Week 1 Flashcards
3 Ways to Diagnose a pregnancy?
- Missed menstrual periods
- Urine or Serum beta HCG
- Dating ultrasound scan (USS)
When are pregnancy dating ultrasounds performed and when are they most accurate? Why?
- Dating scans are done in first trimester usually 8-12 weeks, accurate within 3-5 days
- Dating scans are most accurate at 8-12 weeks because fetus is growing rapidly
- Crown rump length is measured, the body does not bend or twist, hence
measurement is accurate - Dating scans at 12-22 weeks are accurate +/- 10 days
- Dating scan determines the EDD/EDC- Expected Date of Delivery/Expected Date of Confinement
What 6 Significant pieces of information does a dating scan provide?
- Viability
- Expected Date of Delivery
- Singleton or Multiple pregnancy
- Timing of screening tests at different stages in pregnancy
- Determining preterm labour or post dated pregnancy
- Understanding the various disorders of pregnancy at different gestational ages
What are the 2 options for First trimester screening for aneuploidies? Which ones get screened? When can they be performed? How sensitive are they? How is the result reported?
First trimester screening for aneuploidies
- There are 2 screening tests for : Trisomy 21, Trisomy 18, Trisomy 13
- 1. 10+ weeks- NIPT- Non-Invasive Prenatal Test using cell free fetal DNA in
maternal blood. Sensitivity 99%
- 2. 11 weeks to 13 weeks and 6 days- First trimester combined test including Nuchal Translucency Scan + Serum Beta HCG and PAPP-A. Sensitivity 90%.(HCG- Human Gonadotrophic Hormone. PAPP-A- Pregnancy Associated Plasma Protein-A)
- Result is reported as : Low risk or High risk
What are the 2 Definitive tests for aneuploidy? When can each be performed? Who receives them?
- There are 2 definitive tests to confirm aneuploidy:
- Frist Trimester: Chorionic villous sampling from 11 to 13
weeks. CVS is offered to- Maternal age 35+ years, Previous chromosomal abnormality, Family history of genetic disorders, High risk result on first trimester screening.- Second Trimester: Amniocentesis- 15-20 weeks.
- Frist Trimester: Chorionic villous sampling from 11 to 13
What 5 clinical screening tests should be performed at each antenatal visit?
- Symphysio fundal height: For fetal growth. SFH- Measured in tape in centimeters from the upper border of symphysis pubis to the fundus of the uterus. Equals gestational age in cm +/- 2 cm
- BP- Hypertensive disorders in pregnancy, mainly pre-eclampsia
- Urine- For protein and glucose
- Fetal movements- sign of fetal well being
- Weight- more relevant at booking for BMI
Outline an Obstetric History Taking Profunda?
Obstetric history - continued
- Gynaecological history including CST
- Surgical history
- Medical History
- Medication history
- Social history
- Smoking/Alcohol/Illicit drug use
- Allergies
Why are pregnant women more susceptible to anaemia?
Anaemia – haemodilution & increased demand of iron for production of placenta etc.
Also bleeding
What is the definition of labour?
3 Factors determining labour?
= A physiological process involving a sequential integrated set of changes within the myometrium, decidua and uterine cervix.
- These changes sometimes occur over a period of days or weeks and sometimes rapidly in hours.
- The term used to describe the process of birth or the physiological course by which a fetus is expelled from the uterus to the outside world.
Describe the anatomy/dimensions of the maternal pelvis - inlet?
- Imaging of pelvis has shown to be poorly predictive of outcome in labour
Describe the anatomy/dimensions of the maternal pelvis - mid cavity?
Describe the anatomy/dimensions of the maternal pelvis - outlet?
Describe the anatomy/dimensions of the fetal skull?
What are the 4 basic female pelvis types?
Define the following terminologies:
1. Presentation
2. Lie
3. Attitude
4. Position
5. Station
6. Abdominal palpation 5ths palpable
What is the lie of the fetus in each of these images?
- Transverse
- Oblique
Outline the 6 different fetal positions?
Describe the passage of the fetal skull through the pelvis during labour?
- It is the rotation of the fetal head during labour that allows it to negotiate the pelvis.
- The fetal head usually engages in the occipito-transverse position & rotates to occipito- anterior as it passes through the pelvis, allowing the shoulders to engage in the pelvic brim in the transverse position.
- Once the head is born, the shoulders rotate into AP position which facilitates their delivery
What are the 2 functions of uterine contractions?
What signals the onset of labour?
What happens to the cervix throughout pregnancy?
2 functions of uterine contractions
1. to dilate the cervix
2. to push the fetus through the birth canal
- The onset of painful regular contractions signals the onset of labour
- The cervix remains firm & non-compliant during pregnancy
- At term, the cervix softens & uterine contractions become more frequent & regular
Which factors are implicated in the onset of labour?
1st Stage of Labour:
- When does it start/finish?
- 2 Components
- Frequency and duration of contractions?
- Progression of cervical dilatation?
- From commencement of contractions causing cervical, effacement and dilatation to 10cm and/or head on vie
- First stage has 2 components:
1. Latent first stage of labour- It is a period of time when there are painful uterine contractions, cervical change with effacement and dilatation up to 4 cm
2. Established or active labour- when there are regular painful contractions and progressive cervical dilatation from 4 cm to full dilatation
What is a Friedman curve?
What is a Partogram?
Partogram = A composite graphical record of key data- both maternal and fetal, during labour entered against time on a single sheet of paper
What is a FIRST STAGE OF LABOUR-CERVICOGRAPH?
- 2 lines drawn?
- 2 Managemen options for slow progress in labour?
