Obstetrics Flashcards
Physiological changes in pregnancy
See notes
Ectopic pregnancy
Implantation of fertilised ovum outside uterine cavity
Commonly - ampulla, isthmus of fallopian tube
Ectopic RFs
Tube damage - PID, surgery
Previous ectopic
endometriosis
IUS/D
POP
IVF
Ectopic Px
- Lower abdo pain
- 6-8wks amenorrhoea
- PV bleed later
- Brown PV discharge
- Pregnancy sx - breast tenderness
- Cervical motion tenderness
- adnexal mass maybe - don’t examine for - risk of rupture
Ectopic DDx
Miscarriage, ovarian cyst, PID, UTI, abdo ddx
Ectopic Ix
urine pregnancy test
Urinalysis - eg UTI - r/o DDx
Pelvic USS - ?intrauterine pregnancy
TVUS - if nothing seen on pelvic
No pregnancy on US + pregnancy test +ve = pregnancy unknown location -> take serum bHCG
- if bhCG >1500 - ectopic until proven otherwise
- bhCG <1500 - rpt in 48hrs (doubles if viable, halves if miscarriage)
Ectopic Mx
If Rh-, give anti-D
Medical
<35mm, unruptured, no pain, no heartbeat, hCG <1500
- IM methotrexate
Contraception for 3-6mo after as methotrexate teratogenic
Follow up required
Surgical
>35mm, may be ruptured, pain, heartbeat, hCG>5000
- Salpingectomy - if no infertility RFs
- Salpingotomy - if contralateral tube damaged
Conservative
Not 1st line
Stable pts, rupture unlikely, no pain, low bHCG, <35mm
Monitor bHCG to ensure fall
Miscarriage
Loss of pregnancy <24wks gestation
Miscarriage RFs
> 30-35yo
Previous miscarriage
Obesity
smoking
chromosomal abnormalities, uterine abnormalities
aPL syndrome
coagulopathies
Miscarriage types
Threatened
PV bleed, ?painless, os closed, viable
Inevitable
heavy bleed + clots + pain, os opened, non/viable, likely to progress to incomplete
Incomplete
not all POC expelled, pain, PV bleed, OS open, expectant / medical / surgical mx
complete
Hx of bleed, passing clots, pain, now settled, no POC in uterus + proof of prev pregnancy (eg scan), os closed
missed
gestational sac contains dead fetus, no expulsion, light PV bleed / discharge, os closed, no fetal heartbeat on USS
Septic
infected POC, fever, rigors, cervical motion tenderness, discharge/pain, increased WCC/CRP, features of in/complete
medical/surgical mx, IV abx, fluids
Miscarriage Px
PV bleed +/- clots, POC
Haemodynamically unstable
Tender abdo / pain / cramp
POC in cervical canal
Uterine tenderness / adnexal masses
Miscarriage Ix
Urine pregnancy test -> see in EPAU
Bloods - maybe serial serum bHCG (drop if miscarriage, rise if ectopic)
FBC, G+S, rhesus, triple swabs + CRP if fever
TVUS
Measure crown rump length (CRL) - estimate gestation
- <7mm, no fetal heart - rpt scan 7d, then confirm dx if no change
- >7mm + no HB - 2nd opinion before dx
Measure mean sac diameter - if growing alone -> anembryonic pregnancy
- <25mm + no fetal pole - 2nd scan 7d before dx
- >25mm + no fetal pole - 2nd opinion then dx
Miscarriage Mx
Anti-D if needed
Preventing miscarriage
- R/o ectopic
- vaginal pessary progesterone, take until 16wks
- only if PV bleed, threatened miscarriage + hx of miscarriage
Conservative / expectant
- POC pass naturally, remain at home, but unpredictable
- Rpt scan 2wks, pregnancy test 3wks
- Not if heavy bleed / tissue >50mm
- Medical / surgical after 2wks if no change
Medical
- Vaginal misoprostol (prostaglandin E) - stimulate cervical ripening + myometrial contractions - 2nd dose if not passed by 48hrs
- can be at home if <9wks, <40mm
- pregnancy test 3wks, further dose if still +ve
Surgical
- <12wks, manual vacuum aspiration - LA
- Evacuation of retained products of conception (ERPC) - GA - blind suction, risk of uterine perf
- give misoprostol before (soften cervix)
- for unstable pts, infected tissue, molar pregnancy
Recurrent miscarriage
> 3 consecutive miscarriages
Causes
aPL syndrome, DM, thyroid, PCOS, uterine abnormalities, cervical weakness, chromosome abnormalities, smoking, infections, thrombophilias
Ix
aPL ABs, thrombophilia screen
Karyotyping
Pelvic USS - anatomy
Mx
Tx cause
Refer to recurrent miscarriage clinic / geneticist
Termination of pregnancy (TOP)
Elective end to pregnancy
2 registered medical practitioners must agree, <24wks gestation, carry out in NHS approved premise
Can perform at any time during pregnancy if:
- woman’s life at risk
- prevents grave injury to physical / mental health of woman
- substantial risk child would suffer physical / mental abnormalities
TOP Mx
Medical
Mifepristone - antiprogesterone, halts pregnancy
Misoprostol - prostaglandin, softens cervix, stimulates contraction
Surgical
- Under LA / GA
- Dilate cervix, suction if <14wks, forceps evacuation if 14-24wks
Post-abortion
Urine pregnancy test 3wks after to confirm complete
Hyperemesis gravidarum (HG)
Persistent severe vomiting during pregnancy
Starts wk4-7, settle by 20wks, from increase in bHCG
leads to >5% pre-pregnancy wt loss, dehydration, electrolyte imbalances
RFs
First pregnancy, previous HG, raised BMI, multiple pregnancy, molar pregnancy (raised beta-hCG)
Smoking associated with decreased risk
HG Ix / assessment
Triad of 5% pre-pregnancy weight loss, dehydration, electrolyte imbalace is reccomended for diagnosis of HG
H/E - dehydration sx
PUQE score for severity
Measure weight
Urine dip - 1+ ketones, MSU sample
Bloods - FBC, U/E, LFT, amylase, TFTs, ABG
USS fetus - doppler
Referral criteria:
Continued N+V and is unable to keep down liquids or oral antiemetics
Continued N+V with ketonuria and/or weight loss (greater than 5% body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity
HG Mx
Oral fluids, diet advice, oral antiemetics
Admit if severe - IV fluids, IV antiemetics, thiamine, KCl if needed
1st line - cyclizine, prochlorperazine, promethazine, chlorpromazine
2nd line - metoclopramide (5d max - EPSEs), domperidone, ondansetron (1st trim cleft lip/palate risk)
3rd line - IV hydrocortisone, PO prednisolone
Molar pregnancy
pregnancy related tumours (premalignant) from placental trophoblast
