Obstetrics Flashcards
Give 3 physiological cardiorespiratory changes in pregnancy
Increased - RR, HR, SV, CO, plasma volume, preload, O2 consumption, laryngeal oedema
Decreased - SVR, afterload, residual capacity, arterial PO2
When in pregnancy are women with heart disease at greater risk?
When CO is high or rapidly changing - early pregnancy, second trimester, immediately postpartum
Give 3 physiological haematological changes in pregnancy
Increased - plasma volume causing dilutional anaemia, leukocytosis, transferrin and TIBC, coagulation factors
Decreased - iron
Give 3 physiological urinary tract changes in pregnancy
Increased - renal blood flow and GFR, excretion of metabolites, glycosuria, water retention, residual urine volume, UTI risk
Give 3 physiological GI tract changes in pregnancy
Increased - bowel transit
Decreased - LOS pressure, gastric peristalsis, gastric emptying
Give 3 physiological skin changes in pregnancy
Hyperpigmentation - umbilicus, nipples, abdominal midline (linea nigra), face (melasma) Hyperdynamic circulation and high oestrogen - spider naevi, palmar erythema Stretch marks (striae gravidarum)
Give 3 physiological MSK changes in pregnancy
Increased ligamental laxity (back pain, pubic symphysis dysfunction)
Exaggerated lumbar lordosis
Outline the timeline of antenatal care appointments for women with no risk factors
Pre-booking - first contact with health professional Booking appointment and screening 18-20 weeks - anomaly scan (25 weeks) 28 weeks (31 weeks) 36 weeks 38 weeks (40 weeks) 41 weeks 42 weeks
(prim patients have additional appointments)
When should a booking appointment take place and what are the aims?
By 10 weeks Identify risks (e.g. domestic abuse) Screen for abnormalities/illness Obtain initial observations Determine likely gestation Develop rapport and encourage future attendance Provide key health information (e.g. smoking cessation, dietician, dental care, folic acid, alcohol, food) Social work involvement if required
How is an estimated date of delivery calculated?
Naegele’s rule
EDD = LMP + 1 year - 3 months + 7 days
What risk factors should be considered in pregnant women?
Age <18 or >40 Para 0 or para 6+ Low or high BMI Low socioeconomic status Drug/alcohol misuse Previous obstetric problems Vulnerable groups (e.g. asylum seekers) Pre-existing medical conditions (e.g. diabetes, hypertension)
What questions should be asked regarding obstetric history at booking appointment?
Miscarriage >14 weeks Stillbirth Neonatal death Recurrent miscarriage (>3 consecutive) Premature birth Pregnancy induced hypertension Gestational diabetes Rhesus disease Antepartum haemorrhage Induction of labour Operative birth Postpartum haemorrhage Obstetric anal sphincter injury
What screening blood tests are done at booking?
FBC Blood group Sickle cell and thalassaemia Rubella Hep B Syphilis HIV
Give 3 types of fetal screening
Nuchal translucency (11-14 weeks) - Down syndrome
Fetal anomaly scan (18-22 weeks)
Chorionic villus sampling (from 11 weeks)
Amniocentesis (from 15 weeks)
Non-invasive prenatal testing
When is the first trimester?
0-12 weeks
When is the second trimester?
12-20 weeks
From what point is the fetal heart auscultated at antenatal appointments?
18 weeks
Give 5 common problems in pregnancy and their basic management
Nausea and vomiting - admit if severe, antiemetics
Heartburn - antacids, H2 antagonists
Haemorrhoids - avoid constipation
Constipation - increase fluid intake
Pelvic girdle/sciatica/back pain - PT
Anaemia - iron replacement
Carpal tunnel syndrome - exclude pre-eclampsia, PT, splint
Bleeding gums - dental check up
Fatigue - screen for anaemia, physical activity
Itching - consider obstetric cholestasis if >30 weeks
Rashes - antihistamines, steroids
Vaginal discharge - swab
When is the third trimester?
20 weeks-term
What should be covered during antenatal appointments?
BP, urinalysis, auscultation of fetal heart
Ask about pain and vaginal loss
Ask about common pregnancy problems
Ask about foetal movements
Abdominal examination
Evaluation of fetal growth (from 24 weeks)
How is fetal growth evaluated at antenatal appointments?
From 24 weeks
Symphyseal-fundal height - measure fundal height in cm from pubic symphysis to the top of the uterus
Give 3 antenatal complications
Polyhydramnios Oligohydramnios Hypertension and pre-eclampsia Anaemia Impaired glucose tolerance Mental health problems
Define polyhydramnios
Excess of amniotic fluid
Single deepest vertical pool (DVP) >8cm
Amniotic fluid index (AFI) >90th centile for gestation
How does polyhydramnios present?
Large for date
Tense abdomen
Unable to feel fetal parts
What are the complications of polyhydramnios?
Placental abruption Malpresentation Cord prolapse Large for gestational age C-section Postpartum haemorrhage Premature birth Perinatal death
Define oligohydramnios
Deficiency of amniotic fluid
DVP <2cm or AFI <5cm
What are the complications of oligohydramnios?
Poor perinatal outcome Prolonged pregnancy Ruptured membranes IUGR Fetal renal congenital abnormalities Hypoxia (cord compression)
Give 2 symptoms of hypertension in pregnancy which should be asked if there is suspicion of pre-eclampsia
Headache
Visual disturbance
Severe upper abdominal pain
Significant facial/hand/ankle oedema
Give 3 risk factors for hypertension and pre-eclampsia
Nulliparity
FH
Extremes of maternal age
Obesity
Medical condition - hypertension, renal disease, SLE, diabetes
Obstetric factors - multiple pregnancy, previous pre-eclampsia, hydatidiform mole, hydrops
How is anaemia in pregnancy defined and managed?
Hb <105 g/L
Check folate, B12 and ferritin
Oral iron therapy
When should a glucose tolerance test be done in pregnancy?
Glycosuria or risk factors
What are the risk factors of impaired glucose tolerance in pregnancy?
FH diabetes
High BMI
Previous macrosomic baby
Previous GDM
How are pro-pregnancy and pro-labour factors involved in the initiation of labour?
Inhibition of pro-pregnancy - progesterone, NO, catecholamines, relaxin
Activation of pro-labour - oestrogen, oxytocin, prostaglandins, prostaglandin dehydrogenase, CRH, inflammatory mediators
What is the role of NO in labour?
Involved in cervical ripening
What is the role of oxytocin in labour?
Stimulation of uterine contractility - increases frequency and force
What is the role of prostaglandins in labour?
Promote cervical ripening and stimulate uterine contractility
What is the role of inflammatory mediators in labour?
Contribute to cervical ripening and membrane rupture
Stimulate uterine contraction
What is cervical ripening?
