Women's Health 2 (obstetrics) Flashcards
What are baby blues?
low mood seen in the majority of women in the first week or so after birth, particularly first-time mothers
What are the symptoms of baby blues?
mood swings
low mood
anxiety
irritability
tearfulness
What is the prognosis/management for baby blues?
mild symptoms which usually only last a few days and resolve within 2 weeks of delivery
no treatment is required
What causes baby blues? x6
likely to be a reuslt of a combination of:
significant hormonal changes
recovery from birth
fatigue and sleep deprivation
the responsibility of caring for the neonate
establishing feeding
plus all the other changes!
What is postnatal depression?
low mood, anhedonia and low energy following giving birth with a peak around 3 months after birth
What is the management for postnatal depression?
Mild - additional support, self-help and GP follow up
Moderate cases - antidepressant meds e.g. SSRIs and CBT
Severe cases - may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
What is puerperal psychosis?
a rare but severe illness which typically has an onset between 2-3 weeks after delivery where women experience full psychotic symptoms
WHat are the symptoms of puerperal psychosis?
delusions
hallucinations
depression
mania
confusion
thought disorder
What is the management for puerperal psychosis?
urgent assessment and input from specialist mental health services is essential
- admit to mother and baby unit
- CBT
- medications e.g. antidepressants, antipsychotics or mood stabilisers
- electroconvulsive therapy
What is a potential risk of SSRI antidepressants taken during pregnancy?
neonatal abstinence/adaptation syndrome which presents in the 1st few days after birth with symptoms such as irritability and poor feeding
What screening tool is used for postnatal depression? what score suggests postnatal depression?
edinburgh postnatal depression scale
a score of 10+ suggests postnatal depression
What is an ectopic pregnancy?
when a pregnancy is implanted outside the uterus either in the fallopian tubes (MC), cornual region (entrance to fallopian tube), ovary, cervix or abdomen
What is the most common location of an ectopic pregnancy?
fallopain tube
What are some risk factors for ectopic pregnancy? x6
previous ectopic pregnancy
previous pelvic inflammatory disease
previous surgery to the fallopain tubes
intrauterine devices (coils)
older age
smoking
What are the classic features of an ectopic pregnancy? at what point do they usually present?
missed period
constant lower abdo pain in the right or left iliac fossa
vaginal bleeding
lower abdo or pelvic tenderness
cervical motion tenderness (pain when moving the cervix during a bimanual examination)
might be asymptomatic or just ‘not feel right’
usually present at around 6-8 weeks gestation
What are the USS findings which may indicate an ectopic pregnancy?
a gestational sac seen in the fallopian tube
non-specific mass in the tube containing an empty gestational sac which is known as “blob sign”, “bagel sign” or “tubal ring sign”
a mass separate to the ovary which may represent a tubal ectopic pregnancy
empty uterus
fluid in the uterus which can be mistaken for a gestational sac (pseudogestational sac)
What is a pregnancy of unknown location?
when the woman has a positive pregnancy test but there is no evidence of pregnancy on the USS
i.e. could be in abdomen
What is used to monitor a pregnancy of unknown location?
serum human chorionic gonadotrophin (hCG) which is tracked over time
the developing syncytiotrophoblast of the pregnancy produces hCG and in an intrauterine pregnancy this will roughly double every 48 hours (not the case in a miscarriage or ectopic pregnancy)
a rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy
a rise of less than 63% after 48 hours may indicate an ectopic pregnancy
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 or gynaecology service
all ectopic pregnancies need to be terminated as they are not viable pregnancies
3 options:
- expectant management (await natural termination)
- medical management (methotrexate)
- surgical management (salpingectomy or salpingotomy)
What criteria should be met before choosing to treat an ectopic pregnancy with expectant management? x5
unruptured ectopic
adnexal mass <35mm
no visible heartbeat
no significant pain
HCG level <1500 IU/L
What 2 additional criteria are added before choosing medical management of an ectopic pregnnacy?
HCG level <5000 IU/L
Confirmed absence of intrauterine pregnancy on USS
How does methotrexate cause termination of a pregnancy? what are some common side effects
it is a highly teratogenic intramuscular injection which halts the progress of the pregnancy and results in spontaneous termination
side effects:
vaginal bleeding
nausea and vomiting
abdo pain
stomatitis
What happens in a laparoscopic salpingectomy and a laparoscopic salpingotomy?
laparoscopic salpingectomy = 1st line treatment for ectopic pregnancy and involves key-hole surgery to remove the affected fallopian tube, along with the ectopic pregnancy inside the tube
laparoscopic salpingotomy = used in women at increased risk of infertility due to damage to the other tube as the aim is to avoid removing the affected fallopian tube, a cut is made in the fallopian tube and the ectopic pregnancy is removed before closing the tube
What is the bHCG test?
The HCG blood test is a qualitative test known as the serum or the beta HCG test.
