Week 4 Flashcards
External obliques - attachments
What direction do the fibres of these muscles run in?
Attaches to the lower ribs (7-11, sometimes 12), pubic tubercle and linea alba
fibres run in the same line as the external intercostals, “hands in pockets”
Internal obliques - attachments
What direction do the fibres of these muscles run in?
Attachments - lower ribs, thoracolumbar fascia, iliac crest and linea alba
Fibres run in the same direction as the internal intercostals, “hands on chest”
Where does the linea alba run between?
From the xiphoid sternum to the pubic symphisis
Describe the rectus sheath. How does it differ…
- above the arcuate line
- below the arcuate line?
Why does this change occur?
The rectus sheath is immediately deep to the superficial fascia and is a combined aponeuroses of the anterolateral abdominal wall muscles (external ob., internal ob., and transv. abdo.)
- Above the arcuate line, the rectus sheath is split into anterior and posterior leaflets. The anterior leaflet is made up of the external oblique aponeurosis and the anterior portion of the internal oblique aponeurosis. The posterio leaflet is made up of the posterior part of the internal oblique aponeurosis and the transverse abdominis.
- Below the arcuate line, the rectus sheath is all anterior
This change occurs because abdominal organs sit lower in the body due to gravity - having all components of the sheath anteriorly provides more protection for the muscles
The spermatic cord in the male and the round ligament of the uterus in the female pass through which layer of the rectus sheath?
What does this layer become incorporated into in the male?
The spermatic cord and the round ligament pass through the transversalis fascia at the entrance to the deep inguinal ring
In the male, the transversalis fascia extends downwards as the internal spermatic fascia
What nerves supply the anterolateral abdominal wall? From what direction do they enter?
Nerves enter from the lateral direction
The 7th-11th intercostal nerves go on to become the thoracoabdominal nerves after they cross over the costal cartilage
Other nerves involved include subcostal (T12), iliohypogastric (L1) and ilioinguinal (L2)
Describe the arterial supply to the anterolateral abdominal wall
Superior epigastric artery (1.6mm)
- continuation of the internal thoracic arteries
- emerges at the superior aspect of the abdominal wall
- lies posterior to rectus abdominis
Inferior epigastric artery (3mm)
- branch of the external iliac artery
- emerges at the inferior aspect of the abdominal wall
- also lies posterior to rectus abdominis
What layers are passed through when performing a LSCS (lower segment caesarean section) incision?
What other procedure should be performed to make this incision easier?
Skin and fascia
(anterior) rectus sheath as below the arcuate line
Separation laterally of the rectus abdominis muscles
Transversalis fascia and peritoneum
Retract the bladder (urinary catheterisation can be performed to aid this)
Uterine wall
Amniotic sac
What layers are passed through when performing a laparotomy?
These procedures are relatively bloody/bloodless. What does this mean clinically?
Skin and fascia
Line alba
Peritoneum
Relatively bloodless, which means that the wound may be harder to heal and there is an increased risk of wound herniation/dehiscence
When performing laparoscopy and using lateral ports, what vessel must care be taken to avoid?
What landmarks can be used?
When performing lateral ports, care must be taken to avoid the inferior epigastric artery
The IEA emerges just medially to the deep inguinal ring. Hesselbach’s Triangle can be used to help avoid hitting IEA (rectus abdominis medially, inguinal ligament inferiorlaterally and IEA superolaterally)
When performing a hysterectomy, what structures must be carefully avoided? How can this be done?
The ureters should be avoided - they will vermiculate when touched, while uterine arteries will appear pulsatile. Can also use the memory aid “water under the bridge” as the ureter passes inferiorly to the artery and vein
Where might a woman give birth?
Which is most common?
Consultant-led unit
Midwife-led unit
Homebirth
96% of women in the UK still give birth within a hospital setting
Describe Ferguson’s Reflex
Stretching of the cervix causes the release of oxytocin, which stimulates uterine contractions and thus further pressure on the cervix causing more release of oxytocin. POSITIVE FEEDBACK MECHANISM
What do the following hormones do with regards to the onset of labour?
- Progesterone
- Oestrogen
- Oxytocin
Progesterone - keeps the uterus ‘settled’, prevents the formation of gap junctions and hinders the contractibility of myocytes
Oestrogen - makes the uterus contract and promotes prostaglandin production
Oxytocin - initiates and sustains contractions and acts on the uterus lining (decidual tissue) to promote prostaglandin release. Near the end of pregnancy, the number of oxytocin receptors found in myometrial and decidual tissues increases
‘Rupture of membranes’ refers to what? When might this occur?
Refers to rupture of the liquor - fluid that nurtures and protects the foetus and facilitates movement
Timing may be…
- pre-term
- pre-labour
- first stage
- second stage
- “born in a caul”
What cervical changes occur during labour?
Cervix softens through various methods…
- increase in hyaluronic acid leads to an increase in the number of molecules among collagen fibres
- decrease in bridging among collagen fibres = decrease in firmness
- cervical ripening (decrease in fibre collagen alignment and strength, and decrease in tensile strength of the cervix matrix)
What is Bishop’s score used for? What is it made up of?
