Obstetrics - Management Flashcards
Management of major PPH
- Call for help (midwife in charge, obstetric + anaesthetic staff, haematology consultants, blood transfusion laboratory, porters)
ABC
O2 by mask, 10-15l
IV access with 2x14-g cannulae
Take bloods: cross-match 4 units of blood minimum, FBC (to check for DIC), baseline U+E and LFTs, coagulation screen
Keep woman laying flat + warm
IVF until blood transfusion available
ASAP - O-, Rh-, K-negative blood then switch to group specific ASAP
Until blood is available, transfuse up to 3.5L of crystalloid fluids STAT
Stop the bleeding
o Establish cause + exclude other causes than uterine atony
o If the cause is uterine atony
Bimanual uterine compression
Foley catheter, leave in place
• These two bullet points are the first line management of PPH
Oxytocin 5 units slow IV
Ergometrine 0.6mg slow IV or IM (unless there is a hx of HTN or asthma)
Oxytocin infusion, 40iu in 500ml isotonic crystalloids at 125ml/h (unless fluid restriction is necessary)
Carboprost 0.25mg IM repeated at intervals of not less than 15 mins to a maximum of 8 doses (unless there is a hx of asthma)
Misoprostol 800 μg sublingually (low resource settings)
Heat stable carbetocin
o Surgical options – If pharmacological measures fail
Intrauterine Balloon tamponade
• First line where uterine atony is the only/main cause of haemorrhage
Haemostatic brace suturing e.g. the B-Lynch compression suture
Bilateral ligation of uterine arteries
Bilateral ligation of the internal iliac arteries
Selective arterial embolization
Hysterectomy – considered early, esp. in cases of placenta accrete or uterine rupture
Management of minor PPH
- Call for help (midwife in charge, obstetric + anaesthetic staff)
- IV access with a 14-g cannula
- Commence warmed crystalloid infusion
o Urgent venepuncture (20ml) for
Group and screen
FBC
Coagulation screen incl. fibrinogen
o Monitor pulse, BP, RR every 15 mins
What needs to be monitored during a major PPH?
o Continuous monitoring of pulse (ECG), BP (automate BP recording), RR (oximeter), UO (foley catheter)
o Temperature monitoring every 15 mins
o Consider arterial line monitoring + ITU transfer
o Record all parameters on flow chart – e.g. MEOWS chart (modified obstetric early warning system)
o Document fluid balance, blood, blood products, procedures
Where is ergometrine used?
Contraindications?
Used in the management of PPH
unless there is a hx of HTN or asthma
Where is carboprost used?
Contraindications?
Used in the management of PPH
unless there is a hx of asthma
Is there a place for prophylactic oxytocics? When should they be used?
• Prophylactic oxytocics should be routinely used in the 3rd stage of labour
o Vaginal birth – 10 IU IM oxytocin
o Caesarean section – 5 IU slow IV oxytocin (+tranexamic acid 0.5-1.0g)
During PPH when do you transfuse….
FFP
Cryoprecipitate
Platelets
FFP
• If no haemostatic results are available…
o +bleeding is continuing, after 4U of RBC, infuse FFP at a dose 12-15ml/kg/ 4U of FFP
o Early FFP should be considered for conditions with suspected coagulopathy (e.g. placental abruption, amniotic fluid embolism) or where detection of PPH has been delayed
• If PTT/APTT is >1.5x normal + haemorrhage is ongoing - volumes of FFP in excess of 15 ml/kg are needed to correct coagulopathy
Cryoprecipitate
• Plasma fibrinogen level >2g/l should be maintained during ongoing PPH
• Cryoprecipitate should be used for fibrinogen replacement if haemorrhage is ongoing and plasma fibrinogen <2g/l
Platelets
• Should be transfused if haemorrhage is ongoing and when the platelet count is <75 x 10^9/l
Management of secondary PPH
- Iron supplement if Hb has fallen – warn of the risk of constipation
- Assess vaginal microbiology (high vaginal + endocervical swabs)
Clot present on speculum examination
• Remove with tissue forceps, allowing the cervix to close
RPOC
• Elective curettage with abx cover
Endometritis:
• Abx IV or PO
• Sepsis following pregnancy - IV piperacillin/tanzobactim
o Other options for less severe infections – co-amoxiclav, metronidazole, gentamicin
• Severe sepsis following pregnancy - carbapenem + clindamycin
Suspicion of sepsis – urgent hospital referral if red flag signs • Pyrexia >38 • Sustained tachycardia (>90 bpm) • Increased RR (>20 breaths per minute) • Abdominal or chest pain • D +/or V • Uterine/renal angle pain + tenderness • Woman unwell or anxious/distressed
When should you admit someone with hyperemesis gravidarum?
Admission criteria for hyperemesis gravidarum
- Unable to keep down fluids/oral antiemetics
- Ketonuria
- Wright loss >5%
- Co-morbidity (i.e. diabetes) – lower threshold for admission
How do you treat mild/moderate nausea + vomiting in pregnancy / hyperemesis gravidarum?
- KCl
- Vitamin B1 (thiamine)
- VTE
Conservative – without volume depletion
• Diet modification
o Smaller more frequent meals
o Avoid smells and food textures that cause nausea
o Bland-tasting foods, high in carbohydrate, low in fat
- Emotional support
- Ginger- PO 250mg TIDS
- Acupressure
Management of severe cases of nausea and vomiting in pregnancy/ hyperemesis gravidarum
• Oral antihistamines or phenothiazines (1st line) or anti-emetics (2nd line)
o Meclozine or dimenhydrinate or diphenhydramine (oral antihistamines), chlorpromazine or prochlorperazine or promethazine (phenothiazines)
o Metoclopramide or domperidone (dopamine antagonist anti-emetics), ondansetron
• Corticosteroids (3rd line)
o IV hydrocortisone, BD, 100mg (convert to PO when capable)
With volume depletion
• IV hydration
o IV normal saline + KCl + thiamine (vitamin B1) supplementation
o IVF to a) replace the calculated deficit, b) ongoing losses, c) daily fluid maintenance
• Parenteral or rectal anti-emetics
• Nutritional supplementation
o Some patients may require TPN to provide calories and replace electrolytes and nutrients
Other
• Thromboprophylaxis - prophylactic LMWH
• Vitamin supplements
o Thiamine supplements given routinely to all pregnant women admitted to hospital as a result of prolonged vomiting
Summary - Severe cases • Hospitalisation • Anti-histamines or Anti-emetics • IVF • LMWH • Corticosteroids • TPN
Medications used in hyperemesis gravidarum - list some of their side effects
Medication SE • Metoclopramide • metoclopramide + phenothiazines • Ondansetron • Domperidone • Corticosteroids
• Metoclopramide
o < 5 days in order to minimise the risk of neurological and other adverse effects
o used as second line therapy because of EPS
• metoclopramide + phenothiazines
o drug induced EPS
o Oculogyric crises
• Ondansetron
o Increased risk of cleft palate if used during the first trimester
o Limit use of ondansetron during the first trimester
o Should be used as second line due to unknown effects in pregnancy
o Still consider it as an option for patients with severe vomiting in pregnancy in whom first-line treatments have failed
• Domperidone
o should be used at the lowest effective dose for the shortest possible duration
o maximum treatment should not exceed 1 week
o new maximum dose recommended in adults is 30mg/day
o Life-threatening effects on the heart
o Contraindicated in patients with severe hepatic impairment or underlying cardiac disease
o Should not be administered with other drugs that prolong the QR interval or inhibit CYP3A4
• Corticosteroids
o Should be considered after the first trimester
o Use in first trimester – associated with cleft palate
o Should be reserved for cases where standard therapies have failed
Management of chronic hypertension in pregnancy
Chronic hypertension • Offer antihypertensive treatment to pregnant women who have chronic HTN and who are not already on treatment if they have o Sustained SBP >140mmHg o Sustained DBP >90 mmHg • Target = 135/85 mmHg
• Medication
o Labetalol (NOT in asthmatics)
Nifedipine if labetalol is not suitable (Asthmatics)
Methyldopa if labetalol or nifedipine are not suitable
o ASPIRIN 75-150 mg OD from 12 weeks until birth of baby
- appointments every 2 to 4 weeks if hypertension is well-controlled.
- Carry out fetal monitoring (ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery doppler velocimetry) at 28, 32, 36 weeks only
• Offer PIGF-based testing to rule out pre-eclampsia between 20 weeks up to 35 weeks of pregnancy, if women with chronic hypertension are suspected of developing pre-eclampsia
• Postpartum mx of women with chronic hypertension
o Aim to keep BP <140/90mmHg
o Continue antihypertensive tx if required + rw 2 weeks postpartum
o BP monitoring – OD for the first 2 days, at least once bn day 3 + 5
o Medical rw 6-8 weeks after birth
o If on methyldopa during pregnancy, stop within 2 days after birth + change to an alternative antihypertensive treatment
Gestational hypertension mx
• Labetalol (NOT in asthamtics)
o Nifedipine for women in whom labetalol is not suitable (asthmatics)
o Methyldopa if labetalol or nifedipine are not suitable
• Aim to deliver after 37 weeks’ gestation
• Postpartum
o BP monitoring – OD for the first 2 days, at least once bn day 3 + 5
o Continue antihypertensive treatment if required + rw 2 weeks postpartum
o Reduce antihypertensive treatment if their BP falls below 130/80mmHg
o If on methyldopa during pregnancy, stop within 2 days after birth + change to an alternative antihypertensive treatment
o For women with gestational HTN who did not take antihypertensive treatment + have given birth, start antihypertensive treatment if their BP is 150/100mmHg or higher
o Medical rw 6-8 weeks after birth
Management of mild-moderate gestational hypertension
What is considered mild/moderate gestational hypertension?