Late in pregnancy, the cervix softens, effaces and dilates
Prostaglandins increase ripening by inhibiting collagen synthesis and stimulating collagenase activity
How is cervical ripening assessed?
Bishop’s score
0 - <1cm dilation, >2cm length, spines -3, firm, posterior
1 - 1-2cm, 1-2cm, -2, medium, central
2 - 3-4cm, <1cm, -1, soft, anterior
Outline the delivery process
Head at pelvic brim in right/left OT position, neck flexed so presenting diameter is suboccipitobregmatic
Head descends and engages
Head reaches pelvic floor and occiput starts to rotate to OA
Complete rotation
Head delivers by extension
Shoulders rotate into AP diameter with continued descent, head follows in external rotation (restitution)
Anterior shoulder delivers with lateral flexion
Posterior shoulder delivers
How is labour diagnosed?
Uterine contractions, effacement (thinning) and dilatation
Outline the process of effacement
Has occurred when the entire length of the cervix has been ‘taken up’ into the lower segment of the uterus
Begins with the internal os, and proceeds downwards to the external os until the cervical tissue becomes continuous with the uterine walls
What can be seen on speculum examination in a patient with rupture of membranes?
Pool of liquor in the posterior vaginal fornix
What is the risk of prelabour rupture of membranes?
Ascending infection - chorioamnionitis
How should prelabour ROM be managed?
Conservative if mother and baby well
Induction of labour after 24 hours
What is the first stage of labour?
From onset of labour until full cervix dilation
Latent phase (cervix effaced and 3-4cm dilated) and active phase (cervix dilated)
8-18 hours in prim, 5.5-12 hours in multi
What is the second stage of labour?
From full dilation (10cm) until head is delivered Propulsive phase (until head on pelvic floor) and expulsive phase (from urge to bear down until baby delivered) Within 3 hours in prim, 2 hours in multi
What is the third stage of labour?
From delivery until expulsion of placenta/membranes
Recognised by cord lengthening and gush of dark blood, controlled traction on cord (30 mins with oxytocin, 1 hour without)
What assessments are conducted throughout labour?
History
Maternal HR, BP, temperature, urinalysis, partogram recording
Assessment of length, strength and frequency of contractions
Observe - ROM, meconium, bleeding
Assess fetal movements
Abdominal examination - fundal height, engagement, auscultation of fetal heart
CTG recording
Vaginal examination - every 4 hours ideally by the same person
What is station of the presenting part?
Recorded with respect to ischial spines with spines = 0
What positions can the fetal head be in during labour?
Right/left occipitoposterior
Right/left occipitotransverse
Right/left occipitoanterior
Define caput
Caput succedaneum is oedema of the scalp owing to pressure of the head against the rim of the cervix and is classified arbitrarily as ‘+’, ‘++’, or ‘+++’
Define moulding
Describes the change in head shape, which occurs during labour, made possible by movement of the individual scalp bones.
It is classified arbitrarily as ‘+’ if the bones are opposed, ‘++’ if the bones overlap but can be reduced, and ‘+++’ if the bones overlap, but cannot be reduced
When is meconium during labour concerning?
Thick pea-soup green meconium - fetal hypoxia or acidosis
What is injected after delivery of the anterior shoulder in the second stage of labour and why?
IM oxytocin
Reduce risk of postpartum haemorrhage
What is a partogram?
Graph record of clinical findings during labour
Records maternal observations (BP, HR, temp), fetal heart rate, progressive cervical dilatation, descent of the presenting part, strength and frequency of contractions, and colour of amniotic fluid
What is a precipitate labour?
Expulsion of the fetus within <2-3 hours of onset of contractions due to uterine overactivity and can lead to fetal distress
What is a slow labour?
Cervical dilation of <2cm in 4 hours
Inadequate uterine activity
What is a malpresentation?
Any non-vertex position - face, brow, breech, shoulder
Give 3 things associated with breech presentation
Multiple pregnancy Bicornate uterus Fibroids Placenta praevia Polyhydramnios Oligohydramnios NTDs Neuromuscular disorders Autosomal trisomies
To whom and when should external cephalic version (ECV) be offered?
All women with breech presentation at 36/37 weeks
What is malposition? Give an example
Abnormal position of the vertex relative to the maternal pelvis
Occipitoposterior - longer labour, may require oxytocin/c-section
Define prolonged pregnancy
Pregnancy beyond 42 weeks
What are the risks of prolonged pregnancy and how are they reduced?
Intrauterine death and intrapartum hypoxia
Induction of labour is offered at 41-42 weeks (after membrane sweep attempted) - if declined, should do twice weekly CTG and USS
When is induction of labour offered?
When risk of continuing pregnancy outweighs risk of delivery
E.g. prolonged pregnancy, maternal diabetes, twin pregnancy, fetal growth restriction, suspected fetal compromise, hypertensive disorders, deteriorating maternal medical condition, maternal request
What are the contraindications to induction of labour?
Vaginal delivery contraindicated (e.g. placenta praevia, transverse lie)
Caution in previous c-section/uterine surgery
Risk of hyperstimulation in those with previous precipitate labour
What methods are available for induction of labour?
Unfavourable cervix (Bishop score ≤6) - prostaglandins gel/tablet into posterior fornix, reassess after 6 hours, can repeat, ARM after score >6, can cause GI upset Favourable cervix (Bishop score >6) - ARM, synthetic oxytocin (need CTG monitoring)
What are the risks of induction of labour?
Hyperstimulation
Increased operative vaginal delivery
What is augmentation?
The process of accelerating labour which is already underway
Give 2 non-pharmacological methods of pain relief in labour
Maternal support Environment Birthing pools Education (Limited evidence - massage, acupuncture, hypnosis, TENS)
Give 2 pharmacological methods of pain relief in labour
Inhaled analgesics - entonox (50:50 O2 and NO)
Systemic opioid analgesia - IM diamorphine (avoid in 4 hours before delivery)
Pudendal analgesia (instrumental delivery)
Regional analgesia - epidural, spinal
GA (higher risk)
What are the side effects of entonox?
Nausea
Vomiting
Lightheadedness
Give 3 features of epidural anaesthesia for labour
Used for labour, can be topped up for instrumental delivery
Maternal request
Extradural catheter placed
Effect may be patchy
Not associated with - prolonged first stage, c-section, long-term backache
Associated with - prolonged second stage, instrumental delivery
Give 2 features of spinal anaesthesia for labour
Used for operative delivery/surgical management of postpartum complications
Subarachnoid injection lasting 2-4 hours
Dense and reliable analgesia
Give 3 complications of regional anaesthesia
Dural puncture headache Hypotension Local anaesthetic toxicity Accidental total spinal block Neurological complications Bladder dysfunction
Why are pregnant women undergoing GA at increased risk
Reduced gastro-oesophageal tone
Increased intra-abdominal mass
Reduced gastric emptying
Regurgitation of gastric contents and aspiration (pneumonitis)
Difficult and failed intubation more likely
How are spontaneous perineal tears classified?