It helps to determine the HCG levels to understand whether the female is pregnant.
In pregnant women, it also helps to determine the progression and well-being of the pregnancy.
If the HCG levels are normal, it means the baby is healthy.
What is a miscarriage? define early/late
the spontaneous termination of a pregnancy <24 weeks
early miscarriage is before 12 weeks gestation
late miscarriage is between 12-24 weeks gestation
What is a missed miscarriage?
when the foetus is no longer alive, but no symptoms have occurred
cervical os is closed
What is a threatened miscarriage?
mild vaginal bleeding, some abdo pain, with a closed cervix and a foetus that is still alive
What is an inevitable miscarriage?
vaginal bleeding and abdo pain with an open cervix
cervical os is open
What is an incomplete miscarriage?
heavy bleeding with retained products of conception remain in the uterus after the miscarriage
cervical os is open
What is a complete miscarriage?
when a full miscarriage has occurred, and there are no products of conception left in the uterus
cervical os could be open or closed depending on the stage
What is an anembryonic pregnancy?
a gestational sac is present but contains no embryo
What are the 3 key features seen on USS in early pregnancy?
mean gestational sac diameter
foetal pole and crown-rump length
foetal heartbeat
What is the management for miscarriage?
less than 6 weeks gestation:
- expectant management if no pain or complications/risk factors (e.g. previous ectopic)
more than 6 weeks gestation:
- USS to confirm the location and viability of the pregnancy
- expectant management if no pain or infection
- medical management with misoprostol (prostaglandin analogue) to expedite the miscarriage process
- surgical management e.g. manual vacuum aspiration (must be <10 weeks) or electric vacuum aspiration
What is the management for incomplete miscarriage?
misoprostol
evacuation of retained products of conception (surgical procedure under GA)
What are the causes of miscarriage? what are the MC causes in the 1st and 2nd trimesters?
1st trimester MC cause = chromosomal abnormality (50-60%) e.g. trisomy 16
2nd trimester MC cause = incompetent cervix or systemic maternal illness
other causes:
foetal malformations e.g. neural tube defects
uterine structural abnormalities
chronic maternal health factors: thrombophilia, antiphospholipid syndrome, SLE, PCOS, poorly controlled DM, thyroid dysfunction
active maternal infection e.g. rubella, CMV, HSV
iatrogenic causes: amniocentesis and chorionic villus sampling
lifestyle factors: tobacco, alcohol and cocaine
exposure to environmental toxins
advanced maternal/paternal age
What is the definition of recurrent miscarriage?
3 or more miscarriages
What are some causes of recurrent miscarriage? x5
increased maternal age
parental genetic factors
thrombophilic disorders e.g. factor V leiden, factor II, protein S
endocrine disorders
structural uterine abnormalities e.g. uterine septum, uni/bicornate uterus, didelphic uterus, cervical insufficiency, fibroids
WHat are some investigations used in managing recurrent miscarriages? x4
cytogenic analysis of the products of conception
parental karyotyping and genetic counselling
blood tests: HbA1c, antiphospholipid/thrombophilia screen, thyroid function tests
pelvic USS
What is chronic histiocytic intervillositis?
a rare cause of recurrent miscarriage, particularly in the second trimester which can lead to intrauterine growth restriction and intrauterine death
Which legal frameworks relate to termination of pregnancy?
1967 abortion act
1990 human fertilisation and embryology act
What are the criteria required for an abortion? <24 weeks, at any point
An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of the woman or existing children of the family
an abortion can be performed at any time during the pregnancy if:
- 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
What are the legal requirements for an abortion?
2 registered medical practitioners must sign to agree abortion is indicated
It must be carried by a registered medical practitioner in an NHS hospital or approved premise
What are the medications used for medical termination of pregnancy?
mifepristone (anti-progestogen) - blocks the action of progesterone, halting the pregnancy and relaxing the cervix
misoprostol 1-2 days later - prostaglandin analogue which bind the prostaglandin receptors and activates them, softening the cervix and stimulating contractions
What are the options for surgical termination of pregnancy?
cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
cervical dilatation and evacuation using forceps (between 14-24 weeks)
What type of twin pregnancy is associated with the best outcomes?
diamniotic, dichorionic twin pregnancies, as each foetus has their own nutrient supply
What signs on USS determine the type of twin pregnancy?
dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign (triangular appearance where the membrane between the twins meets the chorion)
monochorionic diamniotic twins have a membrane between the twins, with a T sign (the membrane abruptly meets the chorion - single placenta)
monochorionic monoamniotic twins have no membrane separating the twins
What are some of the maternal risks of multiple pregnancy?
anaemia
polyhydramnios
hypertension
malpresentation
spontaneous preterm birth
instrumental delivery or c-section
postpartum haemorrhage
WHat are some of the risks to the foetus/neonate in multiple pregnancy?