includes complete hydatidiform mole, partial hydatidiform mole, choriocarcinoma
Complete hydatidiform mole
Benign tumour of trophoblastic material - empty egg fertilised by single sperm, then duplicates itself
Px
- bleeding in 1/2nd trim
- exaggerated sx of pregnancy - eg HG
- uterus large for dates
- high serum bHCG
- HTN, hyperthyroid (hCG mimics TSH)
Ix
USS - snowstorm appearance
Mx
surgical evacuation
contraception - avoid pregnancy for 12mo
Partial hydatidiform mole
Normal egg fertilised by 2 sperms, or one sperm with duplicate chromosomes
Choriocarcinoma
Cancer of trophoblastic cells of placenta
Mets to lungs
Antenatal care timetable
- 10 visits in 1st pregnancy, 7 visits later on
- 1st trim start ->12wks
- 2nd trim 13->26wks
- 3rd trim 27->term
- Whooping cough vaccine >16wks, flu when available
<10wks - booking, baseline assessment, plan pregnancy
10-14wks - Dating scan - CRL, multiple pregnancy
11-14wks - Down’s screening (increased nuchal thickness, increased bHCG, low PAPPA)
16wks - antenatal appt - results, discussion etc
18-21wks - anomaly scan
24-28wks - OGTT
25,28,31,34,36,38,40,41,42 - other appts
Screening offered for:
anaemia, bacturia, group + Rh, Down’s, fetal abnormalities, hep B, HIV, neural tube defects, RFs for pre-eclampsia, syphilis
No screening for BV, chlamydia, CMV, fragile X, hep C, GBS, toxoplasmosis
Lifestyle advice
400mcg folic acid from before conception -> 12wks (5mg in epileptics, obesity), take vit D, not too much vit A, don’t smoke, avoid certain foods……
Pre-eclampsia
Hypertensive disorder - placental disease
Triad of -> new HTN, proteinuria, oedema
Issue w/ spiral arteries - high resistance, low flow circulation
Pre-eclampsia RFs
Moderate
nulliparity
>40yo
>35BMI
FHx
pregnancy interval >10yrs
multiple pregnancy
High
Chronic HTN
HTN / pre-eclampsia / eclampsia in previous pregnancy
CKD
DM
autoimmune (SLE, aPL etc)
Pre-eclampsia Px
Asym
Headache, visual disturbance, epigastric pain (hepatic capsule distension / infarction)
Sudden oedema
Hyperreflexia
Papilloedema
Pre-eclampsia Dx
New onset BP >140/90 >20wks and 1 of:
- proteinuria
- other organ involvement - eg renal (raised creat), liver, neuro, haem…)
Pre-eclampsia DDx
Essential HTN (HTN <20wks)
Pregnancy induced HTN (PIN) - w/o proteinuria
Eclampsia - seizure
Pre-eclampsia Ix
Urine dip + 24hr collection - protein +++
BP
FBC (low Hb + platelets)
U/E (high urea + creat)
LFTs (raised ALT, AST)
Raised PlGF - placental growth factor
Pre-eclampsia Mx
Labetalol / nifedipine (if asthmatic) / methyldopa
Mg during labour + 24hrs after
> 37wks - initiate birth
34-37wks -> deliver if cannot control BP, reduced sats, deterioration, neuro sx, placental abruption (give steroids)
<34wks - monitor unless indications as above, give Mg + steroids
Pre-eclampsia prophylaxis
aspirin 75mg OD
for women with 1 high RF or >2 moderate
12wks -> birth
Eclampsia
1+ seizure + pre-eclampsia
Eclampsia Px
New onset tonic clonic seizure
Pre-eclampsia (new HTN, proteinuria, >20wks)
Headache, hyperreflexia, N+V, oedema, RUQ pain +/- jaundice, visual disturbance, reduced GCS
Eclampsia Ix
Fundoscopy - papilloedema
Bloods - FBC, U/E, LFTs, coag, BM
Abdo USS + CTG - monitor fetus
CT head
Eclampsia Mx
A-E, left lateral position
MgSO4
- 4g prophylaxis
- 4g with first seizure
- 1g/hr maintenance
- 2g bolus with recurrent seizures
- Too high -> hyperreflexia, resp depression
Labetalol + hydralazine
C-section
Oligohydramnios
reduced amniotic fluid
Amniotic fluid index (AFI) <5th %tile
Oligohydramnios causes
PROM
Fetal renal agenesis (fetus swallows fluid, excreted in urine normally)
IUGR
pre-eclampsia, placental insufficiency (blood to fetal brain rather than kidneys - reduced UO)
Oligohydramnios Px
may have sx of leaking fluid, damp all the time
Oligohydramnios Ix
Fundo-symphysis height
Speculum - pool of fluid in vagina
USS - liquor volume, fetus kidneys, measure size
Bedside tests for proteins if ?PROM
Oligohydramnios Mx
ROM - labour likely in 24-48hrs - if preterm - steroids + IOL
Placental insufficiency - baby likely to be prem - monitor with scans, doppler for umbilical artery
Polyhydramnios
increased amniotic fluid >95%tile
Polyhydramnios causes
idiopathic 50%
fetus cannot swallow - oesophageal atresia, CNS abnormalities
Duodenal atresia - double bubble sign on US
anaemia
fetal hydrops
macrosomia - big babies produce more urine
lithium
maternal diabetes
Polyhydramnios Px
mum can present SOB
Polyhydramnios assessment
Tense uterus on palpation
USS - liquor volume, fetal size
OGTT for mum
Polyhydramnios Mx
Nothing in most
Amnioreduction if severe - but risk of infection / abruption
Indomethacin - enhance water retention, reduce fetal UO, but not >32wks (premature PDA closure)
Examine baby before 1st feed - eg TOF, oesophageal atresia
Breech presentation
Fetus presents buttocks / feet first
Complete - flexed at hips/knees
Frank - flexed at hips, extended at knees (most common)
Footling - one / both legs extended at hip - foot is presenting part
RFs
Multiparity, uterine malformations, fibroids, placenta praevia, prematurity, macrosomia, polyhydramnios, twin pregnancy
Breech px Ix
Examination
USS
Breech px Mx
External cephalic version
- at 36wks, 50% success
- CIs - c-section needed, APH, membrane rupture, multiple pregnancy, previous c-section
C-section
- elective
Vaginal breech birth
- CI - footling
Fetal lie
Fetus against mother long axis
Fetal presentation
fetal part that enters maternal pelvis
Fetal position
Position of head as it exist birth canal
OA / OP
Placenta praevia
placenta fully / partially attached to lower uterine segment
Leads to APH (wk24-term)
Minor - low placenta, doesn’t cover os
Major - lies over internal os
RFs
prev c section, high parity, >40yo, multiple pregnancy, previous praevia
Placenta praevia Px
Antepartum haemorrhage (APH) - painless, spotting/massive bleed
Pain if in labour
Shock in keeping with visible loss
VE -> risk of bleed (do not do)