Pre-labour scoring system used to determine whether or not labour needs to be induced.
Made up of 5 elements…
- Position
- Consistency
- Effacement
- Dilatation
- Station of the pelvis
The higher the score, the more likely induction will be needed
Name the various stages of labour and what each comprises of
First stage (Latent Phase, 3-4cm dilatation, and Active Phase, full dilatation a.k.a. 4-10cm)
Second stage - delivery of baby
Third stage - expulsion of placenta and membranes
Describe the features of the First Stage of labour
Latent Phase
- mild irregular uterine contractions
- cervix shortens and softens
- duration is variable (may last a few days!)
Active Phase
- slow descent of the presenting part
- contractions progressively become more rhythmic and stronger
- analgesia, mobility and parity of the mother increase the variability of this stage
Describe the features of the Second Stage of labour
Spans from complete dilatation of the cervix to delivery of the baby
Nulliparous women
- considered prolonged if exceeding 3 hours (if regional analgesia)
- or considered prolonged if 2 hours with no analgesia
Multiparous women
- considered prolonged if exceeding 2 hours w/ regional analgesia
- or 1 hour with no analgesia
Describe the features of the Third Stage of labour
Describe the difference between expectant and active management at this stage
At what point would removal under GA be considered?
Spans from delivery of the baby to expulsion of the placenta and membranes
Average duration is 10 minutes, however can last 3 hours or longer
expectant management - spontaneous delivery of the placenta
active management - use of oxytocic drugs and controlled cord traction (lowers risk of PPH)
After 1 hour, preparations are made to remove the tissue under general anaesthetic
Explain Braxton Hicks contractions and how they differ from normal contractions.
How does having had previous children affect this phenomenon?
A.k.a. “false labour”
Tightening of the uterine muscles, thought to be in preparation for actual labour
Can start as little as 6 weeks into pregnancy, but typically occur in the 3rd trimester.
Unlike normal contraction, BH contractions are irregular and do not increase in frequency or intensity
BH contractions typically resolve with ambulation/change in activity
Previous pregnancies increase the likelihood of BH contractions due to increased uterus excitability
How can you tell if contractions are “true” and signalling real labour?
How are true contractions brought about?
Timing of the contractions become more evenly spaced and the time between them becomes shorter and shorter
The duration of each contraction also increases, and will also become more painful and intense over time
Oxytocin stimulates the uterus to contract by tightening the top of the uterus and pushing the baby inferiorly into the birth canal. This also usually promotes thinning of the uterus
Three key factors are in interplay between one another during labour, these being Power, Passenger and Passage.
Describe Power
= uterine contraction
The uterus is made up of smooth muscle and connective tissue, with a pacemaker region in the tubal ostia that causes waves to spread downwards. The waves generated from each ostia synchronise with each other
As the upper segment contracts and retracts, the lower segment and cervix relax and stretch
Normal contractions have fundal dominance
Frequency of contractions - 3-4 every 10 mins
Duration - 10-15 seconds, going up to 45 seconds
Three key factors are in interplay between one another during labour, these being Power, Passenger and Passage.
Describe Passage
What are the different types of pelvis? Which is preferred for childbirth?
= journey of the baby through the pelvis
Gynaecoid - most suitable for childbirth
Anthropoid - large oval-shaped inlet w/ large anterio-posterior diameter, but smaller transverse diameter
Android - heart-shaped inlet and narrower from the front. Afro-caribbean women more at risk
Platypelloid
Three key factors are in interplay between one another during labour, these being Power, Passenger and Passage.
Describe Passenger (specifically position)
= baby
Normal position
- longitudinal lie
- cephalic presentation
- vertex is the presenting part
- position is occipito-anterior
- head is flexed
Abnormal position
- presentation - breech, oblique, transverse lie
- position - occipito-posterior
How can foetal position be determined during vaginal examination?
Palpation of the fontanelles
Anterior fontanelle has 4 points (diamond)
Posterior fontanelle has 3 points (triangle)
What analgesia options are available during labour?
Entonox (gas and air) - best option, doesn’t affect the baby and the mother can still push
Paracetamol/co-codamol
Diamorphine (standard for the first stage of labour)
Epidural (useful for induced labour which is typically more painful)
Remifentanyl - not used much any more as it can cause respiratory depression
TENS (transcutaneous electrical nerve stimulation)
What are the 7 cardinal movements of labour?
- engagement (described in 5ths relating to foetal head in pelvis)
- descent (foetal head in occiput transverse position)
- flexion (allows smallest diameter of foetal head to pass first)
- internal rotation
- crowning and extension
- restitution (head returning to the correct anatomical position in relation to the shoulder) and external rotation
- expulsion, anterior shoulder first
Describe foetal crowning
Appearance of a large segment of the foetal head at the introitus
Labia are stretched to full capacity, with largest diameter of foetal head being encircled by the vulval ring
Care of the perineum at this stage is vital to reduce trauma. Deliverer’s hands should guide, but not lead, to minimise risk of tearing
Episiostomy may be required to preserve tissues
Following delivery, when should the foetal cord be clamped?
