WOMEN'S HEALTH 1 - Obstetrics Flashcards
What is meant by baby blues? How long does it last for?
a period of low mood and irritability, which normally starts three to four days after birth, and lasts for 1-2 weeks.
Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.
Happens in over 50% of mothers
What is seen in Postnatal depression? How long must symptoms be going on before a diagnosis can be made?
a depressive episode within the first twelve months postpartum, peak incidence is 2 months after birth
Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of:
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
Symptoms should last at least two weeks before postnatal depression is diagnosed.
What percentage of mothers experience post natal depression? What screening tools can be used to establish this?
Edinburgh Postnatal depression score - Score of 10 or more can indicate depression
Patient Health Questionnaire-9
Around 10% of mothers will experience post natal depression
What is some of the treatment for post natal depression? What would be the medication of choice
self-help strategies and non-directive counselling (‘listening visits’ by a health visitor).
Moderate to severe depression usually requires treatment with antidepressant medication and/or psychotherapy (CBT).
Breast-feeding is not a contraindication for antidepressant treatment, but drugs with low excretion in breastmilk, such as sertraline, are preferred.
High levels of Fluoxetine can transfer in breast milk
What is the problem with SSRIs in pregnancy?
Can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome).
It presents in the first few days after birth with symptoms such as irritability and poor feeding.
What is seen in postpartum psychosis?
Postpartum psychosis – 1-2:1000
Depression
Mania
Psychosis
What is the treatment of puerperal psychosis?
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications
Electroconvulsive therapy (ECT)
What is the partogram
A partogram or partograph is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs.
Outline what is meant by the terms - alert line and action line in reference to the partogram
ALERT Line:
Mean rate of the slowest progress of labour
ACTION Line:
Appropriate action should be taken
If a patient crossed this action line, they were referred into a tertiary unit.
outline some things seen in the partogram
The progress of labor:
cervical dilatation, descent of head (-5 to +5)** and uterine contractions
The fetal condition:
fetal heart rate, color of amniotic fluid and moulding of the fetal skull
Maternal condition:
pulse, BP, temperature, urine output and urine for protein
A separate space is given to enter drugs, IV fluids and oxytocin
According ot current guidelines above what dilation is active labour? What is the rate of dilation needed
Current UK guidelines based off partogram
Active phase≥4cm
Fixed 1cm/hour alert and action lines
WHO definition
Active phase≥5cm
Name some non pharmalogical pain relief options in labour
Water
May help relaxation and contractions feel less painful
Works immediately
TENS
Gentle electric current passes through pads on their back
Can control strength
Mild tingling feeling,reduce backache in early labour
Alternative
Hypotherapy, Acupunucture
Outline the where the pain is coming from in the first and second stages of laboour
First stage -
Pain from lower uterine and cervical change
Visceral afferent nerve fibres
T10-L1 Segments
Second stage -
Pain from distension of the pelvic floor, vagina and perineum
Somatic nerve fibres, pelvic splanchnic and pudendal nerve
S2-S4
Give some pharmacological therapies that can be used to help manage labour pain.
- Gas and air - entonox.
- Paracetamol.
- Opioids e.g. pethidine, diamorphine.
- Epidural.
- Spinal anaesthesia.
PCIA - Patient controlled analgesia
Give 3 potential side effects of opioids.
- Sedation.
- Respiratory depression.
- Nausea and vomiting.
- They cross the placenta readily.
What are some features/considerations for using entonox
Nitrous oxide and oxygen
Works immediately, affects stop immediately when you stop using
Spaced out, nauseas,tiring, mouth dry
Don’t use when pushing
Outline some features/considerations when using PCIA
What is the name of the drug used?
Patient controlled analgesia
Remifentanil
Requires the patient to press a button everytime they feel a contraction coming
Works within 30s and wears off after a few minutes
Often entonox used as well
Baby – may be slow to breath at first
Mum – sickness, sleepiness, slow breathing, O2 via nasal cannula (pulse ox monitoring)
Outline what an Epidural is.
An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF.
What level is an epidural normally administered in and what level does it need to be extended to to cover for an emergency CS?
T8-T10 for normal pain
Extended up to T4 for Emergency CS
What are some things that may point to epidurals needed to be given in childbirth? What are some things where an epidural is contraindicated?
Epidurals may be used to treat maternal conditions that could be worsened by labor and delivery, such as:
Pre-eclampsia
Previous C-section
Breech presentation
Multiple pregnancy
Morbid obesity (BMI ≥40)
Serious cardiovascular or respiratory disease
epidural anaesthesia should reduce blood pressure.
Epidurals are contraindicated in certain situations, including: Severe thrombocytopenia, Coagulopathy, Sepsis, Allergy to (levo)bupivacaine, and Allergy to fentanyl.
What are some drugs given as an epidural? What are some side effects are there of these
Anaesthetic options are levobupivacaine or bupivacaine, usually mixed with fentanyl.
Adverse effects:
Headache after insertion
Hypotension
Can take up to an hour to take an effect
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
Until what week can a women legally have an abortion? What act relates to this
The legal framework for a termination of pregnancy is the 1967 Abortion Act. The 1990 Human Fertilisation and Embryology Act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks.
What are the legal requirements for an abortion?
The legal requirements for an abortion are:
Two registered medical practitioners must sign to agree abortion is indicated
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
There is a conscious clause for doctors in the abortion act
When can an abortion be performed at any time during pregnancy?
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
Outline what would happen in a medical abortion - when do they most commonly happen?
most appropriate earlier in pregnancy, but can be used at any gestation.
It involves two treatments:
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
Outline what happens in a surgical abortion?