Placental praevia Ix
Bloods
CTG
USS - at 20wks, can do TVUS
- minor - rpt at 36wks
- major - rpt at 32wks, plan delivery
Placenta praevia Mx
C-section
Placental abruption
Placenta separates from uterine wall prematurely -> APH, possible fetal compromise
Revealed - bleed drains through cervix
Concealed - bleed remains in uterus, clot forms retroplacentally
Placental abruption Px
APH
Pain
Woody / tense uterus
Shock out of keeping with visible loss
Placenta abruption Ix
Bloods
CTG
USS
Placental abruption Mx
A-E
Fetal distress - emergency c-section
No distress
- <36wks observe, steroids
- >36wks ?vaginal delivery, IOL
Gestational diabetes mellitus (GDM)
Glucose intolerance / insulin resistance in pregnancy
Body can’t produce enough insulin to meet demands, progressive insulin resistance, higher vol needed for normal blood glucose level
RFs
BMI>30, Asian, previous, FHx, PCOS, prev macrosomia
Leads to macrosomia, organomegaly…
GDM Px
Asym
polyuria, polydipsia, fatigue
GDM Ix
OGTT
- measure fasting glucose, drink 75g glucose, rpt plasma glucose in 2hrs
- >5.6 fasting / >7.8 on repeat (2 hour)- dx
- at booking, 24-28wks, at any point if 2+ glycosuria
GDM Mx
Diet / exercise if <7
Metformin if not met within 1-2 weeks
Insulin (straight away if fasting >7)/ not reacted to metformin
Short acting insulin for treatment
Offer insulin if 6-6.9
If pre-existing DM
Weight loss, stop drugs apart from metformin, start insulin, folic acid 5mg preconception ->12wks
Obstetric cholestasis
Aka intrahepatic cholestasis of pregnancy
Cause unsure
Px
3rd trim, pruritis (palms, soles, abdo), jaundice (20%), nausea, anorexia, fatigue, RUQ pain, dark urine, pale stools
DDx
HG, pre-eclampsia, HELLP
Ix
LFTs - raised bilirubin, high PTT?
Mx
Monitor LFTs weekly
IOL at 37-38wks
Risk of prem birth
Ursodeoxycholic acid
Vit K supplements
Anaemia in pregnancy
Low Hb <110 in 1st trim, <105 in 2/3rd trim, <100 post-partum
Check at booking, 28wks
Px
Dizzy, fatigue, SOB, asym, pallor, koilonychia, angular cheilitis
Ix
FBC, serum ferritin (not routine), B12/folate
Mx
Iron supplements, folate if needed
Antiphospholipid (aPL) syndrome
Autoimmune - ABs target phospholipid binding proteins -> thrombosis, miscarriage
aPL Px
Stroke, DVT
Miscarriage
IUGR
Pre-eclampsia
livedo reticularis
renal impairment
Libmann-Sacks endocarditis
Thrombocytopenia
aPL Ix
Anticardolipin AB
Lupus anticoagulant AB
Anti-B2-glycoprotein I AB
aPL Mx
LMWH, continue >6wks post partum
Low dose aspirin 75mg
VTE in pregnancy
Pregnancy is RF - assess risk at booking, any further admission
RFs
>35yo, >30BMI, parity >3, smoker, varicose veins, FHx, multiple pregnancy, IVF, low-risk thrombophilia
Px
DVT / PE
Ix
Doppler first - if positive, avoid scanning chest
ECG, CXR, CTPA if necessary
Mx
LMWH
- >4 RFs - start immediately -> 6wks postnatal
- 3 RFs - 28wks -> 6wks postnatal
- DVT at delivery - continue for >3mo
Fetal varicella syndrome (FVS)
1% risk if mum exposed <20wks, less 20-28wks, none >28wks
Skin scarring, eye defects, limb hypoplasia, microcephaly, LDs
Also shingles in infancy
Severe neonatal varicella - if mother develops rash 5d before birth -> 2d after
- tx - VZIg +/- acyclovir
Mx of chickenpox exposure in pregnancy
If mum had chickenpox, no tx
If doubt mum had chickenpox - check VZV ABs - if none:
- <20wks - give VZIg asap - effective <10d post-exposure
- >20wks - acyclovir 7-14d post exposure
New guidance seems to be oral aciclovir given at 7-14 days post exposure, not immediately for all stages of pregnancy
Mx of chickenpox in pregnancy
> 20wks - oral acyclovir <24hrs of rash
<20wks, consider acyclovir with caution
Serial USS - for abnormalities
GBS colonisation
infant exposed in labour
Streptococci - G+ chain - Strep agalactiae
RFs
prem, prolonged ROM, prev sibling GBS infection, maternal pyrexia
GBS Px
May manifest as chorioamnionitis, endometritis
neonatal sepsis
UTI
GBS Ix
not routinely screened for
Swabs - rectum + vagina
At 35-37wks, or 3-5wks before delivery date
GBS Mx
IV benpen throughout labour if:
- +ve swabs, GBS UTI this pregnancy, previous GBS baby, labour fever, <37wks labour, >18hrs ROM
Abx not needed in c-section
If ROM >37wks, GBS+ve -> IOL - reduce time fetus exposed
If previous GBS infection - offer intrapartum abx prophylaxis - test in late pregnancy, more abx if still +ve
Hep B in pregnancy
Offer screening
Vaccine + Ig to babies born to +ve mums
No breastfeeding transmission
C-section doesn’t really reduce vertical transmission
HIV and pregnancy
Offer screening
4 factors to reduce vertical transmission
Maternal antiretrovirals
C-section
Neonatal antiretrovirals
Bottle feeding - spread by breastfeeding
CMV infection pregnancy
Herpes virus 5, 1/3 transmitted vertically, 5% cause damage
Px
Flu-like sx
Fever, splenomegaly, impaired liver function
Ix
Viral serology for CMV IgM, IgG
Mx
- refer to fetal medicine
- Maternal - no tx if immunocompetent
- Dx fetus - amniocentesis, PCR, >21wks
- Offer TOP if infected
- If no TOP - serial USSs for congenital CMV (IUGR, HSM, low platelets, jaundice, microencephaly)
Parvovirus B19 in pregnancy
Slapped cheek syndrome
Resp droplet / blood spread
Px
Asym, symmetrical arthralgia
Children URTI, flu, erythema infectiosum (slapped cheek)
Ix
Viral serology - IgM, IgG
Mx
Refer to fetal medicine
Mum self-limiting
Risk of fetal hydrops - fluid accumulation, severe anaemia - intrauterine transfusion if found
Rubella infection in pregnancy
Not screened, vaccines, but infection in pregnancy serious for fetus, airborne droplet spread
Px
asym
malaise, headache, coryza, lymphadenopathy, fine maculopapular rash
Ix
IgM, IgG
Mx
- refer to fetal medicine, inform public health
- mother - self-limiting
- <12wks - likely defects - TOP
- 12-20wks - amniocentesis + PCR to confirm - then TOP / US surveillance
- >20wks - no action
Fetal rubella syndrome
Sensorineural deafness, congenital cataracts, congenital heart disease, reduced growth, HMS….