miscarriage
stillbirth
foetal growth restriction
prematurity
twin-twin transfusion syndrome
twin anaemia polycythaemia sequence
congenital abnormalities
What is twin-twin transfusion syndrome?
also called foeto-foetal transfusion syndrome in pregnancies with more than 2 foetuses
when the foetuses share a placenta
this can result in one foetus receiving the majority of the blood supply while the other foetus is starved of blood leading to one twin with fluid overload, heart failure and polyhydramnios and the other with growth restriction, anaemia and oligohydramnios
What is twin anaemia polycythaemia sequence?
similar to twin-twin transfusion syndrome, but less acute
one twin becomes anaemic, while the other develops polycythaemia (raised Hb)
Which pregnancy complications are obese women at increased risk of? x5
miscarriage, stillbirth and recurrent miscarriage
gestational diabetes
pre-ecclampsia
heart problems
sleep apnoea
sepsis
What health problems in a foetus/new born are linked to maternal obesity? x6
congenital disorders
foetal macrosomia
growth problems
childhood asthma
childhood obesity
cognitive problems and developmental delay
What happens to glucose metabolism during pregnancy?
glucose tolerance decreases with increasing gestation after the first trimester
this is largely due to anti-insulin hormones secreted by the placenta in normal pregnancy (human placental lactogen, glucagon and cortisol)
What is gestational diabetes?
diabetes triggered by pregnancy which is caused by reduced insulin sensitivity during pregnancy, and resolves after birth
What are the important risk factors for gestational diabetes? x5
previous gestational diabetes
previous macrosomic baby (>4.5kg)
BMI >30
ethnic origin (black carribbean, middle eastern and south asian)
FH of diabetes (1st deg relative)
What is the screening test of choice for gestational diabetes? what results indicate gestational diabetes?
oral glucose tolerance test
fasting: >5.6mmol/l
at 2 hours >7.8mmol/l
(remember values 5678)
What is the management for gestational diabetes?
fasting glucose <7mmol/l –> diet and exercise for 1-2 weeks, then metformin, then insulin
fasting glucose >7mmol/l –> start insulin +/- metformin
fasting glucose >6mmol/l + macrosomia –> start insulin +/- metformin
glibenclamide (sulfonylurea) is an option for women who decline insulin or cannot tolerate metformin
What are the management/monitoring steps recommended for pregnant women with pre-existing diabetes?
aim for good glucose control
take 5mg folic acid from preconception until 12 weeks gestation
oral diabetic medications other than metformin and insulin should be stopped
retinopathy screening
planned delivery between 37-38+6 weeks
sliding scale insulin regime during labour for women with T1DM
What are babies with diabetic mothers at risk of? x5
neonatal hypoglycaemia
polycythaemia
jaundice
congenital heart disease
cardiomyopathy
What is pre-eclampsia?
new high blood pressure in pregnancy with end-organ dysfunction, notably with proteinuria and oedema
it occurs after 20 weeks gestation, when the spinal arteries of the placenta form abnormally, leading to high vascular resistance in these vessels
What usually happens to women’s blood pressure in pregnancy?
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
What is gestational hypertension?
high blood pressure in pregnancy minus proteinuria
What are the potential consequences of untreated pre-eclampsia? x5
maternal organ damage
foetal growth restriction
seizures
early labour
death (rare)
What are the definitions of chronic hypertension and pregnancy-induced/gestational hypertension?
chronic hypertension = high blood pressure which exists before 20 weeks gestation and is longstanding
pregnancy-induced/gestational hypertension = hypertension occurring after 20 weeks gestation, without proteinuria
What are the high-risk factors for pre-eclampsia?
pre-existing hypertension
previous hypertension in pregnancy
existing autoimmuneconditions (e.g. systemic lupus erythematosus)
diabetes
CKD
What are some moderate-risk factors for pre-eclampsia?
aged 40+
BMI >35
more than 10 yrs since previous pregnancy
multiple pregnancy
first pregnancy
family history of pre-eclampsia
What are some symptoms of pre-eclampsia?
headache
visual disturbance or blurriness
nausea and vomiting
upper abdo or epigastric pain (due to liver swelling)
oedema
reduced urine output
brisk reflexes
What are the diagnostic criteria for pre-eclampsia?
systolic blood pressure >140 mmHg
diastolic blood pressure >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. foetal growth restriction or abnormal Doppler studies)
What is the management for pre-eclampsia?
aspirin for prophylaxis in women with one high risk factor or 2+ moderate risk factors
monitoring at every antenatal appt for evidence of pre-eclampsia - bp, symptom review, urine dipstick
once pre-eclampsia is diagnosed:
scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
bp is monitored closely (at least every 48hrs)
2-weekly USS monitoring of the foetus, amniotic fluid and dopplers
medical management:
1st line labetolol
2nd line nifedipine
3rd line methyldopa (must be stopped within 2 days of birth)
IV mg sulphate is given during labour and in the 24 hrs after to prevent seizures
fluid restriction is used during labour in severe pre-eclampsia or eclampsia to avoid fluid overload
planned early birth may be needed if the BP cannot be controlled or complications occur
What is eclampsia? how is it managed?
