Women's Health Flashcards
Epidemiology of subfertility/infertility
1 in 7 women
50% are due to females
25% due to males
25% are unknown
Increases with age
No family history
Risk factors for subfertility/infertility
Increasing female age Depression Stress STIs Smoking Alcohol intake (even moderate) Overweight or underweight
Causes of infertility (general)
25% ovulatory 20% tubular damage 10% uterine or peritoneal disorders 30% male 25% unknown
What are the 3 WHO classifications for disorders of ovulation
Group 1 - hypothalamic-pituitary failure (low oestrogen, low gonadatrophin)
Group 2 - hypothalamic-pituitary-ovarian failure (normal oestrogen, high or low gonadatrophin)
Group 3 - ovarian failure (raised gonadatrophin, low oestrogen)
Causes of ovulatory dysfunction causing infertility
PCOS
- Pituitary tumours
- Panhypopituitarism (Simmond’s disease)
- Sheehan’s disease (pituitary infarction following PPH)
- Hyperprolactinaemia
- Chromosomal disorders (Turners XO, Klinefelter’s XXY) XXX (increased premature ovarian failure)
- Premature ovarian failure/ menopause
Role of FSH
Follicle stimulating hormone
Stimulates follicle development and oestrogen production
Role of LH
Midcycle LH surge causes ovulation.
Maintains corpus luteum and stimulates progesterone and estradiol production
Causes of infertility - tubes/uterus/cervix
STI (PID from chlamydia or gonorrhoea) Asherman's syndrome (adhesions in uterus and cervix) Deformity of uterus Fibroids Cervical mucus Endometriosis
What drugs can lead to sub/infertility?
Phenothiazines (antipsychotics) Metoclopramide NSAIDs Immunosuppressants Spironolactone Chemotherapy Neuroleptic drugs
Causes of infertility - male
Structural or hormonal
- Genetic (Klinefelters XXY), Kallman syndrome (hypogonatrophic hypogonadism)
- Androgen insensitivity
- Cryptorchidism (testicular dysgenesis)
- Varicocoele
- Pituitary causes (tumours)
- Testicular tumours
- Severe hyperprolactinaemia
- Obstruction
- Erectile dysfunction
- Hypospadias
- Retrograde ejaculation
Advice for couple trying to conceive
Regular sexual intercourse (2-3x per week)
Preparation for pregnancy (folic acid, rubella check, cervical screening)
Decrease stresses
Smoking and alcohol cessation
BMI between 19 and 25
Investigations for sub/infertility
Start if not conceived in 1 year
FEMALE
- Measure mid-luteal progesterone day 21 of 28 (7 days before period
- If irregular cycles measure FH and LSH
- Test thyroid function
- Measure prolactin
- Screen for chlamydia and other STIs
MALE
- Semen analysis
- Screen for STIs
Semen sample should be collected after at least 2 days but less than 7 from sexual abstinence
After referral
- Tubal patency (hysterosalpinography or contrast ultrasonography) HSG
- If co-morbidities the lap and dye testing
- Ovarian reserve testing - on day 3 to predict response to stimulation in IVF
Males - further sperm assessment - microbiology, culture
Imaging of tracts
When should sub/infertility be referred
Follow local guidelines
- Under 36 refer after 1 year
Consider early referral if
- over 36 (6 months)
- known cause for infertility
- history of factors that predispose to infertility
- treatment planned that may result in infertility (chemotherapy)
Management of subfertility/infertility
Treat underlying problem
- Ovulation induction with Clomifene
- Gonadatrophins if clomifene resistant (pulsatile)
- If male obstruction, correct surgically
- Surgical correction of tubes
Different types of assisted conception
Intrauterine insemination In vitro fertilisation Intracytoplasmic sperm injection (ICSI) Donor insemination Oocyte donation
Describe intrauterine insemination
15% success in under 35s
Prepared sperm placed into uterine cavity at ovulation (induced or spontaneous)
Used when
- difficult to have intercourse (unable, disability, psychological)
- HIV+ male (sperm washing)
- Same sex relationships
Describe IVF
33% success in under 35s
25% of treatments result in live births
Offered after 2 years
- Ovarian stimulation prior to IVF with US measured response
- Embyro inserted into uterus
- Progesterone given after embryo for luteal phase support
- transfer single embryo
Under 40s up to 3 cycles - stop once reach 40
Over 40s, 1 cycle if never had IVG, no evidence of low ovarian reserve
Some CCGs in addition
- No previous children, or partner with any children, healthy weight, non-smoker
Describe Intracytoplasmic sperm injection (ICSI)
Single sperm injected into oocyte
Used when severe deficits in sperm or after failed IVF
When can donor insemination be used
Azoospermia
Severe deficits in sperm quality and don’t want ICSI
High risk of transmitting genetic disorder
High risk of transmitting infectious disease to child/partner
Complications of assisted conception
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
Symptoms of ovarian Hyperstimulation syndrome
lower abdo discomfort nausea and vomiting diarrhoea abdo distension ascites rapid weight gain tachycardia hypotension oliguria
What factors should be considered when prescribing contraception?
