 months following treatment.
Common side effects:
- Vaginal bleeding
- Nausea/vomiting
- Abdo pain
- Stomatitis (inflammation in mouth)
What is placenta accreta?
When the placenta implants deeper through endometrium to the myometrium or perimetrium (placenta percreta) due to a defective decidua basalis. As it does not properly separate, this can cause postpartum haemorrhage.
If chorionic villi invade into myometrium, placenta increta. If they simply attach to the myometrium instead of remaining in the decidua basalis, placenta accreta. (INvade = INcreta)
What can cause placenta accreta and what are its risk factors
Previous uterine surgery e.g. C section, curettage procedures.
Previous placenta accreta
Previous endometrial curettage procedures
Previous c section
Multigravida
Increased maternal age
Low lying placenta or placenta praevia
How does placenta accreta normally present
Usually no symptoms during pregnancy, but can be bleeding during third trimester. (antepartum haemorrhage)
May be diagnosed on routine antenatal ultrasounds or at birth, with difficulty delivering placenta.
What is the big worry with placenta accreta
postpartum haemorrhage!
How is placenta accreta managed?
Specialist MDT. Planned delivery between 35-37 weeks. Antenatal steroids given to mature fetal lungs and C section conducted.
Options during C section:
- Hysterectomy (recommended)
- Uterus preserving surgery
- Expectant management (carries significant bleeding and infection risk)
Main 3 causes of major and minor (spotting) antepartum bleeding
Major
- Placenta praevia
- Placental abruption
- Vasa praevia
Minor
- Cervical ectropion
- Infection
- Vaginal abrasion from sex or procedures
What is placenta praevia
When the placenta lies wholly or partly over the cervical os. Major cause of mortality and morbidity, and is indication for C section.
It is a worse version of a low lying placenta, as low lying placentas usually resolve upwards.
How is placenta praevia normally diagnosed?
20 week anomaly scan (transvaginal USS) used to assess placenta position.
Usually asymptomatic but is a cause of 3rd trimester bleeding (antepartum haemorrhage), which can be major
NO Digital vaginal exam, as this could provoke major haemorrh, age.
Grading of placenta praevia
I - Reaches lower segment but not internal os
II - Reaches internal os but doesnt cover it
III - Covers internal os before dilation but not when dilated
IV (major) - Placenta completely covers internal os.
Rf for placenta praevia
Multiparity
Uterine scarring due to previous C section, uterine rupture, or endometriosis
Previous placenta praevia
Advanced maternal age
Mx of placenta previa
Repeat USS at 32 and 36 weeks.
Corticosteroids at 34 and 35+6 weeks to mature fetal lungs.
Planned C section between 36 and 37 weeks.
complications of placenta praevia
Haemorrhage, either before. during or after delivery.
Preterm or low weight birth
Stillbirth
Emergency C section or hysterectomy may be indicated
What is placental abruption
When compromise of the vascular structures supporting the placenta separate from the wall of the uterus causing bleeding into the new space under attachment site. Causes a solid woody feeling abdomen
RF for placental abruption
Preeclampsia
Cocaine use
Smoking
Maternal trauma
Multiparity
Increasing maternal age
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)
Presentation of placental abruption
Sudden, severe, continuous abdominal pain
Tender, tense uterus
Vaginal bleeding (antenatal haemorrhage)
Characteristic “woody” abdomen on palpation suggests large bleed
Shock (tachycardia and hypotension) if severe bleeding
Absent fetal heart suggests fetal death
How can an abruption remain concealed
If cervical os remains closed, or any bleeding occurs away from cervical os, containing blood.
Mx of placental abruption
Fetus alive <36 weeks
- If distressed: Immediate C section
- If not, observation and steroids
Fetus alive >36 weeks
- If distressed, immediate C section
- If not, normal delivery
If fetus is dead, induce delivery.
complications of fetal abruption
Maternal
- Hypovolaemic Shock
- PPH
- DIC
- Renal failure
Fetal
- Intrauterine growth restriction (IUGR)
- Hypoxia
- Death
How is bleeding categorised in placental abruption
Spotting (may not need intervention)
Minor - <50ml
Major 50-1000ml
Massive >1000ml
What is vasa praevia
Rare condition where fetal blood vessels in chorioamniotic membranes cross the interal cervical os. Fetal membranes surround amniotic cavity and developing fetus.