the seizures associated with pre-eclampsia
stabilise mum first and then deliver baby if necessary
IV magnesium sulphate
What is HELLP syndrome?
a combination of features which occur as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
When are women screened for anaemia during pregnancy?
booking clinic
28 weeks gestation
What causes anaemia in pregnancy?
the plasma volume increases during pregnancy which results in a reduction in the haemoglobin concentration
What are the symptoms of anaemia in pregnancy? x4
SOB
fatigue
dizziness
pallor
What are the normal haemoglobin ranges during pregnancy?
booking bloods >110 g/l
28 wks >105 g/l
post partum >100 g/l
What causes of anaemia during pregnancy are indicated by low, normal and raised MCV?
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 for anaemia during pregnancy?
Iron - ferrous sulphate
B12 - intramuscular hydroxycobalamin
Folate - folic acid
What is VTE in pregnancy?
a common and potentially fatal condition which can occur in pregnancy due to the hyper-coagulable state of the blood and its increased risk of thrombosis
What are the risk factors for VTE in pregnancy? x12
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
What is the prophylaxis for VTE in pregnancy?
all pregnant women should have a risk assessment for their risk of VTE at booking and again after birth
women at increased risk of VTE - LMWHs such as enoxaparin, dalteparin should be started at 28 weeks if there are 3 risk factors (high risk) and as soon as possible in very high risk (4+ factors) patients
mechanical prophylaxis such as intermittent pneumatic compression and anti-embolic compression stockings are considered in women with contraindications to LMWH
What is the management for VTE in pregnancy?
LMWHs e.g. enoxaparin
Women with a massive PE and haemodynamic compromise need emergency management with unfractioned heparin, thrombolysis or surgical embolectomy
Why is the wells score not useful in pregnancy?
D-dimers are not helpful in pregnant patients as pregnancy is a cause of a raised D-dimer
What is placenta accreta spectrum?
placenta accreta refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby
it is a spectrum due to the variation in severity in how deep and broad the abnormal implantation extends
What are the 3 types of placenta accreta?
superficial PA - where the placenta implants in the surface of the myometrium, but not beyond
placenta increta - where the placenta attaches deeply into the myometrium
placenta percreta - where the placenta invades past the myometrium and perimetrium, potentially reaching other organs like the bladder
What are some risk factors for placenta accreta? x6
previous placenta accreta
previous endometrial curettage procedures (e.g. for miscarriage or abortion)
previous c-section
multigravida
increased maternal age
low-lying placenta or placenta praevia
When is placenta accreta usually diagnosed and how?
typically asymptomatic during pregnancy
can present with antepartum haemorrhage in the third trimester
may be diagnosed on antenatal USS
may be diagnosed at birth when it is difficult to deliver the placenta - can cause significant postpartum haemorrhage
What is the management for placenta accreta?
if diagnosed before birth delivery is planned between 35 to 36+6 weeks gestation to reduce the risk of spontaneous labour and delivery
options during c-section are:
- hysterectomy (placenta remains in uterus)
- uterus preserving surgery
- expectant management where the placenta is left in place to be reabsorbed over time
Complex uterine surgery
Blood transfusions
Intensive care for the mother
Neonatal intensive care
What is placenta praevia? how is is different from low lying placenta?
where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the foetus
“praevia” = going before
low-lying placenta is when the placenta is within 20mm of the internal cervical os whereas in placenta praevia the placenta is over the internal cervical os
What are 3 important causes of antepartum haemorrage?
placenta praevia
placental abruption
vasa praevia
What are the risks associated with placenta praevia? x6
antepartum haemorrhage
emergency c-section
emergency hysterectomy
maternal anaemia and transfusions
preterm birth and low birth weight
stillbirth
What are the 4 grades of placenta praevia?
- Minor praevia - the placenta is in the lower uterus but not reaching the internal cervical os
- Marginal praevia - the placenta is reaching, but not covering, the internal cervical os
- Partial praevia - the placenta is partially covering the internal cervical os
- Complete praevia - the placenta is completely covering the internal cervical os
What are the risk factors for placenta praevia? x6
previous c-section
previous placenta praevia
older maternal age
maternal smoking
structural uterine abnormalities (e.g. fibroids)
assisted reproduction (e.g. IVF)
How does placenta praevia usually present? at what point is it usually diagnosed?
usually diagnosed at the 20 week anomaly scan
many women have no symptoms but can present with painless vaginal bleeding in later pregnancy (antepartum haemorrhage)
What is the recommended management for placenta praevia?
repeat transvaginal USS at 32 and 36 weeks gestation
corticosteroids given between 34-35+6 weeks to mature the foetal lungs due to high risk of preterm delivery
planned delivery is considerd between 36 and 37 weeks to reduce risk of spontaneous labour and bleeding
planned c-section is required with placenta praevia and low-lying placenta
What is vasa praevia?
where the foetal vessels (2 umbilical arteries and the umbilical vein) are within the foetal membranes and travel exposed across the internal cervical os
the foetal membranes surround the amniotic cavity and developing foetus
What are the 2 types of vasa praevia?