Prime cervix with medciiens - same as the ones used in medical abortion - Misoprostal and mifepristone and osmotic dilators that absorb fluid and open cervical canal
There are two options for surgical abortion:
Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Define puerperium.
The period from placental delivery to 6w after birth - the post-natal period.
the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.
Give 2 endocrine changes that occur during puerperium.
Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progesterone)
Increase of prolactin - as placenta is delivered
Give 3 physiological changes that occur during puerperium.
Involution of the uterus. uterus returning to pre pregnant state
Decidua sheds as lochia. - decidua -maternal uterine tissue
Lactation.
Define Gravidity and Parity?
Gravidity = total number of pregnancies regardless of outcome,
Parity = total number of pregnancies carried over the threshold of viability (24w)
Give 6 physiological changes that occur during pregnancy?
ncreased blood volume, increased cardiac output, increased stroke volume, increased heart rate,
Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre)
Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm
Maternal blood volume up 30%, mostly in 2nd half
red cells up 20% but plasma up 50% → Hb falls
Low grade increase in coagulant activity
rise in fibrinogen and Factors VII, VIII, X
Biochemical changes
calcium requirements increase during pregnancy
especially during 3rd trimester + continues into lactation
increased intra-gastric pressure, decreased gut motility, increased fibrinogen and clotting factors, increased total T3 T4 levels, increased uterine size
Describe the physiology behind the involution of the uterus
There is muscle ischaemia, autolysis and phagocytosis -> involution of the uterus.
- becomes fibrous tissue - more prone to rupture in future prengancies
If can still feel uterus above belly button after a couple of days, be concerned eg Endometrisus
The decidua sheds as lochia, what are the three stages of this process called?
How long does this take?
- Lochia rubra.
- Lochia serosa.
- Lochia alba.
RSA
Generally lasts 4-6 weeks
What is the name of the breast milk that is produced at birth?
Colostrum.
What does colostrum contain?
- Protein rich.
- Vitamin A.
- NaCl.
- GF’s.
- Antibodies.
- Lactoferrin.
Briefly describe the physiology of lactation.
Baby suckles -> nipples send impulses to brain -> prolactin is released from the ant.pituitary -> milk is produced by lactocytes -> oxytocin is released from the post.pituitary -> myoepithelial contraction -> milk ejection.
– Oxytocin –> stimulates milk ejection from the breast as well as uterine contractions
Anterior first (Prolactin), then posterior (Oxy)
Give some benefits for mother and baby of breastfeeding
Maternal:
– Faster uterine involution, bonding, contraception,
– Protection from breast/ovarian/endometrial cancer.
Infant:
– Lower incidence of diarrhoea, necrotising enterocolitis (NEC),
– Lower incidence of otitis media and respiratory tract infections
Milk contains all the nutrients the infant needs (except vitamin D and K) up till 6 months of age.
Name 3 minor things that women are at risk of during puerperium.
- Infection.
- Haemorrhage.
- Fatigue.
- Anaemia.
- Back pain.
- Haemorrhoids.
Name 3 major things that women are at risk of during puerperium.
- Sepsis.
- Sever haemorrhage.
- Pre-eclampsia.
- VTE.
- Prolapse.
- Incontinence.
- Depression.
Give 3 risk factors for sepsis in pregnancy.
- Obesity.
- Anaemia.
- Diabetes.
- Amniocentesis/invasive procedures
.Impaired immunity/ immunosuppressant medication - Prolonged spontaneous rupture of membranes
Group A Strep infection inclose contacts / familymembers
History of pelvic infection
History of group B Strepinfection
What can infections can lead to sepsis in pregnancy?
- Endometritis.
- Skin infections.
- Pyelonephritis.
- Chorioamnionitis.
- Pneumonia.
Define PPH.
Post-partum haemorrhage: >500ml estimated blood loss after birth of baby.
Define major PPH.
> 1500ml blood loss and continuing to bleed/signs of shock.
For a woman of 70kg a blood loss of more than 40% of her total blood volume (2,800mls) is generally regarded as life threatening
Either primary - within first 24 hours (most often immediately after delivery) or secondary - After 24 hours and up to 12 weeks post delivery
What are some causes of a primary Post partum haemorrhage?
Tone (uterine atony most commonly)
Trauma (large baby)
Thrombus (clots)
Tissue (fibroids)
– In addition, it can be caused by abnormalities of the placenta (placenta previa/accrete)
Uterine atony = soft and weak uterus after childbirth. It happens when your uterine muscles don’t contract enough to clamp the placental blood vessels shut after childbirth
What is the management of a post partum haemorrhage?
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
Outline the treatment to help stop the bleeding in a post partum haemorrhage
1st line –> Apply bimanual compression (pressure aims to compress uterine arteries) with fundal massage
– 2nd line is medical management –> IV syntocinon/Syntometrine (oxytocin) 10 units or IM ergometrine (strong vasoconstrictor)
– You can also use IM Carboprost (Haemobate)
(prostaglandin which aids uterine contraction) avoid in asthama!
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
If still bleeding take to operating theatre for surgical approaches.
– 1st line is Bakri balloon tamponade (also called intra-uterine Bakri catheter)–> used if uterine atony is main cause
– If uncontrolled, B-lynch suture or uterine artery embolism
– If still not controlled –> ligate internal branch of the internal iliac artery
– Last resort is hysterectomy
What is secondary PPH? What can cause it?
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
What are some investigations for Secondary PPH and outline the management of it
Investigations involve:
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection
Management depends on the cause:
Surgical evaluation of retained products of conception
Antibiotics for infection
Give 5 risk factors for VTE in pregnancy.
- Increasing gestational age.
- Obesity.
- Smoking.
- C-section.
- Family history.
- Immobility.
