Obstetrics Flashcards
Antenatal screening - Conditions which all pregnant women should be offered screening
Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Syphilis
Antenatal screening - conditions should be offered depending on the history?
Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
Amniotic fluid embolism- definition, epidemiology, aetiology, clinical presentation, diagnosis, mx
Definition:
This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.
Epidemiology:
Rare complication of pregnancy associated with a high mortality rate.Incidence 2/ 100,000 in the U.K .
Aetiology:
- Many risk factors have been associated with amniotic fluid embolism but a clear cause has not been proven. A consistent link has been demonstrated with maternal AGE and INDUCTION of labour. It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.
Clinical presentation:
- The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
- Symptoms include: chills, shivering, sweating, anxiety and coughing.
- Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
Diagnosis:
- Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.
Management:
- Critical care unit by a multidisciplinary team, management is predominantly supportive
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of …
amniotic fluid embolism
Pre-eclampsia- what is it? Predisposes to? High and moderate risk? Features of severe pre-exlampsia?
Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific
Pre-eclampsia is important as it predisposes to the following problems
- fetal: prematurity, intrauterine growth retardation
- eclampsia
- haemorrhage: placental abruption, intra-abdominal, intra-cerebral
- cardiac failure
- multi-organ failure
NICE divide risk factors into high and moderate risk:
High risk factors:
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
Moderate risk factors: - first pregnancy - age 40 years or older - pregnancy interval of more than 10 years - body mass index (BMI) of 35 kg/m² or more at first visit - family history of pre-eclampsia - multiple pregnancy (SMOKING NOT A RISK FACTOR)
Features of severe pre-eclampsia:
- hypertension: typically > 170/110 mmHg and proteinuria as above
- proteinuria: dipstick ++/+++
- headache
- visual disturbance
- papilloedema
- RUQ/epigastric pain
- hyperreflexia
- platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
Perineal tears- Classification
The RCOG has produced guidelines suggesting the following classification of perineal tears:
- first degree: superficial damage with no muscle involvement
- second degree: injury to the perineal muscle, but not involving the anal sphincter
- third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
- 3a: less than 50% of EAS thickness torn
- 3b: more than 50% of EAS thickness torn
- 3c: IAS torn
- fourth degree: injury to perineum involving the anal sphincter complex (EAS and
IAS) and rectal mucosa
Perineal tears - risk factors
Risk factors for perineal tears
- primigravida
- large babies
- precipitant labour
- shoulder dystocia
- forceps delivery
What is Bishop score used for? What does it consist of? Interpretation?
The Bishop score is used to help assess the whether induction of labour will be required.
It has the following components: Cervical position Cervical consistency Cervical effacement Cervical dilation Fetal station
Interpretation:
- a score of < 5 indicates that labour is unlikely to start without induction
- a score of > 9 indicates that labour will most likely commence spontaneously
Magnesium treatment should be started in women with…
How long for?
high risk severe pre-eclampsia, or those with eclampsia
It should be continued for 24 hours after delivery or after last seizure, which ever is later
Eclampsia- what is it? Treatment?
Eclampsia may be defined as the development of seizures in association pre-eclampsia. To recap, pre-eclampsia is defined as:
- condition seen after 20 weeks gestation
- pregnancy-induced hypertension
- proteinuria
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
- should be given once a decision to deliver has been made
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
- urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
–respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
- treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Group B Streptococcus- risk factors , mx?
Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period. It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS. Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.
Risk factors for Group B Streptococcus (GBS) infection:
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection
- maternal pyrexia e.g. secondary to chorioamnionitis
Management
The main points are as follows:
- universal screening for GBS should NOT be offered to all women
- the guidelines also state a maternal request is not an indication for screening
- women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered maternal intravenous ANTIBIOTIC PROPHYLAXIS (IAP) OR testing in late pregnancy and then antibiotics if still positive
- if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
- maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
- maternal intravenous antibiotic prophylaxis should be offered to women in preterm labour regardless of their GBS status
- women with a pyrexia during labour (>38ºC) should also be given intravenous antibiotics
benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Normal laboratory findings in pregnancy?
Reduced urea, reduced creatinine, increased urinary protein loss
(Physiological changes to the circulation results in increased perfusion to the kidneys in pregnancy.)
Pregnancy: physiological changes- what systems are affected
Cardiovascular system Respiratory system Blood Urinary system Biochemical changes Liver Uterus
Pregnancy: physiological changes- cardiovascular system?
