Obstetrics Investigations and Management Flashcards
Investigations for suspected hyperemesis gravidarum
- Examination => signs of dehydration
- Basic observations => reduced BP, high HR, weight and calculate BMI
- Urine dipstick à ketones
- Bloods:
- FBC => increased hct
- U&Es => dehydration
- PUQE score
Mx of hyperemesis gravidarum
- Consider admission for the following patients:
- Women unable to keep oral anti-emetics down
- Continued N&V associated with ketonuria +/- >5% weight loss despite oral anti-emetics
- Confirmed/suspected co-morbidity e.g. UTI
- IV fluid resuscitation and correction of electrolyte abnormalities (usually with KCl)
- IV antiemetics
- 1st line = Cyclizine or promethazine
- 2nd line = metoclopramide/ondansetron
- Thiamine supplementation
- Offer VTE prophylaxis with LMWH
Associations for hyperemesis
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
Smoking associated with decreased risk
Ddx for pre eclampsia
- Pre-eclampsia
- Gestational HTN
- Essential HTN
Mx of eclampsia
- ABC approach
- Labetalol + IV Magnesium sulphate
- Prevent seizures in severe pre-eclampsia
- Treat seizures once they develop
- 4g loading dose
- 1g/hour infusion 24hrs after last fit
- Recurrent fits => further 2-4g over 5-15 mins
- Monitor urine output, reflexes, RR and oxygen sats
labetalol: 1V 50 MG BOLUS (max of 4) CAN ALSO GIVE 200mg PO
First-line treatment for magnesium sulphate induced respiratory depression
Calcium gluconate
10% 10mls over 10mins
Measure sats, RR , ECG
RF for pre eclampsia
High Risk Factor:
- HTN during previous pregnancy
- CKD
- Autoimmune SLE/antiphospholipid
- T1DM/T2DM
- Chronic HTN
Moderate Risk Factor:
- First pregnancy
- >40 years,
- Pregnancy interval 10+ years
- BMI 35+ at booking
- FH of pre-eclampsia
- Multiple pregnancy
Mx of HELLP
- ABC approach
- 1st line in confirmed HELLP is to deliver
- IV Magnesium sulphate
How is high-risk Pre eclampsia managed?
- 75 mg OD aspirin from 12 weeks until birth
For a patient with pre-eclampsia when would you consider delivery?
- Uncontrollable BP despite 3+ antihypertensive classes at full dose
- Maternal sats <90%
- HELLP
- Neuro features
- Placental abruption
- Reversed end-diastolic flow in umbilical artery doppler
- Non-reassuring CTG
- Stillbirth
Ix for suspected Obstetric cholestasis
- Examination => jaundice, excoriation marks, SFH
- Basic observations => BP, HR, temp
- Urine dipstick
-
Bloods:
- LFTs
- Bile acids
- WCC
- Clotting screen – prolonged PT
- CTG
- Abdo USS
Mx of Obstetric cholestasis
- Conservative:
- Topical emollients
- Wear loose fitting clothing
- Medical:
- Ursodeoxycholic acid
- Vit K supplementation
- Monitoring:
- Obstetrician led care
- Regular LFTs and more frequent scans
- Safety net about reduced fetal movements
- Offer induction at 37 weeks
Differentials for PV bleeding in pregnancy
- Placenta praevia
- Placental abruption
- Vasa praevia
- Bloody show
- Cervical ectropion
Ix for PV bleeding
- A to E approach
- Examination – signs of anaemia, tense and tender abdomen
- Basic observations – haemodynamic stability
- CTG
- TVUSS
- Bloods:
- FBC
- Group and save
- Coagulation profile à DIC
- Kleihauer test
Mx of PV bleeding
- A to E approach (IV access and fluid resuscitation)
- Admit until bleeding stops for 24 hours
- <34 weeks administer steroids and consider tocolytics (not in abruption)
- Anti-D prophylaxis
- Continuous fetal monitoring
- EMCS if fetal distress/mother remains haemodynamically unstable
- If low-lying placenta at 32 weeks then repeat TVUSS at 36 weeks
- Deliver:
- If uncomplicated PP: ELCS at 36 weeks onwards
- If placenta accrete spectrum: ELCS at 35 weeks onwards
- Abruption/vasa praevia with fetal or maternal compromise: EMCS
- Stable abruption >34 weeks: consider ELCS or vaginal delivery with active mx of 3rd stage of labour
Ddx for abdo pain
- Placental abruption
- Premature labour
- Braxton-Hick’s contractions
Ix for abdo pain
- A to E approach
- Examination – signs of anaemia, tense and tender abdomen
- Basic observations – haemodynamic stability
- CTG
- TVUSS
- Bloods:
- FBC
- Group and save
- Coagulation profile à DIC
- Kleihauer test
Ix for suspected VTE in pregnancy
DVT
- GE: Unilateral lower limb oedema, erythema, tenderness, low grade pyrexia
- Duplex USS
PE
- GE: tachycardia, tachypnoea, low grade pyrexia, reduced O2 saturation, cardiorespiratory collapse
- Chest auscultation: reduced air entry, creps
- Cardiovascular: Loud P2
- ABG: hypoxia and hypocapnia
- ECG (sinus tachy + S1Q3T3) + CXR
