OBSTETRICS 2: Antenatal vaginal bleeding, screening, care pathway, preterm labour, postpartum care

Question 1

What is an ectopic pregnancy?

Answer 1

Pregnancy outside uterus - usually ampulla of fallopian tube but can be ovarian, cervix etc. too

Approx. 1% pregnancies

Question 2

What are RFs for an ectopic pregnancy?

Answer 2

STI/PID
Prev. surgery (tubes)
Prev. ectopic
IUS
ART (aided reproductive technology)

Question 3

How is ectopic pregnancy investigated?

Answer 3

EXAMINATION: abdo pain, cramping, shoulder tip, bleeding, cervical excitation/tenderness, collapse, pregnancy test

BLOODS: FBC, G&S, hCG, progesterone

USS: confirm diagnosis, free fluid

Question 4

How is ectopic pregnancy managed and what are the complications?

Answer 4

CONSERVATIVE = if stable w/falling hCG serial measurements

MEDICAL = methotrexate

SURGICAL = salpingectomy or salpingostomy - laparoscopic or open

Anti-D prophylaxis

COMPLICATIONS = life threatening, subfertility, psychological

Question 5

What is a miscarriage?

Answer 5

Loss of pregnancy <24/40

20% of pregnancies

Mostly due to chromosomal abnormality

Question 6

What are RFs for miscarriage?

Answer 6

Age
Medical disease e.g. SLE, DM
Structural issues - fibroids
Clotting disorders - e.g. antiphospholipid

Question 7

How are miscarriages investigated?

Answer 7

BEDSIDE EXAM: abdo pain, cramping, bleeding, cervical excitation/tenderness, collapse

BLOODS: FBC, G&S, hCG, progesterone

IMAGING: USS confirm diagnosis

POST DELIVERY: histology

Question 8

What are the different types of miscarriage?

Answer 8

THREATENED = gestational sac, fetal heartbeat + closed cervical os

INEVITABLE = gestational sac, +ve or -ve fetal heartbeat + open cervical os

INCOMPLETE = no fetal heartbeat + open cervical os

COMPLETE = empty uterus, no fetal heartbeat + closed cervical os

INCOMPLETE = gestational sac, no fetal heartbeat, closed cervical os

Question 9

How is miscarriage managed?

Answer 9

CONSERVATIVE = if stable and falling hCG serial measurements

SURGICAL = ERPC, often called surgical miscarriage management

MEDICAL = mifepristone and misoprostol

?anti-D prophylaxis

PSYCHOLOGICAL SUPPORT e.g. helplines (e.g. Tommy’s midwives’ helpline for anyone who’s had pregnancy loss)

Question 10

What is gestational trophoblastic disease? What are the different types?

Answer 10

Benign tumour of trophoblastic tissue

COMPLETE = diploid, paternal origin, duplication of sperm fertilising empty ovum or dispermic fertilisation

PARTIAL = triploid, 2 paternal + 1 maternal gene and may contain fetal parts

Risks inc. malignancy or recurrence

Question 11

How is GTD investigated?

Answer 11

BEDSIDE EXAM: PVB, larger for dates, hyperemesis, sx of hyperthyroid possible (hCG similar to TSH)

BLOODS: FBC, G&S, hcg, progesterone

USS: confirm diagnosis - ‘cluster of grapes’ in complete mole

POST DELIVERY: histology

Question 12

How is GTD managed?

Answer 12

Specialised care in specific centre

MEDICAL = Methotrexate

SURGICAL = ERCP

Serial monitoring of hCG

Avoid pregnancy until normal hCG

Question 13

What is placenta accreta?

Answer 13

Abnormal placentation, assoc. w/uterine surgery, age, IVF

TYPES = accreta, increta and percreta

RISKs = rupture, surgical morbidity, recurrence

Question 14

How is placenta accreta investigated?

Answer 14

BEDSIDE EXAM: low-lying placenta, bleeding/APH, growth restriction

IMAGING: placental localisation on USS, MRI

Question 15

How is placenta accreta managed?

Answer 15

SURGICAL - may be possible to do wedge resection

Caesarean hysterectomy

CONSERVATIVE = leave in situ

Question 16

What is placenta praevia/vasa praevia?

Answer 16

Placenta is overlying or <2cm from internal cervical os

Assoc. w/uterine surgery, age, IVF

TYPES =
- major: completely covering
- minor: partially covering

Vasa praevia = exposed fetal vessels over internal os

Question 17

How is placenta praevia/vasa praevia investigated?

Answer 17

FINDINGS: bleeding, APH, growth restriction

USS: placental localisation

Question 18

What are the risks of low lying placenta/vasa praevia?

Answer 18

APH
Recurrence
Rupture of membranes

Question 19

How is placenta praevia/vasa praevia managed?

Answer 19

C-section, timing of delivery - aim to avoid emergency

Question 20

Roughly outline the antenatal care pathway for a nulliparous woman?

Answer 20

8-14/40 = booking and dating scan

16/40 = MW - alone ask about safeguarding and DV

18-20/40 = MW

20/40 = anomaly scan

25/40 = MW

28/40 = MW bloods (FBC/G&S), start serial growth scans if indicated

MW appts at 31, 34, 36, 38 and 40 weeks, start birth planning

At 40/40 discuss post-dates care

BP, urine dipstick, fetal heartbeat at every appointment

Question 21

Roughly outline the antenatal care pathway for a multiparous woman?