Womens preference and choice Education - must be fully informed Co-morbidities Medications Age and parity Smoking history Weight Family plans (long vs short term) Protection from STIs Exclude pregnancy
MOA of COCP
Prevents conception by acting on hypothalamic-pituitary-ovarian axis to suppress synthesis and secretion of FSH and LH
Inhibits development of ovarian follicles and ovulation
Cervical mucus to prevent sperm penetration
Endometrium to inhibit blastocyst secretion of LH and LSH
Advantages and disadvantages of COCP
Advantages:
Non invasive
Regular and lighter periods, decrease pain
Control time of periods
Can improve acne
Decreases ovarian, endometrial and colorectal cancer
Decrease PMS symptoms
Disadvantages: User dependent Less effective than long acting Side effects VTE risk No protection from STIs Breakthrough bleeding in first few months Increased breast and cervical cancer
When prescribing contraception - what criteria should be checked?
UKMEC - UK Medical Eligibility Criteria 1 - no restriction for use 2 - advantages > disadvantages 3 - risks outweigh advantage - not recommended 4 - use is unacceptable
What questions must be asked before prescribing COCP
Advice to give
Migraine Smoker HTN Thrombophilia Previous VTE FHx of VTE Hyperlipidaemia BP BMI Exclude pregnancy
Start on first day of bleeding (or within 5 days)
Drug interactions
D&V advice - use alterative protection
Need alternative protection for first 7 days
MOA of progestogen only pill POP
Ovulation is inhibited by varying degrees depending on the drug
Delays transport of ovum
Cervical mucus thickens
Endometrium becomes unsuitable for implantation
Advantages and disadvantages of POP
A Non invasive Easily reversible Avoids CV risk of COCP Less restriction Can be used up to 55 and while breastfeeding
D
- Amennorhoea and breakthrough bleeds
- narrower window
- increase risk of cysts
- increased risk of ectopic pregnancy if become pregnant
- Irregular periods
Describe depot progesterone injections and MOA
Every 12 weeks
Long acting reversible progesterone only
Failure rate 2 in 1000
Thickens mucus
Endometrium unsuitable for implantation
Can be used 4 weeks post partum
Advantages and disadvantages of POP
A
- Reliable
- Infrequent
- Low risk
- Low failure rate
- Decreases bleeding
- Used in breast feeding
D
- not quickly reversible
- Decrease bone mineral density
- irregular periods
- weight gain (up to 3kg)
Describe Implanon/implants
Etonogestrel subdermal slow release in upper arm
Failure rate < 1 in 1000
Inhibits ovulation , thickens mucus, thins endometrium
Inserted with local anaesthetic
Can be given 21 days post partum
Can be given straight after termination
Advantages and disadvantages of Implants
A
- No large initial dose or fluctuations
- Low failure rate
- Reversible after 4 days
- Decreased menstrual problems
- Safe
D
- irregular bleeding
- weight, mood and libido changes
- Changes with bleeding DO NOT SETTLE WITH TIME
- Increases risk of congenital malformation
Describe IUD
Copper containing
Long acting
Reversible
T shape, sits in fundus of uterus
Cytotoxic - inflammatory reaction and is spermicidal
Very low failure rate
5-10 years lifespan
Advantages and disadvantages of IUD
A
- Effective, reversible
- Long acting (up to 10 years)
- Can be used as emergency contraception
- No hormones
D
- Spotting
- Increased bleeding and pain in first few cycles
- Perforation 0.2%
- Increased ectopic pregnancy
- Uncomfortable insertion
Describe IUS
Progesterone releasing
Decreased endometrial growth, thickens mucus
Advantages and disadvantages of IUS
A
- effective, convenient
- reversible
- decreased blood loss and dysmenorrhoea
- decrease risk of PID
- local action only
D
- common - irregular periods
- increase ovarian cysts
- increased ectopic pregnancy
- expulsion or perforation
Side effects of progesterone
acne
breast tenderness
headache
mood changes
Describe caps and diaphragms
Rarely used
High failure rate
Diaphragms - thin dome 55-100mm. Lie between posterior fornix and pubic bone
Caps are smaller and fit over cervix, held by suction
Only used if problem with diaphragm
Often used with spermicide
Effectiveness of female barrier contraception
Percentage to conceive
16% - diaphragm
32% parous with cap
16% cap in nulliparous
21% female condom
Describe natural planning and A&D
Calendar methods/temperature/mucus thickness/palpating cervix
A - no side effects. complies with religious beliefs
D - commitment. unreliable. not effective
Steps in fertilisation
12-24 hours after ovulation
Sperm enter vagina and swim to uterus
Prostaglandin in semen stimulate uterine contractility
CAPACITATION (increase speed of sperm tail wiggle, removal of proteins/coatings)
Acrosomal enzymes aid penetration of corona radiata and zona pellucida
ZP3 in zona pellucida acts as sperm receptor and depolarises cell once in contact to prevent polyspermy
Procedure of termination
Offer antibiotic prophylaxis as 10% get genital tract infection (metronidazole +/- doxycycline or arythromycin)
Surgical
- Less than 14 weeks, vacuum aspiration + vaginal misoprostol 3 hours prior
- 14-24 weeks, dilation and evacuation
- Under sedation, local or general
Medical
- 200mg oral mifepristone followed by misoprostol
- NSAID for pain relief
Complications of termination
Infection (10%) Cervical trauma - surgical only Failed termination <1% Haemorrhage Perforation - surgical Long term psychological consequences
What is cryopreservation?