- Multiple pregnancy e.g. twins.
- Previous VTE.
When is a woman at the greatest risk of VTE?
The risk is greatest just after giving birth, in the post partum period.#
Pregnant woman with a previous VTE history: LMWH throughout pregnancy until 6 weeks postnatal
enoxaparin
What medication can be given postnatally to reduce a woman’s risk of VTE?
LMWH. eg Enoxaparin or Dalteparin
TED stockings.
Pregnant woman with a previous VTE history: LMWH throughout pregnancy until 6 weeks postnatal
What is the investigations you would do in a pregant women with a suspected DVT?
Doppler ultrasound
TOM TIP: The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
What are the investigations you would do in a suspected PE in a pregnant women?
Women with suspected pulmonary embolism require:
Chest xray
ECG
CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan.
VQ scan - inhale isotpes and compare the ventilation and perfusion of the lungs - In PE will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue.
What is the management of a massive PE in a pregnant women
Women with a massive PE and haemodynamic compromise need immediate management by an experienced team of medical doctors, obstetricians, radiologists and others.
treat with LMWH first (eg enoxaparin) then investigate to rule in/out
Unfractionated heparin
Thrombolysis
Surgical embolectomy
Describe the physiology behind a post dural puncture headache?
Accidental dural puncture -> CSF leakage and decreased pressure in fluid around the brain.
How would you treat a post dural puncture headache?
Lying flat!
Simple analgesia
Fluids and caffeine??
Epidural blood patch - injecting a bit of patients own blood into epidural sapce to stop leak of CSF
Define sepsis. Define septic shock
Sepsis is a condition where the body launches a large immune response to an infection, causing large systemic inflammation and affecting the functioning of the organs of the body
Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.
What are the two key causes of sepsis in pregnancy?
Chorioamnionitis
Urinary tract infections
What is chorioamnionitis?
What is its most common cause
Chorioamnionitis is an infection of the chorioamniotic membranes (what makes up the sac that surrounds the embryo) and amniotic fluid.
E coli is most common
What are some key features of sepsis?
(3Ts white with sugar)
Temperature <36 or >38 degrees
Tachycardia -Heart rate > 90bpm (PN)
Tachypnoea - Respiratory rate > 20bpm
WCC >12 or <4 x 109/l
Hyperglycaemia >7.7mmol
Low blood pressure
Altered consciousness
Reduced urine output
What is the some of the management steps for dealing with maternal sepsis?
Bloods cultures
Urine output
Fluid Resuscitation
Antibiotics
Lactate
Oxygen
piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.
What is an ectopic pregnancy?
Where does it most commonly occur, and where is the most common site of ruputre/most dangerous?
Is when a pregnancy is is implanted outside the uterus, the most common site fallopian tube. (specifically the ampulla)
most dangerous if in the the isthmus
Can also occur at the entrance to the fallopian tube, ovary, cervix or abdomen
What are sime risk factors for an ectopic pregnancy?
Previous ectopic pregnancy
Previous PID
Previous surgery to the fallopian tubes
Black ethnicity
Intrauterine devices!!
Older age
Smoking
Endometriosis
The progesterone only pill is a risk factor because it slows the passage of the ovum through the fallopian
tube.
in 1/3 of ectopic pregnancies, there will be no risk factors
How may an ectopic pregnancy present?
What is the recurrance rate of one ectopic pregnacy?
typically presents around 6 – 8 weeks gestation.
Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations.
can be asymptomatic
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Shoulder tip pain (referred pain from the diaphragm)
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
18.5%
What is the investigation of choice for an ectopic pregnancy? What would you see on this?
Serum HCG - pregnancy test
BhCG <63% increase over 48h
FBC, clotting, - to see if haemodynamically stable
A transvaginal ultrasound scan - gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign
A mass representing a tubal ectopic pregnancy moves separately to the ovary. (a corpus luteum will look similar to this, but will move with the ovary)
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”) = so is not diagnostic of an ectopic
serum b-HCG can also be performed
What is a pregnancy of unknown location?
When a women has a positive pregnancy test and there is no evidence of pregnancy on an ultrasound scan
How do you monitor a PUL?
What does HCG levels do in an intrauterine pregnacy vs an ectopic or misscarriage?
it is important to obtain a baseline and repeat beta hCG
in 48hrs.
In an intrauterine pregnancy hCG will double every 48 hours, it won’t in an miscarriage or ectopic pregnancy .
Once levels are above 1500 should be able to see on USS
A fall of more than 50% is likely to indicate a miscarriage
What is the management for an ectopic pregnancy?
Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service.
All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy.
3 options
Expectant management (awaiting natural termination, conervative)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)
(Methotrexate: must be stopped at least 6 months before conception in both men and women)
Ectopic pregnancies - What is the criteria for expectant management?
Follow up needs to be possible to ensure successful termination
Patient must be clincally stable and pain free
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1000 IU / l
- repeat hCG on day 2, 4, 7 - should fall my 15% within 7 days , repeat weekly unitl IUL is <20
What are some things to consider when giving methotrexate to manage an ectopic pregnancy?
When would it be appropriate to give?
(Methotrexate: must be stopped at least 6 months before conception in both men and women)
Methotrexate is highly teratogenic (harmful to pregnancy). It is given as an intramuscular injection into a buttock.
Give if size is <35mm
No fetal Heartbeat
hCG <1,500IU/L
can only be done if the patient is willing to attend follow-up.
Women treated with methotrexate are advised not to get pregnant for 3 months following treatment.
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
What are the indications for surgical management of an ectopic pregnancy?
