Antenatal obstetric complications

Question 1

What is symphysis pubis dysfunction?

Answer 1

Loosening of the symphysis pubis, causing the two halves of the pelvis to rub together on movement, resulting in excruciating pain.

Typically occurs in 3rd trimester

Managed with simple analgesia

Question 2

What causes carpal tunnel syndrome in pregnancy?

Answer 2

Soft tissue swelling leads to compression of the median nerve as it crosses the carpal tunnel, leading to numbness in the hand and pain, especially at night

Question 3

What is hyperemesis gravidarum?

Answer 3

Excessive vomiting that is typically seen in the 1st trimester. Usually a result of excess HCG.

Presents with a triad of:

• 5% weight from from weight pre-pregnancy
• Electrolyte imbalance
• Dehydration

Risk factors:

• Twins
• Obesity
• Nulliparity
• Hyperthyroidism
• (Smoking reduces risk)

Question 4

What investigations are done for hyperemesis gravidarum?

Answer 4

PUQE score
High urea (dehydration)
Low potassium
Urine dipstick - Ketonuria
Blood in vomit (Mallory-Weis tear)

Question 5

What is the management of hyperemesis gravidarum?

Answer 5

If mild, can be managed at home:

• Prescribe anti-emetics
  
  • Promethazine/Cyclizine
  • Ondansetron/Metoclopramide

If severe (electrolyte imbalance, dehydration), admit:

• IV fluids
• Electrolyte replacement (Potassium chloride)
• Thiamine (Prevent Wernicke’s)
• Anti-emetics
• Bland diet

Question 6

What are the clinical features of obstetric cholestasis?

Answer 6

Typically occurs in the 3rd trimester

Characterised by significant pruritis (especially in the hands and feet) and abnormal LFTs that resolve itself following delivery

There is increased risk of preterm birth and stillbirth

Normally treated with ursodeoxycholic acid and delivery at 37+0 weeks

Question 7

What are the risks of fibroids during pregnancy?

Answer 7

They may enlarge during pregnancy, this can be problematic if they obstruct the cervix

There is a greater risk of red degeneration, as the fibroid grows, it may become ischaemic, this presents as acute pain, tenderness and vomiting. If it gets severe enough, it may trigger uterine contractions, leading to miscarriage or preterm labour.
This is treated with IV fluids and analgesia

Question 8

What is the risk of a retroverted uterus during pregnancy?

Answer 8

In most cases, as the foetus grows, the retroverted uterus will flip by itself, however in some cases, this does not happen and the pelvis is filled, resulting in compression of the bladder.

This can lead to urinary retention at around week 12-14. Hence, catheterisation is needed till the uterus eventually flips

Question 9

What are the clinical features of UTIs in pregnancy?

Answer 9

You DON’T see the typical symptoms.
Patients present with tachycardia, pyrexia, dehydration and loin tenderness

Investigated with FBC and MSU

Management:
Nitrofurantoin 50 mg QDS for 7 days
Amoxicillin or Oral Cephalosporins

Question 10

What are the clinical features of pyelonephritis

Answer 10

Very high temperatures
Systemic disturbances
Shock
Dehydration

Management:
IV fluids
IV antibiotics (Gentamicin or cephalosporins)
Opiate analgesia
Monitor CTG
Check renal function

Question 11

Which investigation should be performed in a patient with a suspected DVT?

Answer 11

Compress duplex ultrasound

Question 12

Which investigations should be performed in a patient with a suspected PE?

Answer 12

ECG
CXR
Compression duplex ultrasound (if DVT)
V/Q or CTPA

Question 13

How should a DVT/PE during pregnancy be managed?

Answer 13

Therapeutic dose LMWH given daily in two divided doses according to the patient’s weight until 6 weeks postpartum (and at least 3 months in total)

Question 14

How should VTE in a collapsed patient be managed?

Answer 14

Unfractionated heparin
Thrombolysis
Thoracotomy and surgical embolectomy

Question 15

What risks is smoking during pregnancy related to?

Answer 15

Reduces placental perfusion
Placental abruption
Increased perinatal mortality
Smaller baby

Question 16

What is oligohydramnios and what are common causes?

Answer 16

Amniotic fluid index <5th centile for gestational age

Causes:
Renal agenesis
Urinary tract abnormality
Foetal growth restriction and placental insufficiency
NSAIDs
Leakage (i.e. PPROM)

Question 17

What is polyhydramnios and what are common causes?

Answer 17

Amniotic fluid index >95th centile for gestational age

Causes:
Duodenal atresia
Diabetes
Multiple gestation
Oesophageal atresia
Anencephaly

Question 18

What are the causes of breech presentation?

Answer 18

Fibroids
Placenta praevia
Preterm
Uni/Bicornuate uterus
Oligo/Polyhydramnios
Multiple gestation

Question 19

What is the management of breech presentation?

Answer 19

If <36 weeks, baby may turn spontaneously

If still breech by 36 weeks, ECV should be considered.
External cephalic version:
- Normally conducted in week 37
- Mother given Terbutaline (SC) to relax the smooth muscles
- Anti-D should be administered if mother is rhesus negative

If still in breech position, conduct C-section, unless mother is unwilling, then vaginal delivery.

Vaginal delivery:

• Once buttocks present, an episiotomy can help to get it out
• The legs will naturally deliver if they are FLEXED. If extended, then must conduct Pinard manoeuvre
• Loveset’s manoeuvre can help deliver the torso, though normally it happens naturally
• The head is delivered OA by the Mauriceau-Smellie-Veit Manoeuvre

Question 20

How can vaginal bleeding in pregnancy be divided?

Answer 20

<24 weeks gestation = Threatened miscarriage

>24 weeks gestation = Antepartum haemorrhage (Placental abruption/Placenta praevia)