Type I - the foetal vessels are exposed as a velamentous umbilical cord
Type II - the foetal vessels are exposed as they travel to an accessory placental lobe
WHat is the normal anatomy of the umbilical cord?
what are the 2 ways that the foetal vessels in the umbilical cord can be exposed?
the umbilical cord is made up of an umbilical vein which is wrapped around by 2 smaller umbilical arteries
the vessels are surrounded by Wharton’s jelly which is a proactive layer
ways that the vessel can be exposed:
- velamentous umbilical cord where the umbilical cord inserts into the chorioamniotic membranes, and the foetal vessels travel unprotected through the membranes before joining the placenta
- an accessary lobe of the placenta (succenturiate lobe) is connected by foetal vessels which travel through the chorioamniotic membranes between the placental lobes
What are the risk factors for vasa praevia?
low lying placenta
IVF pregnancy
multiple pregnancy
How does vasa praevia usually present? How is it diagnosed?
may be diagnosed by USS during pregnancy (not very reliable)
may present with antepartum haemorrhage, with bleeding during the 2nd or 3rd trimester of pregnancy
may be detected by vaginal examination during labour, when pulsating foetal vessels are seen in the membranes through the dilated cervix
may be detected during labour when foetal distress and dark-red bleeding occur following rupture of the membranes (very high foetal mortality)
What is the management for vasa praevia?
for asymptomatic women with vasa praevia:
- corticosteroids from 32 weeks to mature the foetal lungs
- planned elective c-section at 34-36 weeks
where antepartum haemorrhage occurs, emergency c-section is needed to deliver the foetus before death occurs
What is placental abruption?
when the placenta separates from the wall of the uterus during pregnancy which can result in extensive bleeding from the site of attachment
What are the risk factors for placental abruption? x10
previous placental abruption
pre-eclampsia
bleeding early in pregnancy
trauma
multiple pregnancy
foetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine use
What is the typical presentation of placental abruption/
sudden onset severe CONTINUOUS abdo pain
vaginal bleeding (antepartum haemorrhage)
shock (hypotension and tachycardia)
abnormalities on the CTG indicating foetal distress
characteristic woody -hard, abdomen on palpation, tense uterus, suggesting a large haemorrhage
What are the severity gradings of antepartum haemorrhage?
spotting
minor haemorrhage <50ml blood loss
major haemorrhage 50-100ml blood loss
massive haemorrhage >1000ml blood loss, signs of shock
WHat is a concealed placental abruption?
where the cervical os remains closed so that any bleeding is retained within the uterine cavity
this means that the severity of bleeding can be significantly underestimated
What is the management for placental abruption?
obstetric emergency
Urgent involvement of a senior obstetrician, midwife and anaesthetist
2 x grey cannula
Bloods include FBC, UE, LFT and coagulation studies
Crossmatch 4 units of blood
Fluid and blood resuscitation as required
CTG monitoring of the fetus
Close monitoring of the mother
emergency c-section may be required when the mother is unstable or there is foetal distress
What is postpartum haermorrhage? what blood loss is required for this classification?
bleeding after delivery of the baby and placenta
classified by blood loss of:
500ml after a vaginal delivery
1000ml after a c-section
What volumes of blood loss are classed as minor/major PPH and moderate/severe major PPH?
minor PPH <1000 ml blood loss
major PPH >1000ml blood loss
moderate PPH - 1000-2000 ml blood loss
severe PPH >2000ml blood loss
What is the definition of a primary vs secondary PPH ?
Primary PPH = bleeding within 24 hrs of birth
Secondary PPH = from 24 hrs to 12 weeks after birth
What are the 4 causes of PPH? 4T’s
Tone (uterine atony - MC cause)
Trauma e.g. perineal tear
Tissue (retained placenta)
Thrombin (bleeding disorder)
What are some risk factors for postpartum haemorrhage? x7
LGA
Nulliparity and grand multiparity
Multiple pregnancy
Prolonged labour
Operational delivery
Shoulder dystocia
Previous PPH
What are some preventative measures to reduce the risk and consequences of PPH?
treating anaemia in the antenatal period
giving birth with an empty bladder (a full bladder reduces uterine contraction)
active management of the third stage (IM oxytocin)
IV tranexamic acid in c-section
what is the management for PPH?