Freezing of gametes to preserve fertility
Availability if undergoing treatment that may affect fertility like chemotherapy
If
- will not worsen their condition
- enough time is available before the start of treatment
what is PCOS
polcystic ovarian syndrome
syndrome of polcystic ovaries AND systemic symptoms causing reproductive, metabolic and psychological disturbance
infertility, amenorrhoea, acne and hirsuitism
epidemiology of PCOS
33% of women have polcystic ovaries but not the syndrome
affects 5-10% of reproductive age women
pre menopausal women
onset at age of menarche
pathophysiology of PCOS
unknown but is multifactorial
excess androgen so by theca cells of ovary
insulin resistance
raised LH due to increased production
raised oestrogen
genetic link but no gene found
symptoms of PCOS
oligomenorrhoea infertility or subjectivity acne hirsuitism alopecia obesity psychological- mood swings, depression, anxiety sleep apnoea
signs of PCOS
hirsuitism
alopecia
central obesity
acanthosis nigricans (hyperpigmented skin in folds)
rarely - increased muscle mass, deep voice
what are the diagnostic criteria for PCOS
2 out of 3
- polcystic ovaries on US. 12+ peripheral follicles or increased ovarian volume >10cm3
- oligo ovulation or anovulation
- clinical and/or biochemical signs of hyperandrogenism
investigations for PCOS
total testosterone - normal or slightly raised
free testosterone- may be raised
Sex hormone binding globulin - normal or low
free androgen index- normal or raised
LH - typically raised
LH: FSH >2 with normal FSH
ultrasound. cysts. raised volume
also consider: TFTs, prolactin, cortisol
fasting glucose and lipids
management of PCOS
advice on weight control
if not planning pregnancy
- co-cyprinolol for hirsuitism and acne. induces regular bleeds to decrease endometrial cancer
- COCP: for menstrual irregularity
- metformin
- eflornithine for hirsuitism
- orlistat for weight loss
if planning pregnancy - clomifene - metformin one of both - laparoscopic ovarian drilling or gonadotrophins (if clomifene resistant)
complications of PCOS
infertility amenorrhoea increased CV risk sleep apnoea increased type 2 or gestational diabetes increased pre term birth or pre eclampsia
In Down’s screening what is tested in a quadruple test?
Beta-hcg
AFP (alpha fetoprotein)
Inhibin A
UE3 (unconjugated estriol)
What are the results of serum markers if a baby has Down’s?
PAPP-A - lower in Down's beta-hcg - raised in Down's AFP - lower in Down's UE3 - lower in Down's Inhibin A - raised in Down's
What factors can affect Down’s screening?
Weight Race IVF Diabetes Smokers Twins
Describe nuchal scanning in Downs
- Performed between 11 and 14 weeks
- Measure nuchal pad at nape of neck
- Increased nuchal translucency = higher change of chromosomal abnormality
- 20% false positive rate
Describe amniocentesis
- Sample of amniotic fluid to examine foetal cells
- Done between 12-18 weeks
- Chromosomal, genetic and biochemical analysis
- Management of rhesus disease
- Estimation of maturity
Indicated if:
- Mother over 35
- Previous child with chromosomal abnormality
- antenatal screening
Procedure
- give rhesus prophylaxis where needed
- US guided, 22 gauge spinal needle through abdo wall into uterus
10-20ml aspirated
7% loss of pregnancy is done 12-14 weeks
Describe chorionic villus sampling
Sampling of developing plancenta late in the first trimester to allow examination of foetal karyotype/genotype
- Done transabdominally
Indicated if:
- advanced maternal age
- PHx of chromosomal/genetic abnormality
Procedure
- between 11 and 13 weeks
- US guided needle aspiration
First trimester, 2% miscarry, 2nd trimester 3%
What information should be provided during antenatal care?
FIRST CONTACT
- folic acid supplementation
- lifestyle advice - smoking, drugs, alcohol
- food hygiene
- information on all antenatal screening
AT BOOKING
- nutrition and diet
- place of birth
- exercises
- pregnancy care pathway
- discuss mental health issues
BEFORE or AT 36 weeks
- breastfeeding information
- preparation for labour and birth
- recognising active labour
- care of the new baby
- vitamin K prophylaxis
Lifestyle advice to be given in pregnancy
Folic acid 400 micrograms/day ideally before conception
Avoid vitamin A (teratogenic)
Vitamin D supplementation if darker skin or low
Avoid unpasteurised milk, soft cheese, pate (listeriosis)
Avoid salmonella risk - no raw or partially cooked eggs
Seatbelt placed above and below bump
What screening is done Antenatally?
Anaemia - booking, 28 weeks
Blood grouping - blood group and rhesus D status
Haemoglobinopathies
Foetal anomalies - 18-20 weeks US scan
Infection - MSU early pregnancy, BV, chlamydia, hep B, HIV, syphilis, rubella
Placenta praevia
How is foetal growth monitored?
Symphysis-fundal height from 24 weeks
Management of breech baby at 36 weeks?
external cephalic version
Management of pregnancy over 41 weeks
- Vaginal exam plus membrane sweeping
- Induction offered after 41 weeks
- if declined, twice weekly cardiotocography
At what weeks are antenatal appointments offered?
10 weeks 16 weeks 18-20 weeks - US scan NP - 25 weeks (start symphysis-fundal height) 28 weeks - antiD NP - 31 weeks 34 weeks - 2nd dose antiD 36 weeks 38 weeks NP - 40 weeks 41 weeks - for induction
All appointments - BP and proteinuria
Definition of miscarriage
Loss of pregnancy before 24 weeks of gestation.
Types of miscarriage
Threatened - mild bleeding, little or no pain. Cervical os closed. Ongoing pregnancy
Inevitable - heavy bleeding + clots and pain. Cervical os is open. Pregnancy will not continue
Incomplete - products of conception partially expelled
Missed/silent - foetus is dead but retained. uterus small for dates.