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
Laparoscopic salpingectomy = remove affected fallopian tube - is first-line for women with no other risk factors for infertility
Laparoscopic salpingotomy - used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube - just remove ectopic pregnancy
around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
What is a miscarriage defined by? In what % of pregnacies does a miscarriage occur?
Miscarriage is the spontaneous termination of a pregnancy.
Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.#
Occurs in 20% of pregnancies
Define what a missed miscarriage is
the fetus is no longer alive, but no symptoms have occurred
Define what a
Threatened
Inevitable miscarriage is
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Define what an
Incomplete
Complete
Miscarriage is
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Give some potential causes of miscarriage
Abnormal foetal development.
Uterine abnormality.
Incompetent cervix.
Placental failure.
Multiple pregnancy.
Think structures (uterus, placenta, cervix not working properly)
Give some risk factors for miscarriage.
Age >30.
Smoking.
Excessive alcohol consumption.
Uterine surgery.
Poorly controlled diabetes.
What investigations might you do to determine whether someone has had a miscarriage?
Transvaginal USS.
Serum hCG.
Describe the management of a miscarriage.
missed miscarriage =
oral mifepristone. 48 hours later, misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed
incomplete miscarriage =
a single dose of misoprostol (vaginal, oral or sublingual)
women should be offered antiemetics and pain relief
a pregnancy test should be performed at 3 weeks
Vaginal misoprostol. (helps stimulate uterine contractions, to make sure everything is delivered)
If there is evidence of infection and haemodynamic instability in the context of a miscarriage, surgical intervention with vacuum aspiration would be an appropriate surgical management
Manual vacuum aspiration.
Counseling and support.
What are identical twins known as? What are non identical twins known as?
Monozygotic: identical twins (from a single zygote)
Dizygotic: non-identical (from two different zygotes)
What terms describe whether a placenta and amniotic sack are shared or separated for twins? What combination has the best outcome?
Monoamniotic: single amniotic sac
Diamniotic: two separate amniotic sacs
Monochorionic: share a single placenta
Dichorionic: two separate placentas
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
How is multiple births diagnosed?
on the booking ultrasound scan. Ultrasound is also used to determine the:
Gestational age
Number of placentas (chorionicity) and amniotic sacs (amnionicity)
Risk of Down’s syndrome (as part of the combined test)
What are some maternal complications of having a multiple birth?
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
What are some foteal/neonatal complications of a multiple birth?
Risks to the fetuses and neonates:
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
Outline what happens in Twin-twin transfusion syndrome and Twin anaemia polycythaemia sequence
occurs when the fetuses share a placenta.
one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios.
Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
Name some obstetric conditions that obesity is a huge risk factor for
Pre-eclampsia
Sepsis
Shoulder Dystocia
Gestational diabetes
Name 3 reproductive disorders that are associated with obesity.
PCOS.
Miscarriage.
Infertility.
Outline some physiological changes that happen to glucose metabolism in pregnant women.
Glucose tolerance decreases with increasing gestation after the first trimester
Largely due to anti-insulin hormones secreted by the placenta in normal pregnancy (human placental lactogen, glucagon and cortisol)
What can an increased glucose tolerance seen in prengancy lead to?
Normal women show an approx. doubling of insulin production from the end of the first trimester to the third trimester
Likely to underlie the increased insulin requirements of women with existing diabetes
Lead to the development of abnormal glucose tolerance in gestational diabetes - where there is insufficient insulin secretion to compensate for the insulin resistance
What is Gestational diabetes, and what are some risk factors for getting it?
Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
What tests do you do to screen for gestational diabetes, if there are risk factors?
What week gestation do you do it?
Oral Glucose Tolerance Test
An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
screening is offered at 24-28 weeks,
Normal results are:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than this suggest gestational diabetes
remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.
What is the management of women with gestational diabetes?
The initial management suggested by the NICE guidelines (2015) is:
Fasting glucose less than 7 mmol/l (5.6-7): trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Gestational diabetes is treated with short-acting, but not longer-acting SC insulin
. Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.
What is some of the obstetric management seen in women with diabetes?
Monitoring for pre-eclampsia with regular BP and urine checks
Regular fetal growth scans (usually 28, 32 and 36 weeks) – to assess fetal size, growth velocity and enable delivery planning
Timing of delivery – induction of labour or planned caesarean section
For uncomplicated GDM – delivery by 40+6
For complicated GDM – 37 – 38+6
Intrapartum care
Fetal monitoring
Hourly monitoring of blood glucose
May need variable rate insulin infusion to maintain blood glucose
What is some medication that is given to woman with Diabetes 1 or 2 when they are pregnant? What key screening is offered?
Aspirin 150mg once daily from 12 weeks until delivery – to reduce risk of pre-eclampsia
Folic acid 5mg ideally from preconception (or as early as possible) until 14 weeks
Retinopathy screening should be performed shortly after booking and at 28 weeks gestation.
Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.
Aspirin should be stopped before delivery, as it is contraindicated in breast feeding
What are some complications of gestational diabetes?
macrosomia and neonatal hypoglycaemia.
macrosomia poses a risk of shoulder dystocia
What are some fetal problems assossciated with maternal diabetes?
Why are foetus in mothers w gestational diabetes macrosomic?
congenital malformations
Intrauterine growth restriction
macrosomia =maternal hyperglycaemia
causes fetal hyperglycaemia as glucose crosses the
placenta, foetus secretes more insulin that promotes growth
An increase in foetal blood glucose brings about a
hyperinsulinaem ia in the foetus, leading to increased fat
deposition.
What are some neonatal problems associated with maternal diabetses
- hypoglycaemia
-
respiratory distress syndrome – more common as
lung maturation is delayed -
hypertrophic cardiomyopathy – hypertrophy of the
cardiac septum occurs in some infants. It regresses
over several weeks but may cause heart failure
from reduced left ventricular function -
polycythaemia (venous haematocrit >0.65)
– makes the infant look plethoric. (plethora = polycythaemia of newborns)**
What are some causes of primary hypertension?
