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Obstetrics and Gynaecology > Zero to Finals Obstetrics > Flashcards

Zero to Finals Obstetrics Flashcards

1
Q

Explain the stages of labour:

A

There are three stages of labour:

  • The first stage is from the onset of labour (true contractions) until 10cm cervical dilatation.
  • The second stage is from 10cm cervical dilatation to delivery of the baby.
  • The third stage is from delivery of the baby to delivery of the placenta.
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2
Q

What role do prostaglandins play in pregnancy?

A

They play a crucial role in menstruation and labour by stimulating contraction of the uterine muscles. They also have a role in the ripening of the cervix before delivery.

One key prostaglandin to be aware of is prostaglandin E2. Pessaries containing prostaglandin E2 (dinoprostone) can be used to induce labour.

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3
Q

Explain the first stage of labour and the rate of progression:

A

The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm.

  • Latent phase: From 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
  • Active phase: From 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
  • Transition phase: From 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
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4
Q

What are the three P’s in regard to the second stage of labour?

A

The second stage of labour lasts from 10cm dilatation of the cervix to delivery of the baby. The success of the second stage depends on “the three Ps”: power, passenger and passage.

Passenger: the four descriptive qualities of the fetus - size, attitude, lie, presentation.

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5
Q

What is meant by active management in the third stage of labour?

A

Active management of the third stage is where the midwife or doctor assist in delivery of the placenta - reduces the risk of haemorrhage.

Active management involves giving a dose of intramuscular oxytocin to help the uterus contract and expel the placenta. Careful traction is applied to the umbilical cord to guide the placenta out of the uterus and vagina.

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6
Q

Skim this summary of Braxton-Hicks contractions.

A

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

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7
Q

Latent first stage vs established first stage of labour:

A

The latent first stage is when there are both:

Painful contractions

Changes to the cervix, with effacement and dilation up to 4cm

The established first stage of labour is when there are both:

Regular, painful contractions

Dilatation of the cervix from 4cm onwards

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8
Q

Prolonged rupture of membranes

A

Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

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9
Q

Skim

A

Babies are considered non-viable below 23 weeks gestation. Generally, from 23 to 24 weeks, resuscitation is not considered in babies that do not show signs of life. Babies born at 23 weeks have around a 10% chance of survival. From 24 weeks onwards, there is an increased chance of survival, and full resuscitation is offered.

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10
Q

What is given as prophylaxis for preterm labour?

A

Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery.

Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.

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11
Q

How is rupture of membranes identified?

A

Rupture of membranes can be diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.

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12
Q

Preterm Prelabour Rupture of Membranes managed?

A

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis.

Induction of labour may be offered from 34 weeks to initiate the onset of labour.

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13
Q

What is preterm labour with intact membranes?

A

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

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14
Q

How is preterm labour managed?

A

There are several options for improving the outcomes in preterm labour:

  • Fetal monitoring (CTG or intermittent auscultation)
  • Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
  • Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
  • IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
  • Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth.
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15
Q

What is tocolysis and what medication is used?

A

Tocolysis can be used before 34 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

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16
Q

Explain the use of antenatal steroids?

A

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.

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17
Q

Explain the use of magnesium sulphate in pregnancy.

A

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

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18
Q

What are the complications with using magnesium sulphate to protect against cerebral palsy?

A

Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:

  • Reduced respiratory rate
  • Reduced blood pressure
  • Absent reflexes
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19
Q

What are the indications for induction of labour?

A

Induction of labour can be used where patients go over the due date. IOL is offered between 41 and 42 weeks gestation.

  • Prelabour rupture of membranes
  • Fetal growth restriction
  • Pre-eclampsia
  • Obstetric cholestasis
  • Existing diabetes
  • Intrauterine fetal death
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20
Q

What scoring system is used to determine whether to induce labour?

A

The Bishop score is a scoring system used to determine whether to induce labour.

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21
Q

What are the options for inducting labour?

(in order of first line)

A

Membrane sweep

Vaginal prostaglandin E2 (dinoprostone)

Cervical ripening balloon (CRB)

Artificial rupture of membranes

Oral mifepristone (anti-progesterone) plus misoprostol

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22
Q

Membrane sweep

A

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD.