Habitual/recurrent - 3+ consecutive miscarriages
Septic - complication of incomplete or therapeutic abortion when intrauterine infection occurs
Epidemiology and risk factors for miscarriage
Increases with age
10-15% of pregnancies
85% in the first trimester
RFs
- increased number of births (parity)
- Smoking
- Excess alcohol
- Illicit drug use
- Uterine surgery or abnormalities e.g. incomplete cervix
- Connective tissue disorders (SLE, APLS)
- uncontrolled diabetes
Aetiology of miscarriage
Often no cause found
- Abnormal foetal development - abnormal chromosomes
- Genetically balanced parental translocation
- Placenta failure
- uterine abnormality - bicornuate, fibroids
- Incompetent cervix (2nd trimester)
- Multiple pregnancy
- Autoimmune - SLE, APLS
- PCOS
50% unexplained
Presentation of miscarriage
Vaginal bleeding (heavier bleeding = increased risk)
Abdominal pain
Passed products of conception/clots
50% with threatened miscarriage will later miscarry
- Open cervical os
- Uterine size not appropriate for dates
- Products of conception in cervical canal
Investigations for miscarriage
US - TV, if there is no visible heart beat, a 2nd scan should be done in 7-14 days depending on size of sac
Serum hcg - levels below 1000 in pregnancy of unknown location or complete miscarriage
Management of miscarriage
Support, follow up and counselling
Anti-D to all rhesus negative
CONSERVATIVE
- Expectant, should resolve naturally 7-14 days
- Consider other management if: risk of haemorrhage, late in first trimester, previous adverse miscarriage outcome, infection, coagulopathies
- Pregnancy test 3 weeks after - if still positive, medical or surgical management
MEDICAL
- Vaginal misoprostol, analgesia and anti-emetics
- Causes more pain and bleeding than surgical
- Pregnancy test 3 weeks after
SURGICAL
- If persistent bleeding, haemodynamic instability, retained tissue, gestationaltrophoblastic disease
- Manual vacuum aspiration under local or surgical under GA
- Complications: perforation, cervical tears, adhesions, haemorrhages
- Screen for chlamydia
Types of gestational trophoblastic disease
Can be pre-malignant or malignant - due to abnormal proliferation of trophoblastic tissue.
Pre-malignant
- Complete hydratiform mole
- Partial hydratiform mole
Malignant
- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic disease
- Epitheliod trophoblastic disease
Describe complete molar pregnancies
All genetic material comes from the father when an empty oocyte is fertilised
- No foetal tissue
- 46 XX karyotype
- Placental tissue has marked hyperplasia and gross swelling of villi
- “bunch of grapes” appearance
- 10-15% become malignant, very sensitive to chemo
- No embryo
Describe partial molar pregnancy
- 3 sets of chromosomes
- 2 sperm fertilise at the same time
- 69 chromosomes, 46 paternal, 23 maternal
- embryo visible on early US
- usually diagnosed on histology after miscarriage
- <1% malignancy
Describe complete mole
- Develops form a complete molar pregnancy
- Invades into myometrium
- Uterine mass with elevated hCG
- Responds well to chemo
Describe choriocarcinoma
Synctiotrophoblasts
- Often follows a molar pregnancy but can be post normal pregnancy, ectopic or abortion
- continued vaginal bleeding post-pregnancy
- Often metastasises - lung, brain, GI, liver, kidney
- Can occur up to 20 years post pregnancy
Epidemiology and risk factors for gestational trophoblastic disease
GTD - 1 in 714 births
Complete molar pregnancy - 1-3 per 1000 pregnancies
Partial - 1 per 1000
GTN - 1 in 50,000 live births
RFs
- over 45 or under 16
- previous molar pregnancy
- multiple pregnancy
- menarche over 12, light menstruation
- COCP of history of use
- Asian
Presentation of GTD
Vaginal bleeding in first trimester
Hyperemesis
Rare
- abnormal uterine enlargement
- hyperthyroidism
- anaemia
- respiratory distress
- pre-eclampsia
Investigations for GTD
- hCG (best for follow up)
- Histology for definitive diagnosis (should be done for all products of conception
- US: snowstorm appearance in 2nd trimester, heterogenous mass, no foetal development
- CT if staging for metastatic disease
Management of GTD
Refer for follow up at a trophoblastic screening centre
- Suction curettage
- Uterine pregnancy test at 3 weeks
- Anti D prophylaxis
- SENIOR SURGEON
Follow up
- 2 weekly until hCG normal
- monthly for 6 months after
Chemotherapy
- if choriocarcinoma, mets, heavy bleeding, plateaued or rising hCG
- LOW risk: methotrexate & calcium folinate
- HIGH risk: EMA/CO chemotherapy combination
Epidemiology and RF for ectopic pregnancy
1.1 per 1000 pregnancies
97% in fallopian tubes
2-3% interstitial (not extrauterine part of the tube)
RF
- IVF
- Hx of pelvic infection
- Adhesions from inflammation, infection or endometriosis
- tubal surgery
- IUD/IUD
Symptoms of ectopic pregnancy
Abdominal or pelvic pain Amenorrhoea or missed period Vaginal bleeding (with or without clots)
Dizziness, fainting or syncope Breast tenderness Shoulder tip pain Urinary symptoms Passage of tissue Rectal pain or tenesmus Diarrhoea and vomiting
Signs of ectopic pregnancy
Pelvic or abdominal tenderness Adnexal tenderness Rebound tenderness Cervical tenderness Pallor Abdominal distension Enlarged uterus Tachycardia and/or hypotension Shock or collapse
