Gargi & Emma's Notes - Obstetrics Flashcards
When do most caeses of asthma in pregnancy occur?
Most occur between 24-36 weeks
What is asthma?
Chronic inflammatory airway disease characterized by:
- variable reversible airway obstruction,
- airway hyper-responsiveness
- bronchial inflammation
What are the clinical signs of asthma in pregnancy?
- Wheeze, breathlessness, cough – worse in morning and at night
- Precipitating factors – e.g. cold, drugs (beta blocker, NSAIDs), exercise
- Atopic history
- Tachypnoea, use of accessory muscles, prolonged expiratory phase, polyphonic wheeze, hyperinflated chest
What is classified as a severe attack of asthma in pregnancy?
Severe attack if PEFR <50%, pulse >110, RR > 25, inability to complete sentences
What is classified as a life-threatening attack of asthma in pregnancy?
Life-threatening if:
- confusion,
- coma
- cyanosis,
- PFR <33%,
- silent chest,
- bradycardia,
- hypotension,
What are the investigations for ?asthma in pregnancy?
- Chronic:
- PEFR monitoring
- Acute:
- Basic obs (incl pulse oximetry)
- PEFR
- pulse oximetry
- ABG, FBC, (WCC infection?), U&Es
- blood/sputum cultures
- CXR (exclude other diagnoses)
What is the antenatal management of chronic asthma?
Chronic management:
- Antenatal:
- MDT approach
- Reassurance that asthma medication is safe during pregnancy à continue taking as normal
- Oral corticosteroids have small increased risk of malformations
- Optimise control
- Smoking cessation
- NB stepwise approach is:
- Step 1: salbutamol PRN
- Step 2: add low-dose ICS (400mcg/day)
- Step 3: – + LABA/increase ICS to 800mcg/day
- Step 4: medium-dose ICS (2000mcg/day) + LABA (or theophylline or LTRA)
- Step 5: high-dose ICS + LABA/tiotropium
- Step 6: oral corticosteroid + high-dose ICS + LABA
NB safer to have medications than to have asthma symptoms during pregnancy
What is management of chronic asthma during labour?
- In labour:
- Continue regular medications
- Avoid bronchoconstrictors if severe asthma (e.g. ergometrine, prostaglandins)
- Ensure adequate hydration
- Regional anaesthesia favoured over GA (to decrease risk of bronchospasm)
What is management of acute asthma during pregnancy?
Acute management:
- As for non-pregnant individuals
- Monitor O2 sats, ABG and PEFR
- ABCDE approach, high-flow O2
- Nebulised salbutamol (5mg initially continuous, then 2-4hourly) +/- ipratropium (0.5mg QDS)
- IV hydrocortisone (100-200 IV) followed by oral prednisolone for 5-7d (40mg PO)
- If no improvement: IV magnesium sulphate, IV aminophylline or IV salbutamol
- Summon anaesthetic help if pt getting exhausted PCO2 increasing
- ICU admission and ventilation if severe
- Discharge when PEFR >75% of pts best, diurnal variation <25%, stable on discharge meds for 24h
What are the complications of asthma in pregnancy?
Foetal complications:
- Possible increased risk of FGR & foetal brain injury
- (due to prolonged maternal hypoxia)
- Preterm labour + birth
- Perinatal mortality
- Increased cleft lip risk
- (due to oral corticosteroids use in 1st trimester)
- Inheritance for foetus (6-30%)
What is the prognosis of asthma during pregnancy?
- Prognosis → Severity of asthma remains stable in one third, worsens in another third and improves in the last
- Well-controlled asthma has little effect on pregnancy outcome
What are the 4 hypertensive diseases in pregnancy
- Chronic hypertension
- Gestational hypertension
- Pre-eclampsia
- Eclampsia
How is mild, moderate and severe HTN during pregnancy classified?
- Mild: 140-149 / 90-99
- Moderate: 150-159 / 100-109
- Severe: >=160 / >=110
Define chronic HTN in pregnancy.
Give some causes.
- Chronic hypertension: sustained BP readings ≥140/90 which occurred <20wks gestation or persists for >12wks postpartum
Essential in 90%, secondary in others
Endo – Cushing, pheo, CAH, Conn’s
Renal – RAS, chronic disease
Vasc – coarctation of aorta
RF – old age, ethnicity (Afro-Carib), obesity, smoking, diabetes, FHX, pre-eclampsia
# Define gestational HTN. Describe its aetiology.
- Gestational hypertension: sustained BP readings of ³140/90 after 20wks gestation in a previously normotensive patient, resolving by 12wks postpartum, in the absence of proteinuria
- Aetiology is unknown; may be due to upregulation of the RAAS without the drop in SVR to balance BP
What are the signs of chronic HTN in pregnancy?
Chronic –
- largely asymptomatic,
- BP may be normal in first trimester due to reduced systemic vascular resistance,
- secondary causes – renal bruits (RAS), radio-femoral delay (coarctation)
What are the Ix for ?chronic HTN in pregnancy?