Listeria in pregnancy
G+, causes listeriosis - more likely in pregnant women
From unpasteurised milk, processed meats, blue cheese
Px
asym, flu, pneumonia, meningoencephalitis
Miscarriage, intrauterine death (IUD), severe neonatal infection
Congenital toxoplasmosis
Parasite infection - from faeces of cat which is host
Triad of:
intracranial calcification
hydrocephalus
chorioretinitis
Obesity in pregnancy
increased risk of cx - miscarriage, VTE, GDM, pre-eclampsia, PPH….
Risks to fetus - prematurity, macrosomia, stillbirth….
Mx
Don’t reduce weight by diet whilst pregnant
5mg folic acid
OGTT screen
Placenta accreta spectrum
attachment of placenta to myometrium - past endometrium - due to defective decidua basalis
Placenta does not separate properly during labour -> PPH risk
RFs
Previous c section, placenta praevia
Types
Accreta - attached to myometrium
Increta - invade into myometrium
Percreta - invade through perimetrium
Px
APH in 3rd trim
May dx on antenatal US scans
PPH
Mx
Planned delivery 35-37wks to reduce risk of spontaneous delivery
Antenatal steroids
Several options
- Hysterectomy
- Resect part of myometrium - preserve uterus
- Leave placenta in - reabsorbed over time - bleeding / infection risk
HTN in pregnancy
> 140/90, or increase above booking readings >30/15
Pre-existing HTN
No proteinuria / oedema
Stop ACEi, ARB, thiazides
Target BP 135/85
Labetalol / nifedipine
75mg aspirin 12wks->term
Pregnancy induced HTN (PIH)
>20wks, no proteinuria / oedema
resolves 1mo after birth
Test for PlGF - r/o pre-eclampsia
Labetalol / nifedipine
Pre-eclampsia
PIH + proteinuria, maybe oedema
HELLP syndrome
Haemolysis, Elevated Liver enzymes, Low Platelets
Px
N+V, RUQ pain, lethargy
Ix
Bloods - as above
Mx
deliver baby
Chorioamnionitis
Ascending bacterial infection of amniotic fluid / membranes / placenta
RFs - PPROM (can occur without)
Mx - deliver fetus, c-section if needed, IV abx
Hypothyroidism in pregnancy
Untreated –> miscarriage, anaemia, SGA, pre-eclampsia
Increase levothyroxine dose (crosses placenta during pregnancy) - titrate based on TSH
Epilepsy in pregnancy
Folic acid 5mg from before conception
Pregnancy - worse seizure control - avoid valproate (neural tube defects)
Levetiracetam, lamotrigine, carbamazepine - safer
RA in pregnancy
Should be well controlled for 3-6mo before becoming pregnant
Methotrexate teratogenic
1st line - hydroxychloroquine
Sulfasalazine safe
Corticosteroids for flare ups
Medications in pregnancy
NSAIDs
Block prostaglandins (which keep PDA open) - avoid, esp in 3rd trim
BBs
IUGR, low BM/HR in neonate
ACEi/ARBs
teratogenic
Opiates
withdrawal sx
Warfarin
teratogenic
valproate
neural tube defects
lithium
Ebstein’s anomaly
monitor levels every 4wks, then weekly from 36wks
Avoid in breastfeeding
SSRIs
Balance +/-s
1st trim - congenital heart defects
3rd trim - pulm HTN
Isotretinoin
related to vit A, highly teratogenic
UTI in pregnancy
Pregnant women more at risk
increased risk of preterm, SGA, pre-eclampsia
Test at booking for asymptomatic bacteriuria - higher risk of developing UTI - dip + MC+S
E coli, Klebsiella commonly….