Investigations of ectopic pregnancy
Pregnancy test in all women of child bearing age and lower abdominal pain
- Transvaginal US most accurate
- Need to identify: location of pregnancy, foetal pole, heartbeat
- Serial hCG, 48 hours apart
Management of ectopic pregnancy
- Admit as emergency
- Anti-D prophylaxis in all rhesus negative women
- Conservative if hCG declining and patient clinically well
MEDICAL
- single dose methotrexate
- First line if can return for follow up with no significant pain, unruptured, no intrauterine pregnancy on US and hCG <1500
- Contraception for 3-6 months due to methotrexate teratogenicitiy
SURGICAL
- If can’t come for follow up OR
- significant pain
- adnexal mass >35mm
- Foetal heartbeat visible
- Serum hCG>5000
- Laparoscopic approach preferable
- Salpingectomy
- Complications: bleeding, infection, damage to surrounding organs
Describe BP in pregnancy
Falls slightly in 1st trimester due to decreased vascular resistance
- Falls in 2nd to lowest point at 22-24 weeks
- Increases in 3rd trimester to pre-pregnancy levels
- Falls immediately after birth
Risks of hypertension in pregnancy
Abruptio placentae
Cerebrovascular accident
Disseminated Intravascular Coagulopathy
Intrauterine growth restriction
Prematurity
Intrauterine death
Management of hypertension of pregnancy
Education on symptoms of pre-eclampsia
- US at 34 weeks for foetal growth and amniotic fluid volume
- High risk of pre-eclampsia then 75mg aspirin daily
PRE-EXISTING
- Review medication
- Stop ACEi and ARBs
- Keep BP <150/110
- Test for proteinuria regularly
- US for foetal growth restriction, amniotic fluid volume
MILD - 140/90
- Measure BP twice weekly and urine for protein at each visit
MODERATE - 150-159/100-110
- Measure BP twice weekly
- Start labetalol (alternatives: methyldopa, nifedipine)
- Bloods
SEVERE >160/110
- Admit, discharge when <150
- Measure BP at least 4 times per day
When should aspirin be given in pregnancy?
- Hypertension or pre-eclampsia in past pregnancy
- CKD
- Autoimmune disease
- Diabetes mellitus
- Chronic hypertension
OR 2 of the following
- first pregnancy
- aged over 40
- previous pregnancy over 10 years ago
- BMI > 35
- FHx of pre-eclampsia
- multiple pregnancy
Definition of antepartum haemorrhage
Vaginal bleeding after week 24 of gestation and before 2nd stage of labour
Epidemiology and risk factors for antepartum haemorrhage
3-5% of pregnancies
20% of very preterm babies are associated with APH
RFs depends on causes
- Smoking
- Cocaine use
- Increasing maternal age
- Increased parity
- Pre-eclampsia
- polyhydramnios
Aetiology of APH
No definitive cause found in 50%
- Placenta praevia (insertion of placenta, partially or fully, in lower segment of the uterus)
- Placental abruption (premature separation of normally placed placenta)
- Local causes (vulval, cervical infection, trauma or tumours)
- Domestic violence
- Vasa praevia (bleeding from foetal vessels in foetal membranes, high risk of foetal haemorrhage)
- Uterine rupture
- Inherited bleeding problems
Presentation of APH
Bleeding With pain - abruption Without pain - praevia Uterine contractions Malpresentation or failure of head to engage Signs of foetal distress If severe - hypovolaemic shock
Investigations of APH
FBC
Group and save
Clotting studies
ADMIT
Urgent US for placenta praevia
Foetal monitoring
Rhesus negative women should have Kleihauer test - give anti-D after each bleed
Management of APH
Admit, even if only small amount of bleeding
Estimate blood loss - Minor <50ml, Major 50-1000ml, massive>1000ml
If foetal distress - urgent delivery regardless of gestation
If severe bleeding - mother’s life takes priority
Give corticosteroids if gestation between 24 and 36 weeks
Definition of placenta praevia
Placenta inserted wholly or partially into the lower segment of the uterus
MAJOR - placenta covers internal os of cervix
MINOR - leading edge is in lower segment but not covering the os
Epidemiology and risk factors for placenta praevia
1/200 births
1/1000 are major
Incidence is increasing
RFs
- Previous history of placenta praevia
- Previous C-section
- Increased maternal age
- Increased parity
- Smoking
- Cocaine use during pregnancy
- Previous spontaneous or induced abortion
- Deficient endometrium due to past history of endometritis, manual removal of placenta, curettage
- Assisted conception
Presentation of placenta praevia
Painless bleeding after 28th week - sudden, profuse, does not last long
- 25% have spontaneous labour in the next few days
- Can just have bleeding in labour or membrane rupture
- High presenting part or abnormal lie
- No foetal distress unless complications
- Bleeding provoked by sexual intercourse
Diagnosis/ investigations of placenta praevia
Should have high index of suspicion in bleeding after 20 weeks.
Diagnosis relies on US
- Leading edge may be low on a 20 week scan
- Apparent migration occurs during 2nd and 3rd trimester with development of lower uterine segment
- Cannot exclude placental abruption (this is a clinical diagnosis)
- TV US for all women whose placenta reaches or overlaps cervical os at anomaly scan
- Minor - scan again at 36 weeks
- major - scan again at 32 weeks
Assists in planning and delivery
Management of placenta praevia
MINOR - may be able to deliver vaginally.
