Week 12- OBG Flashcards
Pregnancy-related pelvic girdle pain (PGP) or symphysis pubis dysfunction (SPD)
PGP is a collection of uncomfortable symptoms caused by a stiffness of your pelvic joints or the joints moving unevenly at either the back or front of your pelvis.
Women with PGP may feel pain:
over the pubic bone at the front in the centre, roughly level with your hips
across 1 or both sides of your lower back
in the area between your vagina and anus (perineum)
spreading to your thighs
Some women may feel or hear a clicking or grinding in the pelvic area.
The pain can be worse when:
walking
going up or down stairs
standing on 1 leg (for example, when you’re getting dressed)
turning over in bed
moving your legs apart (for example, when you get out of a car)
Most women with PGP can have a vaginal birth.
Molar Pregnancy
Molar pregnancy is an abnormality of the placenta, caused by a problem when the egg and sperm join together at fertilization.
There are two types of molar pregnancy, complete and partial. Complete molar pregnancies have only placental parts (there is no baby), and form when the sperm fertilizes an empty egg. Because the egg is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, called HCG, so the patient thinks she is pregnant. Unfortunately, an ultrasound (sometimes called a sonogram) will show that there is no baby, only placenta. A partial mole occurs when 2 sperm fertilize an egg. Instead of forming twins, something goes wrong, leading to a pregnancy with an abnormal foetus and an abnormal placenta. The baby has too many chromosomes and almost always dies in the uterus.
Most molar pregnancies occur after a miscarriage, some occur after an ectopic (tubal) pregnancy or even a normal delivery.
Women with a molar pregnancy usually feel pregnant and complain of vaginal spotting or bleeding. Many women with molar pregnancies develop nausea and vomiting. Some even develop rare complications like thyroid disease or very early preeclampsia (toxemia). Preeclampsia occurring earlier than 20 weeks is very worrisome for a molar pregnancy.
Treatment for molar pregnancy
Treatment consists of a D&C (dilation and curettage) of the uterus, where a small vacuum device is inserted into the uterus, under anaesthesia, to remove the molar pregnancy. This must be done very carefully or excessive bleeding and blood clots to the lungs can occur. The placental tissue is sent to the pathologist, who looks under the microscope to make the final diagnosis. An HCG level, and sometimes a thyroid level, are also obtained. In unusual cases, where the patient has completed her childbearing, a hysterectomy may be preferable. Although most cases of molar pregnancy occur after a miscarriage, some occur after ectopic pregnancies or a normal pregnancy. Therefore, women with abnormal bleeding or a persistent cough (especially if it produces blood) should see their doctor for an HCG level to make sure they do not have a molar pregnancy.
When the HCG levels drop then increase again it means that the molar pregnancy has grown from microscopic cells in the wall of the uterus to larger cells. These cells can act like a cancer, and metastasize (spread) to other organs, like the lungs, brain, bones, and vagina. Treatment for recurrent molar pregnancy, called gestational trophoblastic neoplasia, or GTN, in medical terms, usually consists of methotrexate.
Preeclampsia
Preeclampsia is defined as the presence of (1) a systolic blood pressure (SBP) greater than or equal to 140 mm Hg or a diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or higher, on two occasions at least 4 hours apart in a previously normotensive patient, OR (2) an SBP greater than or equal to 160 mm Hg or a DBP greater than or equal to 110 mm Hg or higher.
Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks’ gestation and can present as late as 4-6 weeks post partum. It is clinically defined by hypertension and proteinuria, with or without pathologic oedema.
The most effective treatment for preeclampsia is delivery. You’re at increased risk of seizures, placental abruption, stroke . Labetalol, hydralazine.
Preterm labour and premature rupture of membranes
Preterm birth is significantly more common in young women, those with low body weight (body mass index <19), those of lower social class, unmarried or unsupported mothers, smokers, previous preterm delivery, persistent vaginal bleeding in early pregnancy, and heart disease. Can be caused by: Iatrogenic (induction for medical reasons) Infection Premature rupture of the membranes Multiple pregnancy Polyhydramnios Intrauterine death Foetal abnormalities Uterine abnormalities Cervical incompetence
Risks: Death Respiratory distress syndrome Hypothermia Hypoglycaemia Necrotising enterocolitis Jaundice Infection Retinopathy of prematurity
Management of preterm labour
Suppression of uterine contractions to postpone delivery, or to allow the administration of corticosteroids to the mother and so to her foetus to promote surfactant release in the foetal lung and reduce the incidence of the neonatal respiratory distress syndrome by up to 50%. This effect is only significant at gestations up to 34 weeks; after this it is usual to allow preterm labour to progress.