Fetal vessels consist of 2 umbilical arteries and an umbilical vein.
Pathophysiology of vasa praevia (including types)
Fetal vessels (2 umbilical arteries and umbilical vein) usually protected by umbilical cord (Wharton’s jelly) or by the placenta. 2 cases where they can become exposed:
- Velamentous umbilical cord - cord inserts into chorioamniotic membranes, and vessels travel unprotected through membranes before joining placenta. (TYPE 1)
- Accessory lobe of placenta - AKA a succenturiate lobe. When fetal vessels travel through chorioamniotic membranes between lobes. (TYPE 2)
In vasa praevia, the unprotected vessels travel through membranes and pass across the cervical os, becoming exposed and prone to bleeding. Especially during membrane rupture during labour, which can lead to fetal blood loss and death.
Diagnosis of vasa praevia
May be diagnosed via USS in pregnancy, enabling planned C section.
May present with antepartum haemorrhage.
May be detected during labour, when pulsating vessels seen during dilation.
May be detected when dark red bleeding and fetal distress occur during labour - high mortality.
Mx of vasa praevia
Corticosteroids at 34 weeks
Elective C section 34-36 weeks
What is cord prolapse and whats its most significant risk factor
Where the umbilical cord descends below presenting part of fetus into vagina after rupture of fetal membranes during delivery. If cord is compressed, can cause fetal hypoxia.
Most significant risk factor is an abnormal lie (Unstable, transverse or oblique). Being in an abnormal lie provides space for cord prolapse below presenting part.
Diagnosis of cord prolapse
50% occur at artificial rupture of the membranes. Diagnosis made when fetal heart rate becomes abnormal and cord is palpable or visible vaginally.
Mx of cord prolapse
Obstetric emergency
Push presenting part of baby back and keep cord warm and moist to prevent vasospasm.
Have mother go on all fours (knee-chest position) or in a left lateral lie to draw fetus away from pelvis and reduce compression.
Tocolytic medication (terbutaline) can minimise contractions while waiting for emergency C section
What is rhesus disease?
Rhesus-D is an antigen found on blood cells. A rhesus positive mother won’t need treatment, but if rhesus negative, and her child is rhesus positive, this could be a problem;
If there is an event causing leakage, or when fetal and maternal blood is mixed during labour, the mother’s immune system can become sensitised to the rhesus D antigen, forming anti-D IgG antibodies.
In a second rhesus D positive pregnancy, these can cross the placenta and cause haemolysis of the fetal red blood cells. This is referred to as haemolytic disease of the newborn.
How is rhesus disease prevented?
Test for D antibodies in all Rh negative mothers at booking.
Giving anti-D to non-sensitised mothers at 28 and 34 weeks, and at birth, prevents sensitisation, as once sensitised this is irreversible.
Anti D should be given ASAP (<72hrs) if:
- Delivery of Rh +ve infant in Rh negative woman
- Any termination of pregnancy
- Miscarriage if >12 weeks gestation
- Ectopic pregnancy (unless managed with methotrexate)
- any situation where sensitisation may occur (amniocentesis procedures, antepartum haemorrhage, abdominal trauma)
What test is performed at 20 weeks in rhesus negative women?
Kleinhauer test
- after any sensitising event after 20 weeks, add acid to sample of mother’s blood. Fetal blood is naturally resistant to acid so they are protected against acidosis, keeping their haemoglobin, enabling a measurement of how much fetal blood is in the mother’s blood.
What tests should be done on all babies born to a Rh-ve women
FBC
Blood group
Direct coombs test (Demonstrate antibodies on baby’s RBCs)
What are possible complications to a fetus in rhesus negative pregnancy
Oedematous (hydrops fetalis)
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus (newborn jaundice)
Treated with transfusions and UV phototherapy.
What are some indications for induced labour?