- Explain how a partogram is used to identify abnormal progress in labour and the interventions available to address abnormal progress of labour.
- Alert line: A line drawn from the point of cervical dilatation noted at first vaginal examination in active labour
- Action line: A line parallel and 4 hours to the right of alert line
Management of slow progress in labour when alert line crosses action line:
1. Artificial rupture of membranes
2. Augmentation with oxytocinon infusion
What is a Bishops score and how is it calculated?
Score interpretation?
Bishop score is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It has also been used to assess the likelihood of spontaneous preterm delivery. 0-13
- 8+: Your labor is likely to begin soon. If you were to be induced, successful vaginal delivery is likely.
- 6-7: Induction may or may not be successful. It’s a point where your healthcare provider would need to make a judgment call.
- Less than 5: Your body isn’t prepared for labor and it’s unlikely to start naturally.
2nd Stage of Labour:
- When does it start/finish?
- 7 Components?
= Cervical dilatation from 10 cm to birth of the baby
Components:
1. Descent of the presenting part/head
2. Rotation of head to occipito -anterior position
3. Crowning of vertex at vaginal introitus
4. Anal dilatation
5. Perineal bulging
6. Passive 2nd stage- descent of fetal head due to uterine contractions
7. Active 2nd stage-bearing down effort by the mother
3rd Stage of Labour:
- When does it start/finish?
- What is the sign of placental separation?
- What are the 2 signs of placental descent?
- Physiological vs. Active management of delivery of placenta & membranes?
- What can happen if you pull on the cord prior to placental separation?
= Period from birth of the baby to separation and expulsion of the placenta and membranes.
- Sign of placental separation: Fresh bleeding
- Signs of placental descent: Lengthening of the umbilical cord, uterine fundus rises as placenta descents into lower uterine segment
Uterine inversion – if you pull on the cord prior to placental separation
List the 5 UTEROTONIC AGENTS – DRUGS THAT AID UTERINE CONTRACTION? Mode of Delivery?
- Syntocinon (Synthetic oxytocin. IM, IV, and as Infusion)
- Syntometrine (Syntocinon + Ergometrine) IM
- Ergometrine IM and IV
- Misoprostol PR
- Prostagladin F2 Alpha
6 Options for Analgesia in Labour?
- Role of Epidural Analgesia? Risks & Benefits?
- Mobilisation
- Waterbirth
- Opiods
- Inhalation agents- Entonox ( Oxygen 50%+ Nitrous oxide 50%)
- TENS = Transcutaneous Electrical Nerve Stimulation
- Epidural analgesia
List 5 Causes of Tachycardia in a pregnant woman?
Normal range HR fetus?
Causes of Rise in HR in Mother
1. Maternal sepsis
2. Hemorrhage
3. Pain
4. Physical exertion - eg. labour
5. Dehydration
110-180 normal HR for fetus
List 3 Risks of a Rapid labour?
- Fetal hypoxia if contractions are too frequent – wont relax and will cut off blood supply to uterus
- Perineal trauma
- Atonic post-partum haemorrhage
Define: Gravidity, Parity?
Gravidity: the number of times a woman has been pregnant, regardless of pregnancy outcome
- Nulligravidity: no history of pregnancy = Nulligravid
- Primigravidity: history of one pregnancy = Primigravid
- Multigravidity: history of two or more pregnancies = Multigravid
Parity: Nulliparous, Primiparous, Multiparous
What is Fetal Age? How is it calculated?
What is Gestational age?
what is Conceptional age?
- Fetal age: Counted as completed weeks of gestation and completed days (0–6) of the current week of pregnancy. - E.g., 32 6/7: The patient is 32 weeks and 6 days pregnant.
- Gestational age: estimated fetal age (in weeks and days) calculated from the first day of the last menstrual period.
- Conceptional age: the age (in weeks and days) of the fetus calculated from the day of conception (fertilization)
What is a normal duration of pregnancy?
- Late term pregnancy?
- Post-term pregnancy?
When are the 3 trimesters of pregnancy?
- Normal duration of pregnancy: 40 weeks (280 days)
- From conception: 38 weeks (266 days)
- Late-term pregnancy: a pregnancy between 41 0/7 and 41 6/7 weeks’ gestation
- Post-term pregnancy: a pregnancy that extends beyond ≥ 42 0/7 weeks’ gestation or the estimated date of delivery plus 14 days
- What is a Periviable birth?
- Preterm birth?
- Postterm birth?
Gestional age at birth
- Periviable birth: live birth occurring between 20–25 weeks’ gestation
- Preterm birth: live birth before the completion of 37 weeks of gestation (< 37 0/7 weeks’ gestation)
- Postterm birth: live birth after the completion of 42 weeks of gestation (≥ 42 0/7 weeks’ gestation)
Describe the signs and symptoms of pregnancy.
- 10 Presumptive signs?
- Physical signs? (table)
Presumptive signs
1. Amenorrhea
2. Nausea and vomiting
3. Breast enlargement and tenderness
4. Linea nigra: darkening of the midline skin of the abdomen
5. Hyperpigmentation of the areola
6. Abdominal bloating and constipation
7. Increased weight gain
8. Cravings for or aversions to certain foods
9. Increased urinary frequency
10. Fatigue
Human chorionic gonadotropin (hCG)
- Site of production?
- Function?
- Pregnancy Tests - Urine? Serum? Sensitivity? Timing?
- When does it peak? When does it reach a steady state?