How often should BP be monitored?
What investigations need to be carried out?
How should it be managed?
Mild = 140-149/90-99 Moderate = 150-159/100-109
BP monitoring
1-2/7 until BP is 135/85mmHg or less
Other investigations
• At presentation then weekly – FBC, LFTs, U+Es
• 1-2/7 dipstick proteinuria testing
• PIGF-based testing on 1 occasion if there is suspicion or pre-eclampsia
• Offer fetal heart auscultation at every antenatal appointment
• USS assessment of fetus at dx, If normal repeat every 2-4/52
o USS for fetal growth
o Amniotic fluid volume assessment
o Umbilical artery doppler
• CTG only if clinically indicated
Management
Do not routinely admit to hospital
Offer pharmacological tx if BP remains >140/90mmHg
Labetalol (alternatives: methyldopa, nifedipine)
Aim for BP of 135/85mmHg or less
Labetalol – 1st line (CI in asthma)
Nifedipine – 2nd line
Methyldopa – 3rd line
Management of severe gestational hypertension
What is considered severe gestational hypertension?
How often should BP be monitored?
What investigations need to be carried out?
How should it be managed?
Severe = >160/110 or mean arterial pressure <160/110
BP monitoring
Every 15-30 mins until BP is <160/110mmHg
Other investigations
• At presentation then weekly – FBC, LFTs, U+Es (renal function, electrolytes)
• Daily dipstick proteinuria testing while admitted
• PIGF-based testing on 1 occasion if there is suspicion or pre-eclampsia
• Offer fetal heart auscultation at every antenatal appointment
• USS assessment of fetus at dx, If normal repeat every 2/52 if severe htn persists
o USS for fetal growth
o Amniotic fluid volume assessment
o Umbilical artery doppler
• CTG at dx and then only if clinically indicated
Management
Admit, but if BP falls below 160/110 mmHg manage as for HTN
Offer pharmacological tx to all women
Labetalol (alternatives: methyldopa, nifedipine)
Aim for BP of 135/85 mmHg or less
Labetalol – 1st line (NOT in asthamtics)
Nifedipine – 2nd line
Methyldopa – 3rd line
Management for the prevention of pre-eclampsia
• 75-100 mg aspirin from 12 weeks of gestation until the birth of the baby
o If at high risk of pre-eclampsia (>=1 high risk factors) or if >=2 moderate RF
o High risk factors HTN disease during previous pregnancy CKD Autoimmune disease e.g. SLE or antiphospholipid syndrome T1 or T2DM Chronic HTN
o Moderate RF First pregnancy Pregnancy interval of >10 years >40 y/o BMI >35kg/m2 at first visit FHx of pre-eclampsia Multiple-fetal pregnancy
• High-dose calcium supplementation (>1g/day)
o May reduce the risk of pre-eclampsia and preterm birth, particularly for women with low Calcium diets
o May be an increased risk of HELLP syndrome with calcium supplementation
o Do not use
NO donors, progesterone, diuretics, LMWH
o Do not recommend salt restriction during pregnancy solely to prevent gestational hypertension or pre-eclampsia
Admission criteria for pre-eclapmsia
• Raised BP (>140/90mmHg) with proteinuria >+1
• SBP >160mmHg
• DBP >100mmHg
• Any clinical symptoms or signs of pre-eclampsia/severe pre-eclampsia/eclampsia/impending eclampsia
• Suspected fetal compromise
• Any maternal biochemical/haematological investigations that cause concern e.g. new and persistent
o Rise in Cr (>90 micromol/l, >1mg/100ml)
o Rise in alanine transaminase (>70 IU/l or 2x upper limit of normal range)
o Fall in plt count (<150,000/microlitre)
- Patients can be managed conservatively (i.e. without delivery of the baby) until at least 34 weeks, as long as they are haemodynamically stable, without coagulation abnormalities and in the absence of HELLP
- Delivery of the placenta is the only cure for pre-eclampsia
Management of mild-moderate pre-eclampsia
What is considered mild/moderate pre-eclampsia?
How often should BP be monitored?
What investigations need to be carried out?
How should it be managed?
Mild = 140-149/90-99 Moderate = 150-159/100-109
BP monitoring
At least every 48h + more frequently (4x/day) if woman admitted to hospital
Other investigations
• 2/7 – FBC, LFTs, U+Es (renal function, electrolytes)
• Dipstick proteinuria testing – only repeat if clinically indicated (e.g. new symptoms + signs develop, or uncertainty over dx)
• Offer fetal heart auscultation at every antenatal appointment
• USS assessment of fetus at dx, If normal repeat every 2/52
o USS for fetal growth
o Amniotic fluid volume assessment
o Umbilical artery doppler
• CTG at dx and then only if clinically indicated o Change in foetal movement o Abdominal pain o PVB o Maternal deterioration
Management
Admit if any clinical concerns for the wellbeing of the woman or baby or if high adverse events suggested by the fullPIERS or PREP-S risk prediction models*
Offer pharmacological tx if BP remains >140/90mmHg
Labetalol (alternatives: methyldopa, nifedipine)
Aim for BP of 135/85mmHg or less
Labetalol – 1st line (NOT in asthamtics)
Nifedipine – 2nd line
Methyldopa – 3rd line
*Risk prediction models
o FullPIERS or PREP-S to help guide decisions about the most appropriate place of care (e.g. need for in-utero transfer) + thresholds for intervention
o fullPIERS – intended for use at any time during pregnancy
o PREP-S intended for use up to 34 weeks of pregnancy
o fullPIERS and PREP-S models do not predict outcomes for babies
Management of severe pre-eclampsia
What is considered severe pre-eclampsia?
How often should BP be monitored?
What investigations need to be carried out?
How should it be managed?
Severe = >160/110 or mean arterial pressure >125 mmHg
BP monitoring
Every 15-30 mins until BP is <160/110mmHg
Then at least 4x daily while woman in as inpatient
Other investigations
• 3/7 – FBC, LFTs, U+Es (renal function, electrolytes)
• Dipstick proteinuria testing – only repeat if clinically indicated (e.g. new symptoms + signs develop, or uncertainty over dx)
• Offer fetal heart auscultation at every antenatal appointment
• USS assessment of fetus at dx, If normal repeat every 2/52 if severe htn persists
o USS for fetal growth
o Amniotic fluid volume assessment
o Umbilical artery doppler
• CTG at dx and then only if clinically indicated
o Change in foetal movement
o Abdominal pain
o PVB
o Maternal deterioration
Management
Admit, but if BP falls below 160/110 mmHg manage as for HTN
Offer pharmacological tx to all women
Labetalol (alternatives: methyldopa, nifedipine)
Aim for BP of 135/85mmHg or less
Labetalol – 1st line
Nifedipine – 2nd line
Methyldopa – 3rd line
Management of pre-eclampsia
• Labetalol – 1st line (100mg, BD) – contraindicated in asthma
o Nifedipine – 2nd line – used in asthmatics, causes tocolysis (use methyldopa at term)
o Methyldopa – 3rd line (250mg, BD or TDS)
• Consider early birth if
o If inability to control maternal BP despite using 3 or more classes of antihypertensives in appropriate doses
o Maternal oxygen sats <90%
o Progressive deterioration in liver/renal function, haemolysis, platelet count
o Ongoing neurological features – severe intractable headache, repeated visual scotomata, eclampsia
o Placental abruption
o Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph or stillbirth
• If early birth is planned for women with preterm pre-eclampsia (<34 weeks)
o IV MgSO4
o Antenatal corticosteroids
- Between 34-36+6 weeks – continue surveillance unless delivery indicated in care plan
- > 37 weeks – initiate birth within 24-48 hours
Management of severe pre-eclampsia
• Delivery of fetus + placenta is the only cure
• BP
o Antihypertensive treatment started in women with SBP > 160 mmHg or DBP > 110mmHg
o In women with other markers of potentially severe disease, treatment can be considered at lower degrees of HTN
o Use one of the following
Labetalol (PO or IV)
Nifedipine (oral)
Hydralazine (IV)
o Antihypertensive medication should be continued after delivery as dictated by the BP
It may be necessary to maintain treatment for up to 3 months
- ACEi + ARBs - increased risk of congenital abnormalities
- Thiazide or thiazide-like diuretics - increase risk of congenital abnormalities + neonatal complications
• Seizures
o Prevention
Magnesium sulfate (if there is concern about risk of eclampsia)
Given to women with severe pre-eclampsia who are in a critical care setting if birth is planned within 24h
o Fluid restriction
o Up to 80ml/h or 1ml/kh/h
- Delivery
- Between 34-36+6 weeks – continue surveillance unless delivery indicated in care plan
- > 37 weeks – initiate birth within 24-48 hours
o If <34 weeks of gestation + delivery can be deferred – give corticosteroids
After 24 hours the benefits of conservative management should be reassessed
o Measure BP continually during labour
Management of eclampsia
• Resuscitation
o Place patient in left lateral position
o Secure airway
o O2 administration
• Magnesium sulfate (potent cerebral vasodilator) – Treatment + prophylaxis of seizures
o Continue 24h after last seizure or delivery - whichever is later
o Loading dose of 4g IV over 5 mins, followed by infusion of 1g/hour for 24h
o Recurrent seizures -further dose of 2-4g over 5 mins, intubation to protect the airway + ensure adequate oxygenation
o Monitor: UO, reflexes, RR, O2 sats, ECG
• Hypertension
o Reduce severe HTN (BP >160/110 mmHg or mean arterial pressure >125mmHg) – to reduce the risk of CVA + risk of further seizures
o IV labetalol or hydralazine
Both may precipitate fetal distress
Continuous fetal HR monitoring is necessary
• Fluid therapy
o Close monitoring of fluid intake + UO
• Delivery
o Definitive treatment of eclampsia is delivery
o Attempts to prolong pregnancy in order to improve fetal maturity are unlikely to be of value
o Unsafe to deliver the baby of an unstable mother even if there is fetal distress
o Delivery only when – seizures are controlled, severe hypertension is treated, hypoxia is corrected
• Postpartum