- Bloods – FBC, UE, LFT, Urate, TFTs
- Urinalysis – proteinuria, catecholamines
- Renal artery USS
- Foetus – serial USS for growth
What is the Mx of chronic HTN prior to pregnancy?
- medication changed to non-teratogenic ie methyldopa, nifedipine, labetalol (NOT ACEi/ARBs),
- (increased risk of congenital abnormality/neonatal complications)
- May need reduced doses of other antihypertensives in the first half of pregnancy (when BP drops)
- Lifestyle advice
- Aim to keep BP <150/100
- aspirin 75mg of to reduce pre-eclampsia risk/IUGR.
- Monitor for pre-eclampsia, serial USS for growth, uterine artery Dopplers at 24/40 for risk
What is the Mx of mild chronic/gestational HTN in pregnancy?
- Lifestyle modification
- Consultation with dietitian; aim for limited/no weight gain in obese patients, reduce salt etc.
- Monitor BP around 1/wk to detect changes and signs of pre-eclampsia
What is the Mx of moderate chronic/gestational HTN in pregnancy?
- Lifestyle modification
- Antihypertensives
- Oral labetalol (1st line) à aim for <150/80-100; avoid labetalol in asthma
- Alternatives are methyldopa and nifedipine
- Close monitoring of BP and signs of pre-eclampsia (2x/wk); monitor for FGR
- Aim for delivery >37wks; may be earlier if complications (e.g. IUGR, development of pre-eclampsia)
What is the Mx of severe chronic/gestational HTN in pregnancy?
- Admit to hospital (until BP is <160/110)
- Antihypertensives
- IV labetalol or IV hydralazine
- Convert to oral labetalol/methyldopa when BP is under control
- BP monitoring at least 4x/d; daily urine monitoring for protein, monitor for FGR
- Consider delivery if severe refractory gestational HTN or >37wks
What is the Mx of severe chronic/gestational HTN post-natally?
- In gestational HTN, measure BP daily for 2 days, and at least once between day 3 and 5
- Reduce antihypertensives as their BP falls
- If BP remains high 6-8wks after birth à medical review
What is the prognosis of chronic HTN?
- Maternal risks: pre-eclampsia, abruption, HF, intracerebral haemorrhage
- Pre-eclampsia develops in 1/3
- –> RFs for developing superimposed pre-eclampsia are:
- renal disease,
- maternal age >40yo,
- pre-existing DM,
- multiple pregnancy,
- connective tissue disease (antiphospholipid),
- coarctation of aorta,
- severe HTN,
- BMI >35,
- previous pre-eclampsia
What are the complications of pre-eclampsia?
- Maternal – eclampsia, abruption, CVA, pulmonary oedema, cerebral oedema, renal/liver failure, DIC, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)
- Foetal – IUGR, death
What are the complications of eclampsia?
Eclampsia –
- DIC,
- permanent CNS damage (e.g. cortical blindness),
- CVA (1-2%),
- cardiac arrest,
- ARDS
- renal failure,
- death,
Define pre-eclampsia. Summarise its aetiology.
Proteinuria and hypertension in pregnancy, developing after 20/40.
- Impaired trophoblastic invasion into spinal arteries during placentation
- Resistance in uteroplacental circulation increases → leads to hypoperfusion and ischemia
- Causes release of inflammatory mediators → stimulating widespread endothelial damage, end organdysfunction, oedema
- RF - nulliparity, old mother, FHX, previous hx, pre-existing HTN, new partner, existing renal disease,diabetes, PCOS, multiple pregnancy, obesity
What are the signs of pre-eclampsia?
Pre-eclampsia –
- asymptomatic,
- headache,
- oedema,
- visual disturbance,
- RUQ pain due too liver capsule swelling;
- raised BP, oedema (facial),
- hyperreflexia,
- clonus;
- papillodema;
- RUQ tenderness;
- reduced fundal height
What are the Ix for ?pre-eclampsia?
- Bloods – FBC (low platelets, haemoconcentration), U&E, urate (renal impairment), LFT (increase transaminases), clotting
- Urine – proteinuria, MSU (exclude UTI), 24hr collection (significant protein - >0,3g/24h)
- USS – foetal growth, liquor volume, umbilical artery Doppler
What is the Mx of pre-eclampsia?
Pre-eclampsia – condition will not resolve until after delivery
- Mild/moderate – regular monitoring of BP with urinalysis, blood tests, serial USS, CTGs, antihypertensives (methyldopa, labetalol, nifedipine), delivery 37/40
- Severe/evidence of foetal compromise (NB required delivery) – antihypertensives (labetalol, nifedipine, hydralazine), seizure prophylaxis (IV magnesium sulphate), fluid restrict, fluid balance, steroids if preterm
Define eclampsia. Summarise its aetiology.
grand mal seizures on a background of pre-eclampsia.
- Unclear mechanism, theories related to cerebral vasospasm, hypertensive encephalopathy, tissue oedema, ischemia, haemorrhage
What are the signs of eclampsia?
- headache,
- epigastric tenderness,
- visual disturbances,
- oedema,
- previous findings of hyperreflexia,
- clonus;
- grand mal seizures
What are the Ix for ?eclampsia?