Placental edge <2cm from the os = caesarean section
If anterior, reaching os with history of C-section then treat as placenta accrete
MAJOR
- Deliver by C-section
- No penetrative intercourse
- Should admit to hospital from 34 weeks
- Defer C-section to 38 weeks if possible
Placenta accrete and management
Morbidly adherent placenta
- high risk if placenta praevia with history of C-section
- Requires consultant obstetrician and anaesthetist
- Blood products on site
- MDT pre-op planning
- Deliver baby without disturbing placenta
- DO NOT PERFORM VAGINAL EXAM
Describe implantation bleeding
Light spotting or bleeding
Occurs 10-14 days after conception
NORMAL
Occurs when fertilised egg attaches to lining of uterus
Describe normal placenta at term
Blue-red colour, discoid shape
450g in weight
Maternal surface - divided into lobules or cotyledons with irregular grooves or clefts
Foetal surface - smooth, shiny and translucent, choronic plane covered in amniotic membrane
Describe normal umbilical cord
50-60cm long
Abundant Wharton’s jelly, no true knots
2 umbilical arteries, 1 umbilical vein
Abnormalities of placental shape, size or surfaces
Circumvallate - foetal membranes double back on foetal side around edge of placenta, small central chorioic area inside a paler ring of membranes on foetal side
Succenturiate lobe - accessory lobes, associated with retained placenta and increased infection
Bipartate placenta - bilobed (uncommon)
Placenta membranacea - failure of chorion to atrophy during development, placental cotyledons form envelope around greater part of uterine wall
Describe placenta accreta and levels
PLACENTA ACCRETA
Placenta morbidly attached to uterine wall - chorionic villi penetrate the decidua basalis to attach to myometrium
PLACENTA INCRETA
villi penetrate deeply into myometrium
PLACENTA PERCRETA
villi breech myometrium into perioteum
Epidemiology of placenta accreta
1/2500 deliveries
40% deliver before 38 weeks
C-section planned at 36-37 weeks
RFs
- Previous C-section
- Placenta praevia
- Increased age
Management of placenta accreta
Placenta is left in place with therapeutic uterine artery embolization, surgical internal iliac artery ligation or methotrexate therapy
Elective hysterectomy later has less blood
Describe placental abruption
Premature separation of a normally placed placenta before delivery of the foetus with blood collecting between placenta and uterus
- 30% of all APH
- 6 per 1000 births
Concealed (20%) - haemorrhage confined within uterine cavity, more severe as blood loss usually underestimated
Revealed (80%) - blood drains through cervix
Risk factors for placental abruption
Previous abruption Pre-eclampsia Multiple pregnancy Threatened miscarriage Hypertension Multiparity Past C-section Smoking Non-vertex presentation Cocaine/amphetamines Thrombophilia Intrauterine infections Polyhydramnios Trauma - RTA, domestic violence, iatrogenic
Presentation of placental abruption
Vaginal bleeding Continuous abdominal pain Uterine contractions Shock Foetal distress
CLINICAL DIAGNOSIS
- Tense, tender uterus with woody feel
- Foetal hypoxia with HR abnormality on CTG
- Low platelet count
- Large level of compensation
Management of placental abruption
Mothers life takes priority ABCD Crossmatch 4 units Kleihauer test for anti-D Left lateral position
Delivery -
If foetus alive, C-section or artificial rupture of amniotic membranes
If foetus dead - vaginal delivery
Determining gestational age
Physical exam/US
History - LMP
Naegele’s rule - EDD = -3months + 7 days from LMP
Uterine size - 6-8weeks = small pear, 8-10 weeks = orange, 10-12weeks = grapefruit
16 weeks = midway pubic symphysis and umbilicus
20 weeks = umbilicus
US
- gestational sac diameter (until embryo visible)
- Crown rump length
- After 10 weeks - biparietal diameter and head circumference
Foetal biometry
- Biparietal diameter
- Head circumference
- Femur length
- Abdominal circumference
Symptoms of pregnancy
Amenorrhoea Nausea and vomiting Breast enlargement and tenderness Increased urinary frequency Fatigue
Uterine cramping Abdominal bloating Constipation heartburn SOB Mood changes Food cravings/aversions
Diagnosis of pregnancy
hCG
- first secreted 6-8 days post ovulation
- doubles every 30-50 hours during the first 30 days
- slower rise in abnormal pregnancy
- urine requires high levels to detect
US
- gestational sac at 4-5 weeks
- yolk sac from 5 weeks to 10 weeks
- foetal pole and cardiac activity 5-6 weeks
Reasons for pregnancy false positives
operator error (home kits)
pregnancy loss soon after implantation
interference from hCG from infertility treatment
hCG from tumour
Pituitary hCG secretion in perimenopausal women
Describe pre-eclampsia
Pregnancy induced hypertension in association with proteinuria +/- oedema
Characterised by
- Maternal hypertension
- Proteinuria
- Oedema
- Foetal IUGR
- premature birth
Severe SBP > 160, diastolic >110
Foetus may have neurological damage post-hypoxia
Epidemiology and RF for pre-eclampsia
2nd leading cause of direct maternal death
- 5 per 1000
- Death rate 0.4 per 100,000
- 20% stillbirths without congenital abnormality is caused by pre-eclampsia
- 50% with severe will deliver by 36 weeks
RFs HIGH - past pre-eclampsia, eclampsia, hypertension in a previous pregnancy - pre-existing hypertension - Pre-existing CKD - Pre-existing diabetes - SLE or APLS