Human chorionic gonadotropin (hCG)
- Site of production: placental syncytiotrophoblast
- Function: Maintenance of the corpus luteum during the first 8–10 weeks of pregnancy (LH has a similar function) & Luteal-placental shift: levels decrease after corpus luteum involution (placenta starts synthesizing its own estriol and progesterone)
- Urine β-hCG test (e.g., home pregnancy test): Qualitative test (less sensitive than serum pregnancy test). β-hCG can be detected in urine 14 days after fertilization
- Serum β-hCG test: Quantitative test (high sensitivity). Detectable 6–9 days (on average) after fertilization
Describe the 11 different models of antenatal care.
Based on risk factors and womans choice
Shared care between GP, Midwife and specialist
Specialist obstetric hospital care
Public/Private hospital
Ultrasound findings in normal pregnancy (abdominal or transvaginal)
- At 5 weeks?
- At 5–6 weeks?
- At 6–7 weeks?
- At 10–12 weeks?
- At 18–20 weeks?
What are 3 methods for determining Gestational age and estimated date of delivery?
Describe 9 physiological changes to the CARDIOVASCULAR SYSTEM that occur during pregnancy.
- Why might you hear an innocent systolic murmur?
- Why might the apex beat be displaced?
- Why might the woman get varicosities?
- Innocent systolic murmur - Due to a hyperdynamic state.
- Displaced apex beat - Due to the expanding uterus.
- Varicosities - The uterus presses against the pelvic veins and vena cava, impairing venous return and subsequently increasing the risk of DVT.
Describe the physiological changes to the RESPIRATORY SYSTEM that occur during pregnancy.
Describe 6 physiological changes to the RENAL SYSTEM that occur during pregnancy.
Describe 6 physiological changes to the ENDOCRINE SYSTEM that occur during pregnancy.
Describe 8 physiological changes to the HAEMATOLOGIC SYSTEM that occur during pregnancy.
Describe the physiological changes that occur during pregnancy.
- 5 Skin?
- 3 Reproductive?
- 6 GIT?
- 4 MSK?
Skin
1. Spider angioma
2. Palmar erythema
3. Striae gravidarum: scarring that manifests as erythematous, violaceous, and/or hypopigmented linear striations on the abdomen
4. Hyperpigmentation: chloasma, linea nigra, hyperpigmentation of the nipples
5. Linea nigra and polymorphic eruption of pregnancy
Reproductive system
1. Uterus: increase in size
2. Vulva and vagina: Vaginal discharge
3. Mammary glands: increase in size; breast fullness and tenderness
List 7 Differential diagnoses for Antepartum haemorrhage?
- Placental abruption
- Placenta previa
- Vasa previa
- Uterine rupture
- Still Birth
- Bloody Show
- Cervical trauma
Describe the overall management of Antepartum haemorrhage?
Antepartum Haemorrhage: Placental Abruption
- Definition?
- Epidemiology?
- 7 Predisposing factors?
Definition: The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.
Epidemiology:
- Incidence: ∼ 0.7–1.2% of pregnancies.
- Occurs most often in the third trimester.
- The recurrence rate in subsequent pregnancies is 4–15%.
Antepartum Haemorrhage: Placental Abruption - Clinical Features
- 6 Maternal symptoms?
- 2 Fetal symptoms?
Antepartum Haemorrhage: Placental Abruption
- 3 Types of hemorrhage in placental abruption?
Types of hemorrhage in placental abruption
The type of hemorrhage depends on the location of the abruption.
1. Concealed hemorrhage occurs if the placenta separates from the uterine wall in the middle, but is still attached at the margins. This results in a concealed, retroplacental hemorrhage into the artificial space created between the placenta and the uterus.
2. Revealed hemorrhage occurs if the placenta separates at the margins, leading to vaginal bleeding.
3. Mixed hemorrhage: combination of retroplacental hematoma and revealed vaginal hemorrhage
Antepartum Haemorrhage: Placental Abruption
- Diagnostics? (3)
- Complications? (3)
Placental Abruption - Diagnosis
1. Ultrasound: Low (25%) sensitivity for placental abruption. Placental position and fetal biophysical profile should be assessed. Retroplacental hematoma may be visible.
2. Fetal heart rate tracing:
3. Laboratory studies: CBC, Coagulation studies
Antepartum Haemorrhage: Placental Abruption - Management
- Haemodynamically unstable?
- Haemodynamically stable at less than 34 weeks?
- Haemodynamically stable at 34-36 weeks?
- Haemodynamically stable at less than 36+ weeks?
Antepartum Haemorrhage: Placenta Previa
- Definition?
- Epidemiology?
- 3 Risk Factors?
- Classification?
Placenta Previa
- Definition: Presence of the placenta in the lower uterine segment, which can lead to partial or full obstruction of the internal os; high risk of hemorrhage (rupture of placental vessels) and birth complications
- Epidemiology: ∼ 0.5% of all pregnancies
- Risk Factors:
1. Maternal age > 35 years, multiparity, short intervals between pregnancies
2. Previous curettage or cesarean delivery
3. Previous placenta previa, previous/recurrent abortions
Antepartum Haemorrhage: Placenta Previa
- Diagnostics?
- 5 Clinical Features?
- How does it present differently to Placental abruption?
Placenta Previa - Diagnostics
- Routine prenatal care: transvaginal or transabdominal ultrasound to assess placental position.
- In patients with antepartum hemorrhage, avoid digital vaginal examination unless placenta previa has been ruled out on transvaginal ultrasound.
Antepartum Haemorrhage: Placenta Previa - Management
- Placenta previa detected on routine ultrasound during pregnancy?
- Placenta previa presenting as antepartum hemorrhage?
- Route of delivery?