- SV up 30%, HR up 15% & cardiac output up 40%
- systolic BP is unaltered
- diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
- enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
Pregnancy: physiological changes- Respiratory system?
- Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre)
- Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm
- BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable
Pregnancy: physiological changes- Blood?
- Maternal blood volume up 30%, mostly in 2nd half - red cells up 20% but plasma up 50% Hb falls
- Low grade increase in coagulant activity
- rise in fibrinogen and Factors VII, VIII, X
- fibrinolytic activity is decreased returns to normal after delivery (placental suppression?)
- prepares the mother for placental delivery
- leads to increased risk of thromboembolism
- Platelet count falls
- WCC & ESR rise
Pregnancy: physiological changes- Urinary system?
- blood flow increase by 30%
- GFR increases by 30-60%
- Salt and water reabsorption is increased by elevated sex steroid levels
- Urinary protein losses increase
Pregnancy: physiological changes- Biochemical changes
- Calcium requirements increase during pregnancy
- especially during 3rd trimester + continues into lactation
- calcium is transported actively across the placenta
- serum levels of calcium and phosphate actually fall (with fall in protein)
- ionised levels of calcium remain stable
- Gut absorption of calcium increases substantially - due to increased 1,25 dihydroxy vitamin D
Pregnancy: physiological changes-Liver?
Unlike renal and uterine blood flow, hepatic blood flow doesn’t change
- ALP raised 50% (due to extra production from placenta)
- Albumin levels fall
Pregnancy: physiological changes-Uterus?
100g → 1100g
- hyperplasia → hypertrophy later
- increase in cervical ectropion & discharge
- Braxton-Hicks: non-painful ‘practice contractions’ late in pregnancy (>30 wks)
- retroversion may lead to retention (12-16 wks), usually self corrects
Anomaly scan is when?
18 - 20+6 weeks
Down’s syndrome screening where nuchal scanning is available - when ?
11 - 13+6 weeks
Booking visit - is when?
8 - 12 weeks
Rubella and pregnancy- risks, features, diagnosis, mx
Rubella, also known as German measles, is a viral infection caused by the togavirus. Following the introduction of the MMR vaccine it is now rare. If contracted during pregnancy there is a risk of congenital rubella syndrome. Remember that the incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
Risk
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
Features of congenital rubella syndrome sensorineural deafness congenital cataracts congenital heart disease (e.g. patent ductus arteriosus) growth retardation hepatosplenomegaly purpuric skin lesions 'salt and pepper' chorioretinitis microphthalmia cerebral palsy
Diagnosis
suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
Management
suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
since 2016, rubella immunity is no longer routinely checked at the booking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
Suspected cases of rubella in pregnancy should be …
discussed with the local Health Protection Unit as they can advise on which type of investigations to perform in each individual case.
Galactocele
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
Hypertension in pregnancy - who is at high risk? what should they do?
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
Hypertension in pregnancy - definition
The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Hypertension in pregnancy - - classification?
- Pre-existing hypertension -
- A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
- No proteinuria, no oedema
- Occurs in 3-5% of pregnancies and is more common in older women - Pregnancy-induced hypertension
(PIH, also known as gestational hypertension)
- Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
- No proteinuria, no oedema
- Occurs in around 5-7% of pregnancies
- Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life - Pre-eclampsia
- Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
- Oedema may occur but is now less commonly used as a criteria
- Occurs in around 5% of pregnancies
Cord prolapse- risk factors
Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. This occurs in 1/500 deliveries. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.
Risk factors for cord prolapse include:
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations e.g. Breech, transverse lie
- placenta praevia
- long umbilical cord
- high fetal station
The majority of cord prolapses occur at artificial rupture of the membranes. The diagnosis is usually made when the fetal HEART RATE becomes ABNORMAL and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.
Bishop score of 5? what does it mean?
The Bishop score is used to predict the success of induction
Bishop score is inversely correlated with the labour duration; a patient with score > 8 is likely to achieve a successful vaginal birth without induction. A score of <6 indicates that cervical ripening may be required.
What are the medications recommended for epileptics in pregnancy?
Anti-epileptics in pregnancy can be a tricky subject. Many are known to cause severe congenital defects (both structural and intellectual) and as such the first line of care is good contraceptive advice and planning with the patient in question
Lamotrigine, carbamazepine and levetiracetam are known to have the smallest effects on the developing foetus, however all epileptics who are either pregnant or are planning to become pregnant should be referred to specialist care as soon as possible.