Should be delayed to up to 3 minutes after delivery/cessation of pulsations of cord
This is because immediate clamping has been associated with both short and long-term neonatal problems due to reducing the amount of RBCs to the baby by more than 50%
What classic signs during the Third Stage indicate separation and expulsion of the placenta?
Uterine contractions, hardening and rising
Permanent lengthening of the umbilical cord
Variable amounts of blood gushing
Appearance of the placenta and membranes at the introitus
Expulsion usually occurs 5-10 minutes after delivery, and is considered normal up to 30 minutes
What active management steps may be made during the Third Stage?
Prophylactic administration of synometerine (1ml ampoule containing 500 micrograms ergometrine maleate and 5 IU oxytocin or oxytocin (10 units)
Cord clamping and cutting
Controlled cord traction
Bladder emptying
What is considered to be a normal and abnormal amount of blood loss during labour?
Normal - volume up to 500mls
Abnormal - greater than 500mls, more significance if greater than 1000mls
Any blood loss in labour prior to delivery, apart from “show” is considered abnormal and requires consultant referral
How is haemostasis during labour achieved?
Tonic contractions - uterine muscle ‘lattice arrangement’ strangulates blood vessels
Thrombosis of torn vessel ends - pregnancy is a hypercoagulable state
What is puerperium? What occurs during this stage?
Period of repair and recovery following birth, lasting approx 6 weeks
Vaginal discharge of varying colours over the next few days
Uterus involutes and weight reduces from 1000gms to 50-100gms
Endometrium regenerates after 1 week
Regression, but never back to pre-pregnancy state
How is lactation initiated?
Placental expulsion and a decrease in progesterone and oestrogen (previously blocked prolactin during pregnancy)
What is the normal size of an adult male testis? Name some conditions that may affect this volume
Normal size - 12-15mls
Conditions: cryptoorchidism (undescended testis), Klinefelters, hypogonadism (primary, testicular torsion, infection, anabolic steroid use), varicocele
How do sympathetic and parasympathetic innervation affect erection?
Parasympathetic - vasodilation of the arteries running through the penis, Buck’s fascia surrounding the penis maintains the pressure resulting in compression of the penile veins and maintenance of erection
Sympathetic - vasoconstriction of the arteries running through the penis, reducing blood flow and pressure and allowing blood to flow back through the penile veins
What are the functions of the following tissues?
- Epididymis and vas deferens
- Seminal vesicles
- Prostate gland
- Bulbourethral gland
Epididymis and vas deferens - exit route from the testes to the urethra, site of concentration and storage of sperm, site of sperm maturation
Seminal vesicles - produce semen into ejaculatory duct, supply fructose, secretion of prostaglandins and fibrinogen
Prostate gland - produces alkali fluid and clotting enzymes to cause clotting of sperm in the female reproductive tract
Bulbourethral gland - secretes mucous to act as lubricant
Describe the changes in surface anatomy of the uterus during pregnancy
Height of the fundus goes up and out
At 20 weeks, approximately at the height of the umbilicus
At 36 weeks, approximately the height of the xiphoid process
At term, the height goes down slightly as the baby’s head engages with the pelvis
(approximately 1cm of fundus height per week of pregnancy)
What are some of the main medical problems seen in pregnancy?
Hypertension
Diabetes
Venous thromboembolism VTE
Cardiac disease
Respiratory disease - asthma
Connective tissue disease - APS
Epilepsy
Obesity
How do the following change in pregnancy?
- total blood volume
- heart rate
- stroke volume
- cardiac output
- peripheral vascular resistance
All increase, except PVR which decreases by 15-20%
What kind of heart disease issues may be exacerbated during pregnancy?
Pulmonary hypertension (including Eisenmonger’s, a chronic left-to-right cardiac shunt due to a congenital abnormality that has a 30-60% risk of mortality during pregnancy)
Congenital heart disease
Acquired heart disease
Cardiomyopathy
Artificial heart valves
Ischaemic heart disease
Arrhythmias
What is NYHA classification used for?
Used as a functional assessment of impact of heart disease on function
Class I - no limitation to normal physical activity
Class II - mild symptoms only in normal activity
Class III - marked symptoms during normal activity
Class IV - severe limitations, symptomatic at rest
What cardiac symptoms are common in pregnancy?
Which cardiac complications may prove to be fatal during pregnancy?
Common symptoms - palpitations, extra-systoles and systolic murmurs. These are usually benign
Pulmonary hypertension and fixed pulmonary vascular resistance often result in fatality
What investigations would you perform for the following…
- Ectopic beats
- Sinus tachycardia
- SVT
- Hyperthyroidism
Ectopic beats - ECG
Sinus tach. - ECG, FBC, Thyroid function testing, echocardiography
SVT - ECG/24hr ECG, thyroid function, echo
Hyperthyroidism - thyroid function, ECG
How is lung function affected in pregnancy?