First degree - vaginal epithelium and vulval skin
Second degree - perineal muscles
Third degree - perineum involving anal sphincter complex
Fourth degree - anal sphincter complex and anal/rectal mucosa
What are the indications for episiotomy?
Rigid perineum preventing delivery Large tear thought to be imminent Instrumental delivery Suspected fetal compromise Shoulder dystocia
Why is an episiotomy not carried out routinely in uncomplicated vaginal delivery?
There is no clear evidence that it reduces the incidence of third or fourth degree tears
A spontaneous tear may be less painful than an episiotomy and may also heal better
How is an episiotomy carried out?
Infiltrate local anaesthetic (unless effective regional block)
Make right medio-lateral cut
How is an episiotomy/perineal tear repaired?
Infiltrate local anaesthetic (unless effective regional block)
Perform rectal examination to exclude third and fourth degree tears
Use a rapidly absorbable synthetic suture material to carry out continuous, non-locking and sub-cuticular sutures
Analgesia and ice packs
Advise on perineal care and hygiene
No contraindication to PR analgesia
How long does postnatal care extend?
6 weeks
What are the advantages of skin-to-skin immediately post-birth?
Neonatal thermoregulation, respiratory regulation, increases successful breastfeeding
Maternal stimulation of oxytocin, which increases uterine contractions and milk production
Outline immediate post-birth care of the neonate
Apgar score (1, 5, 10 mins) Clamp and cut umbilical cord after 1 minute Birth weight and temperature Physical examination Record first micturition and feed Vitamin K administration
Outline immediate post-birth care of the mother
Observe vaginal blood loss, palpate fundus to assess contraction Examine for tears and repair Support skin-to-skin Check colour, BP, HR, RR, temperature Offer food Record first micturition Assess VTE risk and commence prophylaxis
Give 3 benefits of breastfeeding for the baby
Reduced infection Reduced vomiting and diarrhoea Reduced childhood leukaemia Reduced obesity Reduced CVD Available on demand Strengthens emotional bond
Give 3 benefits of breastfeeding for the mother
Reduced breast/ovarian cancer risk
Reduced osteoporosis
Reduced CVD
Reduced obesity
What do midwives cover on home visits?
Discuss birth - PTSD
Assess mental health - postnatal depression, suicide
Physical - observations, haemorrhage, anaemia, sepsis, perineum
Discuss contraception
Baby - feeding, changing, safe sleeping, washing
Give 5 postnatal complications
Anaemia
Bowel problems - constipation, fear of defecation, reduced mobility
Breast problems - nipple pain/cracks/bleeding, mastitis, abscess, engorgement
Perineal breakdown
Incontinence - compression of pudendal nerve during delivery
Puerperal pyrexia - genital/urinary/breast infection, DVT/PE
Secondary PPH - uterine infection, retained products of conception
VTE - LMWH, early mobilisation
Mental health problems
Define stillbirth
Baby delivered with no signs of life that is known to have died after 24 weeks (before this is a miscarriage)
What are the risk factors for stillbirth?
Advanced maternal age Maternal obesity Social deprivation Smoking Non-white ethnicity Domestic violence
What are the causes of stillbirth?
Fetal - lethal congenital abnormality, growth restriction, infection, anaemia, haemorrhage, twin to twin transfusion, cord obstruction
Maternal - DKA, pulmonary HTN, antibodies, diabetes
Placental - abruption, pre-eclampsia, maternal renal disease, APL syndrome, thrombophilia, smoking, cocaine use
Structural - uterine abnormality, uterine rupture, placenta praevia, vasa praevia
Intrapartum - asphyxia, trauma
How does stillbirth present?
Reduced fetal movements
Bleeding
Abdominal pain
Asymptomatic - unexpected finding at US
What are the signs of stillbirth on USS?
Absence of fetal heartbeat
Spalding sign (overlapping skull bones)
Hydrops
Define hydrops
Hydrops fetalis, or hydrops, is a condition that occurs when large amounts of fluid build up in a baby’s tissues and organs causing extreme swelling
How is stillbirth managed?
Vaginal birth or c-section
Analgesia as required
What aftercare is important for stillbirth?
Psychological care
Memory box with photos, hand and footprints
Funeral arrangements, consider cultural practices
Suppression of lactation
Maternal investigations
Post-mortem
Communication with community team
Support groups
A meeting to discuss events surrounding loss at 6-8 weeks postnatal
No clear evidence on when should conceive again
More frequent antenatal visits and regular growth scans for future pregnancies
Define miscarriage, stillbirth and livebirth
Miscarriage - any pregnancy loss before 24 weeks gestation
Stillbirth - any fetus born dead at/after 24 weeks
Livebirth - fetus which shows signs of live after delivery at any gestation
How might a miscarriage present in the presence of a positive pregnancy test?
Vaginal bleeding - brown, spotting or heavy, tissue
Pelvic discomfort/pain
Asymptomatic
How should suspected miscarriage be investigated?
Speculum examination Transvaginal USS Examination of products of conception Serum hCG tracking FBC, group and save
What signs indicate miscarriage on USS?
No fetal heart activity >7mm crown-rump length Empty sac Retained tissue (incomplete) Empty uterus (complete, too early, ectopic)
How is miscarriage managed?
Conservative - review every 1-2 weeks
Medical - misoprostol
Surgical - cervical priming with misoprostol and then electrical vacuum aspiration under GA or manual vaccum aspiration under LA
When is anti-D required in a rhesus negative woman who has miscarried?
<12 weeks vaginal bleed and severe pain
<12 weeks medical/surgical management
Any potential sensitising event >12 weeks
Give 5 causes of miscarriage
Unexplained (50%) Maternal age Fetal chromosome abnormality Immunological - lupus anticoagulant and antiphospholipid antibodies Endocrine - PCOS, poorly controlled DM/thyroid Uterine abnormalities Infection Environmental - smoking, alcohol Cervical weakness
How should recurrent miscarriage be managed?
Aspirin and LMWH for antiphospholipid antibodies
Supportive care
What is the most common site for an ectopic pregnancy? Give 2 other possible sites
Tubal (95%) Interstitial Cervical Abdominal Infundibular Ovarian Peritoneal
What are the risk factors for ectopic pregnancy?
Previous ectopic pregnancy
Endometriosis
Pelvic infection (chlamydia)
Pelvic surgery (c-section, sterilisation, appendicectomy)
Contraception (progesterone only pill, IUD/IUS)
Assisted conception
Smoking
What is the incidence of miscarriage?