Answer 21

8-14/40 = booking and dating scan

16/40 = MW - alone ask about safeguarding and DV

20/40 = anomaly scan

28/40 = MW bloods (FBC/G&S), start serial growth scans if indicated

MW appts 34, 36, 38 and 40 weeks, start birth planning

At 40/40 discuss post-dates care

BP, urine dipstick, fetal heartbeat at every appointment

Question 22

What additional checks are done if undergoing doctor led care?

Answer 22

Doctor 1st trimester

20/40 appt

32/40 appt

36/40 appt

Question 23

What antenatal screening is offered in the NHS?

Answer 23

• INFECTIOUS DISEASES: HIV, Hep B, Syphilis - bloods at booking visit
• INHERITED CONDITIONS: sickle cell, thalassaemia, haemoglobinopathies - bloods at booking visit
• FETAL CHROMOSOMAL ABNORMALITIES: trisomy 21, 18, 13
• PHYSICAL CONDITIONS: 20 week anomaly scan e.g. anencephaly, gastroschisis etc.

Question 24

What is the combined screening test?

Answer 24

10-14w
Typically done at ‘dating scan’ ~12w

Combo of nuchal translucency measurement + blood tests (b-hCG, PAPP-A, calculated w/maternal age too)

Question 25

What is the quadruple test?

Answer 25

14-20w - for later bookings or when CST not possible

Blood test: PAPP-A, inhibin, AFP, unconjugated oestriol

Question 26

How are screening results interpreted?

Answer 26

LOWER CHANCE = >1 in 150, no further action, proceed to anomaly scan

HIGHER CHANCE = <1 in 150, further testing offered:
- NIPT (non-invasive prenatal test) - sample of maternal blood assessed for cfDNA

Question 27

What are diagnostic tests for chromosomal abnormalities?

Answer 27

Chorionic villus sampling at 11-14/40

Amniocentesis at >15/40

Risk of miscarriage 0.5-1%

Question 28

What is preterm labour?

Answer 28

Preterm birth <37w

Very preterm <32

Extremely preterm <28w

Question 29

What are immediate and long-term implications for a pre-term baby?

Answer 29

IMMEDIATE
- NEC
- IVH
- retinopathy
- RDS
- sepsis

LONG-TERM
- neonatal death/morbidity
- permanent disability
- chronic lung conditions etc.

Question 30

What are risk factors for pre-term labour?

Answer 30

• prev. PTB
• prev. mid-trimester loss 16-24w
• prev. cervical surgery (LLETZ, biopsy)

IMMUNOLOGICAL = infection, vaginal microbiome

STRUCTURAL = uterine abnormalities e.g. septate uterus

SOCIAL/LIFESTYLE = smoking, drugs, extremes of age, extremes of BMI

Question 31

What are features of pre-term labour and how is investigated?

Answer 31

FEATURES: pain, ROM, bleeding, PV discharge

BEDSIDE: obs, abdominal palpation, speculum, urine MCS, vaginal swab MCS, blood culture

BLOODS: FBC, CRP, G&S

IMAGING: USS, CTG

Specific Ix = fetal fibronectin or tests to confirm ruptured membranes (amnisure, actimPROM)

Question 32

How is pre-term labour managed?

Answer 32

Fetal steroids for lung maturation - 2 doses 12-24 apart, maximal benefit if delivery within 7d, ~23-34w, to reduce RDS

Magnesium sulphate for neuroprotection - aim to administer when delivery is imminent (6hrs) - reduce cerebral palsy incidence

Avoid tocolysis to prevent infection risk

Erythromycin for GBS prophylaxis

Early involvement of neonatal team - ?transfer patient to appropriate unit

Question 33

Summarise preterm prelabour rupture of membranes

Answer 33

Rupture of membanes <37w without the onset of labour

multifactorial causes

80% of cases delivery occurs by 9d

aim to ensure steroids administered, magnesium sulfate if <30w, consider augmentation w/oxytocin

Question 34

What is a cervical cerclage and when is it used?

Answer 34

Helps prevent preterm labour in women with RFs e.g. short cervix

normal cervical length >25mm, can be measured in high risk pts up to 24-28w to assess trend

Elective cerclage - hx or US indicated

Rescue cerclage - 16-28/40 if
- dilated cervix
- intact membranes
- no evidence of infection
- 50-70% ‘take home baby’ rate

Aims to prolong pregnancy - remove at 37w

If gets infection, ROM or into labour, stitch must be removed.

Question 35

Summarise post partum blues?

Answer 35

DEFINITION = mild, self-limiting, low mood

SX = labile mood, poor sleep

IX = edinburgh PND scale, MMSE

MX = reassurance

Complications = recurrence, attachment issues, psychological morbidity, increased risk of suicide

Question 36

Summarise PND?

Answer 36

DEFINITION = pervasive low mood

SX = low mood, decreased appetite, early morning waking, anxiety

IX = EDPS, MMSE

MX = IAPT, CBT, antidepressants

Question 37

Summarise puerperal psychosis?

Answer 37

DEFINITION = acute onset psychotic illness

SX = mania, delusions, hallucinations, thoughts of self-harm

IX = EDPS, MMSE

MX = admission

Question 38

Summarise postpartum thyroiditis?

Answer 38

Three stages:
1. thyrotoxicosis
2. hypothyroidism
3. normal thyroid function

TPO antibodies in 90% of pts

Mx =
- THYROTOXIC PHASE = propranolol for sx control
- HYPOTHYROID PHASE = usually treated w/thyroxine