O2 consumption increases
Metabolic rate increases
Tidal volume increases
Resp rate remains unchanged
Functional residual capacity decreases
PaO2 increases, PaCO2 decreases, arterial pH increases
Breathlessness is common in pregnancy, especially in the third trimester, and is seen at rest/when talking but improves with exertion
What is the most common medical disorder to complicate pregnancy? How often is it recognised? How does pregnancy affect this condition?
Asthma, affects approx 7% of women childbearing age
Often undiagnosed and untreated at time of pregnancy
10% will have an acute exacerbation during pregnancy
Rule of 3rds - 1/3 will get better, 1/3 remain unchanged, and 1/3 will get worse
However, if well-controlled, asthma does not affect pregnancy outcomes. Poorly controlled asthma is a greater risk to pregnancy than the treatment used to manage it
How should women with asthma be managed during labour?
Aim for vaginal delivery
Acute attack unlikely due to the production of endogenous steroids
Women shouldn’t discontinue use of inhalers during labour, inhaled beta-2 agonists don’t affect uterine contractility or onset of labour
If taking oral steroids, give the woman IV hydrocortisone
What is the biggest direct cause of maternal mortality? How does likelihood change during pregnancy?
How does this most commonly present?
VTE - 4-6x increase during pregnancy
85-90% of DVTs occur in the left leg, and more than 70% are in the ileofemoral region
What are the components of Virchow’s Triad and how does pregnancy affect these components to increase the likelihood of VTE development?
Components - hypercoaguability, venous stasis, vascular damage
Both hypercoaguability and venous stasis increase in pregnancy
Vascular damage may occur at birth, and is more likely to occur with forceps delivery
What treatment might be started in high/medium risk women following delivery to prevent puerperal VTE developing?
LMWH as prophylaxis
What are the signs and symptosm of a pulmonary thromboembolism?
Dyspnoea
Chest pain
Faintness, collapse
Haemoptysis
Raised JVP
Focal signs in the chest
What types of thrombophilia should you be aware of that have an association with development of VTE?
Which ones of these see recurrent VTEs?
Antithrombin deficiency - recurrence 32-51%
Protein C deficiency - 22-26%
Protein S deficiency - 12-17%
Factor V Lieden (homo and hetero)
APC resistance
Antiphospholipid syndrome - recurrence up to 70%
Clinically, CTPA and V/Q scans may be used for similar means - what are the features of both?
CTPA
- readily available
- may also detect other pathologies
- has a better sens. and spec. than V/Q
- however, low radiation dose to foetus and a (small) increased risk in developing breast ca in the mother
V/Q
- high negative predictive value in pregnancy
- low radiation dose to maternal breast tissue
Why should women avoid warfarin in pregnancy? How should this be managed?
Are these medications safe during breast feeding?
Warfarin is teratogenic, risk appears to be dose-dependent
Switch to LMWH by 6 weeks gestation
Following pregnancy, switch back to warfarin on day 5
Neither warfarin nor LMWH are contraindicated in breast feeding
Regarding connective tissue diseases and pregnancy, what drugs are safe and what should be avoided?
Safe
- Steroids
- Azathioprine (Inflam. bowel disease, autoimmune conditions, RA, SLE, polymyositis)
- Sulfasalazine (Inflam. bowel disease, active RA)
- Hydroxychloroquine (HCL) (RA, SLE)
- Aspirin
- Etanercept/Infliximab/Rituximab
Not Safe
- NSAIDs
- Cylophosphamides (RA, vasculitides)
- Methotrexate
- Chlorambucil
- Gold
- Penicillamine (RA, Wilson’s Disease, autoimmune hepatitiis)
- Leflunamide
What antibodies are seen in APS?
Antiphospholipid antibodies (aPL) - react with the phospholipid component of the cell membrane
Anticardiolipin (aCL)
Lupus Anticoagulant (LA)
How is APS diagnosed?
Clinically
- Vascular thrombosis
- venous, arterial, small vessel
- Pregnancy morbidity - any of these warrant autoantibody investigation
- greater than or equal to 3 miscarriages in less than 10 weeks
- one or more foetal loss in less than 10 weeks (morphologically normal)
- one or more preterm births due to PET or utero-placental insufficiency
Laboratory
- IgM/IgG aCL
x2 >6 weeks apart
How does APS affect pregnancy outcomes?
Early pregnancy loss - 17%
2nd/3rd trimester IUD - 7%
Preterm birth (<34 weeks) - 35%
Foetal growth restriction - 14%
How is APS managed medically?
Low dose aspirin and LMWH
Epilepsy in pregnant women is a relatively common presentation, however more than half of epileptic women will remain seizure free throughout pregnancy.
What effects on foetal health might maternal seizures have?
Maternal abdominal trauma
Preterm birth
Hypoxia/acidosis
Major/minor congenital malformations
Long term developmental effects
Haemorrhagic disease of the newborn
Risk of childhood epilepsy
At what stage of gestation should women be offered a detailed USS to investigate for foetal abnormality?
18-20 weeks
What factors make intra-partum seizing in epileptic women more likely in pregnancy?
Stress
Pain
Sleep deprivation
Over-breathing
Poor hydration
If an epileptic woman does experience intra-partum seizure, what methods should be taken to promote maternal and foetal mortality?