Prolonged pregnancy (38/39 weeks)
Premature prelabour rupture of membranes where labour doesnt start
Maternal medical problems (diabetes >38 weeks, pre-eclampsia, obstetric cholestasis)
Intrauterine fetal death
What score is used to figure out whether a labour may need to be induced?
Bishop score
Looks at:
Cervical position (anterior best (+ 2))
Cervical consistency (soft best +2)
Cervical effacement (80% best +3, 60-70% +2)
Cervical dilation (>5cm best +3, 3-4 +2)
Fetal station (+1, +2 best (+3), -1,0 +2)
<5 indicates labour unlikely without induction
>8 indicates cervic is ripe and high chance of spontaneous labour, or response to induction
Possible methods of labour induction
Membrane sweep - Finger passes through cervix to rotate against wall of uterus, to separate chorionic membrane from decidua. Adjunct to labour
Vaginal prostaglandin E2 (dinoprostone)
Oral prostaglandin E1 (misoprostol)
Maternal oxytocin infusion
Amniotomy (breaking of waters)
Cervical ripening balloon (passed through endocervical canal to dilate cervix)
What are the NICE guidelines for inducing labour?
Bishop <6, Vaginal or oral prostaglandin (E2 dinoprostone or E1 misoprostol respectively)
- Balloon catheter if high hyperstimulation risk or previous caesarean
- Bishop >6, amniotomy and IV oxytocin.
Complications of labour induction
Uterine hyperstimulation
- Prolonged and frequent uterine contractions (tachysystole)
- Can cause intermittent interruption of bood flow to child causing fetal hypoxemia and acidemia
- Can be treated by stopping prostaglandin or oxytocin, or with tocoloysis
why should vte risk assessment be done in a pregnant women
pregnancy is a vte risk
When are women screened for anaemia in pregnancy, and what are the normal ranges during pregnancy?
Booking clinic and at 28 weeks
Booking: >110g/L
28 weeks: >105g/L
Post partum: >100g/L
What is a physiological cause of a reduced hb concentration in pregnancy
Plasma volume increases, reducing haemoglobin concentration
What is the mc cause of low MCV (mean cell vol) anaemia, as well as normal and high?
Low - Iron
Normal - Physiological, due to plasma volume increase
High - B12/ferritin
Tx of iron def anaemia in pregnancy
Iron replacement (ferrous sulphate 200mg 3 times daily)
(supplementary iron if not pregnant)
mx of b12 deficiency in pregnancy
Test for pernicious anaemia (intrinsic factor antibodies)
- IM Hydroxycobalamin injections
- Oral Cyanocobalamin tablets
mx of folate def in pregnancy
all should be taking 400mcg per day folic acid anyway.
start on folic acid 5mg daily.
What is shoulder dystocia
When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.
Obstetric emergency
Often caused by macrosomias secondary to gestational diabetes
key risk factors for shoulder dystocia
Fetal macrosomia (which is often caused by maternal diabetes)
High maternal BMI
Diabetes
Prolonged labour
How does shoulder dystocia present?
Difficulty delivering the face and head, and obstruction in delivering the shoulders.
Failure of restitution (head remains facing down (occipito-anterior), and does not turn sideways as expected.
Turtle-neck sign (head delivered but retracts back in)
Pain to mother
Mx - shoulder dystocia
Senior help (anaesthetist, paediatrician, obs)
- McRoberts’ manoeuvre (flexion and abduction of the maternal hips, bringing thighs to her abdomen. This increases anterior-posterior angle, by moving pubic symphysis out the way)
- Episiotomy can enlarge vaginal opening
- Pressure to anterior shoulder by pressing suprapubic region of maternal abdomen
Zavanelli manoeuvre involves pushing baby back in to do C section, but can cause maternal morbidity.
comps shoulder dystocia
Maternal
- Postpartum haemorrhage
- Perineal tears
Fetal
- Fetal hypoxia (Subsuquent cerebral palsy)
- Brachial plexus injury and Erb’s palsy.
how to tx hypothyroid in pregnancy
Untreated hypothyroid can lead to miscarriage, anaemia, small for gestational age child
Levo dose should be increased and titrated using TSH level.
epilepsy mx in pregnancy
Take folic acid 5mg, prevent neural tube defects
Manage ideally with single drug. (levetiracetam, lamotrigine, carbamazepine best options)
Sodium valproate causes neural tube defects and developmental delay
Phenytoin causes cleft lip and palate
rheumatoid arthritis mx in pregnancy
Methotrexate (teratogen, and causes miscarriage)
Hydroxycholorquine first line, safe for pregnancy.