Mx
Nitrofurantoin (avoid 3rd trim - neonatal haemolysis)
Amoxicillin, after sensitivities known
Cefalexin
Avoid trimethoprim 1st trim - spina bifida
Vasa praevia
Fetal vessels (2x arteries, 1x vein) normally in umbilical cord, but are in fetal membranes + travel across internal cervical os - prone to bleeding
Px
Dx by US
APH
Fetal distress
Bleed after ROM
Mx
Steroids from 32wks
Elective c-section at 34-36wks
APH - emergency c-section
Multiple pregnancy
Zygote - mono/dizygotic
Amniotic sac - mono/diamniotic
Placenta - mono/dichorionic
Diamniotic, dichorionic twins best outcomes - each fetus has own blood supply
Dx
Booking US scan
- dichorionic, diamniotic - membrane between - lambda / twin peak sign
- monochorionic, diamniotic - T sign
- monochorionic, monoamniotic - no membrane
Mx
FBC (anaemia), regular scans, plan birth for earlier
Steroids, elective c-section, can do vaginal
Twin-twin transfusion syndrome
Fetuses share placenta, one gets all blood, other starved
Recipient - fluid overload, HF, polyhydramnios
Donor - IUGR, anaemia, oligohydramnios
Tx at tertiary centre - laser tx to destroy connection between blood vessels
Twin anaemia polycythaemia sequence
Similar to transfusion syndrome, less acute
One twin anaemia, other polycythaemic
Reduced fetal movts
Can be fetal distress - reduced O2 consumption due to chronic hypoxia - risk of stillbirth, IUGR, placental insufficiency
Fetus felt more and more 18/20wks->32wks, defo by 24wks
RFs - posture, distraction, meds, fetal position, placental position, small fetus
Ix
Handheld doppler
USS if no fetal HB >28wks
CTG if HB >28wks - 30 mins monitoring
If no movts by 24wks - refer to maternal fetal medicine unit
Rhesus incompatibility patho
If mum RhD-, and child RhD+ - if fetal blood enters maternal circulation, RhD Ag recognised as foreign - mum produces ABs (sensitised) to RhD Ag
In later pregnancies, ABs then destroy RBCs in fetus (haemolytic disease of newborn)
Give anti-D prophylaxis to RhD- women - destroys RhD Ags from fetus in maternal bloodstream - prevent sensitisation occurring
Rhesus incompatibility Maternal Mx
Take ABO group + RhD typing at booking, rpt at 28wks
Routine anti-D given:
28wks
34wks
Sensitisation - give anti-D <72hrs
APH, amniocentesis, abdo trauma, at birth of Rh+ infant, TOP, miscarriage >12wks, ectopic, ECV
> 20wks (I think 2nd/3rd trimester)+ sensitisation event - perform Kleinhauer test - see how much fetal blood in maternal bloodstream - see if further anti-D needed - add acid, mum’s cells die, fetal RBCs survive
Rhesus incompatibility baby Mx
When baby born - take cord blood - FBC, group and DAT (direct antiglobulin test) -Coombs - if shows ABs on RBC of baby - haemolysis
Affected fetus:
Hydrops fetalis, jaundice, anaemia, HSM, HF, kernicterus
Mx - transfusions, UV phototherapy
Small for gestational age (SGA)
<10th centile, birth weight <2.5kg
Assess size by estimated weight / abdo circumference
SGA causes - constitutional, IUGR
SGA RFs - previous SGA, obesity smoking, DM, HTN, pre-eclampsia, >35yo, multiple pregnancy
IUGR causes
- placenta mediated - idiopathic, pre-eclampsia, smoking, anaemia…
- fetus mediated - genetic, infection….
IUGR other signs
oligohydramnios, abnormal dopplers, reduced fetal movt, abnormal CTGs
Monitoring
US, SFH, scan uterine artery doppler, amniotic fluid levels….
Mx
Stop smoking, early delivery if concern with growth, test for infection
Large for gestational age (LGA)
macrosomia, >4.5kg, >90th centile
Causes
Constitutional, GDM, prev, maternal obesity, overdue, male
Risks
To mother - shoulder dystocia, failure to progress, perineal tears, instrumental delivery, PPH, uterine rupture
To baby - birth injury, neonatal hypoglycaemia, obesity, T2DM
Ix
USS - r/o polyhydramnios
OGTT
Mx
Deliver in hospital, c-section if needed
Acute fatty liver of pregnancy
Rare cx in 3rd trim / after birth - rapid accumulation of fat in liver - from impaired processing of fatty acids in placenta
Px
abdo pain, N+V, headache, jaundice, hypoglycaemia, ascites, pre-eclampsia
Ix
Raised ALT, AST, bilirubin, WCC
deranged clotting, low platelets
DDx
HELLP - more common
Mx
deliver baby
mx acute liver failure
consider liver transplant
Stillbirth
Birth of dead fetus >24wks - from intrauterine fetal death (IUFD)
Causes
unexplained, various cx - pre-eclampsia, abruption, vasa praevia….
Prevention
Regular scans, stop smoking
report reduced fetal movts, abdo pain, vaginal bleeding
Ix
USS - visualise fetal HB
Mx
Vaginal birth, unless c-section indicated
Induce labour
Dopamine agonist (cabergoline) - suppress lactation
Testing for cause - genetic, post-mortem, XR/MRI, infection tests
Signs of labour
Show - mucus plug
Rupture of membranes
Regular, painful contractions
Dilating cervix
Stages of labour
FIRST STAGE
- Onset of contractions -> 10cm dilatation
- <4cm latent phase, >4cm established phase
- Latent phase - 0-3cm, 0.5cm/hr, irregular contractions
- Active phase - 3-7cm, 1cm/hr, regular cont.
- Transition phase - 7-10cm, 1cm/hr, strong + regular cont.
SECOND STAGE
- 10cm -> delivery of baby
THIRD STAGE
- delivery of placenta
Braxton-Hicks contractions
irregular contractions of uterus, 2/3rd trim - temporary, not labour
Monitoring in labour
FHR/15mins / continuously on CTG
Contractions/30mins
Maternal HR/60mins
Maternal BP, temp/4hrs
VE/4hrs
Lochia
PV discharge, blood, mucus, uterine tissue- for 6wks after birth
Cardiotocography - DR C BRaVADO
Define Risk - CTG Indications
- sepsis, maternal tachy, meconium, pre-eclampsia, induction of labour, labour delay….
Contractions
- No of cont./10mins
- Too few - not progressing
- Too many - uterine hyperstimulation - risk of fetal compromise
Baseline HR
- 110-160 reassuring
- Brady - increased vagal tone, BBs
- Tachy - maternal fever, hypoxia, prem,
Variability
- 5-25 normal
- loss of this - prem, hypoxia
Acceleration
- good sign - occurs with contractions
Decelerations
- Early - dip with contraction - fine (vagal)
- Late - after cont - hypoxia
- variable - intermittent cord compression - hypoxia
- prolonged - 2-10mins - concern
Features are reassuring, non-reassuring, abnormal
CTG categories - normal, suspicious, pathological, need for urgent intervention
Mx
- escalate
- reposition mother, IV fluids if low BP
- fetal scalp stimulation - should see acceleration in response
- fetal scalp blood sampling - eg acidosis
- deliver baby - instruments / emergency c-section
Fetal bradycardia
- 3 mins - call for help
- 6 mins - move to theatre
- 9 mins - prepare for delivery
- 12 mins - deliver baby (by 15 mins)
Drugs in labour
Oxytocin - syntocinon
- Produced in hypothalamus, secreted by pos pit.