life-threatening obstetric emergency
ABC approach:
2 peripheral cannulae
lie the woman flat
bloods with group and save
commence warmed crystalloid infusion
Mechanical:
palpate the uterine fundus and rub it to stimulate contractions
catheterisation to prevent bladder distension and monitor urine output
Medical:
Sytocinon
Ergometrine
Haemobate
Tranexamic acid (TXA)
Surgical:
intrauterine balloon tamponade (1st line) (balloon inserted into the uterus to press against the bleeding)
b-lynch suture (compresses the uterus), ligation of uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
What are the likely causes and the management for secondary PPH?
secondary PPH more likely to be due to retained products of conception or infection
surgical evaluation of retained products of conception
antibiotics for infection
What is instrumental delivery?
a vaginal delivery assisted by either a ventouse suction cup or forceps to help deliver the baby’s head
What are the indications for an instrumental delivery ?
failure to progress
foetal distress
maternal exhaustion
control of the head in various foetal positions
WHat are the risks to the mother associated with an instrumental delivery? x6
postpartum haemorrhage
episiotomy (cut through the area between the vaginal opening and anus to increase the size of the vaginal opening)
perineal tears
injury to the anal sphincter
incontinence of the bladder or bowel
nerve injury (obturator or femoral nerve)
What are the risks to the baby associated with instrumental delivery? x2 what are some rare serious complications? x4
cephalohaematoma with ventouse
facial nerve palsy with forceps
rarely:
subgaleal haemorrhage
intracranial haemorrhage
skull fracture
spinal cord injury
What are the 3 stages of labour?
1st stage - onset of labour (true contractions) until 10cm cervical dilatation
2nd stage - from 10 cm cervical dilatation until delivery of the baby
3rd stage - from delivery of the baby until delivery of the placenta
What occurs in the first stage of labour? x3 phases
cervical dilatation and effacement (thinning) and the falling out of the “show” (cervical mucus plug) to create space for the baby to pass through
Latent phase - 0-3cm dilation of the cervix, progresses at around 0.5cm/hr with irregular contractions
Active phase - 3-7cm cervical dilation, progresses at roughly 1cm/hr with regular contractions
Transition phase - 7-10cm cervical dilation, progresses at roughly 1cm/hr with strong and regular contractions
What are Braxton-Hicks contractions?
occasional irregular contractions of the uterus which are usually felt during the 2nd and 3rd trimester
they are not true contractions and don’t indicate the onset of labour
reduced by staying hydrated and relaxing
What are the 4 signs of labour?
Show (cervical mucus plug)
Rupture of membranes (water breaking)
Regular, painful contractions
Dilating cervix on examination
How are the latent first stage and established first stages of labour defined?
Latent first stage:
- painful contractions
- changes to the cervix with effacement and dilation up to 4cm
Established first stage of labour:
- regular, painful contractions
- dilatation of the cervix from 4cm onwards
How is prematurity defined? When are babies considered non-viable?
birth before 37 weeks gestation
under 28 weeks = extreme preterm
28-32 weeks = very preterm
32-37 weeks = moderate to late preterm
non-viable babies are below 23 weeks gestation
What are the prophylactic measures for preterm labour? who is it offered to?
vaginal progesterone to decrease activity of the myometrium and prevent cervical remodelling in preparation for delivery
cervical cerclage where a stitch is put into the cervix to add support and keep it closed
offered to women with a cervical length less than 25mm on vaginal USS between 16 and 24 weeks gestation
the cerclage is for those who have had a previous premature birth or cervical trauma
What happens in preterm prelabour rupture of membranes?
the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy
How is rupture of membranes diagnosed? What tests can be performed to confirm rupture of membranes?
it can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina
Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
Placental alpha-microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1
What is the management for preterm prelabour rupture of membranes?
prophylactic erythromycin to prevent chorioamnionitis
induction of labour may be offered from 34 weeks to initiate onset of labour
How does preterm labour with intact membranes present and how is it diagnosed?
regular painful contractions and cervical dilatation, without rupture of the amniotic sac
less than 30 weeks gestation - speculum examination to assess for dilatation is enough to offer management of preterm labour
more than 30 weeks gestation - a transvaginal USS is used to assess the cervical length (<15mm –> management of preterm labour is offered, >15mm preterm labour is unlikely)
What are the management options for preterm labour with intact membranes?
foetal monitoring (CTG or intermittent auscultation)
tocolysis with nifedipine (ca2+ blocker which suppresses labour)
maternal corticosteroids (reduce neonatal morbidity and mortality)
IV magnesium sulphate (help protect the baby’s brain)
delayed cord clamping or cord milking (increase the circulating blood volume and Hb in the baby at birth)
What is tocolysis? when can it be used? what medications are used?
the use of medications to stop uterine contractions
can be used between 24 and 33+6 weeks gestation in preterm labour to buy time for further foetal development, administration of maternal steroids or transfer to a more specialist unit
only used as a short term measure (for <48hrs)
nifedipine (Ca2+ channel blocker) = medication of choice
atosiban (oxytocin receptor antagonist) = 2nd line
What is obstructed labour?
