OBSTETRICS 2: Antenatal vaginal bleeding, screening, care pathway, preterm labour, postpartum care Flashcards
What is an ectopic pregnancy?
Pregnancy outside uterus - usually ampulla of fallopian tube but can be ovarian, cervix etc. too
Approx. 1% pregnancies
What are RFs for an ectopic pregnancy?
STI/PID
Prev. surgery (tubes)
Prev. ectopic
IUS
ART (aided reproductive technology)
How is ectopic pregnancy investigated?
EXAMINATION: abdo pain, cramping, shoulder tip, bleeding, cervical excitation/tenderness, collapse, pregnancy test
BLOODS: FBC, G&S, hCG, progesterone
USS: confirm diagnosis, free fluid
How is ectopic pregnancy managed and what are the complications?
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
What is a miscarriage?
Loss of pregnancy <24/40
20% of pregnancies
Mostly due to chromosomal abnormality
What are RFs for miscarriage?
Age
Medical disease e.g. SLE, DM
Structural issues - fibroids
Clotting disorders - e.g. antiphospholipid
How are miscarriages investigated?
BEDSIDE EXAM: abdo pain, cramping, bleeding, cervical excitation/tenderness, collapse
BLOODS: FBC, G&S, hCG, progesterone
IMAGING: USS confirm diagnosis
POST DELIVERY: histology
What are the different types of miscarriage?
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
How is miscarriage managed?
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)
What is gestational trophoblastic disease? What are the different types?
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
How is GTD investigated?
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
How is GTD managed?
Specialised care in specific centre
MEDICAL = Methotrexate
SURGICAL = ERCP
Serial monitoring of hCG
Avoid pregnancy until normal hCG
What is placenta accreta?
Abnormal placentation, assoc. w/uterine surgery, age, IVF
TYPES = accreta, increta and percreta
RISKs = rupture, surgical morbidity, recurrence
How is placenta accreta investigated?
BEDSIDE EXAM: low-lying placenta, bleeding/APH, growth restriction
IMAGING: placental localisation on USS, MRI
How is placenta accreta managed?
SURGICAL - may be possible to do wedge resection
Caesarean hysterectomy
CONSERVATIVE = leave in situ
What is placenta praevia/vasa praevia?
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
How is placenta praevia/vasa praevia investigated?
FINDINGS: bleeding, APH, growth restriction
USS: placental localisation
What are the risks of low lying placenta/vasa praevia?
APH
Recurrence
Rupture of membranes
How is placenta praevia/vasa praevia managed?
C-section, timing of delivery - aim to avoid emergency
Roughly outline the antenatal care pathway for a nulliparous woman?
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
Roughly outline the antenatal care pathway for a multiparous woman?
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
What additional checks are done if undergoing doctor led care?
Doctor 1st trimester
20/40 appt
32/40 appt
36/40 appt
What antenatal screening is offered in the NHS?
- 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.
What is the combined screening test?
10-14w
Typically done at ‘dating scan’ ~12w
Combo of nuchal translucency measurement + blood tests (b-hCG, PAPP-A, calculated w/maternal age too)
What is the quadruple test?
14-20w - for later bookings or when CST not possible
Blood test: PAPP-A, inhibin, AFP, unconjugated oestriol
How are screening results interpreted?
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
What are diagnostic tests for chromosomal abnormalities?
Chorionic villus sampling at 11-14/40
Amniocentesis at >15/40
Risk of miscarriage 0.5-1%
What is preterm labour?
Preterm birth <37w
Very preterm <32
Extremely preterm <28w
What are immediate and long-term implications for a pre-term baby?
IMMEDIATE
- NEC
- IVH
- retinopathy
- RDS
- sepsis
LONG-TERM
- neonatal death/morbidity
- permanent disability
- chronic lung conditions etc.
What are risk factors for pre-term labour?
- 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
What are features of pre-term labour and how is investigated?
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)
How is pre-term labour managed?
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
Summarise preterm prelabour rupture of membranes
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
What is a cervical cerclage and when is it used?
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.
Summarise post partum blues?
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
Summarise PND?
DEFINITION = pervasive low mood
SX = low mood, decreased appetite, early morning waking, anxiety
IX = EDPS, MMSE
MX = IAPT, CBT, antidepressants
Summarise puerperal psychosis?
DEFINITION = acute onset psychotic illness
SX = mania, delusions, hallucinations, thoughts of self-harm
IX = EDPS, MMSE
MX = admission
Summarise postpartum thyroiditis?
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