o High dependency care should be continued for a minimum of 24h
Pre-eclampsia post partum care
Discharge criteria
BP monitoring Inpatient Outpatient Step down care No anitHTN during pregnancy but have high blood pressure PP Consider reducing treatment
Safe antihypertensive in the postnatal period
• Discharge criteria
o No sx of pre-eclampsia
o Blood pressure <150/100mmHg (with or without treatment)
o Blood test results are stable or improving
- Stop methyldopa (if used) within 2 days
- Continue to ask about headaches + epigastric pain whenever BP is taken
• Measure FBC, LFT, Cr 72h after birth
o Only repeat after this if abnormal
• BP monitoring
o Inpatient = BP at least 4x/daily
o Outpatient = BP every other day until targets achieved, then once weekly
o Monitor weekly + arrange medical review at 2 weeks postpartum if still requiring medication
o Monitor BP until the 6-week check + perform a urine dip at 6 week check + arrange repeat FBC, Cr, LFTs if they have not returned to normal
o Step down care when BP <150/100 mmHg + blood tests are stable/improving without any pre-eclamptic symptoms
o start antihypertensive treatment if BP >=150/100
o Consider reducing BP treatment if BP falls below <140/90 mmHg, reduce if it falls below 130/80mmHg
• HTN during postnatal period
o Enalapril
o Monitor maternal renal function + maternal serum potassium
o If black African/Caribbean - nifedipine or amlodipine
o If BP not well controlled with a single medicine -combination of enalapril + nifedipine or amlodipine
o If combination is not tolerated/ineffective – add atenolol or labetalol to the combination treatment or swap medicines already used for atenolol or labetalol
• Breastfeeding
o Avoid diuretics
o Not recommended when breastfeeding – ARBs, ACEi (except enalapril + captopril), Amlodipine
o Safe drugs – labetalol, nifedipine, enalapril, captopril, atenolol, metoprolol
• Follow up + formal postnatal review – to establish if there is chronic hypertension, proteinuria or liver damage
• Outpatient follow up
o Care plan to include – frequency of BP monitoring, thresholds for reducing/stopping treatment/indications for referral and self-monitoring of symptoms
o Referral follow-up to GP
o Advice: 1 in 5 women will get some recurrence of HTN in future pregnancies
Pre-eclampsia
Medications and indications
Anticonvulsants (+reversing agent)
Anthypertensives
CS for fetal lung maturation
Antihypertenives in the postnatal period
• Anticonvulsants – Magnesium sulfate
o If woman has previously had an eclamptic fit
o For women with severe pre-eclampsia in a critical care setting if birth is planned within 24h
o If 1 or more of the following features of severe pre-eclampsia are present
Ongoing or recurring severe headaches
Visual scotomata
N or V
Epigastric pain
Oliguria + severe HTN
Progressive deterioration in lab tests (raised Cr or LFTs, low plt count)
o 1st line – IV magnesium sulfate
Continue 24h after last seizure/delivery
Loading dose of 4g IV over 5 mins, followed by infusion of 1g/hour for 24h
Recurrent seizures - further dose of 2-4g over 5 mins
Monitor: UO, reflexes, RR, O2 sats, ECG
o Reversing agent – Calcium gluconate
10ml, 10% over 10 minutes
• Antihypertensives
o 1st line – Labetalol (PO or IV) – contraindicated in asthma
o 2nd line – Nifedipine (PO) – causes tocolysis (use methyldopa at term)
o 2nd line – Hydralazine (IV)
o NICE: 3rd line for chronic HTN/gestational HTN/pre-eclampsia – methyldopa
• Corticosteroids for fetal lung maturation
o bn 24+0 and 34+6 weeks + at risk of preterm birth
24mg in 2 doses (12mg each, separated by 12 hours)
o If early birth is considered likely within 7 days in women with pre-eclampsia
• Antihypertensives in the postnatal period
o Enalapril
o Monitor maternal renal function + maternal serum potassium
o If black African/Caribbean nifedipine or amlodipine
o If BP not well controlled with a single medicine combination of enalapril + nifedipine or amlodipine
o If combination is not tolerated/ineffective – add atenolol or labetalol to the combination treatment or swap 1 of the medicines already used for atenolol or labetalol
o Avoid diuretics or ARBs
Amniotic fluid embolus management
RCOG – the management of amniotic fluid embolism is supportive rather than specific as there is not proven effective therapy
• Resuscitation
o High flow O2 – most pt will require endotracheal intubation
Signs and symptoms of adequate oxygen delivery + tissue perfusion should be continuously monitored
o Fluids to maintain BP
o If haemodynamically unstable – consider pulmonary artery catheterisation
o If arrhythmias develop – standard treatment
o If she arrests – CPR
o If she does not respond to CPR – perimortem
Caesarean delivery
Within 5 minutes or asap after cardiac arrest
During this time, can also trigger the full protocol for a massive haemorrhage
• Pharmacological
o Inotropic support
o Early, aggressive treatment of coagulopathy should be considered in the presence of bleeding gums or haematuria
FFP – if APTT >1.5x normal
Cryoprecipitate – if fibrinogen <1g/L
Platelets – if plt count <50x10^9/L
Up to 1 L of FFP + 10U of cryoprecipitate (2 packs) may be given empirically in the presence of massive haemorrhage while awaiting results of coagulation studies
o Aggressive treatment of uterine atony (look at management of PPH)
Oxytocics
Ergometrine
Prostaglandins
Packing, bimanual uterine compression, catheterisation, tamponade, Rusch balloons
o CO measurement – ensure fluid overload does not occur
Fluid overload will exacerbate pulmonary oedema + increase the risk of ARDS
• Surgical
o Delivery
o Hysterectomy if bleeding cannot be controlled – should not be delayed until the woman is in extremis
o Uterine artery embolization
• Of those who die, 25% die within the first hour and most of the remainder by 9h after presentation
o Palliative care may be initiated concurrently with resuscitation
When should women with
pre-existing diabetes in pregnancy
Gestational diabetes
deliver and how
pre-existing diabetes in pregnancy - 37+0 to 38+6 weeks - Induction of labour or C-section
Gestational diabetes - 40+6 weeks - Induction of labour or C-section
Pre-existing diabetes in pregnancy
pre-conception care
• Aim for the same capillary plasma glucose target ranges as recommended for all people with T1DM
o HbA1c <48 mmol/mol (6.5%)
o Fasting plasma glucose 5-7mmol/l on waking and
o Plasma glucose level 4-7 mmol/l before meals at other times of the day
- If HbA1c >86 mmol/mol (10%) - do not get pregnant
- Women with BMI >27 kh/m2 should be offered advice on how to lose weight
- Retinal assessment should be offered at the first pre-conception appointment + then every year if no retinopathy is found
• Assessment of diabetic nephropathy before and during pregnancy
o Refer if – creatinine >120μmol/l or eGFR <45ml/min/1.73m2
- 5mg folic acid daily until 12 weeks of gestation to reduce the risk of neural tube defects
- If antihypertensives are needed – methyldopa. Labetalol + nifedipine can also be used
- Benefits of breast-feeding – improved glucose control, easier weight loss
Pre-existing diabetes in pregnancy
Conception
Medication for diabetes and diabetic complications before and during pregnancy
• All other hypoglycaemic agents should be discontinued before pregnancy except metformin + insulin
• Substitute glucose lowering agents with insulin
o Isophane insulin (NPH insulin) – first choice for long-acting insulin during pregnancy
o Consider continuing treatment with long-acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy
o Rapid-acting insulin analogues (aspart and lispro) do not seem to affect pregnancy or the health of the fetus or newborn baby adversely – they are actually associated with fewer episodes of hypoglycaemia, a reduction is postprandial glucose excursions and an improvement in overall glycaemic control compared with regular human insulin
o Continuous SC insulin infusion (insulin pump therapy) may be appropriate for pregnant women who have difficulty achieving glycaemic control with multiple daily injections of insulin without significant disabling hypoglycaemia
o If high glucose after meals – need more short acting
o If high fasting glucose – need more long-acting
o All women treated with insulin during pregnancy should be aware of the risks of hypoglycaemia, particularly in the first trimester + should be advised to always carry a fast-acting form of glucose (dextrose tablets, glucose containing drink) + pregnant women with T1DM should also be prescribed glucagon
• Metformin
o Used as an adjunct or alternative to insulin
o Likely benefits from improved glycaemic control outweigh the potential for harm
• Since insulin resistance increases throughout pregnancy, advice patients to increase their dose of metformin or insulin during the 2nd half of the pregnancy
• Should be stopped before conception or as soon as pregnancy is confirmed
o ACEi
o ARB
o Statins
Pre-existing diabetes in pregnancy
Antenatal care
other medication Clinics Glycaemic control + monitoring Target blood glucose levels HbA1c Insulin treatment + risks of hypoglycaemia Glucose monitoring during pregnancy - what should be offered? What should be tested if they become hyperglycaemic Retinal assessment during pregnancy Renal assessment during pregnancy PET Detecting congenital malformations Monitoring feta growth + well being
• Arrange contact with joint diabetes + obstetric clinic Women with diabetes should be seen every 1-2 weeks during pregnancy by the diabetes care team
• Other medication
o Folic acid 5mg until 12w
o Aspirin from 12w
Glycaemic control + monitoring
• T1DM & T2DM + GDM who are on a multiple daily insulin injection regimen – need to test their fasting, pre-meal + 1h post-meal + bedtime blood glucose levels