- Bloods FBC, clotting, U&E, Urate, LFT, G&S, ABG
- Urine – proteinuria
- Imaging – post seizure – CT head, CXR if signs
What is the Mx of eclampsia?
- Airway and Breathing – oxygen, patency, ventilate if needed
- Circulation – manage on left tilt, ensure large-bore IV access, evaluate pulse and BP
- Drugs – IV magnesium sulphate, 4g loading dose followed by 1g/h (monitor urine output, resp rate, patellar reflexes)
- Recurrent seizures – consider further bolus Mg sulphate, thiopentone, diazepam, IPPV (intermittent positive pressure ventilation), muscle relaxation
- Post seizure – assess chest, control BP (consider IV labetalol/hydralazine), strict fluid management (85ml/hr input, urine output >25mg/h), may require CVP monitoring, deliver baby when mother stabilised, consider ITU.
Define miscarriage
Involuntary, spontaneous loss of a pregnancy before 24wks gestation
- Early miscarriage is <12wks; late miscarriage is 12-24wks; (stillbirth is >24wks)
What is the aetiology of miscarriages?
Most miscarriages are due to chromosomal abnormalities in the embryo (commonly trisomy 16)
What are the different types of miscarriage?
-
Threatened miscarriage: PV bleeding but foetus is still viable
- PV bleeding, closed cervical os, foetal heartbeat visible
-
Inevitable miscarriage: miscarriage is about to occur
- PV bleeding, open cervical os, no foetal heartbeat
-
Incomplete miscarriage: some products of conception expelled and some remain
- PV bleeding, open cervical os, some products of conception expelled
-
Complete miscarriage: products of conception completely expelled
- PV bleeding symptoms resolving, closed cervical os, uterus empty on USS
-
Missed miscarriage: USS diagnosis of miscarriage in the absence of symptoms
- No PV bleeding, closed cervical os, no foetal heartbeat
-
Septic miscarriage: contents of uterus are infected, causing endometritis
- Complete or incomplete miscarriage, plus fever/rigors/uterine tenderness etc.
What are the risk factors for a miscarriage?
- Maternal age >35 (increased embryonic chromosomal abnormalities)
- Previous miscarriage
- Structural abnormalities of the uterus (fibroids, uterine septae, cervical incompetence)
- Parental chromosomal abnormalities (e.g. translocations)
- Endocrine disease (DM, thyroid disease, PCOS)
- Anti-phospholipid syndrome, other clotting abnormalities (FVL, anti-thrombin deficiency)
- Infections, incl bacterial vaginosis
- Obesity, smoking, possibly caffeine
Summarise the epidemiology of miscarriages
- Common –> 20% of pregnancies
- recurrent miscarriages affect 1% women
- Early miscarriages are more common than late miscarriages
What are the symptoms of a miscarriage?
- PV bleeding +/- clots/products of conception
- Suprapubic cramping pain
What are the signs of miscarriage O/E?
- On examination:
- General: assess for signs of shock or pyrexia
- Abdo/bimanual: uterine tenderness, exclude ectopic (adnexal mass, cervical excitation)
- Speculum: cervical os may be open, products of conception may be visible (remove if possible)
What are the signs and symptoms of a missed miscarriage?
- Missed miscarriage is asymptomatic; may be diagnosed at booking USS
What are the investigations for ?miscarriage?
- Urine pregnancy test
-
TVUSS
- Definitive diagnosis
- Miscarriage is suggested by gestational sac >25mm with no visible yolk sac or foetal pole, or CRL >7mm but no foetal heart activity
- If sac diameter is <25mm or CRL is <7mm repeat scan in 7-14d
-
Bloods: serial hCG, rhesus blood group, FBC, CRP (if pyrexial)
- hCG should be done if uncertain about miscarriage diagnosis >50% drop in 48hrs indicates failing pregnancy
What are the investigations for ?reccurrent miscarriage?
Outpatient Ix for recurrent miscarriage:
- Bloods: antiphospholipid antibodies, lupus anticoagulant, anticardiolipin antibodies, inherited thrombophilia screen
- Pelvic USS (structural abnormalities)
- Screen for bacterial vaginosis
- Karyotyping: on products of conception; parental (if POC reports unbalanced structural chromosomal abnormality)
Where should all miscarriage investigations and Tx take place?
EPAU
What is the Mx for Threatened miscarriage?
- ABC approach –> stabilise the patient, replace lost volume
- Analgesia (paracetamol)
- Close monitoring of foetus
What is the Mx for Inevitable/incomplete/missed miscarriage?