Left lateral tilt
IV lorazepam/diazepam or PR diazepam/buccal midazolam
IV phenytoin
May need to expedite for CS delivery to minimise risk of foetal hypoxia/acidosis
How does obestiy affect the following stages in a woman’s reproductive stage?
Pre-pregnancy
Early pregnancy
Antenatal
Labour/delivery
Post-natal
Foetal/neonatal
Post-menopause
Pre-pregnancy - possible menstrual disorders or subfertility
Early pregnancy - miscarriage
Antenatal - foetal anomalies, PET, GDM, VTE
Labour/delivery - Dysfunctional labour, operational delivery
Post-natal - Haemorrhage, infection, VTE
Foetal/neonatal - macrosomia, birth injury, perinatal mortality
Post-menopausal - endometrial hyperplasia, prolapse, incontinence of urine
Specifically in pregnancy, what conditions become more likely in obese and extremely obese women?
Obese
- miscarriage
- gestational diabetes
- hypertension/pre-eclampsia
- VTE
- need for caesarean section
- post-partum haemorrhage
- wound infection
- congenital abnormalities in foetus
Extremely obese
- PET
- GDM
- Caesarean section
- Need for general anaesthetic
- admission to ICU
How does obesity affect perinatal outcomes of the baby?
Congenital abnormalities
Macrosomia
Shoulder dystocia
Stillbirth
Neonatal death
Epidemiology of hypertension in pregnancy…
Hypertension affects ___% of all pregnancies
Mild pre-eclampsia affects ___% of primagravid women
Severe pre-eclampsia affects ___% of primagravid women
Eclampsia affects 1/x pregnancies
Up to ___% of antenatal admissions are due to hypertension
Hypertension affects 10-15% of all pregnancies
Mild pre-eclampsia affects 10% of primagravid women
Severe pre-eclampsia affects 1% of primagravid women
Eclampsia affects 1/3000 pregnancies
Up to 25% of antenatal admissions are due to hypertension
How do the following typically change during pregnancy?
Blood volume
Cardiac output
Stroke volume
Heart rate
Peripheral vascular resistance
Blood volume increases by 30%
Cardiac output increases by 30-50%
Stroke volume increases by 25%
Heart rate increases by 15-25%
Peripheral vascular resistance decreases by 15-20%
Describe the typical pattern of change in blood pressure during pregnancy
BP initially falls in early pregnancy, and will be at its lowest (nadir) at weeks 22-24
It will then steadily rise until pre-pergnancy levels, and may even rise past this.
BP then drops again after delivery, but subsequently rises and peaks at 3/4 days postnatally
What are the 3 main types of hypertension seen in pregnancy?
What type is likely if seen in early pregnancy?
What type might cause hypertension in the second half of pregnancy?
3 main types
- Pre-existing hypertension
- Pregnancy-induced hypertension (PIH)
- Pre-eclampsia
If seen early in pregnancy, likely due to pre-existing hypertension
If newly developing in the second half of the pregnancy, likely PIH or PET
What is the classic triad of symptoms seen in pre-eclampsia?
What is important to note about this triad?
The classic triad is hypertension, proteinuria and oedema
Importantly, the absence of one of the above doesn’t exclude a diagnosis of PET
What are some of the potential risks in a patient with pre-existing hypertension during pregnancy?
Twice as likely to suffer pre-eclampsia
Intrauterine growth restriction
Placental abruption
Early/Late pregnancy pre-eclampsia is more common
Which of these has a higher risk of maternal and foetal complications?
Late pre-eclampsia (34 weeks or more) during pregnancy is much more common
Early pre-eclampsia is a lot less common, however has a higher risk of maternal and foetal complications. It is associated with extensive villous and vascular lesions of the placenta
How is pre-eclampsia caused?
Diffuse vascular endothelial dysfunction causing widespread circulatory disturbance, with no definitive cause identified however it is likely to be due to a number of factors, including…
- abnormal formation and development of the placenta
- immunological factors
- pre-existing maternal pathology e.g. hypertension, obesity, APS etc.
- dietary and environmental factors
- poor trophoblastic invasion results in poor placental perfusion, causing an increase in maternal blood flow and oxidative stress, hypoxia and the release of factors that promote endothelial dysfunction, inflammation etc.
- results affect the brain, liver, kidneys, RBC formation etc.
Pre-eclampsia is a multi-system disease. Provide some examples of how it presents in these different systems
(CNS, Liver, Kidneys, Placenta, Cardiopulmonary etc.)
CNS
- Eclampsia
- Hypertensive encephalopathy
- Intracranial haemorrhage
- Cerebreal oedema
- Cortical blindness
- Cranial nerve palsies
Renal
- Reduced GFR
- Proteinuria
- Increased creatinine, potassium, urea
- Oliguria, anuria
- Acute renal failure
Liver
- Epigastric/RUQ pain - worrying, indicates haemorrhage
- Abnormal liver enzymes
-
HELLP Syndrome - high morbidity/mortality
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
Cardiac/pulmonary
- Pulmonary oedema/ARDS
- PE
Placental disease
- foetal growth restriction
- placental abruption
- IUD
What are some of the signs and symptoms of pre-eclampsia?