It has multifactorial aetiology
Genetic factors – can run in families 40%-60% have a genetic component
Foetal factors – low birth weight is associated with hypertension
Obesity
High alcohol Alcohol intake
Insulin intolerance
Lack of physical activity
Metabolic Syndrome X cluster of conditions, such as high insulin levels, glucose intolerance, low levels of HDLs, central obesity
What are some main causes of secondary hypertension?
○ Renal e.g. CKD
○ Endocrine e.g. Conn’s syndrome, acromegaly, Cushing’s syndrome
○ Coarctation of the aorta
○ Pre-eclampsia occurring during third trimester of pregnancy
Outline the pathophysiology behind some of the issues that hypertension does to the body.
Hypertension - Causes arteries to common less compliant, and narrowing of the lumen
Can lead to Hyaline arteriosclerosis, which is protein deposition in the arterial wall,
Lead to atherosclerosis and aneurysms forming - stroke
Endothelial damage = CAD, ACS
Hypertension medication - what is the first line treatment for someone who is NOT black, and under 55 years
ACE-Inhibitor e.g. Ramipril (or angiotensin receptor blocker e.g. candesartan if contraindicated e.g. due to cough)
Hypertension medication - what is the first line treatment for someone who is black, or over 55 years
calcium channel blocker e.g. amlodipine
Hypertension medication - what is the second line treatment for hypertension?
ACE-inhibitor + CCB
Or if afro Caribbean - CCB and ARB/ACEi or Thiazide like Diuretic
What is the first line medication given to anyone with T2DM, regardless of age or race?
ACEi, eg Ramipril
Hypertension medicine - when would a Angiotensin receptor blocker be given? Give a example of one
eg Candesartan
It’s given instead of an ACE-inhibitor, if a ACE-i is contraindicated.
You give ACE-i to anyone who is younger than 55, or not Black afro Caribbean, or someone with Diabetes at any age .
Define chronic hypertension.
time frames!
A patient with high BP which is diagnosed prior to pregnancy or before week 20 of pregnancy
Their high BP is not resolved postpartum.
Define gestational hypertension.
time frames!
New high BP after 20w gestation and resolves after giving birth. There is no proteinuria or end organ damage
Define preeclampsia and eclampsia - what is the triad seen in preeclampsia?
Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction
Pre-eclampsia features a triad of:
Hypertension
Proteinuria
Oedema
Can also see
Severe headache, visual disturbance, clonus, liver tenderness, abnormal liver enzymes,. plate count low
Eclampsia is when seizures occur as a result of pre-eclampsia.
Outline the pathophysiology behind pre eclampsia
Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction
HWhat are some risk factors for preeclampsia?
High-risk factors are:
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
Moderate-risk factors are:
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
GIve aspirin for either 1 high risk or 2 low risk factors
What are some symptoms of preeclampsia?
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
How can a diagnosis of pre-eclampsia be made?
When would preeclamptic mothers need to go to hospital?
The NICE guidelines (2019) advise a diagnosis can be made with a:
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
. Since pre-eclampsia is being considered the GP should refer the patient to the nearest obstetric emergency department.
What is the prophlyatic managment of pre eclampsia, and when would you give it?
Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with:
A single high-risk factor
Two or more moderate-risk factors
aspirin is CI in breastfeeding btw
What are some risk factors for pre eclampsia, that would warrant giving aspirin 75-150mg daily from 12 weeks gestation until the birth
A single high-risk factor
Two or more moderate-risk factors
High risk factors
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
Moderate
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
What is the management of pre-eclampsia?
Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) is commonly used second-line (needs to be rapidly acting)
Treat coagulation defects,
Check bloods, eg platelet, renal and liver
magnesium sulphate if hyperreflexia (also prevents seizures in pregnant woman w eclampsia) Respiratory rate is the most important parameter to monitor when administering magnesium sulphate for eclampsia, as it can cause respiratory depression
Planned early birth may be necessary if the blood pressure cannot be controlled, or decline in liver or renal function (monitor these closely)
^This should resolve the pre eclampsia
Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.
Limit fluid intake as low protein, so extra fluids can cause oedema
What are some complicatons of pre eclampsia?
Fetal growth restriction. Preeclampsia affects the arteries carrying blood to the placenta
Preterm birth.
Placental abruption.
hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome.
Eclampsia.
Stroke
Renal Failure
oligohydramnos
How do you manage eclampsia?
Whats the key parameter you need to monitor with this medication, and how could you reverese it if needed?
Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate (4g vein over 15 minutes, followed by an infusion of 1g/hour maintained for 24 hours) is used to manage seizures associated with pre-eclampsia.
any seizure in a pregnant woman are always eclampsia until proven otherwise
Respiratory rate is the most important parameter to monitor when administering magnesium sulphate for eclampsia, as it can cause respiratory depression - reverse with Calcium Gluconate
What acronym syndrome can occur as a complication of preeclampsia and eclampsia?
HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:
Haemolysis
Elevated Liver enzymes
Low Platelets
How can pregnancy affect anaemia
2-fold increase in iron requirements -> micro-cytic aneamia.
B12/folate deficiency -> macrocytic anaemia.
During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentratio
What are the normal ranges for hemoglobin during pregnancy?
Booking bloods
> 110 g/l
28 weeks gestation
> 105 g/l
Post partum
> 100 g/l
What pregeancy related causes can be indicated in a normal/high/low MCV anaemia?