20% of all pregnancies
What is the incidence of ectopic pregnancies?
1 in 200
How do ectopic pregnancies present (in the presence of a positive pregnancy test)?
Asymptomatic Vaginal bleeding Pelvic discomfort/pain - localised to one side, referred to shoulder Pain on opening bowels Maternal collapse, hypovolaemic shock
How should suspected ectopic pregnancies be investigated?
Assess if they are haemodynamically stable - if not A-E assessment, involve seniors, prepare for theatre
Examination - peritonism, bimanual (cervical excitation, adenexal mass), vaginal swabs
USS
Examination of POC
Serum hCG tracking
FBC and group and save/crossmatch
How is hCG tracking used in ectopic pregnancy?
Helpful for pregnancy of unknown location and stable patient, measure hCG 48 hours apart
>66% increase - intrauterine pregnancy
<66% increase/<15% decrease - ectopic pregnancy
>15% decrease - failing ectopic
How are non-emergency ectopic pregnancies managed?
Conservative
Medical - methotrexate
Surgical - laparoscopy/laparotomy, salpingostomy/salpingectomy, risk of oophorectomy
When is methotrexate used to manage an ectopic pregnancy?
Medical management of non-emergencies
Criteria - pain free, unruptured ectopic, serum hCG low, able to return for follow up, no medical contraindications (e.g. anaemia)
Is anti-D required in rhesus negative patients after ectopic pregnancy?
Yes
What is gestational trophoblastic disease?
A group of conditions characterised by abnormal proliferation of trophoblastic tissue with production of HCG
Premalignant and malignant forms
What are the 2 types of premalignant gestational trophoblastic disease?
Partial hydatidiform mole
Complete hydatidiform mole
What is a partial hydatidiform mole?
GTD
Triploid - 23 mother + 46 father chromosomes; 2 sperm + 1 egg
Present as failed pregnancy
0.5% risk of malignancy
What is a complete hydatidiform mole?
GTD
Diploid - 46 father chromosomes, empty ovum
1-2% risk of malignancy
What are the 3 types of malignant gestational trophoblastic disease?
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour
What are the risk factors for GTD?
Extremes of maternal age (<20 years = 3x, >40 years = 10x)
Previous molar pregnancy
Ethnicity (Korea, China)
What are the clinical features of GTD?
PV bleeding Enlarged uterus Hyperemesis gravidarum Hyperthyroidism Early onset pre-eclampsia
How is GTD investigated?
USS - snowstorm appearance
Histology (suction curettage)
hCG tracking
Specialist care (Dundee)
What is the incidence of nausea and vomiting in pregnancy and what is the likely cause?
> 50% in first trimester
Associated with hCG levels (similar to TSH)
What is hyperemesis gravidarum?
Persistent vomiting in pregnancy causing weight loss (more than 5% of body mass) and ketosis
What are the complications of hyperemesis gravidarum?
Wernicke's encephalopathy (thiamine deficiency) Central pontine myelinolysis (rapid correction of hyponatraemia) Maternal death (rare)
What are the effects of hyperemesis gravidarum on the baby?
Intrauterine growth restriction
Significantly smaller at birth
How should hyperemesis gravidarum be investigated?
Urine - ketones, rule our UTI
Bloods - U&Es, LFTs, TFTs
USS - check for multiple/molar pregnancy
How is hyperemesis gravidarum managed?
Oral intake advice/dietician input IV fluids (avoid dextrose) Regular antiemetics Ranitidine/omeprazole Thromboprophylaxis Vitamin replacement Oral steroids TPN (extreme) Psychological support Assessment of fetal growth
Do women with epilepsy experience an increase in seizure frequency during pregnancy?
Yes, 1/3rd of them do
Name 2 antiepileptic drugs which are teratogenic
Phenytoin
Carbamazepine
Sodium valproate
What are the teratogen effects of sodium valproate?
Neurocognitive impairment Autism spectrum disorders Attention deficit disorders Neural tube defects Hypospadias Heart defects Craniofacial anomalies Skeletal anomalies Developmental delay
Why are so many antiepileptic drugs teratogenic? What can be done to counteract this?
Decrease availability of serum folate - folate 5mg/day at least 1 month prior to conception
Induce fetal hepatic enzyme activity which reduces vitamin K and causes bleeding - neonatal konakion administration
How should epilepsy be managed in pregnancy?
Pre-pregnancy counselling - monotherapy, folate supplementation
AED dose adjustment/drug monitoring
US/serum screening - abnormalities
Vitamin K - daily for mother from 36 weeks, to neonate IM at birth
Seizure management - diazepam/lorazepam if termination needed
Intrapartum - IV access, continue AEDs, avoid exhaustion, CTG
Post-natal - safety with feeding/bathing, dose modification
Contraception - higher dose may be needed
What contraceptive options are most suitable for patients on enzyme inducing AEDs postnatally?
Copper IUD
IUS
Medroxyprogesterone acetate injections
What AEDs are enzyme inducing?
Carbamazepine
Phenytoin
Phenobarbital
Topiramate
What AEDs are not enzyme inducing?
Sodium valproate
Levetiracetam
Gabapentin
Pregabalin
What are the complications of maternal varicella infection?
Pneumonia
Hepatitis
Encephalitis
Death
What is the risk to the fetus if the mother has been exposed to varicella during pregnancy?
Fetal infection is rare (1-2%)
Fetal varicella syndrome - skin scarring, eye defects, limb hypoplasia, neurological abnormalities
Neonatal infection - severe chickenpox, treat with aciclovir
What can be given to reduce risk of varicella transmission to the fetus when the mother has been exposed?
Varicella zoster immunoglobulin
How can risk from varicella exposure in pregnancy be checked?
History
Maternal IgG levels
How can maternal HIV be transmitted to the baby?
During birth (highest risk)
Prenatal possible
Depends on viral load
How can transmission of HIV from mother to fetus be reduced?
Antiretroviral therapy throughout pregnancy
Keep viral load low
How is a delivery plan made for mothers with HIV?
Viral load <50 at 36 weeks with no contraindications - vaginal delivery
Viral load >50 at 36 weeks - c-section at 38 weeks
How should a newborn of a HIV positive mother be managed after birth?
Post-exposure prophylaxis (zidovudine) within 4 hours after birth for 4 weeks
Avoid breastfeeding
When should neonatal HIV testing be carried out?
During the first 48 hours and prior to hospital discharge
2 weeks post cessation of infant prophylaxis (6 weeks of age)
2 months post cessation of infant prophylaxis (12 weeks of age)
HIV antibody testing for seroreversion should be performed at age 18 months
Outline how rhesus isoimmunisation occurs
Rh+ father
Rh- mother
Rh+ fetus
Rhesus antigens from the developing fetus can enter the mother’s blood during delivery, in response to which the mother will produce anti-Rh antibodies
If a second pregnancy is Rh+, the mother’s anti-Rh antibodies will cross the placenta and damage fetal RBCs
What are the antenatal and postnatal consequences of haemolytic disease of the newborn?