Symptoms - highly variable in presentation and timing
- Headache
- Visual disturbances
- Epigastric/RUQ pain
- Nausea and vomiting
- Rapidly progressive oedema
Signs
- Hypertension
- Proteinuria
- Oedema
- Abdominal tenderness
- Disorientation
- Hyperreflexia/involuntary movements/clonus - worrying, could be eclamptic seizures
Pre-eclampsia - investigations
Us and Es to test renal function/look for proteinuria
Serum urate - one of the first indicators of pathology
LFTs - look for raised ALT
FBC
Coagulation screen
Urine PCR
CTG
USS
What groups are more likely to suffer from pre-eclampsia?
Older women (>40 yrs, risk is doubled)
Overweight women (BMI >30, risk is doubled)
FHx
First pregnancy - 2-3x as likely
Mutltiple pregnancy - twins doubles risk
Previous pre-eclampsia - x7 risk
Pre-existing renal disease/hypertension, diabetes, CTDs and thrombophilias
Which of the following medications used to treat high blood pressure in pregnancy are NOT safe to use while breastfeeding?
Methyl dopa
Labetolol
Nifedipine
Hydrasalazine
Doxazocin
What other antihypertensive drugs should be avoided in pregnancy?
All are safe except Doxazocin
Also avoid diuretics and ACE inhibitors as these can negatively affect the baby
What is the ONLY ‘cure’ for pre-eclampsia?
How is this managed?
Only cure is delivery of the baby
Mother needs to be stabilised before the birth
Steroids may be required, and most women will deliver within 2 weeks of diagnosis
What is eclampsia? How does it present and what group is it most common in?
Eclampsia is a tonic-clonic (grand mal) seizure occurring with features of pre-eclampsia
>1/3 will have a seizure prior to the onset of hypertension/proteinuria
Associated with ischaemia/vasospasm
Most commonly seen in teenagers
What antihypertensive options are available to treat severe pre-eclampsia/eclampsia?
IV Labetolol
IV Hydrasalazine
What are the main prinicples of management in eclampsia?
How are the seizures managed?
Control BP
Stop/prevent seizures
Manage fluid balance
Deliver the baby
Seizure treatment/prophylaxis - magnesium sulphate, loading dose of 4g IV over 5 mins followed with maintenance dose of 1g/hour IV infusion
How should fluid balance be managed in a patient with eclampsia?
Main cause of maternal death in eclampsia is pulmonary oedema
Fluid challenges are potentially dangerous, so it’s safer to run the patient “dry”
What are the 3 main red flag presentations associated with perinatal depression/psychosis?
Recent significant change in mental state or emergence of new symptoms
New thoughts or acts of violent self harm
New and persistent expressions of incompetency as a mother or estrangement from their baby
Good communication between primary care, mental health and maternity servies is critical to good qaulity care for women with mental ill health. How can this be achieved a) at booking and b) with GP input?
a) at booking, there should be a routine enquiry about a current or past history of mental health problems - should cover full range of disorders, not just depression
b) GPs should communicate any past psychiatric history in antenatal referral
Phone calls > letters
Under what circumstances should admission of a mother to a mother and baby unit be considered?
Rapidly changing mental state
Suicidal ideation (esp. if violent)
Significant estrangement from baby
Pervasive feelings of guilt/hopelessness
Beliefs of inadequacy as a mother
Evidence of psychosis
What 3 screening questions should be used at every appointment?
What are some other useful questions to ask?
Screening questions
- during the last month, have you been bothered by feeling down, depressed or hopeless?
- during the last month, have you been bothered by having little interest or pleasure in doing things?
- is this something that you feel you need or want help with?
Other questions
- have you had any new feelings/thoughts which make you disturbed/anxious?
- are you experiencing thoughts of suicide or harming yourself in violent ways?
- are you feeling incompetent/can’t cope/estranged from baby? Are these feelings persistent?
- do you feel this is getting worse?
What is the difference between ‘baby blues’ and puerperal psychosis?
Baby Blues
- seen in 50% of women
- brief period of emotional instability
- presents with being tearful, irritable, anxious and poor sleep confusion
- Occurs 3-10 days after delivery, self-limiting
- treatment is via support and reassurance, medical intervention is rarely needed
Puerperal psychosis
- 0.1% of women
- Usually presents within 2 weeks of delivery and can vary greatly between days i.e. one day fine, the other completely terrible
- presents with sleep disturbance, confusion and irrational ideas. Then progresses to mania, delusions, hallucinations (less ‘fixed’ than in schizophrenia) and confusion
- 5% risk of suicide, 4% risk of infanticide
- risk factors - BPD (50%), previous PP episode, 1st degree relative w/ history
- is a medical emergency and requires admission to specialised mother-and-baby unit
How is puerperal psychosis treated?