Tocolytics
Currently used
β sympathomimetics, such as ritodrine, terbutaline, salbutamol
Magnesium sulphate (used particularly in the United States)
Prostaglandin synthase inhibitors, such as unselective (indomethacin) and selective (cyclo-oxygenase type 2—nimesulide)
Nitric oxide donors, such as glyceryl trinitrate
Calcium channel blockers, such as nifedipine
When the membranes have ruptured, the use of tocolytics is controversial. The concern is that contractions may result from occult chorioamnionitis, and suppressing labour could allow infection to spread. If tocolytics are used in this situation intravenous broad spectrum antibiotics should probably also be given.
Primary Postpartum Haemorrhage
Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500 ml, from the genital tract, within 24 hours of delivery (the most common obstetric haemorrhage):
Minor PPH is estimated blood loss of up to 1000 mls.
Major PPH is any estimated blood loss over 1000 mls.
Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until six weeks postpartum.
The causes of PPH have been described as the “four T’s”:
Tone: uterine atony, distended bladder.
Trauma: lacerations of the uterus, cervix or vagina.
Tissue: retained placenta or clots.
Thrombin: pre-existing or acquired coagulopathy.
The most common cause of PPH is uterine atony, followed by retained placenta.
For major PPH:
Assess airway, breathing, circulation.
Oxygen by mask at 10-15 litres per minute.
IV access with 2 x 14-gauge cannulae.
Keep the woman lying flat and warm.
Transfuse blood as soon as available. Until available, transfuse up to 2 litres of warmed crystalloid Hartmann’s solution and/or 1-2 litres of colloid. Infusions should be warmed and a blood filter not used. In the absence of cross-matched blood, components may be required in line with local hospital guidelines and haematological advice.
Recombinant factor VIIa (rFVIIa) is increasingly frequently used for arresting bleeding in severe haemorrhage.
Examination to establish cause, and exclude other causes than uterine atony (the most common cause).
If the cause is established to be uterine atony, the following measures are taken in turn:
Bimanual uterine compression to stimulate contraction.
Ensure the bladder is empty.
Oxytocin 5 units by slow IV infusion. May require repeat. The latest Cochrane review supports the use of oxytocin as first-line treatment.
Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.
Oxytocin infusion unless fluid restriction is necessary.
Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma. It is licensed only for bleeding after a caesarean section in Europe. It is also sometimes used off licence as an intramyometrial injection.
Misoprostol 1000 micrograms rectally. The Cochrane review determined misoprostol is not as effective as oxytocin, but may be helpful in low resource settings, as it does not need refrigeration or infusion.
Heat-stable carbetocin has been shown to be as effective as oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents[11].
If these physical and pharmacological methods are not succeeding, surgical options as follows:
Balloon tamponade.
Haemostatic brace suturing - eg, the B-Lynch compression suture.
Bilateral ligation of the uterine arteries.
Bilateral ligation of the internal iliac arteries.
Selective arterial embolization.
Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture. If possible, a second consultant should be involved in this decision.
Complications: Hypovolaemic shock. Disseminated intravascular coagulation. Acute kidney injury. Liver failure. Acute (adult) respiratory distress syndrome. Death.
Managing a home birth
Community midwives usually provide the care for home births. A midwife will come out to you when you are in labour to see how you’re getting along. She’ll talk to you and your birth partner, and watch you having a few contractions. She may carry out an internal examination to see how far dilated your cervix is.
Plastic sheeting or bin liners to protect your floor, bed or sofa.
Old towels or sheets to cover the plastic sheeting.
A couple of containers, in case you’re sick during labour.
A warm blanket or throw, in case you get cold.
Bin liners for dirty linen and rubbish.
Newspapers and old sheets or towels can create a covered path between where you labour and give birth, and the toilet.
A desk light or head torch, so your midwife can check your vagina for tears or to check your baby after the birth.
Clean warm towels, a baby blanket
Once the placenta is delivered, your midwife will check to see if you have a tear that needs stitching. Most tears can be stitched up by your midwife. If the placenta doesn’t come away, or if you have a very bad tear, you’ll need to go to hospital.
A physical exam of the baby is required from a physician within three days.
Home vs hospital births
During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation.
Amniocentesis and Chorionic Villus Sampling
prenatal diagnosis for a variety of reasons including a higher chance aneuploidy screening result, fetal structural anomaly, or a known risk of inherited genetic disease.
CVS is usually performed between 11+0 and 13+6 weeks of gestation. If required, CVS can be performed between 14+0 and 14+6 weeks’ gestation. Individualised counselling of the merits of CVS versus amniocentesis should be provided for women considering CVS during this time period. Amniocentesis, performed to obtain amniotic fluid for analysis, is usually offered from 15+0 weeks.
Gestational Trophoblastic Disease
Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.