- ABC approach –> stabilise the patient, replace lost volume
- Manual evacuation of pregnancy tissue visualised in the vagina/cervical os (during speculum exam)
- Analgesia (paracetamol)
- Conservative management:
- Expectant waiting for products of conception to pass
- Must have access to 24hr emergency services
- May follow-up with repeat scans every 2wks until diagnosis of complete miscarriage is made
- Medical management:
-
Misoprostol intravaginally
- Prostaglandin E analogue –> stimulates cervical ripening and myometrial contractions
- Can go home but must have access to 24hr emergency services
- Follow-up with pregnancy test 3wks later
-
Misoprostol intravaginally
- Surgical management:
- surgical evacuation of products of conception –> ERPC (see separate topic)
- Joint 1st line with other management options (patient choice); definite indications are haemodynamic instability and infected tissue
-
Antibiotics may be given prophylactically; always given if signs of infection
- Co-amoxiclav or doxycycline (if at increased risk of Chlamydia infection)
What is the Mx for complete miscarriage?
- ABC approach –> stabilise the patient, replace lost volume
- Analgesia (paracetamol)
What is the Mx for recurrent miscarriage?
- Treat underling cause
- Psychological support and serial USS during pregnancy
What management is necessary for all types of miscarriage?
- Anti-D prophylaxis for all Rh negative patients >12wks gestation, or any gestation if surgical management
- Counselling:
- Ensure patients understand most miscarriages are not recurrent and they are not to blame
- Referral to support groups if necessary
What are the complications of miscarriage?
Complications:
- PV bleeding can be heavy and painful
- Infection
- Psychological upset
- Complications of management
- Conservative: unpredictable timing, heavy bleeding/pain, may need further intervention
- Medical: nausea/vomiting, heavy bleeding/pain, may need surgical intervention (10%)
- Surgical complications (see ERPC)
What is the prognosis of miscarriage?
Most patients: subsequent successful pregnancies; 40% chance of another miscarriage after 3
What is a biochemical pregnancy?
- a biochemical pregnancy is a positive pregnancy test 1-2 days before an expected period, then menstruation and negative pregnancy tests after.
- It is due to pregnancy failure during the early stages of implantation
What is an ectopic pregnancy?
Any pregnancy which is implanted at a site outside the uterine cavity
Which sites are the most common for implantation in ectopic pregnancies?
Most commonly occurs in the fallopian tube (98%) – mainly ampulla
- Can also occur in ovaries, cervix, interstitium of the uterus/tube or peritoneal cavity can be involved
What are the risk factors for an ectopic pregnancy?
- Previous ectopic pregnancy, PID, endometriosis, pelvic surgery (esp. reversal of sterilisation)
- Tubal damage/adhesions interfere with tubal transport
- IUD/IUS in situ
- Reduces the absolute risk of ectopic pregnancy, but increased risk if pregnancy does occur
- Assisted reproduction
- Smoking, increased maternal age (functional alterations of fallopian tube)
How common are ectopic pregnancies?
1% pregnancies are ectopic
What are the symptoms of an ectopic pregnancy?
- Lower abdominal/pelvic pain
- Amenorrhoea (4-10wks)
- PV bleeding/brown discharge (due to suboptimal hCG levels)
- Often scanty dark blood, described as prune juice
What is found in an ectopic pregnancy O/E?
- On examination:
- Adnexal tenderness, possible adnexal mass
What are the symptoms of a ruptured ectopic pregnancy?
- Haemodynamically unstable (pallor, tachycardia, hypotension, increased cap refill)
- Signs of peritonitis (rebound tenderness, guarding)
- Shoulder tip pain (referred pain due to irritation of diaphragm by blood in peritoneal cavity)
What is found O/E in a ruptured ectopic pregnancy?
- On examination:
- Cervical excitation, blood in vaginal vault/fullness in pouch of Douglas
What are the Ix for ?ectopic pregnancy?
- Urine pregnancy test (to confirm pregnancy)
-
TAUSS and TVUSS
- TAUSS is less sensitive than TVUSS; should detect intrauterine pregnancy by 6wks after last period
- Intrauterine pregnancy excludes ectopic pregnancy (unless heterotopic)
- If intrauterine pregnancy is not seen –> TVUSS
- Can confirm diagnosis
- Ectopic is seen by ‘doughnut sign’ (adnexal mass)
- Doppler USS may show increased blood flow to ectopic (‘ring of fire’)
- Free fluid suggests ruptured ectopic
- TAUSS is less sensitive than TVUSS; should detect intrauterine pregnancy by 6wks after last period
-
Serial serum hCG
- If pregnancy cannot be identified on USS (PUL)
- If >1500iU and cannot be visualised on USS, there is increased risk the pregnancy is ectopic
- <63% rise (suboptimal rise) over 48hrs suggests ectopic
- Rule out other differentials if necessary, e.g. urinalysis for UTI, USS to look for ovarian cyst accident etc.
- Group and save/crossmatch if severely compromised; assess Rh status
What is the conservative Mx for an ectopic pregnancy?
- For low-risk, haemodynamically stable, asymptomatic/minimal pain with low/decreasing hCG levels
- Monitor serial hCG levels to ensure it is falling, until undetectable
- Can go home, but ensure 24hr emergency services access and are informed of symptoms of rupture
- If increasing pain, hCG levels are not decreasing or signs of tubal rupture medical/surgical management
What is the medical Mx for an ectopic pregnancy?
