WOMENS HEALTH Flashcards
Sub-fertility
What and management
After ONE Year after trying activity to get pregnant (2-3 times weekly)
Always take history Do 21 day progesterone (or cycle -7) 1st line = life style 2nd = clomifene citrate If hyperprocalin - halt medications, start brominecriptine
Factors = sub fertility
Factors impacting fertility - Alcohol (No more than 1 to 2 units per week), Smoking (reduces fertility), Obesity (over 30 BMI - take longer to conceive), Low body weight (below 19 BMI), tight underwear (Men), Occupation, Amount of sex (should be having every 2-3 days)
Menopause contraception
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Offer IUD
Menopause symtom management
Lifestyle modifications - increase exercise, sleep hygiene,
Hormone replacement therapy (HRT) - CI in breast cancer, oestrogen senstivie cancer, vagnal bledding,endometrial hyperplasia
Give combined oestrogren and progesterone (If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer - if not transdermal can give in MIUD)
Does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch
Risks of HRT
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.Â
Ovarian cancer: increased risk with all HRT.
Urge incontinence
Presentation and management
Âinvoluntary urine leakage accompanied by or immediately preceded by urgency - There are often trigger factors such as hearing running water, cold weather, etc. There are typically large volumes of leakage compared to stress incontinence.
Treat - bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line. oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation).
- mirabegron (a beta-3 agonist) may be useful if there is concern about
stress incontinence
Presentation and management
involuntary leakage of urine during increased intra-abdominal pressure (ie on exertion) - typical after child birth due to detrusor muscle overactivity
RF - childbirth, older age,obesity, white, dementia,pelvic organ prolaspe
Presents with -Involuntary urine leakage on effort, exertion, sneezing, or coughing, vaginal/prolapse,Âusually with frequency and nocturia, in the absence of urinary tract infection or any other obvious pathology.
Investigations
-full exam and history, Bladder diary, Urodynamic studies.
Manage
Lifestyle alterations (ie decrease fluid intake, weight loss)
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. bulking and colpolsuspention
Miscarriage
first trimester the most common cause of miscarriage is chromosomal abnormality (50-60%) (16, 45X)
2nd trimester = incompetence cervix
Other causes are fetal abnormalities or uterine structure abnormalities
Management of miscarriages
Expectant (No pain, less than 35mm(
NO HEART Beat
Medical (Misoprostol)
Surgical (Dilation and curettage (D&C)
RF’s
- Increased maternal age, alcohol, drug use, obesity, high caffeine,
PID management
History, exam - think if acutely unwell ABCDE and Sepsis SIX
White cell count (blood)
TVUS
Pelvic CT/MRIÂ
Laparoscopy
Empirical antibiotics should be started as soon as possible.
- 1st line would be ceftriaxone and doxycylcine (second
levofloxacin)
PID risk factors
RF:Risk factors for developing PID include:-Young age (younger than 25 years). Early age of first coitus. Multiple sexual partners. Recent new partner (within the previous 3 months). History of STI in the woman or her partner
Smears
when ref to colospoy
HPV+ and abnormal smear = colopscopy
High grade dyskaryosis (moderate, severe dyskaryosis or worse) -> ref straight to colposcopy (regardless of HPV)
or 3x inadequate
Fibroid management
Manage
Mirena
tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically short-term
surgery - myomectomy (fertility ) hysteroscopic endometrial ablation, hysterectomy
PCOS management
nvestigations USS FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature Glucose intolerance Manage weight COCP Fertility (think metformin or clomifene)
Endometrious management
Investigation Pregnancy test FBC (anemia) Clotting - von Willebrand disease (vWd) includes von Willebrand factor antigen (vWF:Ag), ristocetin cofactor activity (vWF:RCoF), and factor VIII activity. Imaging USS May need endometrial biopsy Manage Pain if any COCP Transamic acid Surgical abaltion Full hysterectomy
Breast cancer presentation
The typical presentation is a painless breast mass, with/without:
Discharge
Nipple changes
Skin tethering or dimpling
Tethering to underlying tissues, e.g. muscle
Ulceration (late sign)
Ductal carcinoma in situ
Premenopausal and post-menopausal women. Usually patients are 40-60 years of age. May be extensive, and associated with fibrosis, in which case it will be a large palpable mass
Defined as a cancer that has not spread beyond the basement membrane of the ducts
May present as Paget’s Disease of the nipple (rare)
Have a risk of 30-50% of becoming invasive
Which breast cancer?