Antenatal - polyhydramnios, thickened placenta, hydrops, in-utero demise
Postnatal - jaundice, hepatosplenomegaly, pallor, kernicterus, hypoglycaemia
How is risk of rhesus disease assessed?
Maternal blood group and titres
Fetal blood group amniocentesis and free fetal DNA (paternal blood group)
How can rhesus disease be prevented?
Blood transfusion vigilance
Anti-D prophylaxis
When is anti-D required in a Rh- mother?
After management of ectopic pregnancy
After management of molar pregnancy
Therapeutic termination of pregnancy
<12 weeks vaginal bleed which is heavy, repeated or associated with severe pain
<12 weeks medical or surgical management of miscarriage
Potentially sensitising event >12 weeks
What can be done after delivery to determine anti-D requirements
Test cord blood
Test maternal blood
Give 3 physiological skin changes seen in pregnancy
Hyperpigmentation Striae gravidarum Hair and nail changes Angiomas and spider naevi Greasier skin Pruritis
Give 3 common skin diseases in pregnancy
Atopic eruption of pregnancy Acne vulgaris or rosacea Psoriasis Infections (candida, viral warts, varicella) Infestations (scabies) Autoimmune (SLE, pemphigus)
Give 2 specific dermatoses of pregnancy
Atopic eruption of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis
(Obstetric cholestasis)
What is the most common pregnancy rash, when is its onset and what are the 2 types?
Atopic eruption of pregnancy
Early (before 3rd trimester)
Eczematous and prurigo
How is atopic eruption of pregnancy managed?
Emollients
Aqueous cream and menthol
Topical steroids
Antihistamines
Narrow band UVB
Oral steroids
When is polymorphic eruption of pregnancy most likely to occur and what pattern does the rash follow?
3rd trimester or postpartum, mostly primigravid
Lower abdomen affected with umbilical sparing
How is polymorphic eruption of pregnancy managed?
Symptomatic treatment
Emollient, topical steroids, antihistamine
When is pemphigoid gestationis most likely to occur, what does it look like and what is the pathophysiology?
2nd/3rd trimester or pureperium
Urticarial lesions, wheals and bullae
Binding of IgG to skin basement membrane
What are the risks of pemphigoid gestationis?
Premature delivery
Fetal growth restriction
Transient infant blistering
Secondary infection which can cause scarring
How is pemphigoid gestationis managed?
Refer to dermatology and obstetrics
Topical steroids and antihistamines
Additional antenatal surveillance
Oral steroids if severe
Define chronic hypertension in pregnancy
HTN before 20 weeks in absence of hydatidiform mole or persistent HTN beyond 6 weeks postpartum
What are the types of gestational hypertension?
Gestational hypertension without proteinuria
Gestational proteinuria without hypertension
Gestational proteinuric hypertension (pre-eclampsia)
Define pre-eclampsia
Hypertension after 20 weeks gestation with 1 or more of: proteinuria, maternal organ dysfunction or fetal growth restriction
What are the potential forms of maternal organ dysfunction in pre-eclampsia?
Renal insufficiency - creatinine >90 micromol/L
Liver involvement - elevated transaminases (2x normal) and RUQ pain
Neurological complications - eclampsia, altered GCS, blindness, stroke, hyperreflexia, clonus, headache)
Haematological - thrombocytopaenia, DIC, haemolysis
Define eclampsia
Generalised tonic-clonic convulsions in women with pre-eclampsia, if the seizures cannot be attributed to any other causes (epilepsy, cerebral infarction, tumour, ruptured aneurysm)
What are the 2 phases of pre-eclampsia pathophysiology?
Phase 1 - abnormal placentation
Phase 2 - endothelial dysfunction
How does placentation occur in normal pregnancy?
Trophoblast invasion of maternal spiral arteries causes diameter increase 5x converting high resistance low flow to low resistance high flow
How does abnormal placentation occur in pre-eclampsia?
Inadequate trophoblast invasion which causes inadequate placental perfusion
Outline the pathophysiology of endothelial dysfunction in pre-eclampsia
Widespread dysfunction due to oxidative stress from ischaemic placenta which promotes platelet adhesion and thrombosis and disturbs vascular tone
Exaggerated maternal inflammatory response
What are the risk factors for pre-eclampsia?
First pregnancy
FH
Extremes of maternal age
Obesity
Medical - pre-existing HTN, renal disease, diabetes, antiphospholipid antibodies, inherited thrombophilia, CTD
Obstetric - multiple pregnancy, previous pre-eclampsia, hydrops, hydatidiform mole, >10 years since last pregnancy
Give 3 symptoms of pre-eclampsia
Severe headache Severe RUQ/epigastric pain Sudden face/hands/feet swelling Visual disturbance - blurring, flashing, scotoma Vomiting Restlessness/agitation
Give 3 signs of pre-eclampsia
Hypertension Proteinuria Hyperreflexia Raised creatinine Reduced platelets Clonus Haemolytic anaemia Raised liver enzumes Retinal haemorrhages Papilloedema
How is pre-eclampsia investigated?
BP
Urinalysis
Bloods - FBC (low platelets, low Hb, haemolysis on film), LFTs (high ALT/AST), U&Es (low urine output, high urate/urea/creatinine), coagulation (prolonged)
Fetal assessment - symphyseal-fundal height, USS (growth, liquor, umbilical artery doppler), deliver if compromised
What is HELLP and what are its complication?
Severe pre-eclampsia variant requiring delivery
Haemolysis, elevated liver enzymes and low platelets
DIC, placental abruption, acute renal failure, stroke, haemorrhage
How can pre-eclampsia be prevented?
Low dose aspirin (75mg) from 12 weeks inhibits thromboxane A2
How is pre-eclampsia managed?
Control BP Assess fluid balance Prevent eclampsia - magnesium sulphate Consider delivery Optimise postnatal care
What are the indications for delivery in pre-eclampsia?
Maternal - gestation >37 weeks, failure to control BP, deteriorating liver/renal function, progressive fall in platelets, neurological complications
Fetal - abnormal heart rate, deterioration
What drugs can be used to treat HTN in pregnancy? Give a side effect of each
Methyldopa - drowsiness
Labetalol - postural hypotension, fatigue
Hydralazine - hypotension
Nifedipine - flushing, headaches
Give 3 maternal complications of pre-eclampsia
Placental rupture DIC HELLP (10-20%) Pulmonary oedema Aspiration Eclampsia (1%) Liver failure Stroke Death Long term cardiovascular morbidity
Give 3 fetal complications of pre-eclampsia
Pre-term delivery IUGR Hypoxia-neurological injury Perinatal death Long term cardiovascular morbidity (associated with low birth weight)
What is the future risk to mothers with HTN/pre-eclampsia in pregnancy?