• T2DM + GDM who manage their diabetes with exercise changes along or oral therapy or single-dose intermediate-acting or long-acting insulin – test their fasting and 1h post meal blood glucose
• Target blood glucose levels
o Fasting glucose <5.3 mmol/L
o 1h after meal <7.8 mmol/L
o 2h after meal <6.4mmol/L
• HbA1c
o Measure in 2nd and 3rd trimester to assess the level of risk for the pregnancy
o Do not use HbA1c levels routinely to assess a woman’s blood glucose control in the 2nd and 3rd trimesters of pregnancy
o The level of risk for the pregnancy for women with pre-existing diabetes increases with an HbA1c level >48mmol/mol (6.5%)
• Insulin treatment + risks of hypoglycaemia
o Isophane insulin (NPH insulin) – first choice for long-acting insulin during pregnancy
o Consider continuing treatment with long-acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy
o Rapid-acting insulin analogues (aspart + lispro) for pregnant women with diabetes
o Can also offer SC insulin infusion (CSII - continuous SC insulin infusion) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia
o If high glucose after meals – need more short acting
o If high fasting glucose – need more long-acting
o always carry a fast-acting form of glucose (dextrose tablets, glucose containing drink) + pregnant women with T1DM should also be prescribed glucagon
• Intermittently scanned CGM (isCGM) and continuous glucose monitoring (CGM)
o Offer CGM to all pregnant women with T1DM
o Offer isCGM to pregnant women with T1DM who are unable to use continuous glucose monitoring or express a clear preference to it
o Consider CGM for pregnant women who are on insulin therapy but do not have T1DM if
They have problematic severe hypoglycaemia (+/- impaired awareness of hypoglycaemia)
They have unstable glucose levels that are causing concern despite efforts to optimise glycaemic control
• Retinal assessment during pregnancy
o Retinal assessment by digital imaging with mydriasis using tropicamide during their first antenatal clinic appointment unless they had a retinal assessment in the previous 3 months
o Repeat retinal assessment at 28 weeks
o If diabetic retinopathy is present, assess again at 16-20 weeks
o If diabetic retinopathy is diagnosed during pregnancy - ophthalmological follow-up for at least 6 months after the birth of the baby
o Retinopathy needs to be treated before pregnancy begins
o Advise women with diabetes who are planning a pregnancy to defer rapid optimisation of blood glucose control until after they have had retinal assessment and treatment
o Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbA1c in early pregnancy
• Pre-eclampsia
o High risk of pre-eclampsia (includes women with T1DM + T2DM) – take 75mg of aspirin daily from 12 weeks until the birth of the baby
• Detecting congenital malformations
o USS anomaly scan incl. examination of the fetal heart at 20 weeks (4 chambers, outflow tracts, 3 vessels)
• Monitoring fetal growth + well-being
o Offer US monitoring for fetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks
o If there is risk of fetal growth restriction – routine monitoring of fetal wellbeing before 38 weeks (fetal umbilical artery doppler recording, fetal heart rate recording, biophysical profile testing)
Pre-existing diabetes in pregnancy
Intrapartum care
AN steroids Blood glucose monitoring during labour Aim for blood glucose levels Timing and mode of birth Monitoring of blood glucose during GA
• Pre-term labour
o Not contraindicated
o Steroids increase glucose release - If antenatal corticosteroids are needed additional insulin therapy is required to maintain normoglycaemia (often requires admission)
• Blood glucose during labour + birth
o Monitor every hour during labour + birth
o T1DM + T2DM - For women on insulin, consider sliding scale insulin and glucose should be commenced in labour
Aim for blood glucose levels between 4-7 mmol/l
o Consider IV dextrose + insulin infusion from the onset of established labour if difficult to maintain capillary blood glucose within that range
• Timing and mode of birth
o Timing – between 37+0 weeks and 38+6 weeks
o Consider delivery before this in the presence of foetal/maternal complications
o IOL or CS
• Anaesthesia
o Anaesthetic assessment in the third trimester of pregnancy
o If GA for birth, monitor blood glucose every 30 mins from induction of GA until after the baby is born and the woman is fully conscious
Pre-existing diabetes in pregnancy
Care of the baby once delivered
• Should only be admitted to NICU if there is a specific complication – hypoglycaemia, respiratory distress, signs of cardiac decompensation, neonatal encephalopathy, signs of polycythaemia, need IVF/tube feeding, jaundice requiring intense phototherapy + frequent monitoring of bilirubinaemia, born before 34 weeks
• Babies should feed asap after birth
o Within 30 mins
o Then every 2-3h until re-feed glucose levels are at least 2 mmol/L
• Only use additional measures (tube feeding, IV dextrose if)
o Capillary plasma glucose <2.0 mmol/L on 2 consecutive readings
o Abnormal clinical signs
o Baby will not feed orally
• Blood glucose testing
o Carried out routinely in babies of women with diabetes at 2-4 hours after birth to exclude neonatal hypoglycaemia
• Signs of hypoglycaemia in babies + management o Abnormal muscle tone o Level of consciousness o Fits o Apnoea o Rx – IV dextrose
• If signs of heart disease/cardiomyopathy – echo
• Babies discharged
o At least 24 hours old
o Maintaining blood glucose levels
o Feeding well
Pre-existing diabetes in pregnancy
Post-natal care
• Adjust insulin + metformin doses back to those of pre-pregnancy immediately after birth
• Women with insulin-treated pre-existing diabetes
o Should reduce their insulin immediately after birth + monitor their blood glucose levels carefully to establish their appropriate dose
o Are at an increased risk of hypoglycaemia in the postnatal period, especially when breast-feeding – provide advice to have meal or snack available before or during feeds
• Women with pre-existing T2DM who are breast-feeding
o Can continue to take metformin + glibenclamide immediately after birth
o Should avoid other oral blood glucose-lowering agents while breastfeeding
• Women with diabetes who are breastfeeding
o Should continue to avoid any medicines for the treatment of diabetes complications that were discontinued for safety reasons in the pre-conception period
mal
How much folic acid should be taken during pregnancy and until when?
All women should take 400mcg folic acid until the 12th week of pregnancy
Which women should take a higher dose of folic acid?
How much?
From when until when?
Causes of folic acid deficiency ?
High dose folic acid (5mg) needed in women at higher risk of conceiving a child with NTD:
Pregnant obese women (BMI >30 kg/m2) Previous pregnancy with NTD (neural tube defects) FHx of NTD Either partner has NTD Use of anti-epileptic drugs Coeliac disease Diabetes Thalassaemia trait
In these cases 5mg of folic acid should be taken from before conception until the 12th week of pregnancy
• Sickle cell disease, thalassaemia trait, thalassaemia – take 5mg throughout pregnancy
Causes of folic acid deficiency • Phenytoin • Methotrexate • Pregnancy • Alcohol excess
GDM / Gestational Diabetes Melitus mx if
fasting plasma glucose <7 mmol/L at diagnosis
• When women are dx with GDM offer review with the joint diabetes + AN clinic within 1 week
If fasting plasma glucose <7 mmol/L at diagnosis
• Lifestyle modifications – 1st line
o Body loss for women with BMI >27kg/m2
o Diet
o Physical activity – at last 30 mins per day
• Metformin – 2nd line
o If blood glucose targets are not met with diet and exercise changes within 1-2 weeks
• Insulin – 3rd line
o If metformin is contraindicated/unacceptable (SE – decreased appetite, diarrhoea, abdominal pain)
o If blood glucose targets are not met with diet and exercise + metformin, offer insulin as well
• Glibenclamide – 4th line
o For women in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin
• Contraindications
o Gliclazide
o Liraglutide
GDM / Gestational Diabetes Melitus mx if
fasting plasma glucose >7 mmol/L at diagnosis OR fasting plasma glucose 6-6.9 mmol/L with complications (e.g. macrosomia, hydramnios)
If fasting plasma glucose >7 mmol/L at diagnosis OR fasting plasma glucose 6-6.9 mmol/L with complications (e.g. macrosomia, hydramnios)
• Immediate treatment with insulin +/- metformin and
• Changes in diet and exercise
What are the targets for capillary plasma glucose
o Fasting glucose
o 1h after meal
o 2h after meal
for pregnant women with gestational diabetes melitus/ GDM?
• Use the same capillary plasma glucose target levels for women with GDM as for women with pre-existing diabetes
• Targets for capillary plasma glucose
o Fasting glucose <5.3 mmol/L
o 1h after meal <7.8 mmol/L
o 2h after meal <6.4mmol/L
o If women with GDM are on insulin or glibenclamide – should maintain their capillary plasma glucose level >4 mmol/L
Glycaemic control + monitoring in pregnant women with gestational diabetes melitus/GDM who:
a) are on a multiple daily insulin injection regimen
b) who manage their diabetes with exercise changes along or oral therapy or single-dose intermediate-acting or long-acting insulin
Glycaemic control + monitoring
• T1DM & T2DM + GDM who are on a multiple daily insulin injection regimen – need to test their fasting, pre-meal + 1h post-meal + bedtime blood glucose levels
• T2DM + GDM who manage their diabetes with exercise changes along or oral therapy or single-dose intermediate-acting or long-acting insulin – test their fasting and 1h post meal blood glucose
When should women with GDM/gestational diabetes melitus give birth?