There are two subtypes of hydatidiform mole: complete hydatidiform mole, and partial hydatidiform mole.
The four malignant tumours Invasive mole Choriocarcinoma Placental site trophoblastic tumour Epithelioid trophoblastic tumour
Hydatidiform moles are abnormal conceptions with excessive placental development. Conception takes place, but placental tissue grows very fast, rather than supporting the growth of a foetus.
Vaginal bleeding, enlarged uterus, pelvic pain or discomfort, and vomiting too much (hyperemesis) are the most common symptoms of GTD. But GTD also leads to elevated serum hCG (human chorionic gonadotropin hormone). Since pregnancy is by far the most common cause of elevated serum hCG, clinicians generally first suspect a pregnancy with a complication. However, in GTD, the beta subunit of hCG (beta hCG) is also always elevated. Therefore, if GTD is clinically suspected, serum beta hCG is also measured. There might be some signs and symptoms of hyperthyroidism .
Suction curettage is the preferred method of evacuation. Hysterectomy is an alternative if no further pregnancies are wished for by the female patient. Hydatidiform mole also has successfully been treated with systemic (intravenous) methotrexate
Vasa praevia
Vasa praevia occurs when the foetal vessels run through the free placental membranes. Unprotected by placental tissue or Wharton’s jelly of the umbilical cord, a vasa praevia is likely to rupture in active labour, or when amniotomy is performed to induce or augment labour, in particular when located near or over the cervix, under the foetal presenting part. Vasa praevia is classified as type I when the vessel is connected to a velamentous umbilical cord, and type II when it connects the placenta with a succenturiate or accessory lobe.
Vasa praevia may be diagnosed during early labour by vaginal examination, detecting the pulsating foetal vessels inside the internal os, or by the presence of dark-red vaginal bleeding and acute foetal compromise after spontaneous or artificial rupture of the placental membranes. The foetal mortality rate in this situation is at least 60% despite urgent caesarean delivery. However, improved survival rates of over 95% have been reported where the diagnosis has been made antenatally by ultrasound followed by planned caesarean section.
Secondary postpartum haemorrhage
This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.
Aetiology
The two most common causes are:
Infection - endometritis. This occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10. Risk factors are:
Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor, long labour with multiple examinations, manual removal of placenta, mother’s age at extremes of the reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
Symptoms vary but may include:
Fever. Abdominal pain. Offensive smelling lochia. Abnormal vaginal bleeding - postpartum haemorrhage. Abnormal vaginal discharge. Dyspareunia. Dysuria. General malaise. Look for history of extended labour, difficult third stage, ragged placenta, PPH.
Examination
There may be:
Fever.
Rigors.
Tachycardia.
Tenderness of the suprapubic area and adnexae.
Elevated fundus which feels boggy in RPOC.
If sepsis is suspected in the community, urgent referral to hospital is indicated where ‘red flag’ signs and symptoms are present. If the woman appears seriously unwell, by emergency ambulance:
Pyrexia >38°C.
Sustained tachycardia (more than 90 bpm).
Breathlessness (respiratory rate >20 breaths per minute - a serious symptom).
Abdominal or chest pain.
Diarrhoea and/or vomiting.
Uterine or renal angle pain and tenderness.
Woman is generally unwell or seems unduly anxious/distressed.
Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations. If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close.
For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Antibiotic choice should be guided by type and likely source of infection, as well as by local prescribing guidelines. The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactam. For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed
If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of RCOP, as these women are carrying a high risk of uterine perforation.
The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.
Caesarean section
Reasons for the operation include obstructed labour, twin pregnancy, high blood pressure in the mother, breech birth, and problems with the placenta or umbilical cord.
Endometriosis
Endometriosis risk factors include: an early menarche, late menopause, late first sexual encounter, delayed childbearing and nulliparity.
Obstruction to vaginal outflow - eg, hydrocolpos, female genital mutilation or defects in the uterus or Fallopian tubes.
Genetic factors:
Risk for first-degree relatives of women with severe endometriosis is six times higher than that for relatives of unaffected women.
Other risk factors include white ethnicity, low body mass index (BMI) and smoking.
Lymphatic or retrograde flow - main theories of spread.
Dysmenorrhoea. Dyspareunia. Cyclical or chronic pelvic pain. Subfertility. Other symptoms may include bloating, lethargy, constipation and low back pain. Less common symptoms include cyclical rectal bleeding, menorrhagia, diarrhoea and haematuria.
However, there may be:
Posterior fornix or adnexal tenderness.
Palpable nodules in the posterior fornix or adnexal masses (endometriosis can cause cystic lesions on the ovaries, known as ‘chocolate cysts’).
Bluish haemorrhagic nodules visible in the posterior fornix.