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23
Q

Vaginal prostaglandin E2 (dinoprostone)

A

Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour.

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24
Q

Cervical ripening balloon (CRB)

A

Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3).

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25
Q

Artificial rupture of membranes

A

Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.

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26
Q

When are oral mifepristone (anti-progesterone) plus misoprostol indicated?

A

Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred.

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27
Q

What are the two means for monitoring during the induction of labour?

A

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour

Bishop score before and during induction of labour to monitor the progress.

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28
Q

What are the options for failure to progress through the first stage of labour?

A

Most women will give birth within 24 hours of the start of induction of labour.

The options when there is slow or no progress are:

  • Further vaginal prostaglandins
  • Artificial rupture of membranes and oxytocin infusion
  • Cervical ripening balloon (CRB)
  • Elective caesarean section
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29
Q

What is the main complication of vaginal prostaglandins?

A

Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.

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30
Q

How is uterinehyperstimulation defined?

A

Individual uterine contractions lasting more than 2 minutes in duration

More than five uterine contractions every 10 minutes

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31
Q

Uterine hyperstimulation can lead to:

A
  • Fetal compromise, with hypoxia and acidosis
  • Emergency caesarean section
  • Uterine rupture
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32
Q

How is uterine hyperstimulation managed?

A

Removing the vaginal prostaglandins, or stopping the oxytocin infusion

Tocolysis with terbutaline

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33
Q

What is CTG?

A

Cardiotocography (CTG) is used to measure the fetal heart rate and the contractions of the uterus. It is also known as electronic fetal monitoring. It is a useful way of monitoring the condition of the fetus and the activity of labour.

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34
Q

Skim the indications for continuous CTG:

A

Sepsis

Maternal tachycardia (> 120)

Significant meconium

Pre-eclampsia (particularly blood pressure > 160 / 110)

Fresh antepartum haemorrhage

Delay in labour

Use of oxytocin

Disproportionate maternal pain

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35
Q

What are the 5 key features to look for on a CTG?

A

Contractions – the number of uterine contractions per 10 minutes

Baseline rate – the baseline fetal heart rate

Variability – how the fetal heart rate varies up and down around the baseline.

Accelerations – periods where the fetal heart rate spikes

Decelerations – periods where the fetal heart rate drops

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36
Q

What do accelerations indicate?

A

Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.

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37
Q

What are decelerations indications of?

A

Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs.

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38
Q

There is a “rule of 3’s” for fetal bradycardia when they are prolonged:

A

3 minutes – call for help

6 minutes – move to theatre

9 minutes – prepare for delivery

12 minutes – deliver the baby (by 15 minutes)

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39
Q

Skim how to assess a CTG in a structured way:

A

DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order:

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)

C – Contractions

BRa – Baseline Rate

V – Variability

A – Accelerations

D – Decelerations

O – Overall impression (given an overall impression of the CTG and clinical picture)

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40
Q

What does oxytocin do?

A

Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding.

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41
Q

Indications of giving oxytocin:

A

Infusions of oxytocin are used to:

  • Induce labour
  • Progress labour
  • Improve the frequency and strength of uterine contractions
  • Prevent or treat postpartum haemorrhage
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42
Q

When is Misoprostol used?

A

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. It is used as medical management in miscarriage, to help complete the miscarriage. Misoprostol is used alongside mifepristone for abortions, and induction of labour after intrauterine fetal death.

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43
Q

When is mifepristone used?

A

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and ripening the cervix. It enhances the effects of prostaglandins to stimulate contraction of the uterus. Mifepristone is used alongside misoprostol for abortions, and induction of labour after intrauterine fetal death. It is not used during pregnancy with a healthy living fetus.

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44
Q

When is nifedipine used?

A

Nifedipine is a calcium channel blocker that acts to reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy:

  • Reduce blood pressure in hypertension and pre-eclampsia
  • Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour
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45
Q

What is tranexamic acid and when is it used?