Usually occur in pre-menopausal women
Occurs in the lobules and don’t affect the ducts
Very difficult to detect – as it does not present as a lump, or cause many other signs.
Often multifocal and bilateral
No specific features on mammography
Lobular carcinoma in situ
Mucinous carcinoma characteristics
Account for 2-3% of invasive carcinomas
Their borders are not well defined, and they do not cause inversion of the nipple, or tethering of the skin.
Better prognosis than invasive ductal or lobular carcinomas
Breast cancer screening
Women in England who are aged from 50 to their 71st birthday and registered with a GP are automatically invited for screening every 3 years. (mammogram)
You may be eligible for breast cancer screening before the age of 50 if you have a very high risk of developing breast cancer.
Women aged over 70 years are invited to make their own appointments every 3 years.
If you have been found to have an increased risk of developing breast cancer, you may have yearly MRI scans or mammograms, depending on your age and your specific level of risk.
if a faulty gene (for example BRCA1 or BRCA2) has been identified in the family, direct referral to a specialist genetics service should be offered.
What is the triple approach to assessment of abnormalities that are found on screening?
exam, imaging and histology
Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
Ultrasound scanning is more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies. This form of imaging is also routinely used during core biopsies.
A biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy.
Four biopsy procedures
fine needle aspiration (FNA), which uses a very small needle to extract fluid or cells from the abnormal area.
core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.
vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.
wire localization, in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy.
BRCA1
What is the mutation
What does this increase the risk of
Mutation on chromosome 17
Lifetime risk of breast cancer is about 75%
Lifetime risk of ovarian cancer is about 50%
Men with the gene also at increased risk
Also increased risk of bowel cancer, ovarian cancer (50% lifetime risk) and prostatic cancer (men)
BRCA2
What is the mutation
What does this increase the risk of
Mutation on chromosome 13
Lifetime risk of breast cancer 40-85%
Lifetime risk of ovarian cancer <25%
Lifetime risk of breast cancer for men is about 6%
HER2 mutation BC - targeted treatment
Has specific treatment in the form of the monoclonal antibody Trastuzumab (Herceptin). This will bind to the receptor, and cause the production of p27 within the cell, which reduces cell proliferation
As a result of this specific treatment, breast cancers are routinely tested for HER2/neu presence.
ER Positive breast cancer
Treatment?
tamoxifen
PR Positive breast cancer
Treatment?
anastrozole
Tamoxifen Which of the following is an adverse effect of this drug?
Tamoxifen may cause increased risk of endometrial cancer
Paget’s disease of the nipple is most likely to be associated with which lesion
Invasive ductal carcinoma
Brown-green nipple discharge
Duct etasia
This is a condition often found in women around the menopause and occurs due to a dilation of the milk duct as a result of ageing. This may or may not be associated with a small lump right under the nipple.
CA 15-3 is a marker for?
Breast cancer
CA 125 is a marker for?
ovarian cancer
CA 125 is a marker for?
ovarian cancer
CA 19-9
pancreatic cancer
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
Fibroadenoma
Carcinoembryonic antigen (CEA) is a marker for?
Colorectal cancer
Alpha-feto protein (AFP) is a marker for?
Hepatocellular carcinoma, teratoma
Chlamydia (Chlamydia Trachomatis) presentation
Males: Mucopurulent urethral discharge, dysuria, scrotal pain, proctitis.
Females: Mucopurulent vaginal discharge, cervicitis, cervical bleeding upon contact, proctitis, post-coital bleeding, intermenstrual bleeding.