Vaginal delivery should never be attempted outside of the operating room in a patient with low-lying placenta.
Antepartum Haemorrhage: Vasa Previa
- Definition?
- Epidemiology?
- Diagnostics?
- Treatment?
- 3 Clinical features?
- Aetiology?
Vasa Previa = Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture.
- 1/2500 births
- Diagnostics: Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels.
- Treatment: Emergency cesarean delivery if there are signs of fetal distress.
Clinical features
1. Painless vaginal bleeding (fetal blood) that occurs suddenly after rupture of membranes
2. Fetal distress (e.g., fetal bradycardia; decelerations or sinusoidal pattern on fetal heart tracings)
3. Fetal death can occur quickly through exsanguination or asphyxiation if fetal vessels are compressed during labor.
A routine ultrasound done at 18 weeks gestation shows a placenta which reaches the internal cervical os. What would your management be?
When a routine ultrasound at 18 weeks gestation shows a placenta that reaches the internal cervical os, it is referred to as “placenta previa.” Placenta previa is a condition where the placenta partially or completely covers the cervix, the opening of the uterus. This can be a concerning finding as it can lead to complications during pregnancy and childbirth. The management of placenta previa will depend on various factors, including the degree of placental coverage, the woman’s medical history, and the presence of any symptoms or complications.
What is the definition of:
- Preterm labor?
- Preterm birth?
Epidemiology of Preterm labour/birth?
Preterm labor: regular uterine contractions with cervical effacement, dilation, or both before 37 weeks’ gestation.
Preterm birth
- Live birth between 20 0/7 weeks’ and 36 6/7 weeks’ gestation
- WHO subcategories:
- Extremely preterm (< 28 weeks)
- Very preterm (28 to < 32 weeks)
- Moderate to late preterm (32 to < 37 weeks)
List 8 Non-Modifiable risk factors for Preterm birth?
List 9 Modifiable risk factors for Preterm birth?
Nonmodifiable risk factors
1. History of preterm birth (greatest risk factor)
2. Cervical insufficiency
3. Multiple gestations
4. Polyhydramnios
5. Preterm premature rupture of membranes (PPROM)
6. Antepartum hemorrhage caused by: Placenta previa, Placental abruption
7. Uterine anomalies (e.g., anomalies of Mullerian duct fusion, uterine fibroids)
8. Congenital abnormalities of the fetus
4 Clinical Features of Pre-term labour?
- Regular uterine contractions and associated symptoms of labor (e.g., lower back pain)
- Loss of mucus plug (bloody show)
- Cervical effacement and/or cervical dilation
- Rupture of membranes
Preterm Labour - Diagnostics? (4)
- What is Fetal fibronectin?
Fetal fibronectin is a protein that attaches the fetal amniotic sac to the uterus.
You are a country doctor. An 18 year old G1P0 presents at 28 weeks gestation with painful contractions each 6 minutes. What would your management be?
Describe an approach to the management of preterm labour.
Preterm Labour - Tocolysis
- Definition?
- Goal?
- Duration?
- 7 Contraindications?
- 4 Medications? Maternal & Fetal adverse effects?
- Definition: administration of tocolytics to inhibit uterine contractions.
- Goal: prolonging pregnancy to allow for induction of fetal lung maturity and/or transfer to another medical center, if necessary.
- Duration: up to 48 hours
-
Contraindications
1. Maternal-specific drug contraindications
2. Nonreassuring fetal cardiotocography
3. Intrauterine fetal demise
4. Chorioamnionitis
5. Antepartum hemorrhage with hemodynamic instability
6. Severe preeclampsia or eclampsia
7. Lethal fetal anomaly
Outline the management of preterm birth in terms of:
- Fetal neuroprotection?
- Antibiotics?
- Induction of fetal lung maturity?
Fetal neuroprotection
- Definition: administration of antenatal magnesium sulfate to reduce the risk and severity of neurological disorders (e.g., cerebral palsy).
- Indication: preterm labor at < 32 weeks’ gestation.
Antibiotics - Indicated for:
1. GBS prophylaxis
2. Treament of PPROM
Post-term Pregnancy
- Definition?
- 7 Risk Factors - 5 maternal & 2 fetal?
Postterm pregnancy: a pregnancy ≥ 42 0/7 weeks’ gestation.
Post-term Pregnancy - Management
- Definition?
- 7 Risk Factors - 5 maternal & 2 fetal?
Late-term pregnancy
- Begin by confirming whether the gestational age and estimated date of delivery for the pregnancy was accurately calculated.
- First-trimester prenatal ultrasound is preferred over other methods of determining gestational age and estimated date of delivery.
Postterm pregnancy
- Perform induction of labor by 42 0/6 weeks’ gestation.
- Induction unsuccessful: Perform C-section.
- After 42 weeks’ gestation, induction is recommended regardless of cervical favorability in order to avoid complications of postterm pregnancy.
List 5 Maternal complications of Post-term births and 10 Infant complications of post-term births?
Post-term Maternal complications - Associated with increased birth weight and fetal macrosomia:
1. Prolonged stages of labor
2. Obstructed labor
3. Perineal lacerations
4. Postpartum hemorrhage
5. Infections: e.g., chorioamnionitis or endometritis
Prevention of Post-term birth - Membrane Sweeping
- Definition?
- Timing?
- 2 Goals?
- 3 Risks?
What are the 6 Types of pregnancy loss?
- Threatened abortion
- Inevitable abortion
- Missed abortion
- Incomplete abortion
- Complete abortion
- Stillbirth
The terminology used may differ based on the context: e.g., “miscarriage” may be used when communicating with the patient because of the potentially negative connotations of abortion.