Medical management:
- IM methotrexate (anti-folate agent that prevents cell division)
- For haemodynamically stable patients, ideally hCG <1500iU/L (up to 5000), unruptured, without visible heartbeat, <4cm in diameter
- For these patients, medical management is joint 1st line with laparoscopy
- Monitor serial hCG levels to ensure it is falling, until undetectable (usually takes 2-4wks)
- Patient can go home after the injection (but must have access to 24hr emergency services and be informed of signs of rupture)
- May need surgery if treatment fails
What is the surgical Mx for an ectopic pregnancy?
- Joint 1st line with medical management;
- required if:
- haemodynamic instability,
- signs of rupture,
- hCG >5000,
- foetal heartbeat on scan,
- adnexal mass >4cm
- Methods:
- Laparoscopic salpingectomy (most common): ectopic and tube are removed; doesn’t effect fertility if contralateral tube is intact
- Laparoscopic salpingostomy: cut in fallopian tube; done is damage to contralateral tube to preserve future fertility
- Laparotomy if severe haemodynamic compromise
- hCG follow-up is needed after salpingostomy until undetectable (to ensure no residual tissue)
- Anti-D prophylaxis (if Rh negative)
What are the complications of an ectopic pregnancy?
- Fallopian tube rupture
- Recurrent ectopic if tube is salvaged (15% risk in future pregnancies
What are the complications of the Tx for an ectopic pregnancy?
Complications of treatment:
- Conservative management: may rupture, may need medical/surgical treatment anyway
- Medical management: SEs of methotrexate include hepatotoxicity, nephrotoxicity, myelosuppression, teratogenesis (must use contraception for 3-6 months after)
- Surgical management: GA risks, risk of damage to bladder/bowel/ureters, DVT, bleeding, infection, salpingotomy has risk of treatment failure (persistent trophoblast)
What is the prognosis of an ectopic pregnancy?
- 5 deaths/yr in UK;
- conservative management is 80% successful;
- medical/surgical is 90% successful
What is gestational trophoblastic disease?
A group of pregnancy-related tumours
How can gestational trophoblastic disease be divided?
They can be divided into 2 main groups:
- Benign conditions: hydatidiform moles
- Malignant conditions (gestational trophoblastic neoplasia): invasive malignancies that can metastasise, e.g. invasive mole, choriocarcinoma, placental site trophoblastic tumour, epithelioid trophoblastic
What is the aetiology of gestational trophoblastic disease?
Trophoblastic tissue is the part of the blastocyst that normally invades the endometrium
- In GTD, the trophoblastic tissue proliferated more aggressively
- hCG is normally excreted in excess
What are molar pregnancies? What is their aetiology?
Molar pregnancies:
- Due to an abnormality in chromosomal number during fertilisation
- Partial mole:
- One ovum with 23 chromosomes is fertilised by 2 sperm, each with 23 chromosomes –> produces 69 chromosomes (triploidy) (69XXX/69XXY)
- Usually not viable, but if mosaicism exists (foetus has normal karyotype and triploidy is confined to placenta), foetus may be viable
- May contain some evidence of foetal parts, e.g. RBCs
- Complete mole:
- One ovum without any chromosomes is fertilised by one haploid sperm which duplicates, or less commonly, 2 haploid sperm –> leads to 46 chromosomes of parental origin alone (46XX/46XY)
- Do not contain any evidence of foetal parts
- These tumours are usually benign but can become malignant (invasive moles)
What is gestational trophoblastic neoplasia?
- Choriocarcinoma: malignancy of trophoblastic cells of placenta; usually co-exists with molar pregnancy
- Placental site trophoblastic tumour: malignancy of intermediate trophoblasts (anchor placenta to uterus); usually occurs after normal pregnancy
- Epithelioid trophoblastic tumour: malignancy of trophoblastic placental cells; mimics SCC
What are the risk factors of gestational trophoblastic disease?
- extremes of maternal age (<20 or >35),
- previous gestational trophoblastic disease,
- smoking
What is the epidemiology of gestational trophoblastic disease?
- Uncommon : 1/1000 pregnancies
- More common in Asians
What are the symptoms of gestational trophoblastic disease?
- Vaginal bleeding
- Varies from light spotting to heavy bleeding; may include passage of hydropic villi
- Missed period
- Hyperemesis (due to high hCG)
- Hyperthyroidism (rare; due to stimulation of thyroid by high hCG)
What is found O/E in gestational trophoblastic disease?
- Unusually large uterus for gestational age;
- soft, boggy consistency of uterus
What are the Ix for gestational trophoblastic disease?
- Urine pregnancy test
-
Serum hCG
- Markedly elevated; often >100,000iU/L
- Bloods: FBC (anaemia), TSH (normal), blood type
-
TVUSS
- Complete mole has snow-storm appearance of uterine cavity and absence of placental parts
- Partial mole has small placenta with partial foetal development
-
Histological examination of products of conception
- To confirm diagnosis
- Performed post-treatment on molar pregnancies, and all non-viable miscarriages (because many molar pregnancies terminate before symptoms)
- May show placental villi with irregular architecture, oedema with true villous cavitation, trophoblast hyperplasia
- Staging investigations (MRI, CT) if metastatic spread is suspected
What is the Mx of gestational trophoblastic disease?