Sulfasalazine and corticosteroids area also safe
What is post partum thryoiditis
Thyrotoxicosis or hypothyroidism, or both, within 12 months of delivery, in a women with previously no thyroid disease.
How does post partum thyroiditis usually present
3 stages
- Thyrotoxicosis (3 months)
- Hypothyroid (3-6 months)
- Return to normal within a year
Anti-TPO found in 90% of patients
Mx of post partum thyroiditis
Thyrotoxic phase: Propanolol for symptom control (no thyroid drugs)
Hypothyroid phase: Thyroxine
What is breech presentation?
Legs and bottom are presenting part of the fetus (upside down).
Complete breech - legs are fully flexed at the hips and knees
Incomplete breech - One leg flexed at hip and extended at knee.
Extended breech - AKA Frank breech - both legs flexed at hip and extended at knee
Footling breech - Foot presenting through cervix with leg extended.
Mx of breech presentation
Breech before 36 weeks should turn spontaneously. External Cephalic Version can be used from 37 weeks to turn the fetus.
If ECV fails, can be vaginal or caesarean delivery.
If first baby in twins is breech, C Section is required
What is uterine rupture?
Uterine rupture is a complication of labour in which the myometrium (muscle layer of uterus) ruptures.
With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) remains intact. In a complete rupture, the serosa ruptures, causing the uterine contents to spill into the peritoneal cavity.
Causes significant bleeding and has high mortality and morbidity for mother and child
RF for uterine rupture
Previuos C section (scar becomes weak point)
Vaginal birth after C section
Previous uterine surgery
Increased BMI and age
Induction of labour and oxytocin use
High parity
Presentation of uterine rupture
Cessation of uterine contractions
Vaginal bleeding and abdominal pain
Shock (Hypotension, tachycardia, collapse)
How is uterine rupture managed?
Emergency C section, stop bleeding and repair or remove uterus (hysterectomy)
screening test for downs
Combined test - HCG increased , PAPP-A (Pregnancy-Associated Plasma Protein A) reduced, thickened nuchal translucency.
Performed between 11-14 weeks. Trisomy 18 (Edwards) and 13 (Pataus) have similar results but lower hCG.
what is the quadruple test?
Offered later (15-20 weeks)
Alpha fetoprotein, Unconjugated oestriol, hCG, Inhibin A
Downs:
- AFP ↓
- Unconjugated Oestriol ↓
- hCG ↑
- Inhibin A ↑
Edwards:
- Everything ↓
Neural Tube Defects:
- AFP ↑
how can combined and quadruple test results be assessed?
Lower or higher chance
Lower: <1 in 150
Higher: >1 in 150
If higher: offer second screening test (NIPT) or diagnostic test e.g. amniocentesis. NIPT (Non invasive prenatal screening test) is more specific and sensitive.
what is stillbirth?
The death of a fetus after 24 weeks gestation, as a result of intrauterine fetal death. 1 in 200 pregnancies.
Possible causes of stillbirth
Unexplained
Preeclampsia
Placental abruption
Vasa Praevia
Cord prolapse
Thyroid disease
Prevention of stillbirth and 3 key symptoms to always ask during pregnancy
SGA or FGR - Monitor with serial growth scans.
Give aspirin for pre-eclampsia.
3 key symptoms:
- Reduced fetal movements
- Abdominal pain
- Vaginal bleeding
How to diagnose stillbirth
Ultrasound to detect fetal heartbeat.
Kleihauer test if Rhesus-D negative, to check maternal blood mix. Anti-D prophylaxis dose depending on amount mixed.
Vaginal birth, either induced (mifepristone (anti-progesterone) or misoprostol (prostaglandin analogue))
main signs of fetal distress
Abnormal fetal heart rate
Meconium stained amniotic fluid (liquor)
Abnormal fetal scalp blood pH
Decreased movements
Umbilical cord prolapse
When after delivery is contraception required?