Low MCV may indicate iron deficiency
Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy
Raised MCV may indicate B12 or folate deficiency
What is the management of anaemia in pregancy?
How much folate should pregnant woman take a day?
What groups need more
How do you take folate for
iron replacement (e.g. ferrous sulphate 200mg three times daily).
not anaemic but low ferritin - supplementary iron.
. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). -Intramuscular hydroxocobalamin injections
All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily
Women on antiepileptics, who try to conceive, should receive folic acid 5mg instead of 400mcg OD
Diabetics, those with thalasseamia trait, coeliac disease also need 5mg of folic acid as well
as do obese pregnant women (>30BMI)
folic acid daily until the 13th week of pregnancy, (for the first trimester only)
What are the symptoms of gonorrhoeae?
Asymptomatic (50%)
Malodorous, purulent discharge from the urethra, cervix, vagina,3 to 5 days after exposure (40% to 60%)
Simultaneous urethral infection (70% to 90%)
Infection of the pharynx (10% to 20%)
Gonococcal conjunctivitis (can rapidly lead to
blindness)
Polyarthritis
Later on, can cause intermenstraul bleeding, pain when weeing, and lead to PID - which can lead to problems with fertililty
What test do you use to diagnose Gonorrhoea?
Male - urine, or urethreal swab if discharge -
Female - Swab of endocervical cannal
Rectum
NAAT testing for both
if not
Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs
Culture on Gonococcus agar
What is the treatment for gonorrhoea?
A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
What prophylactic antibiotic do we give to women going into labour who have group B streptococcal colonisation, bacteriuria or infection during the current pregnancy, or a clinical diagnosis of chorioamnionitis
Women without chorioamnionitis
Use Benzylpenicillin.
Women with chorioamnionitis
Use Benzylpenicillin plus gentamicin plus metronidazole.
Gentamicin = Aminoglycoside (For gram neg)
Metronidazole = For anaearobic cover
What are some consquences for mother and neonate of a chlamydia infection?
Mother -
Can be Asymptomatic
Preterm labor
Chorioamnionitis
PID
For neonate -
Conjunctivitis
Pneumonia
What would someone with secondary syphilis present with?
ypically starts after the chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions
What is the common presentionation of endometritis? When does it most commonly occur?
Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding.
It occurs most commonly 5–10 days after delivery.
What is Mastitis, and what is the most common cause of it?
This is a condition that refers to inflammation of the breast
– It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus
What are some signs and symptoms of mastitis, and what is the management of it?
Erythematous, tender, swollen area of breast
– Systemic upset with fevers, chills and fatigue
– 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied
– If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days
What is breast engorgement? When and why can it happen?
Caused by vascular
and lymphatic stasis
May occur on days 2–4 postpartum in women who are not nursing
or at any time if breastfeeding is interrupted.
Management conservatively with ice packs and painkillers
What is the presentation of Trichomoniasis? What is the management for it?
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis
What is Oligohydramnios?
This is the term used to describe an abnormally low level of amniotic fluid during pregnancy
– It is characterised by having less than <500ml at 32-36 weeks and amniotic fluid index (AFI) <5th percentile
Prevalence: Rare in early pregnancy, common in postterm pregnancies (12% to 25% at 41 weeks).
What are some Causes of oligohydramnios?
Causes:
– Low production of foetal urine –> Renal agenesis (Potter’s syndrome), dysplastic kidney, obstructive uropathy
– Poor Placental diffusion –> Pre-eclampsia
– Leakage of amniotic fluid –> Premature rupture of membranes - Causes 50% or oligohydramnios
Other causes include congenital infection, fetal cardiac defects, neural tube defects, twin–twin transfusion syndrome, and non-steroidal antiinflammatory drugs
What are some complications that Oligohydrosis can lead to?
– Abnormal lie and development
– Poor respiratory development –> amniotic fluid is needed for maturation of the alveoli, so infants are born with severe respiratory distress
– Foetal muscle contractures (as amniotic fluid allows the fetus to move its limbs in utero)
Amniotic band syndrome (adhesions between the
amnion and fetus causing serious deformities, including limb amputation) or musculoskeletal deformities due to uterine compression (such
as clubfoot) may develop in some cases.
What are some cause of Polyhydramnios?
– It is idiopathic in the majority of cases
Maternal Diabetes, as amniotic fluid is dependent on
degree of glycemic control, and macrosomia (big babies produce more urine)
– Twin-to-twin transfusion syndrome –> leads to oligohydramnios for one and polyhydramnios for the other
– Decreased swallowing of fluid –> foetal oesophageal/duodenal atresia or CNS abnormalities
_ hydrops fetalis (foetal heart failure)
Regarding Malpresentations of a foetus, what are the three definitions that you need to know?
Lie - the relationship between the long axis of the fetus and the mother.
Presentation - the fetal part that first enters the maternal pelvis.
Position – the position of the fetal head as it exits the birth canal.
What are the different types of malpresentation you may see
Cephalic vertex presentation is the most common and is considered the safest
Other presentations include breech, shoulder, face and brow
What are the different types of abnormal lie you may see?
Longitudinal, transverse or oblique
How would you manage abnormal lie?
external cephalic version (ECV) is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.
C section delivery if unsuccessful
It has an approximate success rate of 50% in primiparous women and 60% in multiparous women.
How do you manage the different types of malposition?
Breech – attempt ECV before labour, vaginal breech delivery or C-section
Brow – a C-section is necessary
Face - chin is anterior (mento-anterior) a try normal labour then C section
chin is posterior (mento-posterior) then a C-section is necessary
Shoulder – a C-section is necessary
What are the 3 main types of breach postion? What is the most dangerous?