A

Tranexamic acid is an antifibrinolytic that reduces bleeding. It binds to fibrinogen and prevents it from converting to plasmin. Plasmin is an enzyme the helps break down fibrin blood clots. Therefore, tranexamic acid helps prevent the breakdown of blood clots. It also inhibits the action of fibrin, a protein involved in the formation of blood clots.

Tranexamic acid is used in the prevention and treatment of postpartum haemorrhage.

46
Q

How are women monitored in the first stage of labour?

A

Women are monitored for their progress in the first stage of labour using a partogram. It is worth becoming familiar with partograms and how they are recorded.

47
Q

Skim what is recorded on a partogram

A
  • Cervical dilatation (measured by a 4-hourly vaginal examination)
  • Descent of the fetal head (in relation to the ischial spines)
  • Maternal pulse, blood pressure, temperature and urine output
  • Fetal heart rate
  • Frequency of contractions
  • Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
  • Drugs and fluids that have been given
48
Q

What interventions are used to aid progression during the second stage of labour?

A

Changing positions

Encouragement

Analgesia

Oxytocin

Episiotomy

Instrumental delivery

Caesarean section

49
Q

What are the main options for managing failure to progress?

A

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes

Oxytocin infusion

Instrumental delivery

Caesarean section

50
Q

Skim summary of umbilical cord prolapse:

A

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby.

51
Q

Summary of how shoulder dystocia is managed:

A

Shoulder dystocia is an obstetric emergency and needs to be managed by experienced midwives and obstetricians. The first step is to get help, including anaesthetics and paediatrics. Several techniques can be used to manage the condition and deliver the baby.

Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears.

McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.

Pressure to the anterior shoulder

Rubins manoeuvre involves 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.

52
Q

What are the complications of shoulder dystocia?

A
  • Fetal hypoxia (and subsequent cerebral palsy)
  • Brachial plexus injury and Erb’s palsy
  • Perineal tears
  • Postpartum haemorrhage
53
Q

Long term complications of perineal tears:

A

Urinary incontinence

Anal incontinence and altered bowel habit (third and fourth-degree tears)

Fistula between the vagina and bowel (rare)

Sexual dysfunction and dyspareunia (painful sex)

Psychological and mental health consequences

54
Q

Management of the third stage of labour:

A

Physiological management is where the placenta is delivered by maternal effort without medications or cord traction.

Active management of the third stage is where the midwife or doctor assist in delivering of the placenta. It involves a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.

55
Q

Skim the steps of active management of the third stage:

A

Active management of the third stage involves an intramuscular dose of oxytocin (10 IU) after delivery of the baby.

The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).

The abdomen is palpated to assess for a uterine contraction before delivery of the placenta. Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance. At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse. The aim is to deliver the placenta in one piece.

After delivery the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.

56
Q

How much blood loss is classed as PPH?

A

500ml after a vaginal delivery

1000ml after a caesarean section

57
Q

What are the four causes of PPH?

4T’s

A

T – Tone (uterine atony – the most common cause)

T – Trauma (e.g. perineal tear)

T – Tissue (retained placenta)

T – Thrombin (bleeding disorder)

58
Q

How is PPH managed?

A

Management to stabilise the patient involves:

  • Resuscitation with an ABCDE approach.
  • Lie the woman flat, keep her warm and communicate with her and the partner.
  • Insert two large-bore cannulas.
  • Bloods for FBC, U&E and clotting screen.
  • Group and cross match 4 units.
  • Warmed IV fluid and blood resuscitation as required.
  • Oxygen (regardless of saturations).
  • Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion.
59
Q

The treatment options for stopping the PPH bleeding can be categorised as:

  • Mechanical
  • Medical
  • Surgical
A

The treatment options for stopping the PPH bleeding can be categorised as:

  • Mechanical
  • Medical
  • Surgical
60
Q

Medical and mechanical treatments for PPH:

A

Mechanical treatment options involve:

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)

Catheterisation (bladder distention prevents uterus contractions)

Medical treatment options involve:

Oxytocin (slow injection followed by continuous infusion)

Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)

Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)

Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction

Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding.

61
Q

Surgical interventions for postpartum haemorrhage:

A

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding.