When can POP be started, when can COCP be started, when can IUD be reinserted.
After giving birth, require contraception after day 21.
POP - Can start anytime postpartum. After day 21, use additional contraception for 2 days. (small amount of progesterone enters breast milk but not harmful.)
COCP - Contraindicated if breastfeeding <6 weeks post partum (UKMEC4). UKMEC2 if breastfeeding 6wk-6months.
- DO NOT use in first 21 days due to increased VTE risk. After day 21 use additional contraception for 7 days
IUD - Within 48 hours of childbirth or after 4 weeks
What are the risks of an inter-pregnancy interval of <12 months between birth and conceiving again
Preterm birth
Low birth weight
Small for gestational age
What LAM?
Lactational amenorrhoea method
Natural contraception, when a mother breastfeeds, it delays her periods.
3 criteria MUST be met:
- Exclusively breastfeeding
- No menstrual periods since delivery
- Babys age (less than 6 months)
LAM is over 98% effective. At 6 months, supplementary feeding starts, or cycle returns, so LAM becomes less reliable
What is an elective C section and what are some indications
Planned delivery date, usually after 39 weeks. Done under Spinal Anaethetic
Indications
- Previous C section
- Symptomatic after previous perineal tear
- Placenta and vasa praevia
- Breech
- Multiple pregnancy
- Uncontrolled HIV
- Cervical cancer
What are the 4 categories of emergency c section
1 - Immediate threat to life of baby or mother. Decision to delivery 30 mins
2 - Urgent but not imminent due to compromise of baby or mother. Decision to delivery 75 mins
3 - Delivery required but both baby and mother stable
4 - Elective, Chilling init
most commonly used procedure - c section
transverse lower uterine segment skin incision
- Pfannenstiel: Curved incision 2 fingers width above symphysis
- Joel-Cohen incision: Straight incision slightly higher (recommended)
Blunt dissection used after this to seperate remaining layers, using fingers, blunt instruments, traction. Results in less bleeding, shorter procedure, less risk to baby
comps of c section
Usually very safe and routine.
Surgical
- Bleeding
- Infection
- Pain
- VTE
- Damage to local structures (ureter, bladder, bowel, vessels)
- Ileus, adhesions, hernias
Postpartum
- PPH
- Wound infection
- Wound dehiscence
- Endometritis
Future pregnancy, increased risk of:
- Repeat C section
- Uterine rupture
- Placenta praevia
- Stillbirth
contraindications to vaginal birth after c section
Normally 75% successful
Previous uterine rupture
Classical caesarean scar (vertical)
Other contraindications (previous)
how to prevent vte in c section
Early mobilisation
Anti-embolism stockings, intermittent pneumatic compression of legs
LMWH
What are the types of instrumental delivery, and what are their indications, and whats given with them
Ventouse suction cup + Forceps
Failure to progress (maternal exhaustion)
Fetal distress
Prolonged second stage
Malposition
Head in various positions
Single dose co amoxiclav given to reduce risk of maternal infection post delivery
Risks to baby in instrumental delivery
Ventouse - Cephalohaematoma (swelling on newborn head, usually parietal, doesnt cross suture lines, resolves over months)
Forcep
- Facial nerve palsy (face, ear, taste, tear)
- Face: expression muscles
- Ear: nerve to stapedius
- Taste: Anterior two-thirds of the tongue
- Tear: Parasympathetic fibres to lacrimal glands, aka salivary glands
Risks to mother in instrumental delivery
PPH
Episiotomy (cut between vagina-anus)
Perineal tears
Anal sphincter injury
Incontinence of bladder/bowel
Obturator or femoral nerve injury
Obturator - weakness of hip adduction and rotation, numbness of medial thigh
Femoral - Weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg
What indicates either of the 2 instrumentals?
Ventouse - head must be partially engaged in birth canal. Works for a slightly abnormal position, as vacuum cup can sometimes rotate head.
Forcep - Preferred when rotation necessary (occiput anterior, or transverse positions)
Forcep preferred for:
- Complex rotations
- Narrow pelvic outlet
- Preterm child