MODERATE
- 10+ years since last pregnancy
- first pregnancy
- aged over 40
- BMI>35
- FHx of pre-eclampsia
- multiple pregnancy
Pathophysiology of pre-eclampsia
Suboptimal uteroplacental perfusion associated with maternal inflammatory response and maternal vascular endothelial dysfunction
Phase 1 - Abnormal placentation
NORMAL
- During 6-18 weeks placentation occurs
- Alterations in spiral arteries occur to increase blood supply
- Trophoblasts invade spiral arteries to 5x diameter
- Coverts low flow, high pressure to low resistance, high flow
PRE-ECLAMPSIA
- inadequate trophoblast invasion, inadequate placental perfusion
- Causes IUGR and pre-eclampsia
Phase 2 - endothelial dysfunction
- Platelet adhesion and thrombosis
- Exaggerated maternal systemic inflammatory response
- Decreased organ perfusion - HELLP
Presentation of pre-eclampsia
Systolic BP>140, diastolic >90 in 2nd half of pregnancy with >1+ of proteinuria
- New hypertension
- New proteinuria
SEVERE
- Severe frontal headache
- Sudden swelling (oedema)
- Liver tenderness
- Visual disturbance
- Epigastric pain
- Vomiting
- Low platelet count
- Raised ALT and AST
- Clonus
- HELLP syndrome
- Papilloedema
- Foetal distress
Monitoring of pre-eclampsia
If patient has any risk factors - increasing frequency of BP and urine measurements
Admit if they have:
- BP>140/90, >1+ proteinuria
- Systolic BP >160
- Diastolic >100
- Any symptoms or signs
Investigations of pre-eclampsia
- Urinanalysis - microscopy, culture
- Frequent monitoring of FBC, LFTs, renal function, electrolytes & urate
- Look for HELLP syndrome
- Clotting if severe or thrombocytopaenia
- 24 hour urine for protein and creatinine
- Assessment of foetus - US and amniotic fluid
HELLP
Haemolysis
Elevated Liver enzymes
Low Platelets
Management of pre-eclampsia
Conservatively until at least 34 weeks where possible (no HELLP)
Delivery of the placenta is the ONLY cure
SEVERE
- Antihypertensives (labetolol) if BP>160/110
Can also use nifedipine or hydralazine
- Magnesium sulphate to prevent seizures
- Fluid restruction - to minimise fluid overload which can result in pulmonary oedema
- Delivery
- If under 34 weeks, give corticosteroids
- Method of delivery depends on presentation of foetus, foetal condition and chance of success
- IM syntocinon to prevent haemorrhage
- Prophylaxis against VTE
Management of eclampsia
Resuscitation Magnesium sulphate as anticonvulsant Intubation may be required if repeated seizures IV labetalol or hydralazine Continuous foetal monitoring Monitor fluid intake, and urine output Attempts to prolong pregnancy not of use
- it is unsafe to deliver a baby from an unstable mother
- Control seizures, reduce HTN and correct hypoxia
- c-section
Complications of pre-eclampsia
Haemolysis HELLP AKI DIC Adult respiratory distress syndrome Cerebrovascular haemorrhage
Prevention of pre-eclampsia
75mg aspirin from 12 weeks if high risk
Maternal issues associated with substance misuse in pregnancy
Low nutrition Risk of anaemia Oral hygiene issues Infection from needles Increased risk of mental health problems Increased obstetric complications Increased premature delivery
Foetal issues associated with substance misuse in pregnancy
IUGR Pre-term delivery Increase perinatal mortality Increased miscarriage Increased placental abruption
Management of opioid addiction in pregnancy
Maintenance with methadone to stop/minimise illicit use
Detox in first trimester has high miscarriage risk
Can detox in 2nd or 3rd trimester, small frequent reductions
Withdrawal will increase foetal distress and still birth
Management of a cocaine use in pregnancy
STOP - no safe prescribed alternative
Risks of cocaine in pregnancy
Increased miscarriage, still birth
PROM
Placental abruption
Preterm labour
For baby
- stroke
- poor growth
- deformed limbs
- feedbing problems
- brain damage
- SIDS
NO BREAST FEEDING
Risks of opiates in pregnancy
Increased pre term delivery
Still born
IUGR
Increased neonatal death
Neonatal withdrawal syndrome - high pitch cry, poor feeding, tremors, irritability, D&V, sweating, seizures
Heroin = NO BREAST FEEDING Opiates = OK to breastfeed
Induction of labour
60-80% success rate
Starting labour by uterine stimulation. Approximately 20% of births.
Offer to women in healthy pregnancy over 41 weeks to decrease risk of still birth
Offer to diabetic women before term
Offer if PROM after 37 weeks
- Membrane sweep
- Prostaglandin gel or pessary (PV)
- Oxytocin +/- artificial rupture of membranes
Monitor with CTG for myometrial over-reaction
Contraindications for induction of labour
Severe placenta praevia Transverse foetal lie Severe cephalopelvic disproportion Cervix <4 on Bishop's score Active primary genital herpes infection High and floating foetal head (risk of prolapsed cord)
Complications of induction of labour
Uterine Hyperstimulation - foetal distress, hypoxic damage
Uterine rupture
Intrauterine infection with prolonged membrane rupture
Prolapsed cord if presenting part not engaged
Amniotic fluid embolization
Atonic PPH
Prevention for instrumental delivery
Presence of supporting person with the woman at all times
Mother labouring in upright or left lateral position
Avoidance of epidurals
What is Bishop’s system?