Intrahepatic cholestasis of pregnancy increases the risk of …
Stillbirth or prematurity
Intrahepatic cholestasis of pregnancy- features, mx
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth- increases the risk of stillbirth
Features
- pruritus - may be intense - typical worse palms, soles and abdomen
(without rash in the third trimester)
- clinically detectable jaundice occurs in around 20% of patients
- raised bilirubin is seen in > 90% of cases
Management
- induction of labour at 37 weeks is common practice but may not be evidence based
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
Caesarean section - Indications, serious and frequent risks, VBAC
There are two main types of caesarean section:
lower segment caesarean section: now comprises 99% of cases
classic caesarean section: longitudinal incision in the upper segment of the uterus
Indications (apart from cephalopelvic disproportion/praevia, most are relative) - absolute cephalopelvic disproportion - placenta praevia grades 3/4 - pre-eclampsia - post-maturity - IUGR - fetal distress in labour/prolapsed cord - failure of labour to progress - malpresentations: brow - placental abruption: only if fetal distress; if dead deliver vaginally - vaginal infection e.g. active herpes - cervical cancer (disseminates cancer cells)
The RCOG advise clinicians to make women aware of serious and frequent risks:
'SERIOUS' Maternal: - emergency hysterectomy - need for further surgery at a later date, including curettage (retained placental tissue) - admission to intensive care unit - thromboembolic disease - bladder injury - ureteric injury - death (1 in 12,000)
Future pregnancies:
- increased risk of uterine rupture during subsequent pregnancies/deliveries
- increased risk of antepartum stillbirth
- increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
‘FREQUENT’
Maternal:
- persistent wound and abdominal discomfort in the first few months after surgery
- increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
- readmission to hospital
- haemorrhage
- infection (wound, endometritis, UTI)
Fetal:
- lacerations, one to two babies in every 100
Other complications which are recognised but not specificially mentioned in the RCOG document include;
- prolonged ileus
- subfertility: due to postoperative adhesions
Vaginal birth after caesarean (VBAC)
- If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
- around 70-75% of women in this situation have a successful vaginal delivery
- contraindications include previous uterine rupture or classical caesarean scar
Post-partum mental health problems- screen
Post-partum mental health problems range from the ‘baby-blues’ to puerperal psychosis.
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
- 10-item questionnaire, with a maximum score of 30
- indicates how the mother has felt over the previous week
- score > 13 indicates a ‘depressive illness of varying severity’
- sensitivity and specificity > 90%
- includes a question about self-harm
Post-partum mental health problems - conditions
- Baby-blues’
- Seen in around 60-70% of women
- Seen in around 60-70% of women
- Typically seen 3-7 days following birth and is more common in primips
- Mothers are characteristically anxious, tearful and irritable
Reassurance and support, the health visitor has a key role
- Postnatal depression
- Affects around 10% of women
- Most cases start within a month and typically peaks at 3 months
- Features are similar to depression seen in other circumstances
As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
- paroxetine is recommended by SIGN because of the low milk/plasma ratio
- *fluoxetine is best avoided due to a long half-life
- Puerperal psychosis
ffects approximately 0.2% of women
- Onset usually within the first 2-3 weeks following birth
- Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
- Admission to hospital is usually required
- There is around a 25-50% risk of recurrence following future pregnancies
Chickenpox exposure in pregnancy- risks
Chickenpox is caused by primary infection with varicella-zoster virus. Shingles is caused by the reactivation of dormant virus in dorsal root ganglion. In pregnancy, there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Risks to the mother
- 5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)
- risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
- studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
- features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Other risks to the fetus
- shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Given a likely diagnosis of pre-eclampsia, what is the most important sign to elicit?
Brisk reflexes are commonly associated with pre-eclampsia
Poor interaction with the baby - could suggest?
this is very unusual, including in women with postnatal depression
Hence, points towards significant mental health problems
Labour stages?
Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
Labour: stage 1
Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
Presentation
90% of babies are vertex
Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.
False Labour?
- Occurs in the last 4 weeks of pregnancy
- Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.
Folic acid- its function, causes and consequences of folic acid deficiency
Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.
Functions
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess
Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
neural tube defects
Prevention of neural tube defects (NTD) during pregnancy:
- all women should take 400mcg of folic acid until the 12th week of pregnancy
(Currently it is recommended that all women who are planning to become pregnant should take a supplement of 400 micrograms of folic acid per day whilst trying to conceive )
- women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
- women are considered higher risk if any of the following apply:
- → either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
- → the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- → the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
An ultrasound is indicated if lochia persists beyond…
6 weeks
What is Lochia?