Expectant management - A management strategy that involves serial clinical monitoring (i.e., intermittent screening for symptoms of disease).
- Symptoms will resolve or will progress to inevitable, incomplete, or complete abortion.
3 Clinical Features of Spontaneous Abortion (Miscarriage?
Aetiology?
- 5 Maternal?
- 3 Fetoplacental?
- 4 Miscellaneous?
Clinical Features
1. Vaginal bleeding
2. Abdominal pain or cramping
3. Loss of pregnancy symptoms (e.g., breast tenderness, nausea)
Spontaneous abortion (Miscarriage)
- Clinical evaluation? (2)
- Lab studies? (1)
- Ultrasound?
Clinical evaluation
1. Bimanual pelvic exam
2. Speculum exam - Assess for cervical dilatation and retained POC. & Confirm that the source of bleeding is uterine.
Laboratory studies
1. Serial serum β-hCG: Downtrending levels suggest a failed pregnancy.
Spontaneous abortion (Miscarriage) - Management
- Approach - Stable patients?
- Approach - All patients?
Spontaneous abortion (Miscarriage) - Management
- Threatened abortion?
- Inevitable abortion, incomplete abortion, or missed abortion?
Threatened abortion
- Expectant management: Symptoms will resolve or progress to inevitable, incomplete, or complete abortion.
- Advise the patient to avoid strenuous physical activity.
- Repeat pelvic ultrasound in one week.
Septic Abortion
- Defintion?
- Aetiology?
- 5 Clinical features?
- Management?
Septic Abortion
- Definition: an infection of the placenta and fetus before 20 weeks’ gestation which is inevitably associated with fetal death.
- Etiology: Complication of missed, inevitable, or incomplete abortion, Vaginal and/or uterine instrumentation.
Stillbirth
- Definition?
- 2 Clinical features?
- 2 Complications?
- 5 Diagnostics?
Stillbirth = Fetal death after 20 weeks’ gestation (also called “intrauterine fetal demise”)
Clinical features
1. Absence of fetal movements and cardiac activity
2. Delivery of a fetus with no signs of life
Complications
1. Retained products of conception
2. Endometritis
Stillbirth - Aetiology
- 6 Maternal?
- 7 Fetoplacental?
- 2 Miscellaneous?
Stillbirth - Management
- Timing of delivery?
- Method of delivery?
- Supportive measures?
Define:
- Ectopic pregnancy?
- Tubal pregnancy?
- Interstitial pregnancy?
- Complicated ectopic pregnancy?
- Uncomplicated ectopic pregnancy?
- Heterotopic pregnancy?
5 Localizations of Ectopic pregnancies in order of frequency?
- Fallopian tube (∼ 95% of cases): Ampulla (∼ 70%), Isthmus (∼ 15%), Fimbriae (∼ 8%)
- Interstitial/cornual pregnancy (∼ 2%): implantation of gestational sac in the cornua of a bicornuate or septate uterus
- Ovary (∼ 3% )
- Abdomen (∼ 1%)
- Cervix (< 1%)
Risk factors for ectopic pregnancy
- 8 Anatomic alteration of the fallopian tubes?
- 6 Non-anatomical risk factors?
Clinical Features of Ectopic Pregnancy
- 8 General symptoms?
- Tubal rupture?
A woman presents to emergency department at 7 weeks amenorrhoea. She has severe lower abdominal pain and has fainted a couple of times. Her BP in 90/70mmHg and pulse is 110/min. How will you assess, diagnose and manage?
Outline an approach to the management of suspected Ectopic pregnancy.
- Hemodynamically unstable vs stable patients?
- Every woman of reproductive age with abdominal pain should undergo a pregnancy test, regardless of contraception use.
- Up to 20% of patients with ectopic pregnancy can be hemodynamically unstable and require immediate therapy. Do not delay stabilization and definitive treatment to confirm the diagnosis!
What are 5 Lab tests you would order for a patient presenting with suspected Ectopic pregnancy?
- FBC: Anemia may be seen in patients with vaginal bleeding.
- Blood type and screen: ABO and Rh testing to identify patients who might need Rho immunization
- LFTs
- U&Es: to determine baseline liver and renal function
Describe the role of Ultrasound in the diagnosis of Ectopic Pregnancy.
- 2 Types?
- Indication?
- Supportive findings?
Transabdominal ultrasound (TAUS)
- Can be used to exclude differential diagnoses (e.g., acute appendicitis)
- Provides a general picture of the pelvic anatomy and upper abdomen but is less sensitive than TVUS in detecting extrauterine pregnancy
- POCUS can be performed using the transabdominal approach to rapidly rule in IUP if present.
When is an Exploratory laparoscopy indicated in Ectopic pregnancy? (2)
When is an Endometrial biopsy indicated in Ectopic pregnancy? (1) & What are the findings? (2)
Exploratory laparoscopy - Indications
1. Unstable patients suspected of having an ectopic pregnancy
2. In pregnancy of unknown location if the location is still uncertain after 7–10 days
Do not delay laparoscopy in unstable patients with suspected ectopic pregnancy!
Give a list of 7 differential diagnoses of lower abdominal pain in women of reproductive age?
- Ectopic pregnancy
- PID
- Appendicitis
- Kidney stones
- Ovarian cyst rupture
- Ovarian torsion
- Pelvic cellulitis
Describe an approach to the management of Ectopic pregnancy?
- Supportive care?
Approach to Ectopic Pregnancy
Unstable patients:
- Begin acute stabilization.