- If DVT suspected also duplex USS
- If CXR abnormal à CTPA in preference to V/Q
- If V/Q or CTPA normal but clinical suspicion high repeat or use alternative Ix
- Bloods: FBC, U&Es, LFT, Clotting
Risk of CTPA or V/Q scan in pregnancy
- V/Q has slightly increased risk of childhood cancer
- CTPA has higher risk of maternal breast cancer
- In both situations, the absolute risk is very small
Mx of VTE in pregnancy
- LMWH (enoxaparin) titrated against booking weight
- Treat upon clinical suspicion whilst awaiting results
- If USS negative then discontinue but repeat USS on day 3 and 7
- Continue for the rest of pregnancy
- Discontinue 24 hrs before delivery
- Do not give until 4 hours after spinal
- Continue 6/52 after delivery or until 3 months Tx in total
- Monitor platelets and peak anti-Xa levels
- Massive PE
- A to E approach
- MDT
- IV unfractionated heparin
- Consider thrombolysis/thrombectomy
Ix for DM in Preganancy
- Examination – SFH, signs or pre-eclampsia, BP, HR
- Urine dip => glucose, proteinuria
- Bloods:
- FBC
- Fasting blood glucose/OGTT à followed by capillary glucose monitoring
- TFTs
- LFTs
- Monitoring:
- CTG
- Serial USS scans for growth and liquor volume
Management of Chronic HTN in pregnancy
- Aim for target BP 135/85
- Switch from ACEi/ARBs to labetalol
- 2nd line = Nifedipine
- 3rd line = Methyldopa (stop within 2 days after birth)
- Placental growth factor testing 20-35 weeks
- Anti-hypertensive review 2 weeks post delivery
Management of Gestational HTN
- Aim for target BP 135/85
- BP monitoring twice a week and dipstick proteinuria tests
- Placental growth factor testing if pre-eclampsia suspected 20-35 weeks
- Labetalol or nifedipine if contra-indicated
- Reduce anti-HTN if BP<130/80 post-natally
Management of previous diabetes
-
Preconceptual:
- Optimisation of glucose control
- Folate 5mg
-
Medical:
- Optimise diet
- Consider converting oral hypoglycaemic to insulin
- Likely to require increasing doses of insulin
-
Pregnancy:
- Capillary blood glucose monitoring (monthly HbA1c is offered)
- Monitor for pre-eclampsia à aspirin 75mg OD from 12 weeks
- Serial USS for foetal growth
-
Delivery:
- Sliding scale in labour (38 weeks)
- MDT – if large then recommend C-section
-
Postpartum:
- Return to pre-pregnancy doses of medications immediately to avoid hypos
- Start feeding neonate within 30 mins and fed frequently to prevent hypoglycaemia
Management of GDM
- Medical:
- Diet/exerecise control for 2 weeks
- Metformin +/- insulin
- > 7 fasting start insulin immediately
- Glibenclamide should only be offered for women who cannot tolerate metformin
- Pregnancy/delivery: As for pre-existing
- Postpartum: Stop insulin after delivery, fasting blood glucose measured at 6/52 postpartum
Risk Factors for GDM
- previous baby >4.5kg
- BMI >30
- Race
- Polyhydramnios
- previous GDM
- previous unexplained stillbirth
- 1st degree relative with DM
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
- 2 hour after meals: 6.4 mmol/l
Complications of GDM
- Foetus: hyperglycaemia can affect development (NTD, hyperinsulinemia, shoulder dystocia, macrosomia (more than 8 pounds), polyhydramnios due to increased urination.
- Neonatal: hypoglycaemia can occur when born due to change in glucose in its environment.
- Mother: increased insulin requirement, UTI and wound infection postpartum, increased risk of C-section, increased risk of preterm delivery
Types of breech presentation
- Frank breech
- Complete or flexed breech
- Footling breech
RF for breech presentation
- Maternal: multiparity, uterine fibroids, previous breech, placenta praevia
- Foetal: preterm delivery, oligohydramnios, foetal macrosomia, multiple pregnancy
Contraindications for ECV
- If C-section is required
- Abnormal CTG
- Ruptured membranes
- Multiple pregnancy
Sensitising events for which you give anti-D immunoglobulin
- ECV
- Surgical management of miscarriage or ectopic pregnancy
- Abdominal trauma
- Amniocentesis or chorionic villus sampling
- Antepartum haemorrhage
Causes of IUGR
- Infection
- Smoking
- Drinking
- Genetic problems with the baby
- Pre-existing medical problems (e.g. hypertension, kidney disease)
How do you date scans in pregnancy?
- CRL: 10-14 weeks
- Head Circumference: 14-20 weeks
How can you induce a labour?
- Membrane sweep (to try and stimulate labour)
- Propess (24 hour pessary)
- Prostin gel (may be used 6 hourly to further ripen the cervix)
- Artificial rupture of membranes
IUGR: Concerning sign-on doppler?