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue during the puerperium (which may continue for 6 weeks after childbirth)
(presents for the first 2 weeks following giving birth, whether this is by vaginal birth or caesarian section.)
- Puerperium is the period of approximately six weeks after childbirth during which time the woman’s reproductive organs return to normal. Lochia is a normal part of this process..
Breech presentation- Risk factors , Management
In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity
Risk factors for breech presentation
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
Cord prolapse is more common in breech presentations
Management
- if < 36 weeks: many fetuses will turn spontaneously
- if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
- if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
Information to help decision making - the RCOG recommend:
- ‘Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.’
- ‘Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.’
Absolute contraindications to ECV:
- where caesarean delivery is required
- antepartum haemorrhage within the last 7 days
- abnormal cardiotocography
- major uterine anomaly
- ruptured membranes
- multiple pregnancy
MMR vaccination in pregnancy?
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant; to avoid becoming pregnant for 28 days after receipt of MMR vaccine
Pre-eclampsia and gestational hypertension would occur …
after 20 weeks gestation
Signs of labour include
- regular and painful uterine contractions
- a show (shedding of mucous plug)
- rupture of the membranes (not always)
- shortening and dilation of the cervix
Monitoring in Labour
- FHR monitored every 15min (or continuously via CTG)
- Contractions assessed every 30min
- Maternal pulse rate assessed every 60min
- Maternal BP and temp should be checked every 4 hours
- VE should be offered every 4 hours to check progression of labour
- Maternal urine should be checked for ketones and protein every 4 hours
Sheehan’s syndrome
- Is a complication of severe postpartum haemorrhage (PPH)
- the pituitary gland undergoes ischaemic necrosis
- can manifest as hypopituitarism
- The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery
- Diagnosis - inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
Mastitis mx
Mastitis affects around 1 in 10 breastfeeding women. The BNF advises to treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Minor’ breastfeeding problems
- frequent feeding in a breastfed infant is not alone a sign of low milk supply
- nipple pain: may be caused by a poor latch
- blocked duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
- nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby
Engorgement - breast feeding
Breast engorgement is one of the causes of breast pain in breastfeeding women. It usually occurs in the first few days after the infant is born and almost always affects both breasts. The pain or discomfort is typically worse just before a feed. Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle. Fever may be present but usually settles within 24 hours. The breasts may appear red. Complications include blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply.
Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.
Raynaud’s disease of the nipple
In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.
Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
What is Fetal fibronectin (fFN)?
a protein that is released from the gestational sac.
High Fetal fibronectin - indication?
Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN
Administering steroids can cause what effect on diabetics?
hyperglycemia
-therefore close attention should be paid to the blood glucose measurements.
Pregnancy: diabetes mellitus- risk factors
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
- women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
- women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes
- fasting glucose is >= 5.6 mmol/l
- 2-hour glucose is >= 7.8 mmol/l
Management of gestational diabetes
- newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
- women should be taught about selfmonitoring of blood glucose
- advice about diet (including eating foods with a low glycaemic index) and exercise should be given
- if the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
- if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
- if glucose targets are still not met insulin should be added to diet/exercise/metformin
- if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered - glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Management of pre-existing diabetes
- weight loss for women with BMI of > 27 kg/m^2
- stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- folic acid 5 mg/day from pre-conception to 12 weeks gestation
- aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
- detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- tight glycaemic control reduces complication rates
- treat retinopathy as can worsen during pregnancy
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Fasting- 5.3 mmol/l
1 hour after meals- 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
During a lower segment Caesarian section, the following lies in between the skin and the fetus…
Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
Red flag for puerperal psychosis
An abrupt change in mental state
Preterm prelabour rupture of the membranes- complications , mx
Preterm prelabour rupture of the membranes (PPROM) occurs in around 2% of pregnancies but is associated with around 40% of preterm deliveries
Complications of PPROM
- fetal: prematurity, infection, pulmonary hypoplasia
- maternal: chorioamnionitis
A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection. Ultrasound may also be useful to show oligohydramnios.
Management
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral ERYTHROMYCIN should be given for 10 days
- antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
Ectopic pregnancy- risk factors and features
This is the single most important cause of abdominal pain to exclude in early pregnancy
0.5% of all pregnancies are ectopic
Risk factors (anything slowing the ovum’s passage to the uterus)
- damage to tubes (salpingitis, surgery)
- previous ectopic
- IVF (3% of pregnancies are ectopic)
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm
vaginal bleeding: usually less than a normal period, may be dark brown in colour
history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
Risk of prematurity (being premature)
increased mortality depends on gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of newborn, hearing problems
What is the most common cause of primary postpartum haemorrhage (PPH)?