- Obtain an immediate OB/GYN consult for emergency surgery.
Stable patients: Determine whether medical, surgical, or expectant management is appropriate.
- Consider clinical, laboratory, and radiological findings.
- Share decision-making with patients in consultation with OB/GYN.
All patients: Provide adequate supportive care.
What is the medical management of ectopic pregnancy?
- MOA of the drug?
- 6 Indications for the drug?
- 7 Complete contraindications?
Methotrexate
Mechanism of action: inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.
Indications
1. Uncomplicated ectopic pregnancies
2. Hemodynamically stable patients
3. Unruptured mass
4. β-hCG ≤ 2,000–5,000 mlU/mL
5. Mass size < 3.5 cm
6. No fetal heartbeat
Describe the non-urgent surgical management of ectopic pregnancy?
- 4 Indications?
- Approach?
- Procedure?
What is meant by Expectant management of Ectopic Pregnancy?
- 3 Indications?
- Considerations during expectant management?
- 2 Causes for Conversion to medical or surgical therapy?
Asymptomatic patients with very low β-hCG levels may experience spontaneous resolution of ectopic pregnancy without medical or surgical treatment. Consider this approach in select patients after consultation with OB/GYN.
5 Clinical signs/sxs of Ectopic pregnancy that suggest it may be ruptured?
- Acute stabilisation? (3)
- Indications for emergency surgery? (4)
- Approach to emergency surgery?
- Procedure?
Suspect ruptured ectopic pregnancy in patients in their first trimester with any of the following:
1. Clinical features of shock: e.g., tachycardia, hypotension, pallor
2. Severe abdominal or pelvic pain
3. Peritoneal signs on examination
4. Significant vaginal bleeding
5. Clinical deterioration after receiving MTX therapy
Acute stabilization
1. Start immediate IV fluid resuscitation.
2. Rapidly deliver blood transfusion as soon as blood products are available.
3. If hypotension persists, start vasopressors.
A pregnant woman has some painless vaginal bleeding at 10 weeks. On bi-manual examination the uterus is 10 weeks size and non-tender, the cervix is closed and fetal heart rate is present. How would you manage her? What would you tell her about the possible outcome?
Vaginal bleeding, Closed cervix & fetal heart rate present = the woman has either had a threatened abortion.
What options are available to a woman with an unwanted pregnancy of 10 weeks gestation? How would you facilitate a choice? What follow up is required?
After 9 weeks = surgical abortion.
Abortions can be performed at up to week 20 of pregnancy in WA. Abortion after 20 weeks is very restricted.
Define: Post Partum Haemorrhage
- Primary?
- Secondary?
- Epidemiology?
PPH: Blood loss ≥ 1000 mL or blood loss manifesting with features of hypovolemia within 24 hours of delivery.
Primary PPH: blood loss ≤ 24 hours postpartum (more common)
Secondary PPH: blood loss from 24 hours to 12 weeks postpartum
List 5 Causes of Primary PPH & 4 Causes of Secondary PPH?
Primary PPH
1. Uterine atony
2. Uterine inversion
3. Abnormal placental separation - Retained placenta or Abnormal placentation
4. Birth trauma
5. Velamentous cord insertion
Secondary PPH
1. Retained products of conception
2. Subinvolution of the placental site
3. Coagulation disorder - Acquired or Inherited
4. Postpartum endometritis
Primary PPH - Uterine atony
- Definition?
- Epidemiology?
- Pathophysiology?
Primary PPH - Uterine Atony
- Definition: Failure of the uterus to effectively contract after complete or incomplete delivery of the placenta, which can lead to severe postpartum bleeding from the myometrial vessels.
- Epidemiology: Most common cause of PPH cases (approx. 80%)
- Pathophysiology: Normally, the myometrium contracts and compresses the spiral arteries, which stops bleeding after delivery. Failure of the myometrium to effectively contract can lead to rapid and severe hemorrhage.
Primary PPH - Uterine atony
- 2 Clinical features?
- 2 Diagnostics?
- 3 Complications?
- Risk factors? (AEIOU)
Primary PPH - Uterine Atony
Clinical features
1. Profuse vaginal bleeding
2. Soft, enlarged (increased fundal height), boggy ascending uterus
Diagnosis
1. Bimanual pelvic exam after emptying the bladder.
2. Speculum examination of the vagina and cervix to evaluate possible sources of extrauterine bleeding (e.g., vaginal injury caused during birth)
Complications
1. Anemia
2. Hypovolemic shock
3. Sheehan syndrome
Outline the treatment for Primary PPH caused by Uterine Atony.
- Haemorrhage control - Uterotonic agents?
- Surgical procedures?
Primary PPH - Uterine Inversion
- Definition?
- Epidemiology?
- Pathophysiology?
Primary PPH - Uterine Inversion
- Definition: An obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus, usually following vaginal delivery.
- Epidemiology: Uncommon complication of vaginal birth, Morbidity and mortality may occur in ∼ 41% of cases
- Pathophysiology: Partial uterine wall relaxation → prolapse of the uterine wall through the cervical orifice, and if simultaneous downward traction of the uterus is performed → inversion of the uterus
Primary PPH - Uterine Inversion
- Classification by degree of inversion? (2)
- Classification by time of onset? (2)
- Classification by time of aetiology? (2)
Degree of inversion
1. Partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix
2. Complete uterine inversion: uterine fundus collapses into the endometrial cavity and descends through the cervix, but remains within the vaginal introitus
3. Uterine prolapse: uterine fundus descends through the vaginal introitus
Primary PPH - Uterine inversion
- Diagnosis?
- 11 Risk Factors?