Increased risk of high BP in later life/gestational HTN in future pregnancies/pre-eclampsia in future pregnancies
Outline the physiology of glucose in pregnancy
Increasing insulin resistance in pregnancy
Insulin production doubles from 1st to 3rd trimester
Ketosis and glycosuria common
How is hyperglycaemia driven by placental hormones in pregnancy?
Placenta produces lactogen and somatomammotrophin -> increased insulin resistance and production -> if insulin resistance without capacity to produce insulin, hyperglycaemia/gestational diabetes occurs
What are the effects of high glucose in pre-existing diabetes on the fetus?
Increased rate of fetal congenital abnormalities - cardiac defects, NTDs, renal abnormalities
What is the pathophysiology of macrosomia?
Glucose crosses placenta but insulin does not
Fetus produces insulin from 10 weeks
Increased maternal glucose -> increased fetal glucose -> increased fetal insulin production -> macrosomia
What are the complications of macrosomia?
Intrauterine death
Shoulder dystocia
How do insulin requirements change with gestation?
1st trimester - static/decrease
2nd trimester - increase
3rd trimester - increase/slight decrease towards term
What are the obstetric complications of diabetes?
UTI
Operative delivery
Pre-eclampsia
Polyhydramnios - pre-term labour, malpresentation
What are the risks of pre-existing/gestational diabetes in pregnancy?
Pre-existing - miscarriage, congenital malformation, stillbirth, neonatal death
Gestational - neonatal hypoglycaemia, perinatal death
Both - fetal macrosomia, birth trauma, c-section, induction, transient neonatal morbidity, obesity/diabetes in baby’s later life
What are the risks to the fetus in maternal diabetes?
Hypoglycemia Hypocalcemia Hyperbilirubinemia/ polycythemia Idiopathic RDS Delayed lung maturity Prematurity Predisposition to obesity and diabetes in later life
Why is pre-conception care important in women with diabetes? What should this involve?
Good glycaemic control prior to conception is ideal
Risks and how to reduce them, diet/weight/exercise, management of diabetes, retinal and renal assessment, timing of contraception cessation, frequency of appointments and support
What should pre-pregnancy glucose targets be?
Fasting - 5-7 mmol/L
HbA1c - <48 mmol/L
What antenatal care will be required for pregnant women with diabetes?
Folic acid - 5mg pre-conception to 12 weeks
Early booking appointment
Obstetric review - 4 weekly until 28 weeks, 2 weekly until 36 weeks, weekly until delivery
Monitor fetal growth
Serum screening and detailed anomaly scan
Retinal and renal screening - booking and 28 weeks
Planned delivery between 37 and 38+6 weeks
What are the risk factors for gestational diabetes? What should be done about them?
BMI above 30 kg/m2
Previous macrosomic baby weighing 4.5 kg or above
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
Minority ethnic family origin with a high prevalence of diabetes
If any one factor identified at booking offer testing for GDM at 24-28 weeks using 2 hour 75g OGTT
How is gestational diabetes diagnosed?
2 hour 75g OGTT
A fasting plasma glucose level of 5.6 mmol/litre or above or
a 2-hour plasma glucose level of 7.8 mmol/litre or above
How is gestational diabetes managed?
Antenatal - diet and exercise, metformin and insulin, delivery no later than 40+6
Intrapartum - glucose between 4-7 mmol/L
Postpartum - stop all treatment, 6 week fasting glucose, annual review
Outline the role of thyroid hormones in pregnancy
Fetal thyroxine obtained from mother as thyroid gland becomes functional at 12 weeks
Iodide is lost through urine and placenta to cause deficiency which mean pregnant women require additional iodine
Thyroid hormones are increased in pregnancy (peak at mid-gestation)
What are the complications of untreated thyroid disease in pregnancy?
Abnormal neuropsychological development
Miscarriage
Stillbirth
Placental abruption, prematurity
How does pregnancy mimic hyperthyroidism and what are the best discriminators?
Mimics - heat intolerance, palpitations, palmar erythema, goitre, emotional lability, tachycardia, increased T4, suppressed TSH
Discriminators - weight loss, eye signs, pretibial myxoedema, tremor
What treatments are available for hyperthyroidism in pregnancy?
Anti-thyroid drugs - carbimazole, PTU Beta-blockade - propranolol Serial biochemical monitoring Requirements reduced in pregnancy Check neonatal TFTs if breast feeding mother on high dose Surgery (rare) Radioiodine (contraindicated)
What is postpartum thyroiditis?
Occurs 1-3 months postpartum
Presentation - transient hyperthyroidism -> subsequent hypothyroidism (may be confused with postnatal depression) -> often remits with resolution after 1 year
What are the risk factors for twin pregnancy?
Assisted conception
Advanced maternal age
West African ethnic origin
Family history
Define zygosity, chorionicity and amnionicity
Zygosity - number of fertilised eggs
Chorionicity - number of placentas
Amnionicity - number of sacs
What is the most common multiple pregnancy type?
Dizygotic twins
Define dizygotic twins
2 eggs, 2 sperm
Not identical
Define monozygotic twins
1 egg, 1 sperm
Identical
May be any combination of di/mono chorionic/amniotic
What signs on USS can show if twins are dichorionic or monochorionic?
Lamda sign - dichorionic
T sign - monochorionic
What are the maternal risks of multiple pregnancy?
Antenatal - all risks increased; hyperemesis gravidarum, pre-eclampsia, gestational diabetes, placenta praevia
Intrapartum
Postpartum - haemorrhage, depression, anxiety, relationship difficulties
What are the fetal risks of multiple pregnancy?
Miscarriage (one or both)
Congenital anomaly
Growth restriction (regular USS)
Preterm delivery
What are the fetal risks of multiple pregnancy in monochorionic twins and why?
Acute transfusion, twin-twin transfusion syndrome, twin reversed arterial perfusion
Commnication between circulations via placental anastomoses
What options are available for prenatal diagnosis?
Bloods - screening, free fetal DNA
USS - chorionicity, nuchal translucency
Invasive - amniocentesis, CVS
What is the median gestation at delivery for multiple pregnancy?
Twins - 37 weeks
Triplets - 34 weeks
When and how should delivery be planned for in multiple pregnancy?
Elective delivery - aim for vaginal but risk of c-section, may request elevtive c-section
DCDA - 37 weeks
MCDA - 36 weeks
What management should be used in delivering multiple pregnancy?
Maternal - BP, IV access, fluids, ranitidine
Fetal - continuous CTG, abdominal and fetal scalp electrode
What 3 factors contribute to increased risk of postpartum haemorrhage in multiple pregnancy?