No later than 40+6 weeks
Post-partum care of women with GDM/ gestational diabetes melitus
o Should stop blood glucose-lowering therapy immediately after birth
o Offer a fasting plasma glucose test 6-13 weeks after birth to exclude diabetes
Fasting plasma glucose level <6.0 mmol/L or HbA1c <39mmol/mol (5.7%)– low probability of having diabetes at the moment, moderate probability of developing T2DM they will need an annual test to check that their blood glucose levels are normal
Fasting plasma glucose 6.0mmol/l-6.9 mmol/l or HbA1c 39-47 mmol/mol (5.7%-6.4%) – high risk of developing T2DM
Fasting plasma glucose >7.0mmol/l or HbA1c >48 mmol/mol (6.5%) – (likely to) have T2DM (50%) + offer a test to confirm this
o Offer an annual HbA1c test to women with gestational diabetes who have a negative postnatal test for diabetes
o Offer women with gestational diabetes
early self-monitoring of blood glucose
an OGTT in future pregnancies
Offer a subsequent OGTT (24-28 weeks) if the first OGTT results in early pregnancy are normal
• (2h OGTT asap after booking + 2h OGTT at 24-28 weeks if first OGTT is normal)
Ectopic pregnancy management - expectant management
• Admit as an emergency
Conservative (expectant) management:
• Pregnancy of <6 weeks gestation who are bleeding but not in pain and do not have RF (e.g. previous ectopic pregnancy) (NICE) or
• USS dx of ectopic pregnancy + a decreasing βhCG level initially less than 1500 iu/l (RCOG) or
• Clinically stable and pain free women (NICE) or
• Have a tubal ectopic pregnancy measuring <35mm with no visible heartbeat on TVUSS (NICE) or
• Have serum hcg levels of <1000IU/L (NICE) or
• Are able to return for follow up (NICE)
• If expectant management - Repeat hCG levels
o Performed for women with a tubal ectopic pregnancy being managed expectantly on days 2, 4, 7 after the original test
If hcg levels drop by >15% from the previous value on days 2, 4 and 7 - repeat weekly until a negative result (<20 IU/L) is obtained or
If hcg levels do not fall by 15%/stay the same/rise from the previous value - seek senior advise to help decide further management
referral criteria for suspected ectopic pregnancy
Referral to hospital for urgent assessment via the early pregnancy assessment service or on-call gynaecologist out of hours • Pain + abdominal tenderness • Pelvic tenderness • Cervical motion tenderness • Vaginal bleeding
Ectopic pregnancy management - medical management
• Admit as an emergency
Medical management • Single dose methotrexate o First line in women who are able to return for follow-up and who have the following No significant pain Unruptured ectopic pregnancy with adnexal mass <35mm + no visible heartbeat No intrauterine pregnancy seen on USS Serum hCG <1500 IU/L • Consider if bhcg <5000iu/l
o SE – abdominal pain, N+V, reversible impaired liver function
o Avoid
Conceiving 3/12 after methotrexate – Contraception should be used for 3-6 months - methotrexate is teratogenic
Sexual intercourse during treatment
Alcohol and prolonged exposure to sunlight
o Need for follow up
• Blood tests
• Day 1 – BHCG, U+Es, LFTs, FBC, blood group
• Days 4+7 – Repeat bhcg levels
• If drop >15% between days 4 + 7 1 bhcg per week until negative (hcg <15iu/l) [RCOG]
• If no fall by >15% repeat TVUS (exclude ectopic fetal cardiac activity + presence of hemoperitoneum), consider second dose of methotrexate if still fulfils criteria for medical management
Ectopic pregnancy management - surgical management
Surgical management • Offered to those who cannot return for follow-up after methotrexate or to those who have an ectopic pregnancy and any of the following o Significant pain o Adnexal mass >35mm o Fetal heartbeat visible on scan o Serum hCG level >5000 IU/L
• Laparoscopic approach is preferable to an open approach
o No RF for infertility (presence of a healthy contralateral tube) - Salpingectomy
Urine pregnancy test at 3/52
o RF for infertility (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, previous PID) - Salpingotomy
Salpingotomy - risk of persistent trophoblast - need for serum β-hCG level follow up
• 1 serum hcg measurement 7 days after surgery, then 1 serum hcg measurement per week until a negative result is obtained
Salpingectomy - urine pregnancy test after 3 weeks – further assessment if is positive
Up to 1 in 5 women may need further treatment – methotrexate +/or salpingectomy
Copper IUD should not be used if you’ve had a laparoscopic salpingectomy
• Anti- rhesus D prophylaxis(250iU)
o Offered to all women who have surgical removal of an ectopic pregnancy or where bleeding is repeated, heavy or associated with abdominal pain
o No Kleihauer needed
Kleihauer test checks level of foetal blood in maternal circulation
o Do not offer anti-rhesus D prophylaxis to women who
Receive solely medical treatment for their ectopic pregnancy or miscarriage or
Threatened/complete miscarriage or
PUL
Ectopic pregnancies - which women can be offered a choice of medial or surgical treatment
Offer the choice of either methotrexate or surgical management:
• Women with an ectopic pregnancy who have a serum hCG of >1500 IU/L but <5000 IU/L and
• Who are able to return for follow up and
• Have no significant pain and
• Have an unruptured ectopic pregnancy with an adnexal mass <35mm with no visible heartbeat and
• No intrauterine pregnancy (as confirmed on an USS)
o If women choose methotrexate - their chance of needing further intervention is increased - they may need to be urgently admitted if their condition deteriorates
Placenta praevia management
Symptomatic + asymptomatic women with low-lying placenta or placenta praevia
Symptomatic + asymptomatic women with low-lying placenta or placenta praevia
• Single course of antenatal CS therapy recommended between 34+0 week and 35+6 weeks of gestation
- Appropriate prior to 34+0 weeks of gestation in women at higher risk of preterm birth
- Prevention and treatment of anaemia during the antenatal period
- Do not have penetrative intercourse
• Placental edge <20mm from the os
o Need for C-section, especially if it is posterior or thick
o If head has engaged at the time of planned C-section review with TVS again as the lower segment continues to develop after 36 weeks
• Manage woman as if she has placenta accreta if all of the following apply
o Anterior placenta reaching the os
o Previous C-section
Placenta praevia asymptomatic women mx
Asymptomatic women
• Rescan at 32 weeks
o If still low lying/praevia – rescan at 36 weeks
- If uncomplicated low lying/praevia at 36 weeks – delivery should be considered between 36+0 and 37+0 weeks of gestation
- Counselling re. risks of preterm delivery and obstetric haemorrhage
- Avoid sex
- If home-based care - close proximity to the hospital, constant presence of a companion, fully informed consent from the woman
Placenta praevia management
Minimal bleeding
- Make sure that the cause is clearly local vaginal bleeding
- Exclude cervical carcinoma (smear hx, direct visualisation of the cervix)
- Symptomatic management
- If bleeding settles, admit 48h for observation
Placenta praevia management
Recurrent bleeding
• Tailor antenatal care incl. hospitalisation to individual woman’s needs + social circumstances
o No penetrative intercourse
o Encouraged to stay in hospital from 34 weeks
• If hospital admission
o Assess RF for VTE – balance risk of developing a VTE against the risk of bleeding from a placenta praevia or a low lying placenta
• If home-based care - close proximity to the hospital, constant presence of a companion, fully informed consent from the woman
o Woman should attend hospital immediately if she experiences any bleeding, contractions, pain (incl. vague suprapubic period-like aches)
• Delivery through a C-section
o Women presenting with placenta previa or low-lying placenta + a hx of vaginal bleeding or other associated RF for preterm delivery - Late preterm (34+0 to 36+6 weeks of gestation) delivery should be considered
• Tocolysis
o May be considered for 48h to facilitate administration of antenatal corticosteroids
o If delivery is indicated based on maternal/fetal concerns, tocolysis should not be used in an attempt to prolong gestation
Placenta praevia management
Symptomatic placenta praevia (presenting with acute painless bleeding) mx
Investigations: • Do not perform a vaginal examination o Do not perform a bimanual o Speculum ok to assess bleeding o This may start torrential bleeding in the presence of placenta praevia
• Assess blood loss + cross-match for possible transfusion
o FBC, G+S, consider crossmath
o Kleihauer test
• Continuous foetal monitoring
• Scans
o CTG if >27 weeks
o Umbilical artery dopplers every 2 weeks
o Growth scan
• Admit pt until bleeding has stopped (+keep them in for 48h to observe)
o ABC – IV access + fluids
o Resuscitation – mother is priority
- Anti-D immunoglobulin if Rh -ve and Kleihauer test
- IOL if early foetal compromise
• Appropriate surgical intervention may be required
o Severe bleeding/mother haemodynamically unstable/evidence of foetal distress - deliver baby urgently whatever its gestational age