Chlamydia (Chlamydia Trachomatis) test and management
Nucleic Acid Amplification Test (NAAT)
- Can take 2 weeks to show up.
1.Doxycycline 100mg PO twice daily for 7 days (contraindicated in pregnancy)
or
Azithromycin 1g PO, followed by 500mg daily for 2 days
2.Full STI Screen
3.Contact tracing and partner notification offered (No sex until all partners tested and treated)
4. Test of cure (TOC) 5 weeks; <25yrs repeat in 3m
ALWAYS CONTACT TRACE
Complications of Chlamydia
COMPLICATIONS: • Pelvic inflammatory disease (PID)- increases the risk of ectopic pregnancy and infertility • Epididymitis • Prostatitis • Reactive arthritis
Gonorrhoea
(Neisseria Gonorrhoea)
presentation
Males: Mucopurulent urethral discharge, dysuria, orchitis.
Females: Mucopurulent cervical discharge with cervicitis, cervical bleeding upon contact, dyspareunia, pelvic pain.
Rectal infection can cause: rectal bleeding
Gonorrhoea Test and management
- Nucleic Acid Amplification Test (NAAT)
- Can take 2 weeks to show up. - Cultures (urethral, cervical, anal and oropharyngeal) to assess abx susceptibility.
- microscopy diagnosis: Gram-negative intracellular diplococci
1.Ceftriaxone 1g IM single dose
or
Ciprofloxacin 500mg PO single dose (only where antimicrobial sensitivities are known prior to treatment)
or
Cefixime 400mg PO single dose with Azithromycin 2g PO single dose (if IM injection is contraindicated)
2.Full STI Screen
3. Contact trace
• Fitz-Hugh-Curtis syndrome
- secondary to PID there is inflammation of the hepatic capsule leading to perihepatic adhesions
Syphillis ( Treponema Pallidum) test and treatment
Dark ground microscopy of chancre fluid – (shows motile spring-shaped bacteria in primary syphilis).
Syphilis PCR swab ulcerated lesion.
Treponemal-specific serology remains positive throughout life: EIA, TPHA, TPPA
Cardiolipin serology tests indicator of disease activity, staging and treatment efficacy. These include: Rapid Plasma Reagin (RPR), Venereal Disease Research Laboratory (VDRL)
Repeated at 12 weeks post-exposure, and if considered high-risk at 6 weeks as well
Benzathene benzylpenicillin IM injection, however, the dose depends on the nature of the infection
Prednisolone is given alongside antibiotics in cases of neurosyphilis.
Primary, secondary and early latent syphilis: Benzathine benzylpenicillin 2.4 million units IM injection as a single dose
Late latent, cardiovascular and gummatous syphilis: Benzathine benzylpenicillin 2.4 million units IM injection weekly for three weeks (three doses)
- Full STI Screen
- Contact trace
Herpes (HSV-1 and HSV-2) test and treatment
HSV PCR from swabs taken from lesions (burst the lesion)
Some centres use NAAT
HSV does not form part of routine STI screening in the UK!!!
Primary episode: Aciclovir 400mg oral three times a day for 5 days (commenced within 5 days of symptom onset)
Recurrent episodes: Aciclovir 800mg oral three times a day for 2 days
Prophylaxis in patients with >5 episodes per year: Aciclovir 400mg twice daily
Saltwater baths, topical petroleum jelly, oral analgesia and topical lidocaine gel can be used for pain control.
- Full STI Screen
- No need for contact tracing, but patients should be advised to refrain from sex when have lesions and disclose in relationships. Condoms can reduce the rate of spread and should be encouraged.
Trichomoniasis (Trichomonas vaginalis) presentation
Females: Vaginal discharge (thin, frothy yellow coloured with a ‘fishy’ smell), vulval pruritus, vulvovaginitis, dysuria, dyspareunia
Males: urethral discharge, dysuria, balanitis
Trichomoniasis (Trichomonas vaginalis) treatment
Metronidazole 2g oral as a single dose or 400-500mg twice daily for 5-7 days (note alcohol should be avoided during treatment and for 72 hours afterwards)
A full STI screen including blood tests should be performed. Contact tracing and partner notification need to be offered.