Tone - large floppy uterus
Tissue - 2x placentas
Trauma - 2 babies
What is acute transfusion (multiple pregnancy)?
Death of one twin in utero leads to increased risk of hypoxic-ischaemic injury in survivor due to acute transfusion from healthy to dying twin
Risk of exsanguination of healthy twin into dying twin, therefore double IUD
How is acute transfusion managed?
Increased monitoring of survivor for anaemia and transfusional brain injury
Delivery not indicated unless near term
What is twin to twin transfusion syndrome?
Chronic net shunting from one twin to the other
Donor twin - growth restricted, oliguric, anhydramnios
Recipient twin - polyuric, polyhydramnios, cardiac problems, hydrops
How does twin to twin transfusion syndrome present and how is it diagnosed?
16-25 weeks, different liquor volumes
USS - liquor volume, bladder visualisation, cord dopplers, oedema/ascites
Outline the staging used for twin to twin transfusion syndrome
Quintero staging
- Discordant liquor volumes
- Bladder not seen in donor
- Abnormal dopplers
- Fetal hydrops
- Death of one or both twins
How is twin to twin transfusion syndrome managed?
Fetoscopic laser ablation of anastomoses
Cord occlusion
Management in quaternary centre (London)
What is the prognosis for twin to twin transfusion syndrome?
2/3rds of fetuses die or are brain damage
What is twin reversed arterial perfusion syndrome?
2 cords linked by a large arterio-arterial anastomosis which allows retrograde perfusion - pump twin and perfused twin
How is twin reversed arterial perfusion syndrome managed?
Ablation of anastomosis
What are the risks of monoamniotic twins?
Cord entanglement
Placental anastomoses
What are the associations of breech presentation?
Multiple pregnancy Bicornuate uterus Fibroids Placenta praevia Polyhydramnios Oligohydramnios Fetal anomaly - NTD, NMD
What is the incidence of breech presentation through pregnancy?
20 weeks - 40%
32 weeks - 25%
Term - 3-4%
What are the 3 breech birth positions?
Flexed
Footling
Extended
What are the risks of vaginal delivery in breech presentation?
Intracranial injury Widespread bruising Damage to internal organs Spinal cord transection Umbilical cord prolapse Hypoxia
What are the risks of c-section in breech presentation?
Surgical morbidity and mortality
What is an ECV?
External cephalic version
Attempting to manually turn a breech baby from buttocks/foot first to head first
When should ECV be offered, what is the success rate and what monitoring should be done?
All women with breech presentation at term (36 weeks in nulliparous, 37 weeks in multiparous)
Success rate 50%, 5% recurrence
CTG before and after procedure
Give 3 absolute contraindications to ECV
When CS required regardless (e.g. placenta praevia)
Antepartum haemorrhage within the last 7 days
Abnormal CTG
Major uterine anomaly
Ruptured membranes
Multiple pregnancy (except delivery of second twin)
Absence of maternal consent
Give 3 relative contraindications to ECV
Nuchal cord Fetal growth restriction Proteinuric pre-eclampsia Oligohydramnios Major fetal anomalies Hyperextended fetal head Morbid maternal obesity
How should preterm breech presentation be managed?
Decision should be based on stage of labour, type of breech, fetal well-being, availability of physician skilled in vaginal breech delivery
Define preterm, preterm labour, preterm prelabour rupture of membranes and low birth weight
Preterm - gestation <37 weeks
Preterm labour - regular contractions + effacement and dilatation of cervix at 20-37 weeks
PPROM - rupture of fetal membranes <37 weeks and before labour
Low birth weight - <2501g
What are the causes of preterm birth?
Spontaneous labour, unknown cause
Elective delivery (e.g. due to maternal hypertension, fetal growth problems or haemorrhage)
Preterm premature ruptured membranes
Multiple pregnancy
What causes preterm labour?
Unknown
Infection may be implicated - inflammation of chorioamniotic membranes causes prostaglandin release
What is the baby’s chance of survival following pre-term delivery?
<22 weeks: close to zero 22 weeks: 10% 24 weeks: 60% 27 weeks: 89% 31 weeks: 95% 34 weeks: equivalent to baby born at full term
What complications are associated with preterm delivery?
Mortality Lung disease Cerebral palsy Blindness Deafness Developmental/behavioural problems
What is the role of maternal steroids in preterm delivery and how are they administered?
Increase pulmonary surfactant production by type II pneumocytes to reduce risk of RDS
Also reduces risk of intraventricular cerebral haemorrhage, neonatal death, necrotising enterocolitis and ICU admission
IM dexamethasone in divided doses over 24 hours
How is antepartum haemorrhage classified?
Minor - <50ml
Major - 50-1000ml
Massive - >1000ml +/- hypovolaemic shock
What are the causes of antepartum haemorrhage?
Local - vulva, vagina, cervix (ectropion, polyp, carcinoma), labour show
Placental - placenta praevia, placental abruption
Unexplained
Define placenta praevia
Placenta encroaches upon the lower segment of the uterus, with the lower segment arbitrarily defined by ultrasound scanning as extending 5 cm from the internal cervical os
What is the main risk factor for placenta praevia?
Previous c-section
How is placenta praevia classified?
Minor (I and II) - encroaches lower uterine segment, reaches internal os
Major (III and IV) - covers part of internal os, completely covers internal os
What are the delivery options for minor placental praevia and how is this decided?
Vaginal delivery may be possible
Assess engagement of the presenting part, and actual distance of the placenta from the internal (by ultrasound) – must be >2cm
Does a low lying placenta at 20 week scan confirm placenta praevia? Why?
No
As the uterus grows from the lower segment upwards, the placenta appears to move upwards with advancing gestation
Low placenta at 24 weeks - 2% will be low lying at term
What are the complications of placenta praevia?
Sudden unpredictable major haemorrhage
Major haemorrhage at c-section due to inefficient lower uterus contraction
Morbidly adherent placenta (abnormally invasive or placenta accreta)
How is placenta praevia managed?
Admit from 30-32 weeks until delivery if bleeding
Elective delivery at 38-39 weeks unless haemorrhage occurs sooner
What is an abnormally invasive placenta?
Placenta invades the myometrium and cannot be readily separated from the uterus following delivery
Usually diagnosed with ultrasound antenatally to evaluate the presence and degree of invasion
What are the risks of an abnormally invasive placenta?
Massive PPH
Requirement for hysterectomy
What is placental abruption?
Retroplacental haemorrhage (bleeding between the placenta and the uterus) which usually involves some degree of placental separation - results in a reduced area for gas exchange between the fetal and maternal circulations predisposing to fetal hypoxia and acidosis
Give 3 risk factors for placental abruption
Previous abruption Hypertension/pre-eclampsia Thrombophilia Premature rupture of membranes Multiple pregnancy Folic acid deficiency Cocaine Smoking Social deprivation
What is the importance of concealed abruption?