also known as labour dystocia
when the baby cannot exit the pelvis because it is physically blocked during childbirth although the uterus is contracting normally
What are the main causes of obstructed labour?
a large or abnormally positioned baby
small pelvis
problems with the birth canal (e.g. narrow vagina and perineum due to FGM or tumours)
What are some risks caused by obstructed labour?
maternal infection
uterine rupture
postpartum bleeding
How is obstructed labour managed?
manual manoeuvres to reposition the baby
c-section
vacuum extraction
symphysiotomy (surgical opening of the symphysis pubis)
What is shoulder dystocia?
when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered
obstetric emergency
How does shoulder dystocia present? what are some concerning signs?
difficulty delviering the face and head, and obstruction in delivering the shoulders after delivery of the head
failure of restitution - the head remains face downwards and does not turn sideways as expected after delivery of the head
turtle-neck sign - where the head is delivered but then retracts back into the vagina
What is the management for shoulder dystocia? (acronym)
H - call for help
E - elevate for episiotomy
L - legs into McRoberts
P - Suprapubic pressure
E - enter pelvis
R - rotational maneouvres
R - remove posterior arm
R - replace head and deliver by LSCS if required
What is the management for shoulder dystocia? more detailed
Episiotomy
McRoberts manoeuvre - hyperflexion of the mother at the hip (bringing knees to the abdomen) whch provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way
Pressure to the anterior shoulder - involves pressing on the suprapubic region of the abdomen to encourage the shoulder down and under the pubic symphysis
Rubins manoeuvre - reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis
Wood’s screw manoeuvre - (performed during a Rubins manoeuvre) the other hand is used to reach into the vagina and put pressure on the anterior aspect of the posterior shoulder - the top shoulder is pushed forwards and the bottom shoulder is pushed backwards, rotating the baby and helping delivery
Zavanelli manoevre - where the baby’s head is pushed back into the vagina so that the baby can be delivered by emergency c-section
WHat are they key complications of shoulder dystocia?
fetal hypoxia (subsequent cerebral palsy)
brachial plexus injury and Erb’s palsy
perineal tears
PPH
What is uterine rupture?
a complication of labour where the myometrium ruptures
can be incomplete (uterine dehiscence) where the uterine serosa (perimetrium) surrounding the uterus remains intact
or incomplete where the serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity
What are the risk factors for uterine rupture?
main = previous c-section (scar becomes a point of weakness)
vaginal birth after c-section
previous uterine surgery
increased BMI
high parity
increased age
induction of labour
use of oxytocin to stimulate contractions
What are the signs and symptoms of uterine rupture? x6
abdominal pain
vaginal bleeding
ceasing of uterine contractions
hypotension
tachycardia
collapse
What is the management for uterine rupture?
obstetric emergency!
emergency c-section is needed to remove the baby, stop any bleeding and repair or removed the uterus
What is cord prolapse? what does this put the foetus at significant risk of?
when the umbilical cord descends below the presenting part of the foetus and through the cervix into the vagina, after rupture of the foetal membranes
significant risk of cord compression, resulting in foetal hypoxia
WHat are some other risk factors for cord prolapse? x5
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
What is the most significant risk factor for cord prolapse?
when the foetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique) as this allows space for the cord to prolapse below the presenting part
How is cord prolapse diagnosed and managed>
suspected when there are signs of foetal distress on the CTG
diagnosed by vaginal examination
emergency c-section is indicated when cord prolapse occurs
trendelenburg position (feet high er than the head)
the presenting part of the foetus may be pushed back into the uterus to relieve compression
the patient is asked to go on ‘all fours’ until preparations for an immediate c-section have been carried out
tocolytics can be used to reduce uterine contractions
What is cephalopelvic disproportion?
when there is a mismatch between the size of the foetal head and the maternal pelvis causing difficulty in the safe passage of the foetus through the birth canal
How is cephalopelvic disproportion?
usually requires c-section when diagnosed in active labour
if the cause is due to the foetus being too large, the obstetrician may recommend induction of labour for earlier delivery
What are the 4 categories of c-section?
Category 1 - immediate threat to life of mother or baby. Decision to delivery time is 30 minutes.
Category 2 - not an imminent threat to life, but c-section is required urgently due to compromise of the mother or baby.
Decision to delivery time is 75 minutes.
Category 3 - delivery is required, but mother and baby are stable
Category 4 - elective c-section.
What are some situations ehich require CAT1 c-section? x5
suspected uterine rupture
major placental abruption
cord prolapse
fetal hypoxia
persistent foetal bradycardia
What are the possible initial incisions used in caesarian section?
Most commonly used skin incision is a transverse lower uterine segment incision which can be either:
Pfannestiel incision = curved incision 2 fingers with above the pubic symphysis
Joel-cohen incision = straight incision slightly higher up
A vertical incision down the middle of the abdomen is also possible, but this is rarely used and only in certain circumstances such as very premature deliveries and anterior placenta praevia.