Advise that all forms of sexual intercourse need to be avoided until both parties are tested and treated. Test of cure is not routinely required.
Nutrition in pregnancy
Vitamin D recommendation?
women with darker skin (such as those of African, African–Caribbean or South Asian family origin
women who have limited exposure to sunlight, such as women who are housebound or confined indoors for long periods, or who cover their skin for cultural reasons.
Gestation date scan
10 weeks 0 days and 13 weeks 6 days to determine gestational age and to detect multiple pregnancies
Date of Abnormality scan
normally between 18 weeks 0 days and 20 weeks 6 days.
Routine screening in pregnancy
Anemia
Testing for blood group and rhesus D status in early pregnancy (antenatal anti‑D prophylaxis is offered to all non‑sensitised pregnant women who are rhesus D‑negative)
sickle cell diseases and thalassaemias, including carrier status ((ideally by 10 weeks)
Down’s syndrome (‘combined test’ (nuchal translucency, beta‑human chorionic gonadotrophin, pregnancy‑associated plasma protein‑A) (11 weeks 0 days and 13 weeks 6 days)
Asymptomatic bacteriuria by midstream urine culture early in pregnancy
Serological screening for hepatitis B virus
HIV infection
Screening for syphilis should be offered to all pregnant women
Routine screening in pregnancy is NOT offered for
BV Chlamydia Cytomegalovirus Fragile X Hep C Group B strep Toxoplamosis
Gestational Hypertension
pregnant women at high and moderate risk of pre-eclampsia - prescribe?
50 mg of aspirin1 daily from 12 weeks until the birth of the bab
Factors that = High risk of Pre-eclampsia
- hypertensive disease during a previous pregnancy
- chronic kidney disease
- autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension.
Factors that = Moderate risk of Pre-eclampsia
1 + first pregnancy age 40 years or older pregnancy interval of more than 10 years BMI of 35 kg/m2 or more at first visit family history of pre-eclampsia multi-fetal pregnancy.
Target blood pressure in pregnancy (women on BP med)
135/85 mmHg or less.
Chronic hypertension in pregnant women - Treat?
1st line labetalol
2nd line nifedipine
3rd line methyldopa
BP in pregnancy to admit?
BP to give Labetalol
160/110
140/90
Postpartum hemorrhage?
what is Minor
Major (moderate and severe)
minor (500–1000 ml) or major (more than 1000 ml). Major could be divided to moderate (1000–2000 ml) or severe (more than 2000 ml).
Causes of Postpartum hemorrhage?
4 T’s
Tone - (multiple pregancy,prolonged labour, prior haemoraage, large baby)
Trauma - (ie Episiotomy)
Tissue - retained tissue ie placenta acretia
Thromin
Urine atony management
Fundus massage, IV synmaticn (cause contractions) TXA, Intrauterine balloon tamponade worse case = hysterectomy
RF for pre-eclampsia
age 40 years or older nulliparity pregnancy interval of more than 10 years family history of pre‑eclampsia previous history of pre‑eclampsia body mass index 30 kg/m2 or above pre‑existing vascular disease such as hypertension pre‑existing renal disease multiple pregnancy.
Pre eclampsia presentation
Can present w/
severe headache
problems with vision, such as blurring or flashing before the eyes
severe pain just below the ribs
Vomiting
sudden swelling of the face, hands or feet.
Thresholds for considering planned early birth in pre-ecampsia
inability to control maternal BP despite using 3 or more classes of antihypertensives in appropriate doses
maternal pulse oximetry less than 90%
progressive deterioration in liver function, renal function, haemolysis, or platelet count
ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
placental abruption
reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth.
What is HELLP
(haemolysis, elevated liver enzymes and low platelet count)
HELLP
Presents with tired, retaining fluid, headache, nausea, upper right abdominal pain, blurry vision, nosebleeds, and seizures.
Complications may include disseminated intravascular coagulation, placental abruption, and kidney failure
he only current recommended and most effective treatment is delivery of the baby, as the signs and symptoms diminish and gradually disappear following the delivery of the placenta.