Requires emergency admission to specialised mother and baby unit (as opposed to psychiatry unit where mother and baby will be separated)
Treated w/ antidepressants, antipsychotics, mood stabilisers and ECT
Shows an 80% 10 year recurrence however and 25% will go on to develop BPD
How is post-natal depression different to Baby Blues and Peurperal Psychosis?
Affects 10% of women, with 1/3rd last at least a year
Symptoms - tearfullness, irritability, anxiety, anhedonia and poor sleep, weight loss
Onset is typically 2-6 weeks postnatally
Can affect bonding w/ baby, child development, marriage
If mild/moderate, managed w/ self-help and counselling
If moderate/severe - psychotherapy + antidepressants
What mood stabiliser is contraindicated with breast feeding?
Lithium
How are antidepressants tolerated in…
- 1st trimester
- 3rd trimester
- breastfeeding
In particular, which drugs should be avoided?
1st trimester
- generally antidepressants don’t cause an increased risk of malformations or spontaneous abortion
- avoid Paroxetine - increased risk of foetal heart defects
3rd trimester
- increased risk of neonatal persistent pulmonary hypertension with SSRIs taken after 20 weeks
- increased risk of low birth weight/prematurity (however, also happens in untreated depression)
Breastfeeding
- all SSRIs/TCAs are present in breast milk but no reported adverse effects on neonatal development
- best to use - Sertraline, paroxetine, imipramine
- avoid - citalopram, doxepin
- lowest risk SSRIs - Sertraline, fluoxetine
- TCAs are lower risk than SSRIs - imapramine, amitriptyline
Are benzodiazepines safe in pregnancy?
Generally, avoid BZDs in pregnancy
Increased risk of malformations in 1st trimester
Increased risk of floppy baby syndrome in 3rd trimester
risk of lethargy + weight loss in breastfeeding
Are antipsychotics safe in pregnancy? Which ones should be avoided?
By and large, antipsychotics are okay during pregnancy, with more evidence of the typicals being safer than atypicals. All are excreted in breast milk (no evidence of foetal toxicity/altered development)
Avoid clozapine - risk of agranulocytosis
Avoid olanzapine - increased risk of gest. diabetes and weight gain
Avoid depot antipsychotics
Avoid anticholinergics for EPSE in pregnancy
Is lithium safe in pregnancy?
1st trimester - increased risk of foetal abnormality, can be continued if clinically indicated but avoid sudden discontinuation
3rd trimester - monitor levels closely, lithium toxicity can mimic PET
Breastfeeding - avoid, high levels in breast milk
Can Sodium Valproate be used in pregnancy?
No, better just to avoid it altogether, risk of neural tube defect is too high
Even avoid as much as possible in women of child bearing age that may become pregnant
What other mood stabilisers should be avoided in pregnancy?
Carbamazepine - increased risk of neural tube defects, facial dysmorphism, fingernail hypoplasia
Lamotrigine - increased risk of oral cleft, avoid in first trimester. Risk of SJS in breast feeding
What pain relief options are available to a woman about to give birth?
Which of these can only be delivered in a hospital?
Entonox (laughing gas)
Paracetamol/co-codamol
Diamorphine
TENS
Remifentanyl (can only be given in hospital)
Epidural/Spinal (can only be given in hospital)
What are the 4 grades of tears that can occur during childbirth?
Grade I - common
Grade II - into vaginal skin
Grade III - into perineum and anal sphincters
Grade IV - into rectum
What does DR C BRAVADO stand for, and what is it used for?
DR - define risk
C - contractions
BRa - baseline rate
V - variability
A - accelertions
D - decelerations
O - overall assessment
Used when reading CTGs
Early/Late decelerations on a CTG are considered abnormal. Which of these could indicate hypoxia of the foetus?
Late decelerations are abnormal, while early decelerations are physiologically normal
Both could indicate hypoxia of the foetus - in a normal contraction, oxygen to the foetus is impaired due to squeezing of the baby’s head.
What are accelerations on a CTG a result of? Are these normal or abnormal?
Accelerations are a response to stress e.g. movement or contractions.
These are a normal occurrence
What are the normal ranges for foetal heart rate and variability in HR?
Foetal heart rate should be between 120-160 bpm
Variability within the baseline should be >5bpm
What 3 Ps could potentially cause difficulties during labour?
Power - force of uterine contractions
Passage - pelvis of mother
Passenger - foetus
What is the optimal position of the baby for delivery?
Direct occiputo-anterior
What are the different types of urinary incontinence?
Stress UI - involuntary urine leakage in response to exertion/increased intra-abdominal pressure e.g. cough/sneeze
Urgency UI - involuntary urine leakage accompanied with or immediately preceded by a sudden, immediate urge to void that cannot be delayed
Mixed UI - associated with both urgency and exertion
Overactive bladder (OAB) - urgency that can occur with or without urinary incontinence, usually also with frequency and nocturia
What are some of the associated factors that contribute to urinary incontinence?
Age
Parity
Obesity
Pregnancy
Obstetric history
Menopause
UTI
Smoking
When taking a clinical history of urinary incontinence, what should be explored?
Need to classify as stress urinary uncontinence or urgency/OAB
Ask patient to record a bladder diary over 3 days
Ask about caffeine intake
Explore Storage symptoms
- frequency
- nocturia
- urgency
- constant leaking?