- Clinical features - 5 acute & 5 chronic?
- Uncontrolled cord traction and/or excessive fundal pressure (Credé maneuver) during the third stage of labour
- Fetal macrosomia
- Previous uterine inversion
- Use of uterine muscle relaxants during the antepartum period (e.g., MgSO4)
- Difficult removal of the placenta
- Nulliparity
- Uterine anomalies (e.g., relaxed lower uterine segment and cervix)
- Uterine leiomyoma
- Placenta accreta
- Retained placental tissue.
- Prolonged delivery
Primary PPH - Uterine inversion
- Treatment?
- 3 Complications?
Complications of Uterine Inversion
1. Hypovolemic shock
2. Neurogenic shock
3. Maternal death
Primary PPH - Abnormal Placental separation: Retained placenta
- Definition?
- Epidemiology?
- Aetiology? (3)
Primary PPH: Retained placenta
- Definition: Retention of the placental tissue inside the uterine cavity following the first 30 min postpartum.
- Epidemiology: Approx. 3% of vaginal deliveries
- Etiology:
1. Atonic uterus:
2. Placenta accreta spectrum
3. Premature closure of the cervix obstructing placental expulsion
Primary PPH - Abnormal Placental separation: Retained placenta
- Classification? (2)
- Clinical Features? (3)
- Diagnosis? (2)
- Risk Factors? (8)
Primary PPH - Retained placenta
Classification
1. Adherent placenta: a placenta that is not detached because of insufficient uterine contractions (e.g., uterine atony)
2. Trapped placenta: a detached placenta that cannot be delivered spontaneously or with light cord traction because of cervical closure
Clinical Features:
1. Main feature: severe bleeding before placental delivery
2. Physical examination: Inability to completely separate the placenta during the third stage of labor
3. Speculum inspection: visualization of placental fragments or fetal membranes within the uterus
Diagnosis:
1. Postpartum manual palpation and speculum inspection of the placenta and fetal membranes
2. Ultrasound: showing a focal endometrial mass
Primary PPH - Abnormal Placental separation: Retained placenta
- Treatment?
List & Explain 5 Examinations/Investigations for Post Partum Haemorrhage?
9 Complications of PPH?
Complications of PPH
1. Anemia
2. Hypovolemic shock
3. Thromboembolism
4. Sheehan syndrome
5. Infection
6. Maternal death
7. Disseminated intravascular coagulation
8. Fetal death (due to velamentous cord insertion)
9. Abdominal compartment syndrome
Primary PPH - Abnormal Placental separation: Abnormal placentation
- Definition?
- Epidemiology?
- 2 Pathophysiology theories?
Primary PPH - Abnormal placentation
- Definition: Defective decidual layer of the placenta leading to abnormal attachment and separation during postpartum period
- Epidemiology: Placental detachment abnormalities due to anatomical causes occur in up to 1% of all pregnancies.
- Pathophysiology: The exact pathogenesis is unknown
- Two main theories include
1. Defective decidua: complete or partial lack of decidua in an area of previous scarring within the endometrial-myometrial interface
2. Excessive trophoblastic invasion: abnormal growth → uncontrolled invasion of villi through the myometrium, including its vascular system
Primary PPH - Abnormal Placental separation: Abnormal placentation
- 3 Classifications?
The types of abnormal placental attachment: Placenta Accreta “Attaches” to the myometrium, placenta Increta “Invades” the myometrium, and placenta Percreta “Perforates” the myometrium.
Primary PPH - Abnormal Placental separation: Abnormal placentation
- 7 Risk Factors?
Risk factors - Any prior damage to the endometrium
1. History of uterine surgery (e.g., endometrial ablation, hysteroscopic removal of intrauterine adhesions, dilatation, curettage)
2. Prior births by cesarean delivery
3. Placenta previa
4. Multiparity
5. Advanced maternal age
6. Assisted reproduction procedures
7. Asherman syndrome
Primary PPH - Abnormal Placental separation: Abnormal placentation
- 4 Clinical features?
- Prognosis?
- Treatment?
Clinical features of Abnormal placentation
1. Abnormal uterine bleeding
2. Postpartum hemorrhage at the time of attempted manual separation of the placenta
3. Fever
4. Rarely, hematuria in placenta percreta
Prognosis
- Morbidity is approx. 27%
- Placenta percreta has the highest complication rate.
Primary PPH - Birth Trauma
- 3 Complications?
- Definition of Puerperal hematoma? 3 Types?
Birth trauma can result in bleeding lacerations, puerperal hematomas, and/or uterine rupture.
**Puerperal hematoma **= an accumulation of blood in the vulva, vagina, or retroperitoneum, most commonly caused by iatrogenic injury during childbirth. Subtypes include:
1. Vulvar hematoma: accumulation of blood in the vulvar soft tissue
2. Vaginal hematoma: accumulation of blood in the vaginal soft tissue
3. Retroperitoneal hematoma: accumulation of blood in the retroperitoneal space
Primary PPH - Birth Trauma: Puerperal hematoma
- Epidemiology?
- Aetiology?
- 8 Clinical features?
- Treatment?
Primary PPH - Puerperal hematoma
Epidemiology
- Second most common cause (20% of individuals with postpartum hemorrhage)
- Estimated incidence of puerperal hematoma ranges from 1:300 to 1:1500 deliveries.