- Ripens cervix, stimulates contractions, role in lactation in breastfeeding
- Used for - induction, progression, improve contraction frequency / strength, prevent PPH
Ergometrine
- Stimulates smooth muscle contraction
- Delivery of placenta, prevent PPH - only after delivery of baby
- S/Es - HTN, D+V, angina. Avoid in eclampsia / HTN
Syntometrine
- Combination of oxytocin + ergometrine
Nifedipine
- CCB - first line for tocolysis in preterm labour
Atosiban
- Oxytocin receptor antagonist
- For tocolysis, eg premature labour, when nifedipine contraindicated
Prostaglandins - dinoprostone (prostaglandin E2)
- Induction of labour - stimulate contractions, ripen cervix
- Pessaries, tablets, gel
- (Lower BP - vasodilation, NSAIDs inhibit this action - increase BP - avoid in pregnancy)
Misoprostol
- Prostaglandin analogue
- Medical mx in miscarriage, IOL in IUFD - used alongside mifepristone
Mifepristone
- Anti-progesterone, halts pregnancy, ripens cervix, stimulates contractions
- Used with misoprostol for abortions, IOL in IUFD
Carboprost
- Synthetic prostaglandin analogue, stimulates uterine contraction
- Given IM in PPH, where ergometrine and oxytocin have been inadequate
- Avoid in asthma
Terbutaline
- B2 agonist - suppresses uterus smooth muscle contractions - used for tocolysis in uterine hyperstimulation
TXA
- Antifibrinolytic, binds to plasminogen, prevents it converting into plasmin (which dissolves fibrin in clots), reduces bleeding
- PPH
Failure to progress
Labour not progressing at satisfactory rate - increased risk to fetus and mother - more likely in first labour
Causes
Power - contractions
Passenger - baby size, presentation
Passage - pelvis etc
Psyche - motivation
Delay definitions
1st stage - <2cm dilatation 4hrs / slowing if multiparous
2nd stage - 2hrs pushing if 1st baby, 1hr if multiparous
3rd stage - >30mins with active mx, >60mins physiological
Mx
- ARM - amniotomy
- oxytocin infusion
- instrumental delivery
- c-section
Pain relief in labour
Paracetamol, codeine, entenox
IM pethidine / diamorphine
- opioids, make mum drowsy, can cause resp depression in neonate
PCA - remifentanil
- anaesthetic support - naloxone + atropine on standby
Epidural
- catheter in epidural (outside dura) space - inject levobupivacaine + fentanyl
- S/Es - headache, hypotension, weak legs, nerve damage, prolonged 2nd stage, likely instrumental delivery
Spinal - in CSF, subarachnoid
Combined spinal + epidural (CSE)
Instrumental delivery
- After 3 pulls, abandon
- Give single dose co-amox
Indications
- inadequate progress, maternal exhaustion, ?fetal compromise, clinical concern (eg APH)
Need to be
- fully dilated, ROM, cephalic px, empty bladder, adequate pain relief…
Ventouse
- vacuum cup on baby head
- less painful, less maternal injury
- cephalohaematoma, fetal retinal haemorrhage
Forceps
- lower fetal cx risk, higher maternal risk
- 3/4th degree tears
- facial nerve palsy to baby
Maternal injuries
Femoral
Obturator
Perineal tears
1st degree
- superficial, no muscle, no repair
2nd degree
- perineal muscle, suture on ward
3rd degree
- perineum + anal sphincter - external/internal - theatre repair
- 3a - <50% EAS thickness torn
- 3b - >50% EAS torn
- 3c - IAS torn
4th degree
- Perineum, EAS/IAS + rectal mucosa - theatre repair
Give PR diclofenac + abx
Episiotomy
- cut perineum, use LA, cut 45 degrees diagonally
Perineal massage
- reduce tear risk, massage from 34wks on, warm towels during delivery
Mx of 3rd stage
Physiological
Deliver placenta by maternal effort
Active
IM oxytocin
helps uterus contract
Careful traction of umbilical cord, suprapubic pressure
Reduces bleeding risk
N+V S/E
Premature labour
SROM - spontaneous ROM
PROM - prelabour rupture of membranes - rupture >1hr before labour onset, >37wks
PPROM - preterm PROM - <37wks - cx
Prematurity - birth <37wks, non-viable <23wks
Prophylaxis of preterm labour
Offer to women with cervix length <25mm, 16-24wks
Vaginal progesterone
- Gel / pessary
- maintain pregnancy
Cervical cerclage
- put stitch into cervix (under GA / spinal)
- Rescue cerclage - 26-28wks, cervical dilatation, w/o ROM
PROM / PPROM
Fetal membranes normally weaken in time for labour, but may rupture early due to - early activation of normal processes, infection, genetics
RFs
- smoking, previous PROM / prem, PV bleed in pregnancy, infection, amniocentesis, polyhydramnios, multiple pregnancy
PROM / PPROM Px
Broken waters - painless pop + gush, may be gradual
Lack of normal discharge (washed away)
Pooling in posterior fornix - speculum
PROM / PPROM Ix
Actim-PROM - swab for IGFBP-1 - high in amniotic fluid
Amnisure - for PAMG-1
High vaginal swab - GBS
PROM / PPROM Mx
Majority go into labour in 24-48hrs
Penicillin / clindamycin if GBS
> 36wks
- w+w for 24hrs
- IOL >24hrs
34-36wks
- prophylactic erythromycin (10d course / until labour)
- corticosteroids
- IOL + delivery
24-33wks
- erythromycin, steroids
- expectant until 34 wks
- avoid sex
Preterm labour + intact membranes
Regular painful contractions, cervical dilation, no ROM
Dx
- speculum - dilatation seen - <30wks clinical assessment only to offer Mx of preterm labour, >30wks offer TVUS assess - <15mm offer mx, >15mm preterm labour unlikely
- fetal fibronectin - in vagina
Mx
- CTG
- Tocolytics - nifedipine
- <35wks - dexamethasone
- <34wks MgSO4 - prevent CP
Induction of labour (IOL)
Start labour artificially
Indications
- Prolonged gestation
- P/PROM
- maternal health problems - HTN, preclampsia
- IUGR
- IUFD
Contraindications
- same as vaginal birth CIs
- if prev c-section - can only induce if consultant says
Methods of IOL
Vaginal prostaglandins - prostaglandin E2
- ripen cervix, role in uterus contraction
- tablet, gel, pessary
Amniotomy - amnihook
- rupture membranes artificially
- add IV oxytocin - increase contractions
Cervical ripening balloon (CRB)
- insert into cervix, gently inflate
Membrane sweep
- insert gloved finger through cervix, rotate against fetal membranes
If IUFD - mifepristone + misoprostol
IOL monitoring
Bishop Score - assess cervical ripeness, likelihood of need of IOL
- considers dilatation, length, station (relative to ischial spine), consistency, position
- >_8 - cervix ripe, high chance response to IOL / spontaneous
- <5 - IOL likely needed
CTG
- continuous
- fetal scalp electrode (FSE) alternative
IOL Cx
Failure, cord prolapse, infection
Uterine hyperstimulation
- contractions too long / frequent - fetal distress
- give terbutaline (tocolytic)
C-section + indications
99% lower segment c-section, classic was longitudinal in upper segment
Indications
- placenta praevia, pre-eclampsia, IUGR/fetal distress, failure to progress, breech, abruption, infection (eg herpes), cervical cancer, previous 3/4th
C-section categories