- Referral to specialist centre (CX, Sheffield, Dundee) for treatment and follow-up
Molar pregnancy:
- Surgery:
- ERPC
- Serial serum hCG levels (persistent/rising suggests malignancy)
- Anti-D prophylaxis if mother is Rh negative
- Avoid pregnancy until 6 months of normal hCG levels
Malignant conditions or mole that has not resolved:
- Chemotherapy (methotrexate + folic acid)
What are the complications of gestational trophoblastic disease?
-
Recurrence of molar pregnancy (1%; 20% if 2 or more molar pregnancies)
- hCG samples are needed in every future pregnancy to exclude recurrence
-
Gestational trophoblastic neoplasia
- Follows 15% complete moles and 0.5% partial moles; may occur in normal pregnancy
- Diagnosis made with persistently elevated/rising hCG
- Highly malignant but sensitive to chemotherapy –> 95% cure rate
What is placenta praevia?
- Placenta abnormally attached to the lower uterine segment
How is placenta praevia classified?
Classified into complete, partial, marginal or low-lying
- Complete: placenta covers the entire internal cervical os
- Partial: placenta covers a portion of the internal cervical os
- Marginal: edge of placenta lies within 2cm of the internal cervical os
- Low-lying placenta: edge of placenta lies within 2-3.5cm of the internal cervical os
- N.B. complete and partial are AKA major placenta praevia (overlying cervical os); the others are minor placenta praevia (not covering cervical os)
What happens to the placenta in praevia as the pregnancy progresses?
- Placenta praevia often moves upwards as pregnancy progresses (because lower segment of uterus forms in 3rd trimester –> rest of myometrium moves upwards)
- More likely if low-lying placenta and marginal, some partial
What is the major risk in placenta praevia?
Placenta praevia gives increased risk of haemorrhage
- Possibly due to defective attachment to uterine wall, or damage as foetus moves into lower uterine segment
- Bleeding is from maternal circulation (not foetal) –> more likely to compromise mother if serious
What are the risk factors for placenta praevia?
- previous C-section (or other uterine scarring),
- IVF,
- previous placenta praevia,
- age >40yo,
- high parity
What is the epidemiology of placenta praevia?
- 0.5% pregnancies at term;
- much higher at 20wks
What are the symptoms of placenta praevia?
- Usually detected on routine USS
-
Painless vaginal bleeding in 2nd/3rd trimester
- Varies from spotting to haemorrhage; often intermittent bleeds increasing in frequency/intensity
- Spontaneous or provoked (e.g. by vaginal examination)
What is seen O/E in placenta praevia?
- examination:
- Breech presentation and transverse lie are common
- Foetal head high (not engaged)
- Speculum (assess bleeding)
What are the Ix for ?placenta praevia?
-
Ix for ALL antepartum haemorrhage:
- Thorough history: how much bleeding, onset, fresh/brown, SROM, provoked (post-coital), abdo pain, foetal movements, cervical smears
-
Examination:
- General: pallor, cap refill, HR, BP
- Obstetric: palpable contractions, lie and presentation of foetus, CTG
-
Assess bleeding: externally, speculum (look for blood, clots, cervical dilatation, SROM)
- Do not do bimanual in PV bleed (unless placenta praevia excluded, as risk of massive bleeding) or ruptured membranes (infection risk)
- Swabs: exclude infection if bleeding is minimal
- Basic obs
- Bloods: FBC, clotting, group and save, cross match (if transfusion likely), U&Es, LFTs (exclude PET/HELLP, organ dysfunction), Kleihauer test (if RhD -ve)
- CTG
-
USS (preferably TVUSS)
- Definitive diagnosis of placenta praevia
- Used for monitoring previous diagnosis
Which investigation must be excluded in ?placenta praevia?
- Do not do bimanual in PV bleed (unless placenta praevia excluded, as risk of massive bleeding) or ruptured membranes (infection risk)
What is the Mx of antepartum haemorrhage e.g. in placenta praevia?
- ABCDE, senior help, IV access, fluids/blood transfusion, CTG, urgent USS
- Consider antifibrinolytics (tranexamic acid)
- Admit (all women with bleeding)
- Anti-D if necessary
- If severe bleeding, not stabilised by resuscitation emergency C-section
What is the Mx of placenta praevia if identified at 20wk scan?
- Advice about pelvic rest: no penetrative sex, no douching; advise to go to hospital if bleeding
-
Re-scan at 28-32wks
- Non-complete is likely to have moved superiorly –> no further Ix
- Complete is unlikely to resolve
- If unresolved –> follow management of confirmed placenta praevi
What is the Mx of confirmed placenta praevia?