B-Lynch suture – putting a suture around the uterus to compress it.

Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow.

Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life.

62
Q

Summary of secondary postpartum haemorrhage:

A

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Investigations involve:

Ultrasound for retained products of conception

Endocervical and high vaginal swabs for infection

Management depends on the cause:

Surgical evaluation of retained products of conception

Antibiotics for infection

63
Q

What are the two key causes of sepsis in pregnancy?

A

Chorioamnionitis

Urinary tract infections

64
Q

Chorioamnionitis

A

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.

65
Q

Management of maternal sepsis:

A

Three tests:

  • Blood lactate level
  • Blood cultures
  • Urine output

Three treatments:

  • Oxygen to maintain oxygen saturations 94-98%
  • Empirical broad-spectrum antibiotics
  • IV fluids
66
Q

Uterine rupture (read)

A

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

67
Q

What is the biggest risk factor of uterine rupture?

A

The main risk factor for uterine rupture is a previous caesarean section.

68
Q

Presentation of uterine rupture:

A

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of:

  • Abdominal pain
  • Vaginal bleeding
  • Ceasing of uterine contractions
  • Hypotension
  • Tachycardia
  • Collapse
69
Q

Management of uterine rupture:

A

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

70
Q

Placenta accreta

A

Placenta accreta is a serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.

71
Q

Placenta previa

A

Placenta previa occurs when a baby’s placenta partially or totally covers the mother’s cervix — the outlet for the uterus. Placenta previa can cause severe bleeding during pregnancy and delivery. If you have placenta previa, you might bleed throughout your pregnancy and during your delivery.

72
Q

Placental abruption

A

Placental abruption is where a part or all of the placenta separates from the wall of the uterus prematurely. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery.

Woody uterus

73
Q

What time period in pregnancy do ectopics usually present?

A

Ectopic pregnancy typically presents around 6 – 8 weeks gestation.

Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain.

74
Q

Classic features of ectopic:

A
  • Missed period
  • Constant lower abdominal pain in the right or left iliac fossa
  • Vaginal bleeding
  • Lower abdominal or pelvic tenderness
  • Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
75
Q

How is ectopic pregnancy diagnosed?

A

A transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage. A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.

76
Q

Management of ectopic pregnancy?

A

Perform a pregnancy test in all women with abdominal or pelvic pain that may be caused by an ectopic pregnancy. Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service.

All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy.

There are three options for terminating an ectopic pregnancy:

  • Expectant management (awaiting natural termination)
  • Medical management (methotrexate)
  • Surgical management (salpingectomy or salpingotomy)
77
Q

Surgical management of ectopic

A

Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.

Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.

78
Q

Miscarriage

A

Miscarriage is the spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.

79
Q

Inevitable miscarriage

A

Inevitable miscarriage – vaginal bleeding with an open cervix.

80
Q

Terms of misscarriage

A

Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred

Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive.

Inevitable miscarriage – vaginal bleeding with an open cervix.

Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage.

Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus.

Anembryonic pregnancy – a gestational sac is present but contains no embryo.

81
Q

Management of miscarriage of less than 6 weeks:

A

Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment.

82
Q

There are three options for managing a miscarriage:

A
  • Expectant management (do nothing and await a spontaneous miscarriage)
  • Medical management (misoprostol)
  • Surgical management
83
Q

Expectant miscarriage

A

Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.

84
Q

Medical management of miscarriage

A

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.

Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.

85
Q

Side effects of misoprostol:

A
  • Heavier bleeding
  • Pain
  • Vomiting
  • Diarrhoea
86
Q

Surgical management of miscarriage

A

There are two options for surgical management of a miscarriage:

  • Manual vacuum aspiration under local anaesthetic as an outpatient
  • Electric vacuum aspiration under general anaesthetic
87
Q

Incomplete miscarriage

A

An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.

There are two options for treating an incomplete miscarriage:

  • Medical management (misoprostol).
  • Surgical management (evacuation of retained products of conception).
88
Q

Recurrent miscarriage - when are they investigated?