Advise continuous cardiotocography if any of the following risk factors are present at initial assessment or arise during labour:
maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
fresh vaginal bleeding that develops in labour
severe hypertension: 160/110
contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes (tachysystole)
oxytocin use.
Reading CTG
baseline rate - reassuring = 110 to 160 beats/minute - non-reassuring: (100 to 109 or 161 to 180 beats/minute) - abnormal: below 100 beats/minute or above 180 beats/minute.
baseline variability - reassuring = 5 to 25 beats/minute, non-reassuring:less than 5 beats/minute for 30 to 50 minutes or more than 25 beats/minute for 15 to 25 minutes - abnormal:less than 5 beats/minute for more than 50 minutes, more than 25 beats/minute for more than 25 minutes or sinusoidal.
presence or absence of decelerations, and concerning characteristics of variable decelerations if present (see decelerations)
presence of accelerations - the presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy
Shoulder dystonia Risk factors
you have had shoulder dystocia before you have diabetes
your body mass index (BMI) is 30 or more your labour is induced
you have a long labour
you have an assisted vaginal birth (forceps or ventouse).
Shoulder dystonia Management
reposition you to give your baby more room inside the vagina; you will be asked to lie on your back with your legs pushed outwards and up towards your chest (this is known as the McRoberts manoeuvre)
Screw = 2nd line
Consider making a cut (episiotomy) to enlarge the vaginal opening.
Shoulder dystonia Complications
Maternal - Vaginal tears -> postpartum haemorrhage
Fetal -> Brachial plexus injury (BPI), which may cause loss of movement to the arm. The most common type of BPI is called Erb’s palsy. It is usually temporary and movement will return within hours or days. Permanent damage is rare.
What is Hydrosalpinx?
How does this present?
The fallopian tube is blocked and fills with serous or clear fluid near the ovary -> major cause for distal tubal occlusion is pelvic inflammatory disease (PID), usually as a consequence of an ascending infection by chlamydia or gonorrhea
Ovarian Mass
Present and investigations
Can present with pain, bleeding, bloating
Diagnosis – USS, Ca-125, CT, fine needle biopsy - If follicular cyst -repeat in 6weeks to see if cyst has reduced
small (less than 50 mm diameter) simple ovarian cysts
- Management
generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
simple ovarian cysts of 50–70 mm in diameter- management
should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
Endomterial polpys
Presentation
RF
Investigations
Presents - Irregular menstrual bleeding, infertility, Bleeding between menstrual periods
RF - Being perimenopausal or postmenopausal, Having high blood pressure (hypertension), Being obese, Taking tamoxifen, a drug therapy for breast cancer
Investigating - history/exam, TVUSS, biopsy
Diabetic pregnancy RF
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
Management of gestational diabetes
newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
women should be taught about selfmonitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Management of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
aspirin 75mg/day from 12 weeks until the birth of the baby, to reduce the risk of pre-eclampsia
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Placental abruption
Causes
Cause - not known but associated factors: proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age
Placental abruption clinical features
Clinical features shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems
Placental abruption Management
Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Fetus dead
induce vaginal delivery
Chorioamnionitis
ascending bacterial infection of the amniotic fluid / membranes / placenta
The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens.
Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.
Induction of labour
Indications
prolonged pregnancy, e.g. > 12 days after estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
rhesus incompatibility
Method membrane sweep intravaginal prostaglandins breaking of waters oxytocin
C-sec indications
Indications (apart from cephalopelvic disproportion/praevia, most are relative) absolute cephalopelvic disproportion placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)
Serious Risks of C-section
Maternal: emergency hysterectomy need for further surgery at a later date, including curettage (retained placental tissue) admission to intensive care unit thromboembolic disease bladder injury ureteric injury death (1 in 12,000)
Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
Frequent risk of C-section
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
HIV in pregnancy - reducing vertical transmission
Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)
HIV pregnancy - mode of delivery
Mode of delivery
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