o if bleeding during delivery + pharmacological measures fail to control haemorrhage - initiate intrauterine tamponade +/or surgical haemostatic techniques incl. interventional radiological techniques
o Consider hysterectomy in severe cases if conservative medical + surgical interventions prove ineffective
• If immediate delivery is not likely (mother haemodynamically stable, no evidence of foetal distress)
o Admit until bleeding has stopped + for a further 48h for observation
o Maternal steroids – to promote fetal lung development + reduce the risk of respiratory distress syndrome + intraventricular haemorrhage
o Rescan at 36 weeks
- If still low-lying placenta – recommend elective CS at 36+0-37+0 weeks gestation
Placenta praevia management
Placenta praevia w a hx of C-section (placenta accreta suspected)
• High risk of placenta accreta in women with placenta praevia who have previously had a c-section
• Dx
o Antenatal imaging techniques – e.g. grey scale/colour flow Doppler, 3D ultrasonography
o Can help raise the suspicion of a morbidly adherent placenta
o Should be considered in any situation where any part of the placenta lies under the previous C-section scar, even if not praevia
o Definitive dx can only be made at surgery
• Care bundle for suspected placenta accreta (6 elements of good care)
o Consultant obstetrician planned + directly supervising delivery
o Consultant anaesthetist planned + directly supervising anaesthetic at delivery
o Blood and blood products available on site
o MDT involvement in pre-operative planning
o Discussion + consent incl. possible interventions e.g. hysterectomy, leaving the placenta in place
o Locally available level 2 critical care bed
• Uterus should be opened at a site distant from the placenta, delivering the baby without disrupting the placenta
o Then – conservative mx of the placenta or hysterectomy if accreta is confirmed
Placenta praevia management
Mode of delivery
- Women presenting with placenta previa or low-lying placenta + a hx of vaginal bleeding or other associated RF for preterm delivery
- If uncomplicated placenta praevia
- Third trimester asymptomatic low-lying placenta
- Grade I
- Grade III + IV
- Women presenting with placenta previa or low-lying placenta + a hx of vaginal bleeding or other associated RF for preterm delivery - Late preterm (34+0 to 36+6 weeks of gestation) delivery should be considered
- If uncomplicated placenta praevia - delivery should be considered between 36+0 and 37+0 weeks of gestation
- Third trimester asymptomatic low-lying placenta - consider the distance between the placental edge + the fetal head position relative to the leading edge of the placenta on TVS
- Grade I - can delivery vaginally
- Grade III + IV - C-section
- Consultant obstetrician + consultant anaesthetist should be present within the delivery or theatre suite when the surgery is occurring
- Consider vertical skin and/or uterine incisions when the fetus is in transverse lie to avoid the placenta, particularly below 28 weeks of gestation
Vasa praevia mx
• Confirmed vasa praevia in the third trimester
o Elective C-section prior to the rupture of membranes
o Prophylactic hospitalisation form 30-32 weeks of gestation in women with confirmed vasa praevia should be individualised and based on a combination of factors, incl. multiple pregnancy, antenatal bleeding and threatened premature labour
• Bleeding vasa praevia
o Emergency C-section
o Neonatal resuscitation (incl. the use of blood transfusion)
o Delivery should not be delayed while trying to confirm the diagnosis (fetal exsanguination can occur rapidly, high perinatal mortality)
• After birth
o Placental pathological examination to confirm the diagnosis
In particular where stillbirth has occurred or where there has been acute fetal compromise during delivery
Mild placental abruption mx
- Stop tobacco/cocaine/amphetamine misuse
- If vaginal bleeding -stop taking anticoagulant medication + go to hospital
• Mild – if preterm + stable – conservative management with close monitoring – IOL at term
o Admit for at least 48h or until bleeding stops
o Anti-D Ig
Severe placental abruption mx
• ABC, emergency CS, 3x wide bore cannulae, fluids, blood transfusions, correct coagulopathies
o FBC, G+S, crossmatch, Kleihauer test (and anti-D if needed), clotting screen, steroids (between 24-34+6w)
o CTG (if >27w), consider IOL if fetal compromise, TVUSS (?placenta praevia)
• Resuscitate mother – ABCD
o Evaluate circulation
IV access, FBC, coagulation screen, U+E, Kleihauer test, crossmatch 4 units
Position in left lateral position tilted + keep the woman warm
Principles of fluid replacement + administration of blood products are the same for APH as they are for PPH
Fluid – Until blood is available, infuse up to 2L of warmed crystalloid Hartmann’s solution +/or 1-2L of colloid as rapidly as required
Blood-product replacement – With continuous massive haemorrhage + whilst awaiting coagulation studies + haematology advice - give up to 4 units of FFP (1l) and 10 units (2 packs) of cryoprecipitate empirically
Blood transfusion - Measure central venous pressure (CVP) + adjust transfusion accordingly
Antifibrinolytics
o Asses fetus and decide on delivery
If fetus is alive – C-section or artificial rupture of the amniotic membranes – monitor the fetus + switch to Caesarean if fetal distress develops
If fetus is dead + haemorrhage is controlled – vaginal delivery
If fetus is dead + abruption is massive – C-section to control haemorrhage
If bleeding has settled + delivery is not imminent – maternal steroids to promote fetal lung development + reduce the risk of RDS and intraventricular haemorrhage
- CTG once mother is stable or resuscitation has commenced, to aid decision making on the mode of delivery
- Anti-D ig
- Admit for at least 48h or until bleeding stops
• If bleeding settles, consider discharging home with weekly serial growth scans until term
o Placental abruption + abnormal CTG or mother is haemodynamically unstable - delivery (irrespective of gestation)
o Antenatal Corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth
24mg in 2 doses (12mg each, separated by 12 hours)
If mum is haemodynamically unstable, we wont have enough time to give steroids
• Preterm pregnancy
o Placental abruption + normal CTG (no evidence of foetal distress) and mother haemodynamically stable - conservative (expectant) management
>37 w - IOL
<37 w - steroids + admit to antenatal ward for close monitoring
- If a woman presents with spotting and has a PHx of IUD resulting from placental abruption - hospitalisation
- APH – Consider using ergometrine-oxytocin for the third stage of labour (to reduce the risk of PPH)
Management of woman presenting with spotting and has a PHx of IUD resulting from placental abruption
Hospitalisation
Managing diabetes while breastfeeding - which drugs are safe to use?
- Metformin is safe
- Exenatide, liraglutide, sitagliptin to be avoided
- Sulfonylureas (gliclazide) – to be avoided – risk of neonatal hypoglycaemia
Mx of epilepsy in pregnancy
• Lamotrigine has been increasingly prescribed in pregnancy
• Once an unplanned pregnancy has been discovered it is usually too late for changes to be made to the epilepsy treatment regimen
o The risk of harm to the mother + fetus from convulsive seizures outweighs the risk of continued therapy
• Sodium valproate
o Should never be used for epilepsy in women with childbearing potential unless there is no effective treatment available
o Women on valproate with unplanned pregnancy refer urgently to a specialist but continue treatment until they are seen
• Need to balance risk of AEDs with the effect of seizures foetal + maternal hypoxia
• If treatment with AEDs must continue throughout pregnancy o Monotherapy o Lowest effective dose o Preferred AEDs – lamotrigine o Contraindicated – sodium valproate
• Folic acid
o 5mg per day before any possibility of pregnancy + throughout the first trimester
o To reduce the risk of neural tube defects, major congenital malformation and AED-related cognitive deficits
Contraception options for women on enzyme inducing anticonvulsants/drugs
• Anticonvulsants that induce liver enzymes (phenytoin, barbiturates, primidone, topiramate, carbamazepine, oxacarbazepine)
o Depot medroxyprogesterone acetate
o IUCD
o LNG-IUS
o Barrier methods
o Natural family planning methods
o NOT recommended: POP, progestogen implant
Interaction between lamotrigine and oestrogen
• Oestrogen-based contraceptive
o Can result in a sig. reduction of lamotrigine levels
o Can lead to loss of seizure control
o Women taking lamotrigine monotherapy and oestrogen-containing contraceptives should be informed of the potential in seizures due to fall in the levels of lamotrigine
What should be discussed with the woman if she wants to stop taking AEDs during pregnancy?
• Possibility of status epilepticus + SUDEP should be discussed with all women + girls who plan to stop AED therapy
o Status epilepticus = convulsive seizure that continues for a prolonged period of time (longer than 5 minutes), or convulsive seizures that occur one after the other with no recovery between.