A

Miscarriage is relatively common. Recurrent miscarriage is classed as three or more consecutive miscarriages.

Three or more first-trimester miscarriages

One or more second-trimester miscarriages

89
Q

Causes of miscarriage:

A

Idiopathic (particularly in older women)

Antiphospholipid syndrome

Hereditary thrombophilias

Uterine abnormalities

Genetic factors in parents (e.g. balanced translocations in parental chromosomes)

Chronic histiocytic intervillositis

Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

90
Q

Antiphospholipid syndrome and miscarriage

A

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

Antiphospholipid syndrome can occur on its own, or secondary to an autoimmune condition such as systemic lupus erythematosus.

91
Q

Top tip:

A

If you remember one cause of recurrent miscarriages, remember antiphospholipid syndrome. Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of deep vein thrombosis. Test for antiphospholipid antibodies, and treatment is with aspirin and LMWH.

92
Q

Investigations for recurrent miscarriage:

A

Antiphospholipid antibodies

Testing for hereditary thrombophilias

Pelvic ultrasound

Genetic testing of the products of conception from the third or future miscarriages

Genetic testing on parents

93
Q

Hydatidiform mole

A

A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.

94
Q

A complete mole

A

A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.

95
Q

A partial mole

A

A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.

96
Q

How to identify molar pregnancy vs normal pregnancy:

A

More severe morning sickness

Vaginal bleeding

Increased enlargement of the uterus

Abnormally high hCG

Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

97
Q

How is a molar pregnancy diagnosed?

A

Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.

Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

98
Q

How is molar pregnancy managed?

A

Management involves evacuation of the uterus to remove the mole. The products of conception need to be sent for histological examination to confirm a molar pregnancy. Patients should be referred to the gestational trophoblastic disease centre for management and follow up. The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.

99
Q

What is the latest gestational age where an abortion is legal?

A

24 weeks

100
Q

Medication abortion involves what treatments?

A

Mifepristone (anti-progestogen)

Misoprostol (prostaglandin analogue) 1 – 2 day later

101
Q

Explaination of medical termination of pregnancy:

A

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.

Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.

102
Q

Nausea and vomiting in pregnancy starts in the first trimester, peaking around what time?

A

8 – 12 weeks gestation.

103
Q

Hyperemesis gravidum

A

Hyper- refers to lots, -emesis refers to vomiting and gravida- relates to pregnancy.

104
Q

What is thought to cause hyperemesis gravidum?

A

The placenta produces human chorionic gonadotropin (hCG) during pregnancy. This hormone is thought to be responsible for nausea and vomiting.

Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies due to the higher hCG levels. It also tends to be worse in the first pregnancy and overweight or obese women.

105
Q

Guidelines for diagnosis of hyperemesis gravidum:

A

More than 5 % weight loss compared with before pregnancy

Dehydration

Electrolyte imbalance

106
Q

How is Hyperemesis gravidum managed?

A

Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are:

  1. Prochlorperazine (stemetil)
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide
107
Q

When should one be admitted with hyperemesis gravidum?

A

Mild cases can be managed with oral antiemetics at home. Admission should be considered when:

  • Unable to tolerate oral antiemetics or keep down any fluids
  • More than 5 % weight loss compared with pre-pregnancy
  • Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
  • Other medical conditions need treating that required admission
108
Q

Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:

Management of severe cases…?

A
  • IV or IM antiemetics
  • IV fluids (normal saline with added potassium chloride)
  • Daily monitoring of U&Es while having IV therapy
  • Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
  • Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
109
Q

Presentation of placental abruption:

A

Placental abruption typically presents with painful vaginal bleeding (bleeding may not be visible if it is concealed). If the woman is in labour, inquire about pain between contractions.

On examination, the uterus may be woody (tense all of the time) and painful on palpation.

110
Q

Vaginal bleeding with open cervix =

A

Inevitable misscarriage

111
Q

Most likely site of an ectopic?

A

Ampulla of fallopian tube

112
Q

Brain bleeds in babies?

A

IVH in premature infants, Subdural Haematoma in Shaken Baby Syndrome.

Obstetrics and Gynaecology (11 decks)

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