Clinical features
1. Features of hematoma or bleeding laceration of the female genital tract
2. Severe pain in the labia, pelvis and/or perineum ≤ 24 hours after delivery
3. Severe bleeding, hypovolemic shock
4. Vaginal hematoma: protruding, tender, palpable vaginal mass
5. Features of retroperitoneal hematoma
6. Pelvic pain
7. Signs and symptoms of hypovolemia (e.g., tachycardia, hypotension, diaphoresis, pale skin, dizziness)
8. Features of uterine rupture
Primary PPH - Velamentous Cord Insertion
- Definition?
- Epidemiology?
- 5 Risk factors?
- Pathogenesis - 2 theories?
- 3 Clinical features?
Primary PPH - Velamentous Cord Insertion
Definition: Abnormal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by thin fetal membranes, in the absence of protective Wharton jelly.
Epidemiology:
- Occurs in 1% of single pregnancies
- Up to 15% in twin pregnancies
- Associated with increased risk of hemorrhage during the third stage of labor
Risk factors
1. Placenta previa
2. Low-lying placenta
3. Multiple pregnancies
4. Assisted reproduction procedures (e.g., in vitro fertilization)
5. Succenturiate placenta
Primary PPH - Velamentous Cord Insertion
- Diagnosis?
- Management?
- 5 Complications?
Complications of Velamentous Cord Insertion
1. Vasa previa
2. Fetal death
3. Premature infant
4. Fetal growth restriction
5. Fetal malformation
Secondary PPH - Subinvolution of the placental site
- Definition?
- Epidemiology?
- 6 Risk Factors?
Secondary PPH - Subinvolution of the placental site
- Definition: A condition in which the uterus remains abnormally large following delivery because of the persistence of dilated uteroplacental vessels
- Epidemiology: Occurs most commonly in the second week postpartum. Second most common cause of secondary postpartum hemorrhage (13% of affected individuals).
- Risk factors
1. Multiparity
2. Cesarean delivery
3. Uterine atony
4. Endometritis
5. Coagulopathy
6. Retained products of conception
Secondary PPH - Subinvolution of the placental site
- 4 Clinical features?
- Diagnostics?
- Treatment?
Secondary PPH - Subinvolution of the placental site
Clinical features
1. Abnormal, severe uterine bleeding, most commonly during second week postpartum
2. Fever, chills
3. Lower abdominal pain
4. Signs of hypovolemia
Outline the steps in an Obstetric Examination?
List 6 Reasons why a Fetus might be small for its Gestational Age?
SMALL FOR GESTATIONAL AGE
1. Wrong dates
2. Fetal growth restriction
3. Oligohydramnios
4. Preterm rupture of membranes
5. Fetal death in utero
6. Transverse lie
Name the different types of fetal lie
Outline the types of abnormal presentation
Miscarriage
- Epidemiology?
- 3 Signs & Symptoms?
- 6 Known Causes?
Miscarriage
* Bleeding in first trimester
* Bleeding in first trimester affects 20-30% of pregnancies.
* Approximately 50% of those who bleed may miscarry.
* 10-15% of clinically recognised pregnancies will miscarry.
Symptoms and Signs
1. Vaginal bleeding: Spotting or Heavy bleeding with clots.
2. Pain and cramping in lower abdomen.
3. Haemodynamic compromise: Weakness, dizziness, collapse, vasovagal attacks- mainly in incomplete miscarriage
Classification of Miscarriage
- Threatened miscarriage?
- Inevitable miscarriage?
- Incomplete miscarriage?
- Complete miscarriage?
- Anembryonic pregnancy ( Blighted ovum)?
- Missed miscarriage?
- Pregnancy of Unknown Location (PUL)?
Classification of miscarriages
* Anembryonic pregnancy ( Blighted ovum): Empty gestation sac with mean diameter >25mm, there is no fetal pole
* Missed miscarriage: Fetal pole >7mm with no cardiac activity. Usually diagnosed at routine scan for dating. No bleeding or pain. Miscarriage is called missed because the woman has no pain or bleeding
* Pregnancy of Unknown Location (PUL): Empty uterus on scan. Needs serial hCG to confirm whether complete miscarriage, pregnancy too early to visualize or ectopic pregnancy
Describe an approach to Early pregnancy bleeding
- Exam?
- 5 Ixs?
- Management?
Investigations
1. FBC
2. Group and Hold if heavy bleeding
3. Rhesus status for all pregnancy related bleeding
4. Serum Beta hCG especially if Pregnancy of Unknown Location
5. Pelvic Ultrasound scan: Transabdominal and Transvaginal ultrasound scan to confirm pregnancy, site of pregnancy, gestational age, viability, multiple gestation
List 9 Risk Factors for Ectopic pregnancy?
- Clinical presentation? (7)
Risk factors for ectopic pregnancy
2. Previous ectopic pregnancy
2. Previous tubal surgery
3. History of pelvic inflammatory disease- chlamydia/gonorrhoea
4. History of subfertility
5. Advancing maternal age
6. History of smoking
7. Assisted conception- IVF, ICSI
8. Intrauterine contraceptive device in situ
9. Emergency contraception use
Ectopic Pregnancy
- 5 Clinical signs?
- 5 Investigations?
- Management - Unruptured vs. Ruptured?
Investigations
1. Urinary hCG
2. Serum quantitative hCG- important to decide method of treatment and confirm successful resolution of trophoblastic tissue ( especially after medical management or in spontaneous resolution)
3. FBC
4. Group and Hold and Crossmatch if blood transfusion is necessary and for Blood group and Rhesus status
5. Pelvic ultrasound scan: A combination of lower abdominal and transvaginal scan
Do not send a patient in shock for a formal ultrasound scan. FAST (Focussed Abdominal Scan in Trauma) scan may be performed in ED to confirm haemoperitoneum!!