Cat 1 - 30 mins, immediate threat to life of mother/baby
Cat 2 - 75 mins - maternal / fetal compromise - not immediately life-threatening
Cat 3 - delivery required, mother + baby stable
Cat 4 - elective c-section, >39wks to reduce TTN
C-section risks
Serious
Emergency hysterectomy, further surgery, ICU, VTE, bladder/ureter injury, death, future uterine rupture, placenta praevia/accreta
Frequent
Persistent abdo pain, rpt c-section, haemorrhage, infection, fetal laceration
C-section procedure
- Send FBC, group and save
- Prescribe ranitidine (H2 receptor antagonist) +/- metoclopramide - reduce vomit / aspiration risk
- Calculate VTE risk score - Stockings, LMWH
- Epidural / spinal / general anaesthetic
- Left lateral position
- Skin incision
- Sharp / blunt dissection through layers - skin, camper fascia, scarpa fascia, rectus sheath, rectus muscle, abdominal peritoneum (parietal)
- Visceral peritoneum cut, pushed down to reflect bladder
- Uterine incision made below, baby delivered
- Oxytocin 5 units given IV to aid delivery of placenta
- Everything closed
Vaginal birth after c-section (VBAC)
Most appropriate method >37wks with 1 previous c-section
70-75% successful
Mx
deliver in hospital
continuous CTG
Avoid induction / augmentation
CIs
uterine rupture, classical caesarean scar
Shoulder dystocia
anterior shoulder stuck on pubic symphysis in delivery
leads to fetal hypoxia, risk of brachial plexus injury
(less commonly posterior shoulder on sacral promontory)
Shoulder dystocia RFs
Pre-labour
Previous, macrosomia, DM, BMI>30, IOL
Intrapartum
prolonged 1st/2nd stage labour, secondary arrest, IV oxytocin augmentation, instrumentation
Shoulder dystocia Px
- Difficulty delivering head/chin
- failure of restitution - remains OA, doesn’t turn to look to side
- Turtle head sign - fetal head retracts
Shoulder dystocia Mx
Call for help, stop pushing, routine axial traction, ?episiotomy
1st line
- McRoberts - knees to chest
- suprapubic pressure
2nd line
- posterior arm - insert hand + grab
- internal rotation - pressure on shoulders to rotate baby 180 degrees
- roll onto all 4s, repeat
Further
- cleidotomy - fracture baby clavicle
- symphysiotomy - cut pubic symphysis
- Zavenelli - return fetal head to pelvis, deliver via c-section
Post-delivery
- active mx 3rd stage
- PR - exclude 3/4th tear
- debrief parents,
- physiotherapy / paediatric review
Amniotic fluid embolism (AFE)
rare cause of maternal collapse
fetal / amniotic fluid enters mother’s bloodstream, stimulates reaction
AFE Px
- majority in labour / c-section / post-partum
- chills, shivering, sweating, anxiety, coughing
- cyanosis, hypoxia, resp arrest, hypotension, shock, seizure, MI, DIC
AFE Ix
- Dx of exclusion
- post-mortem - fetal squamous cells + debris in pulmonary vasculature
- bloods, ECG, CXR
AFE Mx
A-E
Anaesthetics, haem, ICU
Umbilical cord prolapse
Cord descends through cervix with / before presenting part of fetus
Fetal hypoxia from occlusion of cord / vasospasm from cold
Overt / complete - cord past presenting part
Occult / incomplete - alongside presenting part
RFs - ARM, prem, multiparity…..
Cord prolapse Px
Non-reassuring fetal HR
Examine to confirm
May have PV bleed
Cord prolapse Mx
Avoid handling cord (keep warm + wet) - reduce vasospasm
Manually elevate presenting part of fetus
Fill bladder with 500ml warm normal saline
Knee/chest position / left lateral position
Tocolysis - terbutaline
Deliver via c-section
If fully dilated / vaginal imminent - encourage pushing / instrumental delivery
Uterine rupture
Full thickness tear of uterine muscle / serosa - typically occurs during labour
Incomplete - peritoneum intact, remains within uterus
Complete - peritoneum torn, uterine contents escape
RFs
prev c-section / uterine surgery, IOL, obstructed labour
Uterine rupture Px
- sudden severe abdo pain, constant
- shoulder tip pain (diaphragmatic irritation)
- PV bleed
- shock
- fetal distress
- contractions stop
Uterine rupture ddx
Abruption - abdo pain +/- PV bleed - woody/tense uterus on palpation
Placenta praevia - painless PV bleed
Vasa praevia - ruptured membranes, painless PV bleed, fetal bradycardia
Uterine rupture Ix
CTG
Catheter - look for haematuria
USS
Uterine rupture Mx
A-E
Blood resus
C-section to deliver, repair uterus or remove
Primary PPH
> 500ml PV bleed <24hrs delivery
Minor - 500-1000
Major - >1000
Primary PPH causes
Tone
Uterus fails to contract properly
Tissue
retention of placental tissue, prevents contraction
Trauma
from instrument, episiotomy, c-section
Thrombin
coagulopathies
vascular (placental abruption, HTN, pre-eclampsia)
Primary PPH Px
PV bleed
Haemorrhagic shock
Dizzy, SOB, palpitations…
Primary PPH Ix
Bloods - FBC, G+S, crossmatch 4-6 units, coag, U/E, LFTs, gas
Primary PPH Mx
A-E
MHP
Atony
- Bimanual compression, insert catheter
- Oxytocin (syntocinon), ergometrine (avoid in HTN), carboprost, misoprostol
- Surgery - intrauterine balloon tamponade, B-lynch suture, artery ligation, hysterectomy
Trauma
- surgical repair
Tissue
- IV oxytocin
- surgery for evac
Thrombin
- correct
Active mx of 3rd stage to prevent
Secondary PPH
PV bleed 24hrs->12wks post-partum
Causes - endometritis, retained placental tissue
Secondary PPH Px
Excessive PV bleed, spotting
10% massive haemorrhage
If infection - fever, rigors, lower abdo pain, foul smelling lochia
Secondary PPH Ix
Bloods, inc cultures
Pelvic USS - retained tissue
Secondary PPH Mx
Abx
- Ampicillin (clindamycin if pen allergic) + metronidazole
- Add gentamicin if endomyometritis / sepsis
Uterotonics
- eg oxytocin, prostaglandins
Surgery
- if bleeding heavily, eg balloon catheter
Uterine inversion
uterus turns insure out, fundus drops down through uterine cavity
Complete - through to introitus
Uterine inversion Px
PPH
Maternal shock / collapse
Palpate on VE
See uterus at introitus
Uterine inversion Mx
Johnson manoeuvre - push back up with hand, oxytocin to stimulate contraction
Hydrostatic - fill vagina with fluid, tight seal needed
Surgery - laparotomy
Routine post-natal care
6wk check
- GP, general stuff
Menstruation
- Lochia to begin
- breastfeeding -> more oxytocin -> more bleeding
- lactational amenorrhoea - absence of periods with breastfeeding
- bottlefeeding - periods begin 3wks after birth
Contraception
- fertility returns 21d after birth
- lactational amenorrhoea 98% effective as contraception up to 6mo post partum
- POP + implant safe for breastfeeding
- if breastfeeding, avoid cOCP until >6wks
- coil - insert <48hrs >4wks after birth
Baby blues
60-70%, 3-7d after birth, more common in primips
Px
mood swings, low mood, anxiety, irritable, tearful
Mx
reassure, support
health visitor important
sx resolve <2wks
Post-natal depression
10%, start <1mo, peak at 3mo
Px
depression sx - low mood, anhedonia, low energy….