Absence or reversal of end-diastolic flow
Investigations for PROM
- Examination – temp, HR, BP, uterine tenderness
- Urine dip and MC&S
- Sterile speculum examination
- Offensive discharge
- Pooling of amniotic fluid
- If no pooling: swab for:
- insulin-like growth factor-binding protein-1 (IGFBP-1) or
- placental alpha micro-globulin-1 (PAMG-1)
- Bloods:
- FBC – raised WCC
- CRP
- CTG
Management of PROM
- Admit for monitoring (48-72 hours)
- Antenatal steroids
- Abx: erythromycin 250mg QDS for 10 days or until established labour => penicillin if not tolerated
- Offer MgSO4 if 24-29 weeks
- Monitor temperature (4 hours)
- Aim to deliver after 34 weeks or earlier if infection
- Consider rescue cervical cerclage between 16-28 weeks with dilated cervix an unruptured fetal membranes
- Do not offer if PV bleeding, infection or uterine contractions
- 23> weeks then consider termination of pregnancy
Complications of PROM
- Complications for mother: sepsis and placental abruption
- Foetal: chorioamnionitis, cord prolapse. PTL, pulmonary hypoplasia, limb contractures, death
Examples of tocolytics
- Nifedipine
- Atosiban
What screening test can be used if you are unsure about whether a patient is in labour or not?
- Foetal fibronectin
What might be used as neuroprotection in a preterm delivery?
MgSO4
What are the stages of labour?
- Stage 1: onset of regular contractions to full dilatation of the cervix
- Stage 2: full dilatation to delivery of the baby
- Stage 3: from delivery of the baby to delivery of the placenta and membranes
Causes of prolonged labour
- Malposition
- Epidural analgesia
- Obstructed labour (e.g. CPD)
How can you actively manage the third stage of labour?
- IM syntocinon/ergometrine injection
- Controlled cord traction
- Should last < 30 mins
How do you induce labour?
- Membrane sweep
- Propess (24 hours)
- Prostin (can be given 6 hourly)
- ARM
- Syntocinon
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.
- Patient on all fours
Featurs of 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
When should a woman take 5mg of folic acid?
- 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).
Management of uterine atony
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine
- intramuscular carboprost
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade
- Other: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
RF for PPH
- 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)
Definition of PPH
- Primary PPH: >500 ml in 24 hours
- Secondary PPH: 24 hours - 12 weeks
- due to retained placental tissue or endometritis
What is the combined test and when is it offered?
Consists of:
- Nuchal translucency measurement
- Serum B-HCG
- Pregnancy-associated plasma protein A (PAPP-A)
Result:
- Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
- trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
Offered:
- 11 - 13+6 weeks
What is the alternative to the combined test?
If women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks
Triple test:
- human chorionic gonadotrophin
- alpha-fetoprotein
- unconjugated oestriol
Quadruple test:
- Human chorionic gonadotrophin
- alpha-fetoprotein
- unconjugated oestriol
- inhibin-A
What is the difference between amniocentesis and CVS?

What is meant by SGA? What is IUGR?
The weight of the fetus is less than the tenth centile for age
IUGR: doesn’t live up to its growth potential. These can often be SGA babies
Common causes of SGA
- Constitutional factors
- Idiopathic
- Maternal disease, e.g. pre-eclampsia Smoking
- Multiple pregnancy
Investigations for SGA/ IUGR
- History
- Examination
- General
- Abdo
- SFH
- BP and urinanalysis
- Imaging
- CTG
- USS
- UmbA doppler (can see how healthy the blood flow is to the baby)
- Foetal middle cerebral artery doppler (for cardiovascular distress, fetal anaemia and fetal hypoxia)
Causes of IUGR
We measure this by looking at the abdominal circumference of the foetus
Symmetrical (<20 weeks of gestation)
- Chromosomal
- Congenital Anomalies (NTD, CHD)
- Congenital infections
Asymmetrical (Mama, Made, Poor, Uterus) (>20 weeks)
- Maternal HTN
- Maternal APS
- Placental Insufficiency
- Uterine anomalies
- Substance abuse
When can ECV be managed?
- 36 weeks for nullips
- 37 weeks for multips
Investigations for APH
- Bloods
- Full blood count
- Group and cross-match
- Coagulation screen
- Urea and electrolytes
- Cardiotocography (CTG) (immediate)
- Ultrasound scan (USS) to determine placental site/fetal viability
Management
- If heavy bleed: catheterize and record hourly urine output
Definition and investigations for reduced foetal movement
Less than 10 movements within 2 hours (>28 weeks)
If the patient is past 28 weeks:
- Handheld doppler to confirm fetal heartbeat
- Not detectable, ultrasound should be offered immediately
- Heartbeat was detected, CTG should be used for 20 minutes to monitor the heart rate.
Investigations for PROM
- Sterile speculum (look for pooling in the posterior vaginal wall)
- Test for the following if no pooling:
- Insulin-like growth factor binding protein‑1 (IGFBP-1)
- Placental alpha-microglobulin 1 (PAMG-1)
Oligohydramnios definition and causes
- < 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile
Causes
- premature rupture of membranes
- fetal renal problems e.g. renal agenesis
- intrauterine growth restriction
- post-term gestation
- pre-eclampsia