Uterine atony (It entails failure of the uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis. Uterine atony is associated with overdistension, which may be due to multiple gestation, macrosomia, polyhydramnios or other causes.)
First line management for uterine atony?
IV Syntocinon (oxytocin),
followed by 0.5 mg of ergometrine
Postpartum haemorrhage- risk factors
Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary
Primary PPH
- occurs within 24 hours
- affects around 5-7% of deliveries
- most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors
Risk factors for primary PPH include*:
- previous PPH
- prolonged labour
- pre-eclampsia
- increased maternal age
- polyhydramnios
- emergency Caesarean section
- placenta praevia, placenta accreta
- macrosomia
- ritodrine (a beta-2 -adrenergic receptor agonist used for tocolysis)
Secondary PPH
- occurs between 24 hours to 12 weeks**
- due to retained placental tissue or endometritis
*the effect of parity on the risk of PPH is complicated. It was previously though multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
**previously the definition of secondary PPH was 24 hours - 6 weeks. Please see the RCOG guidelines for more details
Postpartum haemorrhage- management
Management
- ABC including two peripheral cannulae, 14 gauge
- IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
- IM carboprost
- if medical options failure to control the bleeding then surgical options will need to be urgently considered
- the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
- other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
- if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Rheumatoid arthritis: pregnancy- key points
Rheumatoid arthritis (RA) typically develops in women of a reproductive age. Issues surrounding conception are therefore commonly encountered. There are no current published guidelines regarding how patients considering conception should be managed although expert reviews are largely in agreement.
Key points
- patients with early or poorly controlled RA should be advised to defer conception until their disease is more stable
- RA symptoms tend to IMPROVE in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery
- methotrexate is NOT safe in pregnancy and needs to be stopped at least 6 MONTHS before conception
- leflunomide is not safe in pregnancy
- sulfasalazine and hydroxychloroquine are considered safe in pregnancy
interestingly studies looking - TNF-α blockers - not any significant increase in adverse outcome
- low-dose corticosteroids may be used in pregnancy to control symptoms
- NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
- patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
Chorioamnionitis
Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency.
It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta.
The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens.
Chorioamnionitis is a clinical diagnosis and is suggested by uterine tenderness and foul-smelling discharge. Baseline fetal tachycardia supports the diagnosis.
Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.
Early signs of pre-eclampsia include …
hypertension and proteinuria. Other symptoms of pre-eclampsia include abdominal pain, nausea, vomiting and visual disturbance.
Management of chickenpox exposure
Management of chickenpox EXPOSURE in pregnancy
- if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for VARICELLA ANTIBODIES
- if the pregnant woman is NOT IMMUNE to varicella she should be given varicella-zoster IMMUNOGLOBULIN (VZIG) as soon as possible (VZIG is effective up to 10 days post exposure)
(The purpose of VZIG is to help prevent or attenuate chickenpox in non-immune individuals. VZIG has no therapeutic benefit once the chickenpox rash has started. Aciclovir can be given within 24 hours of the onset of the rash.)
pre-eclampsia is defined as..
condition seen after 20 weeks gestation
pregnancy-induced hypertension
proteinuria
Breast feeding: suppressing lactation ?
Techniques:
- stop the lactation reflex i.e. stop suckling/expressing
- supportive measures: well-supported bra and analgesia
- cabergoline is the medication of choice if required
Retained products - presentation?
Can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed.
- pain and heavy vaginal bleeding since delivery
- heavy, offensive lochia
- boggy poorly contracted uterus above the umbilicus
(The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected)
This lady needs and urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed
Normal CTG?
accelerations present, variability >5bpm (Variability should be 5-25bpm )
no decelerations,
HR 110-160
What does Cardiotocography monitor?
records pressure changes in the uterus using internal or external pressure transducers
- A cardiotocogram (CTG) measures fetal heart rate and uterine contractions.
The normal fetal heart rate is?
between 100-160 / min
Baseline bradycardia on CTG- what is it? and causes?
Heart rate < 100 /min
- Increased fetal vagal tone, maternal beta-blocker use
Baseline tachycardia on CTG? what is it? and causes?
Heart rate > 160 /min
- Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
Loss of baseline variability on CTG? what is it? and causes?