Which AEDs are safe to use during pregnancy?
o Sodium valproate – neural tube defects – NO
o Phenytoin – cleft palate – NO
o Lamotrigine + levetiracetam – lowest rate of congenital malformations – YES
o Carbamazepine – least teratogenic of the old antiepileptics
Management of a pregnant woman presenting with seizures in the second half of the pregnancy
assess for eclampsia before changing anti-epileptic treatment
• Delivery mode + timing in women with epilepsy
• Delivery mode + timing unaffected unless seizures are increasing in frequency
Intrapartum mx of women with epilepsy
- Women should deliver in a centre with adequate facilities for maternal + neonatal resuscitation
- The risk of seizures in labour is low
- Risk of tonic-clonic seizure during the labour and the 24h after birth is low
• During labour
o Should continue to take their AEDs
If this cannot be tolerated orally parenteral alternative
o Adequate analgesia + appropriate care in labour to minimise RF for seizures e.g. insomnia, stress, dehydration
Pain relief in labour should be prioritised in WWE TENS (transcutaneous electrical nerve stimulation), NO + O2 (Entonox), regional anaesthesia
Diamorphine should be used in preference to pethidine
Pethidine should be used with caution in WWE for analgesia in labour
o Long-acting benzodiazepines e.g. clobazam can be considered if there is a very high risk of seizures in the peripartum period
o IV access in case of seizure IV benzodiazepine (e.g. lorazepam, diazepam) – recommended to terminate any seizures
Seizures should be terminated asap to avoid maternal + fetal hypoxia + acidosis
o If BZD used to terminate seizure loss of baseline variability of the fetal heart rate tracing can be expected for approx. 1h
o Continuous CTG
Recommended in women at high risk of a seizure in labour
Following an intrapartum seizure (GTC seizures are associated with hypoxia)
• To be avoided
o Birthing pools
o Hyperventilation + maternal exhaustion
Management of all babies born to WWE taking enzyme-inducing AEDs right after birth
• All babies born to WWE taking enzyme-inducing AEDs
o Should be offered 1mg of IM vitamin K
o To prevent haemorrhagic disease of the newborn
Post-natal mx of women with epilepsy
• Overall chance of seizures during + immediately after delivery is low but relatively higher than during pregnancy
• AEs should be continued postnatally
o If doses have been increased during pregnancy Medication requirement is likely to fall in the puerperium Toxicity may occur - review within 10 days of delivery
• Withdrawal effects in the newborn may occur with some AEDs – esp. BZD, phenobarbital
• Breastfeeding
o Encourage breastfeeding
o Breastfeeding for most women taking AEDs generally safe, should be encouraged
o Drowsiness in breast-fed babies primidone, phenobarbital, benzodiazepines
- Risk of postpartum seizures, particularly in the setting of sleep deprivation, stress, pain
- Juvenile myoclonic epilepsy in mother– myoclonic jerks tend to be more frequent in the early morning, often around the time of infant waking
- Restart contraception
Women with epilepsy - Information on safe-handling of the neonate – To reduce the risk of injury if the mother has a seizure
o Change or feed the baby on the floor
o Avoid baby slings
o Minimise climbing of stairs
o Avoid bathing the baby when alone
Mx after treatment of pregnant women for asymptomatic bacteriuria
• Once treatment is completed, check for resolution
o After taking abx pregnant women will have another urine culture done to make sure the bacteria were killed
o If culture is negative screen for re-infection periodically until they give birth
Mx of pregnant women with UTI
Send urine for MCS
Start abx immediately
Change abx according to susceptibility when results of MCS are back - using a narrow-spectrum abx wherever possible
• Adverse effects of abx – diarrhoea + nausea
• Safety netting – Seek medical help if abx are taken and
o Symptoms worsen rapidly or significantly at any time or
o Symptoms do not start to improve within 48h of taking the abx or
o Person becomes systemically unwell
• Refer if they have any symptoms or signs suggesting a more serious illness or condition e.g. sepsis
Prevention of UTI in pregnant women
- Drink plenty of fluids – at least 8 glasses of water per day
- Avoid alcohol, citrus juices, spicy food, caffeinated drinks which can irritate the bladder
- Don’t douche
- Wipe front to back after bowel movement
- Urinate shortly after having sex
- Cranberry products
Asymptomatic bacteriuria in pregnancy mx
• Confirm with a repeat sample
• Offer an immediate antibiotic but send MSU before starting – choose from
o Nitrofurantoin
If eGFR >45ml/min
100mg modified-release BD 7/7
Avoid at term – may produce neonatal haemolysis
o Amoxicillin
Only if culture results available + susceptible
500mg TDS 7/7
o Cefalexin
500mg BD 7/7
• Duration – 7 day course
• If GBS bacteriuria identified
o Write in notes – Ensure antenatal services are made aware
o In addition to the treatment at the time of dx, IAP (intrapartum abx prophylaxis) will be required – IV benzylpenicillin intrapartum
• Advise women to seek urgent medical review if any symptoms develop
Trimethoprim in pregnancy
o Trimethoprim
Contraindicated in pregnancy
Folate antagonist teratogenic risk in the first trimester
Can sometimes be used in pregnancy when given with folic acid 5mg daily in the first trimester
Safe in breastfeeding women
Lower UTI in pregnancy mc
• Immediate prescription of abx but send MSU before starting
o Nitrofurantoin
First line
Usual dose – 100mg modified-release BD 7/7
If eGFR >45ml/min
Not recommended at term pregnancy may produce neonatal haemolysis
o Second line:
Amoxicillin – 500mg TDS for 7/7
• Recommended only if culture results are available + bacteria are susceptible (high resistance rates)
Cefalexin – 500mg BD for 7/7
Second line at usual doses
• if lower UTI symptoms do not improve on a 1st-choice abx taken for at least 48h
• if first-choice abx are not suitable
Pyelonephritis in pregnancy mx
• Cephalexin
o First-choice oral abx
o 500mg BD/TDS for 7-10/7
o Severe infections – 1g-1.5g TDS/QDS
• Cefuroxime
o First line IV abx
o If vomiting, unable to take oral abx or severely unwell
o 750mg – 1.5g TDS/QDS
• Refer to specialist for advice
Pre-conception counselling - hyperthyroidism
• Untreated hyperthyroidism in women lighter, irregular periods, difficulty conceiving
• After treatment
o If woman has had recent radioactive iodine treatment advise her to avoid becoming pregnancy for at least 6 months after the treatment
o Planning a pregnancy – blood test to check thyroid function
o If TFTs are not within the euthyroid range Advise delaying conception + using correct contraception until thyroid function has normalised
o Not planning a pregnancy – contraception during + after treatment (normal fertility can return extremely quickly)
• Advise woman to seek immediate medical advice if pregnancy is suspected or confirmed
• Referral to an endocrinologist specialist
o Check serum TSH, FT4 (free thyroxine levels)
o Consider checking TPOAb status (thyroid peroxidase antibody)
- Offer advice of sources of information and support
- Radioactive iodine is contraindicated in people who are pregnant/trying to become pregnant within the next 4-6 months - obliterates the fetal thyroid, risk of inducing fetal hypothyroidism
Hyperthyroidism in pregnancy - mx once pregnancy is confirmed
• Urgent specialist referral
o Check TSH, FT4, FT3 for all women
o TRAbs
Hyperthyroidism in pregnancy - how do you manage it taking into account the physiological changes that occur during pregnancy?
• Pregnancy increases thyroid hormone requirements
o Women often require lower doses of antithyroid drugs during pregnancy
o 1/3 women are able to stop treatment altogether during pregnancy
o Grave’s disease tends to enter remission as pregnancy proceeds doses can usually be reduced or withdrawn in the 3rd trimester
• Many women with mild hyperthyroidism during pregnancy are not treated
o Mild hyperthyroidism is managed with adequate hydration + low calcium diet
if antithyroid drugs are needed during pregnancy, which drugs are used?
o Propylthiouracil
o Women on carbimazole (CMZ) should change to propylthiouracil (PTU)
PTU may cross the placenta less readily than (CMZ)
CMZ has been associated with teratogenic defects
Thiamazole + carbimazole are associated with more common + severe birth defects than propylthiouracil
If CMZ is the only choice use that – risks of untreated maternal hyperthyroidism outweigh those of potential teratogenicity
o “Block and replace” should not be used in pregnancy
• Medications to continue in labour
Effects of antithyroid drugs on fetus
o Can cross the placenta and affect fetal thyroid function
o Have been associated with birth defects
o Lowest possible dose of antithyroid drugs should be used
SE of antithyroid drugs
o Skin rash 7-12% o Agranulocytosis 0.1-0.5% o Severe liver damage o Fetal hypothyroidism From high doses crossing the placenta – use low doses
Hyperthyroidism in pregnancy - symptomatic tx, preparation for surgery, mx of thyroid storm
o Propranolol
Associated with neonatal hypoglycaemia, apnoea, bradycardia, IUGR
Use should be minimised
Fetal growth should be closely monitored
o Labetalol
o CCB – discouraged as their effects on the fetus are not known
o Uses of BB beyond a few weeks may adversely affect the fetus – not advised
o Beta blockers contraindicated if there is a hx of – asthma, bradycardia, heart block
Pre-conception counselling - hypothyroidism
• Untreated/undertreated hypothyroidism in women longer or heavier periods anaemia or periods may stop completely
• Check TFTs before conception
o If TFTs are not within the euthyroid range Advise delaying conception + using correct contraception until the woman is stabilised on levothyroxine (LT4) treatment
o Experts recommend that if you are on LT4, TSH level should ideally be kept in the lower half of the reference range(<2.5 mU/l) before + during pregnancy risk of miscarriage
- Inform that there is likely to be an increased demand for LT4 during pregnancy
- Her LT4 dose must be adjusted asap in pregnancy to reduce the risk of obstetric + neonatal complications
- Advise woman to seek immediate medical advice if pregnancy is suspected or confirmed
- Offer advice of sources of information and support