Ix
Edinburgh Postnatal Depression Scale - >10/30 suggests dx
Mx
CBT
Sertraline, paroxetine
Puerperal psychosis
0.2%, <2-3wks birth
Px
mood swings - depression / mania
Hallucinations, delusions
confusion, thought disorder
Mx
Admit to mother + baby unit
CBT
Antidepressants, antipsychotics, mood stabilisers, ECT if needed
25-50% recurrence
Endometritis
infection of endometrium, more common in c-sections
Px
foul smelling discharge
bleed, abdo / pelvic pain, fever, sepsis
can be weeks later
Ix
Vaginal swabs, urine culture, US to r/o POC
Mx
Sepsis - clindamycin + gent
Oral coamox if more well
Retained POC
pregnancy related tissue (eg placenta, fetal membrane) remains in uterus after delivery
Can happen after miscarriage / TOP
Px
PV bleed, unresolving
Abnormal PV discharge
Lower abdo / pelvic pain
Fever - infection
Ix
US
Mx
ERPC - evacuation of retained POC - under GA
Post-partum anaemia
Hb<100 post-partum
Often PPH
Mx
FBC
<100, start oral iron
<90, iron infusion - but risk of reaction, also active infection is CI
<70/80 - blood transfusion
Mastitis
Inflammation of breast tissue +/- infection, common cx of breastfeeding - S aureus
risk of abscess development
Px
Breast pain, tender, unilateral
Warm, red, inflamed
Nipple discharge, fever
Mx
continue breastfeeding, heatpacks / analgesia
No improvement - fluclox / erythromycin
Milk -> MC+S
Fluconazole for candida
Post-partum thyroiditis
Changes to thyroid function in first year
Stages
thyrotoxicosis <3mo
hypothyroid 3-6mo
function normal <1yr
Px
thyrotoxicosis - anxiety, irritable, sweating, heat, tachycardia, wt loss, fatigue, diarrhoea
hypothyroid - wt gain, fatigue, dry skin, coarse hair, hair loss, low mood, fluid retention, heavy periods, constipation
Ix - TFTs
Thyrotoxicosis - raised T3/4, low TSH
Hypothyroid - low T3/4, raised TSH
Mx
TFTs every 6-8wks
Propranolol for thyrotoxicosis
Levothyroxine for hypothyroid
Annual monitoring after resolution
Sheehan’s syndrome
Rare cx of PPH - drop in BV -> avascular necrosis of pituitary gland
Only ant pit - TSH, ACTH, FSH, LH, GH, prolactin (oxytocin, ADH not affected)
Px
reduced lactation
amenorrhoea
adrenal insufficiency / crisis, hypothyroid
Mx
Endo referral
Oestrogen, progesterone
Hydrocortisone
Levothyroxine
GH
Puerperal infection
T>38 <14 after birth
Causes
endometritis, UTI, wound infection, mastitis, VTE
Px
Fever >38, rigors, low abdo pain, foul PV discharge
Mx
Endometritis - IV abx - clindamycin + gent
Tx cause
Injectable contraceptives?
Depo provera- given IM every 12 weeks
Inhibits ovulation. Also thickens cervical mucus
Cannot be reversed, fertility return can take up to 12 months
Adverse effects-
Irregular bleeding
Weight gain
Osteoporosis risk
CI- Current breast cancer UKMEC 4
COCP missed pill advice?
If 1 pill missed at any time in the cycle- take the last pill even if it means taking two pills in one day and continue taking pills daily, one each day, no additional contraception needed
If 2+ missed pills
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily
Use condoms or abstain until taken pills for 7 days in a row
If pills are missed in week 1- emergency contraception should be considered if she had unprotected sex in pill free interval or in week 1
Week 2- no need for emergency contraception after 7 days of pill
Week 3- finish pills in current pack and start a new pack the next day, omitting the pill free interval
Postpartum contraception
After giving birth, women require contraception after day 21
Progestogen-only pill POP
Can start at any time postpartum
After day 21 addition contraception should be used for first 2 days
COCP-
UKMEC 4 if breastfeeding <6 weks post partum
UKMEC 2- if breast feeding 6weeks-6months postpartim
May reduce breast milk prodcution
Not used in first 21 days due to increased VTE risk
Additional contraception for first 7 days
IUD or IUS can be inserted within 48 hours of childbirth or after 4 weeks
Lactational amenorrhoea method (LAM)- 98% effective providing women is fully breast feeding, amenorrhoeic and <6 months post partum
UKMEC 4 for COCP?
More than 35 years old and smoking more than 15 cigarettes/day
Migraine with aura
History of thromboembolic disease or thrombogenic mutation
History of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
Positive antiphospholipid antibodies (e.g. in SLE)
Prematurity risks?
Increased mortality depends on gestation
Respiratory distress syndrome
Necrotizing enterocolitis
Intraventricular haemorrhage
Hypothermia, infection, jaundice, chronic lung disease
Retinopathy of prematurity- cause of visual impairment in premature before 32 weeks
Hearing probelms