< 5 beats / min
- due to maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol), - foetal acidosis (usually due to HYPOXIA)
- PREMATURITY (< 28 weeks,),
Early deceleration on CTG? what is it? and causes?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
- Usually an innocuous feature and indicates head compression
Late deceleration on CTG? what is it? and causes?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
- Indicates fetal distress e.g. asphyxia or placental insufficiency
Therefore:
- urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis ( A pH of >7.2 in labour is considered normal.)
Variable decelerations on CTG? what is it? and causes?
Independent of contractions
- May indicate cord compression
Venous thromboembolism in pregnancy
- Pregnancy is a risk factor for developing venous thromboembolism (VTE).
- A risk assessment should be completed at booking and on any subsequent hospital admission.
- A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
- A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.
Risk factors that increase the womans likelihood of developing VTE ?
These risk factors include: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
What blood test is used to monitor treatment of VTE?
Anti-Xa
(A way to remember:
cleXAne = Xa - clexane is brand name for enoxaparin )
Cord prolapse- mx
For management of cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression.
Tocolytics may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.
The patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in caesarian sections being used in breech presentations.
The umbilical cord is palpable vaginally above the level of the introitus - what does this indicate?
Cord prolapse
which occurs after membrane rupture when the umbilical cord descends below the presenting part of the fetus.
Placenta praevia- features, CF, Ix
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
Associated factors
- multiparity
- multiple pregnancy
- embryos are more likely to implant on a lower segment scar from previous caesarean section
Clinical features
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds previously before large
Investigations
- placenta praevia is often picked up on the routine 20 week abdominal ultrasound
- the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
Placenta praevia - Classical grading?
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV - placenta completely covers the internal os
What treatment would you advise to reduce the risk of pre-eclampsia?
Aspirin 75mg
- Women at high RISK of pre-eclampsia are advised to take 75 mg of aspirin daily from 12 weeks until the birth
NOTE: (Offer pharmacological treatment if BP remains above 140/90 mmHg’) - labetalol
HELLP syndrome- what is it?
s a severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
HELLP syndrome - CF?
A typical patient might present with:
- malaise, nausea, vomiting, and headache.
- Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.
Pregnancy: jaundice- Intrahepatic cholestasis of pregnancy
Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester. It is the most common liver disease of pregnancy.
Features
- pruritus, often in the palms and soles
- no rash (although skin changes may be seen due to scratching)
- raised bilirubin
Management
- ursodeoxycholic acid is used for symptomatic relief
weekly liver function tests
women are typically induced at 37 weeks
Complications include an increased rate of stillbirth. It is not generally associated with increased maternal morbidity
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Features
- abdominal pain
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre-eclampsia
Investigations
- ALT is typically elevated e.g. 500 u/l
Management
- support care
- once stabilised delivery is the definitive management
Vasa praevia - what is it? features?
- Vasa praevia describes a complication in which fetal blood vessels cross or run near the internal orifice of the uterus.
- The vessels can be easily compromised when supporting membranes rupture, leading to frank bleeding.
The classic triad of vasa praevia is:
- rupture of membranes
- followed by painless vaginal bleeding
- fetal bradycardia.
Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant.
Although ultrasound scans can detect vasa praevia, many cases are undetectable antenatally.
A baby is diagnosed with foetal macrosomia if they have a birth weight …
> 4kg regardless of their gestational age
(Foetal macrosomia can cause dystocia which may result in injuries to both the mother and baby. Dystocia may also require an operative vaginal delivery or Caesarean-section)
Erb’s palsy occurs due to damage to the UPPER brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.
Klumpke’s palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand.
Shoulder dystocia
Shoulder dystocia is a complication of vaginal cephalic delivery.
Shoulder dystocia is a cause of both maternal and fetal morbidity.
It is associated with postpartum haemorrhage and perineal tears with respect to the former, and brachial plexus injury with respect to the latter, amongst other complications. Neonatal death occasionally occurs.
Key risk factors for shoulder dystocia include :
- fetal macrosomia
- high maternal body mass index
- diabetes mellitus
- prolonged labour
It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis. Additionally help should be called as soon as shoulder dystocia is identified
- and McRoberts’ manoeuvre should be performed.
- -This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen. This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options. Oxytocin administration is not indicated in shoulder dystocia.
Management of chickenpox in pregnancy
- if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
- there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
- oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
What is a common cause of itch in third trimester of of pregnancy?
Intrahepatic cholestasis of pregnancy.
- give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT. Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment.