– Complete –> this is where the complete caudal end of the fetus is in the lower segment
- Frank –> this is the most common where buttocks occupy the lower segment
– Footling –> this is the most dangerous form where the foot is in the pelvis
What are some risk factors for a breach delivery?
– Mother –> Malformations of the uterus, large fibroids, previous uterine surgery
– Pregnancy –> Placenta Praevia, poly/oligohydramnios, prematurity
What is a Uterine ruputre? What are the two types
Uterine rupture refers to a full-thickness disruption of the uterine muscle and overlying serosa. It typically occurs during labour, and can extend to affect the bladder or broad ligament.
There are two main types:
Incomplete – uterine serosa (perimetrium) surrounding the uterus remains intact.. In this case, the uterine contents remain within the uterus.
Complete – complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
What is the presentation of a uterine rupture?
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
How many stages of labour are there? What 2 things can trigger the onset of labour?
There are 3 stages.
in the third trimester, before Labor starts , a woman might have a plug of mucus and blood fall out of the opening to the cervix sometimes called the bloody shell
other times the amniotic sac might rupture sometimes called water breaking either of these can trigger the onset of Labor - this releases loads of prostaglandins which stimulate labour
Outline what happens in the first stage of labour.
The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner from front to back).
Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. (can take 24 hours in primgravida)
Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. (can take 4-6 hours in primigravida) (examination every 4 hours)
Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
What does the second stage of labour consist of, and what does this stage depend on?
The second stage of labour lasts from 10cm dilatation of the cervix to delivery of the baby
The success of the second stage depends on “the three Ps”: power, passenger and passage.
What descriptive qualities are outline in “passenger” in the second stage of labour?
Size: particularly the size of the head as this is the largest part.
Attitude: the posture of the fetus. For example, how the back is rounded and how the head and limbs are flexed.
Lie: the position of the fetus in relation to the mother’s body:
Presentation: the part of the fetus closest to the cervix:
What happens in the third stage of labour?
The third stage of labour is from the completed birth of the baby to the delivery of the placenta.
Can be done naturally/physiologically
or Active management from Dr or Midwife
==>involves giving a dose of intramuscular oxytocin to help the uterus contract and expel the placenta.
Careful traction is applied to the umbilical cord to guide the placenta out of the uterus and vagina.
Give some risk factors for having a premature baby.
Intra-amniotic infection 50
Multiple gestation 40
Placental abruption 35
Third trimester vaginal bleeding 10
Second trimester vaginal bleeding 2
Prior preterm delivery 2–5
numbers are relative risk
What things are seen in the clinical picture of Premmature rupture of the membranes?
A history of Gush of fluid causing a woman to be constantly wet
On speculum exam
Pooling of fluid in posterior vaginal fornix.
Or
Absence of vaginal discharge.
1 A pool of vaginal fluid
2 Fluid turns nitrazine paper blue (pH of amniotic fluid
is 7.0–7.7 compared with vaginal pH of 4.5)
3 Microscopic ‘ferning’ of vaginal fluid (refers to crystallization of amniotic fluid on drying)
Note: bimanual examinations
should be avoided (because
they promote ascending intraamniotic infection)
What other investigations woudl you do in a patient who has undergone PROM?
- Urine analysis and culture for UTI/asymptomatic bacteriuroia
- Cervical test or culture for C. trachomatis/N. gonorrhoea
- Vaginal tests for bacterial vaginosis (BV) and trichomoniasis
- Introital/rectal culture for group B streptococcus (GBS)
Basically just loads of tests for microbes!
What are some risk factors for cord prolapse?
Malpresentation (breech, transverse lie), polyhydramnios, small fetus, prematurity.
50% of patients with an umbilical cord prolapse will have undergone artificial rupture of membranes.
What things suggested a diagnosis of cord prolapse
Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.
50% of patients with an umbilical cord prolapse will have undergone artificial rupture of membranes.
What manouvers can be done to prevent damage caused by a cord prolapse?
When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord.
Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.
Can insert fluid into baldder via catheriter if at home
What are the two main things used in an instrumental delivery?
What is recommended to be given after an instrumental delivery
ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery
A single dose of co-amoxiclav is recommended after instrumental delivery to reduce the risk of maternal infection.
What is an episiotomy? Why do doctors do it?
a cut in the area between the vagina and anus (perineum) during childbirth, to make the opening of the vagina a bit wider, allowing the baby to come through it more easily.
Sometimes a woman’s perineum may tear as their baby comes out. In some births, an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly.
Episiotomy is equivalent to a second-degree perineal laceration
Describe a first degree vaginal tear.
First degree - tear within vaginal mucosa only.
Describe a second degree vaginal tear.
Second degree - tear into sub-cutaneous tissue.
Describe a third degree vaginal tear.
Third degree - laceration extends into external anal sphincter.
Describe a fourth degree vaginal tear.
Fourth degree - laceration extends through external anal sphincter into rectal mucosa.
What is shoulder dystocia?
When anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered
It requires specific maneuvers to facilitate delivery.
With babies head out, uterus will still be contracting, but baby will want to breathe - but it can’t, because chest is compressed
Outline what happens in mcRoberts Manoeuvre, and what happens in Woodscrew Manoeuvre.
McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Rubins manouvre = (press on the posterior shoulder to allow the anterior shoulder extra room)
Woodscrew - putting a hand in the vagina and rotating the foetus 180 degrees in attempt to ‘dislodge’ the anterior shoulder from the symphysis pubis.
The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery
Normal physiology - what are the 3 layers of the uterine wall? Where does the placenta normally attatch?
Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels
Myometrium, the middle layer that contains smooth muscle
Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)
Usually the placenta attaches to the endometrium. This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby.
What happens in placenta accreta?