‘Revealed’ blood (bleeding from the vagina) may not reflect the total blood loss and a woman may have considerable retroplacental bleeding without any external loss at all – a ‘concealed abruption’, the most hazardous type of abruption
How is placental abruption managed?
Light bleeding - inpatient observation and surveillance of growth
Major haemorrhage - urgent delivery
How is a concealed abruption inferred?
Degree of pain
Uterine tenderness
Evidence of hypovolaemic shock
How is intrauterine fetal death managed?
Vaginal delivery unless systemic maternal risks are such that waiting for vaginal delivery over c-section will be disadvantageous
What are the complications of vaginal delivery for intrauterine fetal death?
Major blood loss
Hypovolaemic shock
Multisystem organ failure
DIC
How do women presenting with placenta praevia differ from those with placental abruption?
Praevia - usually painless bleeding, with non-engaged presenting part, soft uterus
Abruption - usually painful bleeding, with hard “woody” uterus (‘couvelaire’ uterus)
What should be asked/checked in a patient with suspected APH?
Ask - when bleeding started? how much blood has been lost? when did the baby last move?
Observe - is the mother in pain? (suggests abruption or labour) is there blood on the bed, her legs or the floor? is the mother pale? are there signs of hypovolaemic shock? (low blood pressure, tachycardia)
What examinations should be done in suspected APH?
General inspection and observations
Abdominal examination
USS - determine placental site, assess fetal wellbeing
CTG - if gestation >26 weeks, fetal heart doppler if <26 weeks
Speculum can be carried out, if placenta not low
How is APH managed?
Admit until bleeding stops
Anti-D if rhesus -ve
If major haemorrhage/fetal compromise - maternal resuscitation and consider delivery
What is the role of MBBRACE UK?
Surveillance of maternal deaths
Confidential enquiries into maternal deaths during and up to 1 year after pregnancy
Confidential enquiries into cases of serious maternal morbidity
Surveillance of perinatal death (including late fetal loss, stillbirth and neonatal death)
Confidential enquires into stillbirths, infant deaths and serious infant morbidity
In relation to maternal deaths, define direct, indirect, coincidental and late
Direct - consequence of a disorder specific to pregnancy (e.g. haemorrhage)
Indirect - resulting from existing disease/disease developed during pregnancy (e.g. psychiatric)
Coincidental - incidental/accidental death not due to or aggravated by pregnancy (e.g. RTA)
Late - occurring >42 days but <1 year after pregnancy
What are the most common causes of maternal mortality?
Heart disease Blood clots Epilepsy and stroke Sepsis Mental health conditions Bleeding Cancer Pre-eclampsia
What inequalities are evident from maternal mortality data?
Ethnic group - black women 5x higher risk of death
Age
Deprived
What is the role of the PROMPT Maternity Foundation?
Reduce preventable harm for mothers and their babies
What are non-technical skills?
Cognitive and interpersonal skills that complement practical and technical competencies - situational awareness, decision making, leadership, communication and team working
Give 5 emergencies in obstetrics
Obstetric cause - PPH, APH (placenta praevia, vasa previa, abruption, uterine rupture), eclampsia, amniotic fluid embolus, uterine inversion, intra-abdominal bleeding, genital tract haematoma, fetal malpresentation, fetal distress
Incidental causes - massive VTE, ruptured hepatic/splenic/aortic aneurysm, ruptured liver/spleen, MI, cardiac arrythmia/failure, CVA, anaphylactic/septic shock, substance abuse
Define postpartum haemorrhage
Any bleeding from or in to the genital tract following delivery of the infant
Primary – occurring within 24 hours of delivery
Secondary – occurring between 24 hours and 12 weeks postnatally
Give 2 antenatal risk factors for PPH
Placental abruption
Placenta praevia
Multiple pregnancy
Pre-eclampsia/gestational hypertension
Give 2 intrapartum risk factors for PPH
C-section Induction of labour Retained placenta Mediolateral episiotomy Operative vaginal delivery Prolonged labour (>12 hours) Large baby (>4kg) Pyrexia in labour Age >40
How is PPH managed?
Call for help - midwife, obstetrician, anaesthetist, haematology, blood transfusion lab
Assess using A-E - oxygen, fluid balance, blood transfusion, blood products, keep patient warm
Bloods - FBC, coagulation, U&Es, LFTs, crossmatch, bedside Hb
Weigh all swabs to estimate blood loss
Treatment - bimanual uterine compression, empty bladder, oxytocin, ergometrine, carpoprost, misoprostol
How can uterine contractility be promoted medically?
Syntocin (injection & infusion)
Ergometrine (injection)
Carboprost (IM injection)
Misoprostol (suppository)
How can PPH be managed in theatre?
Examine to check if uterus is contracted
Intrauterine balloon tamponade, brace suture, interventional radiology
Surgery - bilateral uterine/internal iliac artery ligation, hysterectomy, uterine artery embolisation
HDU/ICU care
What are the 3 severities of abnormal placentation?
Accreta
Increta
Percreta
How is secondary PPH managed?
Removal of retained tissue/treat infection
Consider balloon tamponade
Define maternal collapse
An acute event involving the cardiorespiratory systems and/or brain, resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to six weeks after delivery
How is maternal collapse managed?
ALS
What manoeuvre may be useful to reduce aortocaval compression in CPR of a pregnant woman?
Manual left lateral uterine displacement
When should a perimortem c-section be performed?
No response to CPR after 4 minutes and uterus approximately 20 week size
Aim to deliver in 5 minutes
What does perimortem c-section aim to do?
Primarily to save mothers life Increases venous return Improves ease of ventilation Allow CPR in supine position Reduced O2 requirement following delivery
In addition to the 4H’s and 4T’s of cardiac arrest, what 2 other conditions should be considered in pregnant women?
Eclampsia (including magnesium toxicity)
Amniotic fluid embolism
What is the most common cause of death from pre-eclampsia?
Intracranial haemorrhage secondary to uncontrolled hypertension
When should magnesium sulphate be considered in pre-eclampsia?
Primary prophylaxis - women with severe pre-eclampsia where birth is planned within the next 24 hours
Secondary prophylaxis - after eclamptic fit
Should be continued for 24 hours from time of commencement or for 24 hours after delivery
What monitoring is necessary for patients on magnesium sulphate?
Urine output
Deep tendon reflexes
Respiratory rate
Give 2 signs of magnesium sulphate toxicity and how it can be treated
Loss of deep tendon reflexes, respiratory depression, respiratory arrest, cardiac arrest
IV calcium gluconate