What are the layers of the abdomen which need to be dissected during a c-section? x8
skin
subcutaneous tissue
fascia/rectus sheath
rectus abdominis muscles
peritoneum
vesicouterine peritoneum (and baldder)
uterus
amniotic sac
What medications can be given due reduce the risks during c-section?
H2 receptor antagonists e.g. ratinidine or proton pump inhibitors (aspiration pneumonitis)
Prophylactic antibiotics (infection0
Oxytocin (PPH)
Low molecular weight heparin (Venous thromboembolism)
What are the 2 key causes of sepsis in pregnancy?
Chorioamnionitis
UTIs
What is chorioamnionitis?
an infection of the chorioamniotic membranes and amniotic fluid which most commonly occurs later in pregnancy and during labour
can be caused by a large variety of bacteria
What are the additional signs and symptoms of sepsis related to chorioamnionitis?
abdo pain
uterine tenderness
vaginal discharge
What are the additional signs and symptoms of sepsis related to a UTI?
dysuria
urinary frequency
suprapubic pain or discomfort
renal angle pain (with pyelonephritis)
vomiting (with pyelonephritis)
WHat is the management for maternal sepsis?
SEPSIS 6 (take blood lactate, blood cultures, urine output and give oxygen, antibiotics and IV fluids
continuous maternal and foetal monitoring is required
early delivery or emergency c-section may be needed
strong antibiotics which cover gram+ve, gram -ve and anaerobes are required e.g. piperacillin and tazobactam (tazocin) plus gentamicin
What is oligohydramnios? what are some causes?
reduced amniotic fluid, definitions vary but include <500ml at 32-36 weeks and an amniotic fluid index <5th percentile
causes:
premature rupture of membranes
potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
intrauterine growth restriction
post-term gestation
pre-eclampsia
what is polyhydramnios?
excess amniotic fluid, >1500ml
defined as the presence of amniotic fluid pool depth greater than 10cm on USS
What are some causes of polyhydramnios? x5
aneuploidy
maternal diabetes
congenital abnormalities
multiple gestations
often unexplained
What are some consequences of a chlamydia infection in pregnancy for mother and neonate?
Mother
- asymptomatic
- preterm labour
- chorioamnionitis
- PID
Neonate
- conjunctivitis
- pneumonia
What is the treatment for chlamydia in pregancy?
oral erythromycin (14 days) or oral azithromycin (macrolides)
What are some potential consequences of syphilis in pregnancy? x3
miscarriage
stillbirth
baby’s death shortly after birth
approx 40% of babies born to women with untreated syphilis can be stillborn or die from the infection as a newborn
What is the treatment for syphilis in pregnancy?
penicillin G
What are some risk factors for group B strep infection in pregnancy?
preterm birth
previous baby with GBS infection
waters broken more than 24 hrs before birth
What is uterine atony?
when the uterus doesn’t contract properly during or after childbirth
this is due to an impaired response to oxytonin
After delivery, the uterine muscles of the myometrium usually continue to contract in order to halt bleeding from the spinal arteries, which supply the endometrium with blood and help prevent postpartum haemorrhage. With uterine atony, these muscle don’t contract and so the person is at risk of PPH.
considered an obstetric emergency
What are some risk factors for uterine atony? x6
primiparity
grand parity
long-lasting labour
excessive exposure to labour-inducing medications like synthetic oxytocin
BMI >40
previous PPH
What is the treatment for uterine atony?
active management of the third stage of labour
–> uterine massage, while pulling the end of the umbilical cord to detach the placenta
medication to imprve the tone of the uterus
–> synthetic oxytocin, methylergonovine and prostaglandins
tamponade techniques and potentially surgery may be needed if conservative measures fail to resolve bleeding
How are rhesus-D negative women managed in pregnancy?
anti-D IM injections at 28 weeks and birth as well as at any time where sensitisation may occur e.g. antepartum haemorrhage, amniocentesis, abdo trauma
the anti-D medication works by attaching itself to the rhesus-D antigens on the foetal RBCs in the mothers circulation, causing them to be destroyed
this prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen
it acts as a prevention for the mother becoming sensitised to the rhesus-D antigen
What is the Kleihauer test?
a test to check how much foetal blood has passed into the mother’s blood during a sensitisation event
usually used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required
What is Meig’s syndrome?
3 key features:
- benign ovarian tumour
- ascites
- pleural effusion
rare condition usually occurring in women over 40 and the ovarian tumour is usually a fibroma
What are some risk factors for GBS infection? x4
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
What is the risk of GBS infection in pregnancy for women who’ve had GBS in a previous pregnancy? What should these women be offered?
risk of maternal GBS carriage in this pregnancy is 50%.
they should be offered intrapartum antibiotic prophylaxis OR testing in late pregnancy and then antibiotics if still positive
What is the antibiotic of choice for GBS prophylaxis?
IV benzylpencillin