Explore Voiding symptoms
- hesitancy
- straining to void?
- poor flow?
Post-micturation symptoms
- incontinence
- incomplete bladder emptying
When performing a clinical examination on a woman complaining of incontinence, what should be explored?
BMI
Abdominal exam - look for masses including bladder
Vaginal exam - atrophy, prolapse, fistula
PR - assess tone and look for masses
Assess cognition, looking for impairment
Urinary incontinence - after examination, what investigations would you perform?
Urinalysis - main things to exclude are cancers and renal stones
Post-void residual analysis
Urodynamics (although this logistically unpleasant to perform)
Cystoscopy
Imaging
Urinary incontinence - conservative management
Limit caffeine and fluid intake
Weight loss
Pelvic floor exercises - 3 months
Bladder training - 6 weeks
Antimuscarinics can be used to treat an overactive bladder. Name some.
How do they work?
What are the side effects?
Antimuscarinics - oxybutinin, tolterodine, darifenicin
How they work
- reduce the intra-vesical pressure
- increase compliance
- raise the volume threshold for micturition
- reduce the number of uninhibited bladder contractions
Side effects (of all antimuscarinics)
- dry mouth
- constipation
- blurred vision
- somnolence
Because of side effects, most patients do not complete the first 3 months of treatment with antimuscarinics
What new class of drug, tolerated better than antimuscarinics, are now being used to treat overactive bladders?
How do they work?
What is the downside?
Beta 3 agonists - mirabegron
Selective agonist of the beta3 adrenoreceptors in the bladder with low intrinsic activity for beta1 and beta2.
Causes relaxation of the smooth muscle in the bladder. Increase the voiding interval and inhibit spontaneous bladder contractions during filling.
Work well, but they’re expensive
What other treatments are there for overactive bladder?
Desmopressin
Topical oestrogen
Botox
Percutaneous sacral nerve stimulation
Augmentation cystoplasty (surgical)
How can stress urinary incontinence be treated, other than conservatively?
SNRIs - duloxetine, increases the intraurethral closing pressure
Pessaries
Surgery
- tension free tape
- colposuspension
- intramural bulking agents
What compartments can pelvic organ prolapse be divided into? Give an example of each
Anterior - cystocele (most common form of POP)
Middle/Apical - enterocele
Posterior - rectocele
Complete eversion (all compartments) - complete uterine procidentia
Cystocele - symptoms
More commonly bladder symptoms
- bulging
- pressure
- mass
- difficulty voiding, incomplete emptying
- difficulty inserting tampons
- dysparenuria
Enterocele - symptoms
As with cystocele
- bulging
- pressure
- mass
- difficulty voiding and incomplete emptying
- difficulty inserting tampons
- dysparenuria
Rectocele - symptoms
More commonly bowel symptoms
- difficulty defaecating
- incomplete emptying
- difficulty inserting tampon
What are some of the contributing factors that increase the risk of pelvic organ prolapse?
Age
Parity and history of vaginal delivery
Obesity
Post-menopausal oestrogen deficiency
Neurological conditions e.g. spina bifida, muscular dystrophy
Genetic connective tissue disorders e.g. Marfan’s, Ehlers-Danlos
When someone presents with a suspected prolapse and you are trying to work out which type, what kind of questions would you ask them?
Pressure or dragging?
Urinary symptoms - would indicate cystocele or enterocele
Bowel symptoms - would indicate rectocele
Sexual dysfunction or difficulty inserting tampon - enterocele
What scoring system is used for pelvic organ prolapse?
Pelvic Organ Prolapse Quantification System (POP-Q)
Staging
- Stage 0 - no prolapse
- Stage 1 - 1cm above hymenal ring (“fixed point”)
- Stage 2 - -1 and +1 in relation to hymen
- Stage 3 - >1cm beyond hymen
- Stage 4 - complete vaginal eversion
What management options are there for pelvic organ prolapse?
Depends largely on the patient’s choice
Conservative management - reduce BMI, pelvic floor exercises for 3 months
Mechanical devices (pessaries)
Surgery
What are some of the potential complications associated with pessaries?
What should you do to use a pessary as effectively as possible?
Failure/discomfort
Discharge
Ulcerations (possibly resulting in fistula formation)
Fibrous bands developing
Replace every 6 months and use topical oestrogen alongside
What surgical options are available to manage pelvic organ prolapse?
Anterior or posterior vaginal repair
Apical - vaginal (sacrospinous fixation, colpocliesis which is basically just closing over the vagina), abdominal (sacrohysteropexy, sacrocolpopexy, pectopexy)
What does DR C BRAVADO refer to and what is it used for?
Mneumonic for intepreting Foetal Heart Rate tracings
DR - define risk (low or high)
C - contractions (comment on frquency)
BRa - Baseline Rate (bradycardia, normal, or tachycardia)
V - Variability (at least 10-15bpm, persistent reduced variability is bad)
A - Accelerations
D - Decelerations
O - Overall assessment (category I, II or III)