With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond
There are three further definitions, depending on the depth of the insertion
Outline the 3 definitions along the specturem of placenta accreata
Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
Placenta increta is where the placenta attaches deeply into the myometrium
Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
A - I - P = alphabetical in terms of depth
What are the three main methods of induction of labour
Vaginal Prostaglandins- act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus - mainstay
Amniotomy where the membranes are ruptured artificially using an instrument called an amnihook. Give artificial oxytocin (Syntocinon) alongside will be to increase the strength and frequency of contractions.
Membrane sweep - It is classified as an adjunct of IOL. Performing it increases the likelihood of spontaneous delivery. Done by inserting a gloved finger through cervix and rotating it against the fetal membranes, aiming to separate the chorionic membrane from the decidua.
With amniotomy and membrane sweep, this process releases prostaglandins in an attempt to expedite labour
What are some absolute indications for a C section?
Maternal
* Failed induction of labor
* Failure to progress (labor dystocia)
* Cephalopelvic disproportion
Uteroplacental
* Previous uterine surgery (classical cesarean)
* Prior uterine rupture
* Outlet obstruction (fibroids)
* Placenta previa, large placental abruption
Fetal
* “Fetal distress”/non-reassuring fetal testing
* Cord prolapse
* Fetal malpresentation (transverse lie)
What is placenta praevia
Placenta praevia is where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.
Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os
Praevia directly translates from Latin as “going before”
What are some risk factors for placenta praevia?
Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
indeed, In a large Norwegian study in 2006 it was found that there was a six-fold higher risk of placenta praevia in singleton pregnancies conceived by assisted fertilisation compared with naturally conceived pregnancies.
What is the management for placenta praevia?
repeat transvaginal ultrasound scan at 32 and 36 weeks
Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs
Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).
As main complicaton is bleeding, may need
Emergency caesarean section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
If mother is Rh negative and foeus is Rh postive, then give Anti D - to prevent mother sensitisation
If a woman with known placenta praevia goes into labour (with or without bleeding), an emergency caesarean section should be performed
What is placental abruption ?
when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates.
What are the types of placental abruption?
Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.
Concealed abruption is opposed to revealed abruption, where the Fblood loss is observed via the vagina.
What is Vasa Praevia? What can it lead to
Vasa praevia is a condition in which the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.
No major maternal risk , but major fetal risk
What are some causes/risk factors of vasa praevia?
Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta.
An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.
Risk factors
Low lying placenta
IVF pregnancy
Multiple pregnancy
Give 3 causes of serious antepartum haemorrhage.
placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality.
Can also be unexplained
Outline what happens in hemolytic disease of the newborn (also known as Erythroblastosis fetalis)
Happens when rhesus anitgens on surface of mother and foetus RBC aren’t compatabile
If mother is rhesus D negative, and fetus is Rhesus D postive, foetal blood can cross placenta and enter mothers bloodstream
==> Mother will recognise the rhesus D antigen as foreign and produce antibodies to it ==> (mother becomes sensitised to rhesus D antigens)
Usually not a problem in inital pregnacy
If pregnant again, mothers anti-D antibodies can cross the placenta.
If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack its own red blood cells
What are the causes of infertility, as a percentage?
Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (20%)
Uterine problems (10%)
Unexplained (25%)
40% of infertile couples have a mix of male and female causes.
What things do you investigate in a couple struggling to conceive?
Ovulation / ovarian function / ovarian reserve
Semen Quality
Tubal Patency (+ Uterus)
Hormone testing in infertility treatment - what does levels of FSH and LH indicate?
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
High LH may suggest polycystic ovarian syndrome (PCOS).
Hormone testing in infertility treatment - what does levels of progesterone and anti mullerian hormone indicate?
When in a womens cycle can they be tested?
A rise in progesterone 7 days before end of cycle indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
Ideally, (length of cycle minus 7 days) peak luteal progesterone levels should be 10ng/ml or higher
Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
infertility treatment - outline the management of anovulation
The options when anovulation is the cause of infertility include:
Weight loss for overweight patients with PCOS can restore ovulation
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
treatment of anovulaton - how does Clomifene and Ovarian drilling work?
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
What are some treatment options for tubal disease in infertility?
The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include:
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
In vitro fertilisation (IVF)
What is a CTG? How should it be operate?
Operation
Two transducers are placed on the abdomen to get the CTG readout:
One above the fetal heart to monitor the fetal heartbeat
One near the fundus of the uterus to monitor the uterine contractions
The transducer above the fetal heart monitors the heartbeat using Doppler ultrasound. The transducer above the fundus uses ultrasound to assess the tension in the uterine wall, indicating uterine contraction.
CTG - what are some key features to look at on a CTG
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops
CTG: outline reassuring, non-reassuring and abnormal values for variability
Reassuring 5 – 25
Non-reassuring Less than 5 for 30 – 50 minutes or More than 25 for 15 – 25 minutes
Abnormal Less than 5 for over 50 minutes or More than 25 for over 25 minutes
CTG: are decelerations reassuring or non-reassuring? Why do decelerations happen?
Decelerations are non-reassuring.
Foetal hypoxia causes them
due to a lack of oxygen to the unborn baby, causes the foetal heart rate to decelerate because the baby’s body recognizes the low oxygen levels and tries to compensate by slowing down the heart rate in an attempt to conserve oxygen and maintain vital functions.
CTG: what are early decelerations?
Early decelerations are seen just before a uterine contraction. They may be due to foetal head compression.
CTG: what are late decelerations?
Late decelerations are seen just after uterine contraction. They may be due to placental insufficiency and are often more sinister.
CTG: what are variable decelerations?
When there is a mixture of early and late decelerations.