- Admit if bleeding; admission can be delayed if asymptomatic (give advice given if found at 20 week scan)
- Corticosteroids if <34wks
- Anti-D if necessary
-
Plan for delivery:
- Complete/partial placenta praevia: C-section at 37wks
- If presents in labour –> emergency C-section
- Marginal/low-lying placenta: await normal vaginal delivery
- If pre-term labour: tocolytics and corticosteroids (to allow for transfer to experienced centre); C-section if labour progresses, anti-D
- Complete/partial placenta praevia: C-section at 37wks
What are the complications of placenta praevia?
- Haemorrhage (antepartum, intraoperative, PPH)
- Preterm labour
- Need for C-section
- Placenta accreta (abnormally adherent placenta)
- Adheres to myometrium, usually in previous scar
- Prevents placental separation risk of haemorrhage (may need hysterectomy)
- IUGR, foetal death
What is the prognosis of placenta praevia?
- Non-complete placenta praevia is likely to resolve by term
- Prognosis is generally good; increased risk of recurrence in subsequent pregnancies
What is the definition of antenatal haemorrhage:?
bleeding after 24wks
What are some causes of antenatal haemorrhage?
- placenta praevia,
- placental abruption,
- marginal placental bleed,
- vasa praevia,
- uterine rupture,
- local genital causes (polyps, ectropion, infections)
What is vasa praevia?
Foetal blood vessels traverse the foetal membranes over the internal cervical os
What is the aetiology of vasa praevia?
Blood vessels may arise from a velamentous insertion or accessory placental lobes
- Velamentous insertion: normally, the umbilical cord inserts into the middle of the placenta; in velamentous insertion it inserts into the foetal membranes then travels within the membranes to the placenta
- Accessory placental lobes: vessels may be joining accessory placental lobes to the main placenta
The vessels are not protected by umbilical cord or placental tissue –> high risk of rupture when membranes rupture
- Leads to massive foetal bleeding and foetal compromise
What are the risk factors for vasa praevia?
- multiple gestation,
- IVF
What are the symptoms of vasa praevia?
- Triad of:
- Painless fresh vaginal bleeding
- Ruptured membranes
- Foetal distress
- May be detected antenatally on USS
What are the Ix for ?vasa praevia?
- CTG
-
Alkali denaturation test
- NaOH mixed with blood –> foetal Hb is resistant to denaturation with 1% NaOH present
- Determines immediately if blood if foetal (turns pink) or maternal (turns yellow)
What is the Mx of vasa praevia if detected before bleeding?
If detected before:
- Admission from 32weks (allows emergency C-section if membranes rupture)
- Corticosteroids
- Elective C-section before rupture of membranes (35-36wks)
What is the Mx of vasa praevia if detected once bleeding occurs?
- ABCDE (see full management of antepartum haemorrhage in placenta praevia)
- Immediate C-section
What are the complications and prognosis of vasa praevia?
Very high foetal mortality –> 50%, increasing to 75% if membranes rupture
What is placental abruption?
Separation of the placenta from the uterine wall before delivery of the foetus
What is the aetiology of placental abruption?
May be due to direct abdominal trauma, indirect trauma or vasospasm (e.g. cocaine use)
- Thought to occur following rupture of maternal vessels within basal layer of endometrium –> accumulation of blood and splitting of the placental attachment from the basal layer
- The detached portion is unable to function –> foetal compromise
- Bleeding is maternal and/or foetal
What are the types of placental abruption?
There are 2 types of placental abruption:
- Revealed: bleeding drains through the cervix –> vaginal bleeding
-
Concealed: bleeding remains in the uterus, usually forming a retroplacental haematoma
- Bleeding is not visible but may be severe
Abruption can involve the whole placental (total) or only part of the placenta (marginal)
- A marginal bleed is large enough to cause bleeding but not enough to cause maternal/foetal compromise
What are the risk factors of placental abruption?
- previous placental abruption,
- pre-eclampsia/HTN,
- smoking,
- cocaine,
- trauma,
- chorioamnionitis,
- oligohydramnios,
- polyhydramnios (sudden decrease in pressure when membranes rupture),
- multiple pregnancy
Which type of placental abruption is the most common?
partial is most common
What are the symptoms of placental abruption?
- Abdominal pain (due to retroplacental blood)
- Vaginal bleeding (if revealed)
- Often dark
What is seen O/E in ?placental abruption?
- On examination:
- Couvelaire uterus: woody (tense) uterus due to blood, painful
- Signs of maternal collapse
When is placental abruption considered as severe?
- Abruption is considered severe if:
- foetal/maternal death,
- foetal distress,
- preterm birth,
- IUGR,
- DIC,
- renal failure,
- hypovolaemic shock,
- need for transfusion/hysterectomy
What are the Ix for ?placenta praevia?
- Investigations for antepartum bleeding:
- Thorough history: how much bleeding, onset, fresh/brown, SROM, provoked (post-coital), abdo pain, foetal movements, cervical smears
-
Examination:
- General: pallor, cap refill, HR, BP
- Obstetric: palpable contractions, lie and presentation of foetus, CTG
-
Assess bleeding: externally, speculum (look for blood, clots, cervical dilatation, SROM)
- Do not do bimanual in PV bleed (unless placenta praevia excluded, as risk of massive bleeding) or ruptured membranes (infection risk)
- Swabs: exclude infection if bleeding is minimal
- History and exam
- Bloods: FBC, clotting, G&S, cross match, U&Es, LFTs, Kleihauer test
- CTG
-
USS
- May show retroplacental haematoma
- Poor negative predictive value don’t use to exclude abruption
What is the inital Mx of placental abruption?