Score for ripeness of cervix
>8 = successful delivery
Classification of forceps deliveries
OUTLET - foetal scalp visible, labia separated
Foetal skull has reached pelvic floor
Rotation required > 45 degrees
LOW - leading point (not caput) is at +2, rotation required
MIDCAVITY - head 1/5 palpable per abdomen, leading point >2+ but not above ischial spines
HIGH = not recommeded
Indications for instrumental delivery
Presumed or diagnosed foetal compromise
Protect head during breech delivery
MATERNAL Avoid Valsalva manourvre Hypertensive crisis CV disease Myasthenia gravis Spinal cord injury
Inadequate progress
- Active stage > 2 hours in nulliparous, >1 hour in multiparous
- Maternal fatigue
Contraindications for instrumental delivery
Predisposition to fractures in foetus
Bleeding tendency or active bleeding in foetus
Face presentation
Vacuum extractor should not be used under 34 weeks
Requirements for an instrumental delivery
Fully dilated cervix Occipital-anterior position Ruptured membranes Cephalic presentation Engaged presenting part Pain relief adequate Sphincter (bladder) empty
Mediolateral episiotomy before instrumental delivery to reduce tears
If unsuccessful with 3 pulls - c-section
Indications for episiotomy
Rigid perineum preventing delivery Large tear imminent Instrumetnal delivery Shoulder dystocia Vaginal breech delivery
What is an episiotomy
Right mediolateral incision with local anaesthetic
Degrees of tears
1st - injury to vaginal epithelium and vulval skin only
2nd - injury to perineal muscles but not anal sphincter
3rd - injury to perineum, involving anal sphincter
4th - injury to perineum, anal sphincter complex and anal or rectal mucosa
Indications for induction of labour
uteroplacental insufficiency prolonged pregnancy > 41 weeks IUGR Oligo or anhydramnios Abnormal uterine or umbilical artery Doppler Non-reassuring CTG PROM Severe pre-eclampsia, eclampsia Intrauterine death of foetus APH Chorioamnitis
Severe hypertension
Uncontrolled diabetes
Deteriorating renal function
Malignancy
Methods for induction of labour
Cervical ripening
- Separation of membranes from the cervix - stretch and sweep
Amniotomy
- Artificial rupture of membranes
Prostaglandins - DINOPROSTONE
- Intravaginally as tablets or gel
- VE after 6 hours
- CTG before and after
- Only 2 doses as risk of Hyperstimulation
Oxytocin infusion
- best after rupture of membranes
- wait 6 hours after prostaglandins
- continuous CTG and want 3-4 contractions in 10 minutes
First stage of labour
Begins with regular contractions when the foetal presenting part has reached true pelvis
End when the cervix is fully dilated (10 cm)
Latent phase
- 2-24 hours
- Cotnractions not painful, 5-10 minute intervals
- Cervix dilating slowily
ACTIVE PHASE
- Primi - 12-14 hours, multi 6-10 hours
- Start when cervix 3-4 cm dilated
- Rapid dilation 0.5-1cm per hour
- Foetal head descends into maternal pelvis and foetal neck flexes
Management of first stage of labour
Hourly temp and HR
4 hourly BP
30 minute monitoring frequency of contractions
Foetal HR auscultated for 1 minute immediately after a contraction every 15 minutes
Should be 100-160
VE every 4 hours
Discuss need for pain relief
Second stage of labour
Starts when cervix is fully dilated
Ends with birth of baby
Contractions are stronger, 2-5 minute intervals lasting 60-90 seconds
Primigravida 60 minutes, multi 30 minutes
Feotal head descends and rotates anteriorly
Wants to push
After head through, shoulders rotate to allow shoulders through
Midwife/doctor present throughout
Monitor contractions, and foetal HR ever 5 minutes
Push during contractions, relax between
If >2 hours nulliparous or > 1 hour multiparous then consider instrumental delivery or c-section
Third stage of labour
Starts with birth of baby
Ends with delivery of placenta and membranes
Separation of placenta occurs immediately after birth
20-30 minutes or 5-15 with active management
Haemorrhaging prevented by contraction of uterine muscle fibres
Separation noted by gush of blood, prominence of fundus in abdomen and lengthening of umbilical cord
Management of 3rd stage of labour
Expectant - uterus rubbed up to produce contraction, uterus pushed to vagina to aid expulsion
Active - IM oxytocin after birth
Controlled traction of umbilical cord to aid expulsion
Examine placenta and membranes for completeness
Braxton Hicks contraction
Mild
Irregular
Non-progressive
can occur from 30 weeks, more common after 36 weeks
Poor progress in 1st stage of labour
- Criteria
- Causes
Criteria
<2cm progression in 4 hours
- Slowing in progress in parous woman
Insufficient uterine activity (power) Malpositions, malpresentation, large baby (passenger) Inadequate pelvis (passage)
Management of poor progress in 1st stage of labour
Amniotomy and reassess in 2 hours
Amniotomy + oxytocin infusion
C-section if foetal distress
Benefits of active management of 3rd stage of labour
Decreased PPH Decreased length of time in 3rd stage Decrease blood loss Decreased post-natal anaemia Decreased transfusions
Definition of premature labour
Contractions of sufficient strength and frequency to effect progressive effacement and dilation of cervix before 37 weeks
Very premature is before 32 weeks