Hypothyroidism in pregnancy - mx once pregnancy is confirmed
• Check TFTs immediately once pregnancy is confirmed
o Interpret results using a pregnancy-related reference range
o Discuss urgently with an endocrinologist regarding initiation/changes to dosage of LT4 + TFT monitoring while waiting for specialist review
Hypothyroidism in pregnancy - mx
• Levothyroxine
• It may be necessary to increase the dose of levothyroxine in the first trimester of pregnancy
o By 25-30%
o dose should be increased by approx. 25-50 mcg daily or LT4 dose should be doubled on 2 days of the week even if currently euthyroid To provide sufficient supply of thyroid hormones to the baby
o Repeat TFTs in 4 weeks + perform in each trimester, make adjustments if necessary
• Continue thyroid replacement therapy throughout pregnancy
o Aim for biochemical euthyroid (TSH <4mmol/L)
o TSH + T4 levels are checked every 8 weeks
- Dose adjusted in small increments to normalise TSH
- Long half-life of levothyroxine (1 week) – TSH should be measured 4-6 weeks after initiation of therapy or dosage change
Things that may increase levothyroxine requirements in a hypothyroid pregnant woman
o Nephrotic syndrome
o Malabsorption (e.g. coeliac disease)
o Concomitant use of iron/cholestyramine/calcium/sucralfate/anticonvulsants (e.g. phenytoin, phenobarbital, carbamazepine), rifampin, sertraline
o Gaviscon
o Iron/calcium/Gaviscon – should be taken several hours before or after the LT4 these can alter the absorption of levothyroxine
Post-partum mx of a hypothyroid patient
- For many women following delivery, the LT4 dose should be reduced to pre-pregnancy levels
- TFTs monitoring at 6-8 weeks postnatal check with GP
- Breastfeeding – safe when on LT4
- In the UK, all babies have a heel-prick blood test to screen for hypothyroidism shortly after birth
- Treatment can be started very quickly if baby needs LT3
- Hypothyroidism is rare in newborn babies in the UK
Post-partum mx of a hyperthyroid patient
• TFTs after delivery
o Mother – six weeks, 3 months
o Neonate – 6hours, few days later (neonate will have metabolised any maternal antithyroid drugs by this time)
• Check TSH, FT4 levels 6-8 weeks postpartum (post-natal check), particularly if the woman has any of the following
o Goitre
o Sx of thyroiditis
o Hx of postpartum thyroiditis or positive TPOAbs
o Hx of autoimmune thyroid disease e.g. Graves’ disease
- For many women following delivery, the LT4 dose should be reduced to pre-pregnancy levels
- Serum TSH should be checked after 6 weeks
- Once stable, TSH should be measured at least annually
- For women who have previously had Graves’ disease (but not had thyroid surgery or radioiodine) may relapse at any stage but the risk rises after giving birth + remains high for up to a year
BF in hyperthyroidism
• Breastfeeding
o Antithyroid drugs at low-moderate doses are thought to be safe during breastfeeding
o Usually taken in smaller doses over 2-3x/day following a feed
o If higher doses are required blood test to check whether baby’s thyroid is being affected
o Mothers with Grave’s disease who are not taking antithyroid drugs can safely breastfeed
Post partum thyroiditis mx
• Three stages – thyrotoxicosis hypothyroidism euthyroid
o Refer to an endocrinologist specialist to differentiate between suspected PPT from Grave’s disease
• Check TFTs 4-8 weeks after resolution of the thyrotoxic phase to screen for the hypothyroid phase – or sooner if symptoms develop
o Thyrotoxic phase – propranolol (ant-thyroid drugs are not used)
o Hypothyroid phase – thyroxine
Hypothyroidism phase
o If it persists, may need to take LT4 tablets most women are able to stop taking these tablets after 6-12 months
o Around 1/3 of women develop permanent hypothyroidism need LT4 for the long term
o Symptomatic women who are breastfeeding + those planning another pregnancy treated with LT4
o Untreated asymptomatic women who are not planning a pregnancy reassessment in 4-8 weeks if TSH remains above the reference range consider starting treatment with LT4
o Untreated asymptomatic women check TFTs every 4-8 weeks until thyroid function normalises
Follow up after resolution of PPT
o Annual TFT monitoring for all women with a history of postpartum thyroiditis which has been resolved
o TFTs before next conception to ensure that hypothyroidism hasn’t developed
- 50% risk that you develop a recurrence of PPT in subsequent pregnancies
- Offer advice on source of information and support
Which teratogenic drugs must be stopped during pregnancy in a patient with heart disease?
o ACEi, ARBs, thiazide diuretics, statins, warfarin
Antenatal monitoring of a pregnant patient with cardiac disease
• Arrange contact with joint cardiac + obstetric clinic
o Every 2-4 weeks until 24w gestation + weekly thereafter
• Monitoring
o Maternal echo at booking + repeat at 28 weeks
o Specialist foetal cardiac scan at 22 weeks
• Anticoagulation – LMWH SC
o Patients with congenital heart disease who have pulmonary HTN or artificial valves
o Those at risk of AF
• Vasodilators (hydralazine, nitrates, amlodipine) – to afterload in the presence of ventricular dysfunction
Intrapartum mx of a pregnant patient with cardiac disease
• In most cases – wait for spontaneous labour
o 2nd stage kept short with elective forceps or ventouse delivery - maternal effort + need for an increased CO
o 3rd stage – active management with syntocinon alone
Syntocinon is a vasodilator introduce it slowly
Avoid ergometrine – dangerous (vasoconstriction, hypotension, HF)
• C-section for those where any effort is dangerous
• IOL in very high-risk women to ensure that delivery occurs at a predictable time with all the personnel present
o Epidural – to reduce pain-related cardiac strain
o Risk of maternal hypotension
• Prophylactic abx for all women with structural heart defects
o risk of bacterial endocarditis
• PPH dangerous can lead to cardiovascular instability
Postnatal mx of a pregnant patient with cardiac disease
• Monitoring
o Transfer to HDU for close monitoring for first 12-28h
o Arrange obstetric + cardiac F/U
Summary of the management of a pregnant patient with cardiac disease
- Echocardiogram at booking and at 28 weeks
- Anticoagulation may be necessary
- Avoid IOL if possible
- Use prophylactic antibiotics
- Ensure fluid balance
- Avoid supine position
- Discuss regional/epidural anaesthesia
- Keep the second stage short
- Use syntocinon judiciously
Puerperal cardiomyopathy + myositis/ Peripartum cardiomyopathy mx
o Pulmonary oedema – salt restriction, diuretics
o Vasodilators (hydralazine, nitrates, amlodipine) – to afterload in the presence of ventricular dysfunction
o If at high risk of thromboembolism – anticoagulation
o Post-partum ACEi (not given antenatally fetotoxic)
o Time of delivery should be dictated by obstetric considerations
Obstetric cholestasis monitoring
- LFTs + bile acid levels – weekly until delivery
- Doppler + CTG – twice weekly until delivery
- Women with persistent pruritus + normal biochemistry should have LFTs (+bile acid levels) repeated every 1-2 weeks (until pruritus resolves)
• Postnatal resolution of pruritus + abnormal LFTs should be confirmed
o Postnatally, LFTs should be deferred for at least 10 days
Obstetric cholestasis mx
• Women should be booked in under consultant-led team-based care and give birth in a hospital unit
• Conservative
o Wear cool, loose, cotton clothing
o Soak in a cool bath
o Apply ice packs for short periods in affected areas
o Advise paying close attention to fetal movements
• Ursodeoxycholic acid (UDCA)
o Mainstay of medical management
o Improves pruritus + liver function
o But lack of robust data concerning protection against stillbirth + safety to the fetus or neonate
• Antihistamines (e.g. chlorphenamine)
o Improve sleep
o No impact on pruritus
• Vitamin K
o If prothrombin time is prolonged/ if there is steatorrhoea
o Water soluble vitamin K (menadiol sodium phosphate) in doses of 5-10mg daily
o Avoid vitamin K late in pregnancy + labour – risk of neonatal haemolytic anaemia, hyperbilirubinaemia, kernicterus
Obstetric cholestasis delivery
• Induction at 37+0 weeks
o Aim to deliver no later than 40 weeks
o Perinatal + maternal morbidity increase from 37 weeks of gestation onwards
o Advise to delivery in labour ward, with continuous CTG monitoring
• Offer continuous fetal monitoring in labour
Obstetric cholestasis PN monitoring
- Postnatally, LFTs should be deferred for at least 10 days
* Measure LFTs at the 6-week PN check to ensure resolution
Acute fatty liver of pregnancy mx
• Supportive care stabilisation
o Admit to ITU
o Continuous maternal and fetal monitoring
o Correct coagulopathy, electrolytes, hypoglycaemia
• Consider early delivery
o As soon as maternal condition is stable or
o As soon as possible if maternal condition deteriorating
o Delivery is the definitive management to prevent deterioration
HELLP syndrome mx
• Most effective treatment of HELLP – prompt delivery
o Delivery of fetus after 34 weeks of gestation if multisystem disease is present
o If fetus <34 weeks + delivery can be deferred – give CS to promote fetal lung maturation
- Magnesium sulfate
- Transfusion of RBC, plt, FFP and cryoprecipitate or fibrinogen as indicated clinically by blood and coagulation tests
• Postpartum HELLP syndrome – treated with plasma exchange
- BP control is essential
- If severe liver damage transplantation
- There is no proven treatment or prophylaxis for HELLP syndrome
Anaemia in pregnancy AN mx
• Routine iron replacement in pregnancy is not recommended in the UK
o If given routinely, iron supplementation causes iron overload leading to haemochromatosis, placental insufficiency
o Dietary advice
Iron – green leafy vegetables, nuts, beans, seeds
Folate – green leafy vegetables, nuts, yeast, liver
B12 – meat and dairy
o Oral iron supplements (repletion through diet alone is not possible)
Ferrous iron salts – oral ferrous sulphate
40-80mg every morning
Check Hb at 2-3 weeks to ensure adequate response
Advice – on an empty stomach with water or a source of vitamin C, other multivitamins + antacids or iron-rich food with substances which inhibit its absorption (e.g. tea, coffee, or foods rich in calcium) should not be taken at the same time
SE – black stools, constipation, abdominal pain
Once Hb is in the normal range
• Replacement to continue for 3 months and
• At least 6 weeks post-partum to replenish iron stores