Initial management:
- ABCDE, IV access, fluids/blood transfusion, CTG
- Consider antifibrinolytics (tranexamic acid)
- Admit (even without vaginal bleeding if uterine tenderness)
- Anti-D if necessary
- If severe bleeding, not stabilised by resuscitation emergency C-section
What are the next steps in Mx of a placental abruption?
Management depends on health of foetus:
- Foetal demise (death):
- Aim to minimise morbidity to mother
- Vaginal delivery (+/- IOL) if mother is stable; emergency C-section if mother is unstable
- Live foetus >34wks:
- Reassuring foetal/maternal status:
- Vaginal delivery (+/- IOL)
- Unstable foetal/maternal status:
- Emergency C-section
- Reassuring foetal/maternal status:
- Live foetus <34wks:
- Reassuring foetal/maternal status:
- Admission
- Conservative management regular USS and CTG
- Corticosteroids
- If preterm labour: consider tocolytics
- Plan for delivery at 37wks (risk of stillbirth if later)
- Unstable foetal/maternal status:
- Emergency C-section
- Reassuring foetal/maternal status:
What are the complications of placental abruption?
Complications:
- Maternal:
- Haemorrhage
- DIC
- Renal failure
- Foetal:
- IUGR
- Preterm birth
- Stillbirth, perinatal death
What is the prognosis of placental abruption?
- Foetal prognosis depends on gestational age (30% overall)
- Maternal prognosis depends on blood loss
What is acute fatty liver of pregnancy?
Fatty infiltration of hepatocytes during pregnancy, without any inflammation or necrosis
What is the aetiology of acute fatty liver of pregnancy?
Likely to be due to a mitochondrial disorder which affects fatty acid oxidation
- May lead to hepatorenal failure, DIC and hypoglycaemia
What are the risk factors for acute fatty liver of pregnancy?
- nulliparity,
- multiple pregnancy,
- pre-eclampsia,
- obesity,
- male foetus
What are the symptoms of acute fatty liver of pregnancy?
- Usually presents around 35wks (but can occur earlier or immediately after delivery)
- Nausea and vomiting
- Abdominal pain, liver tenderness
- Pruritis
- Jaundice
- Ascites
- Bleeding/coagulopathy
What are the Ix for ?acute fatty liver of pregnancy?
- Bloods: FBC (assess Hb, thrombocytopenia, WCC often high), clotting screen, LFTs (raised AST/ALT), serum bilirubin (raised), U&Es (may cause renal failure), glucose (may cause hypoglycaemia)
- USS
-
Biopsy
- Would be diagnostic (fatty infiltrates) but coagulation problems often contraindicate
What is the Mx for acute fatty liver of pregnancy?
- Supportive treatment:
- Fluid management
- Correct clotting defects (FFP, platelets, blood transfusion)
- Correct hypoglycaemia
- Prompt delivery
- Screen infants for defects in mitochondrial fatty acid oxidation
What are the complications of acute fatty liver of pregnancy?
Complications:
- DIC, bleeding
- Fulminant liver failure, renal failure
- Hypoglycaemia
- Pancreatitis
- Death (10-20% maternal mortality; 20-30% foetal mortality)
What is the prognosis of acute fatty liver of pregnancy?
Usually resolves after delivery; low recurrence rate
What is obstetric (intrahepatic) cholestasis?
Pruritic condition of pregnancy characterised by itching without a skin rash and abnormal LFTs
What is the aetiology of obstetric (intrahepatic) cholestasis?
Multifactorial aetiology –> hormonal, genetic and environmental interactions
- Due to abnormal sensitivity to the cholestatic effects of oestrogens –> build-up of bile acids in the liver –> deposition in skin and placenta –> itching
- Foetal morbidity is due to limited ability of the foetal liver to remove bile acids from blood, and the vasoconstricting effect of bile acids on placental veins
What are the risk factors for obstetric (intrahepatic) cholestasis?
- previous Hx/FHx,
- Hx Hep C,
- age >35yo,
- multiple pregnancy
What are the symptoms of obstetric (intrahepatic) cholestasis?
- Usually presents in 2nd half of pregnancy
- Intense pruritis
- Usually affects palms of hands and soles of feet; spares face
- Excoriation
- No rash
- Occasionally mild jaundice
What are the Ix for ?obstetric cholestasis?
-
Bloods:
- Bile acids (raised)
- LFTs (abnormal, esp raised AST/ALT)
- Coagulation profile (coagulopathy indicates more severe disease)
- Fasting serum cholesterol (usually elevated)
- Hep C virology
- Exclude other causes of liver dysfunction if necessary (e.g. HELLP, fatty liver of pregnancy, gallstones, etc.)
What is the Mx for obstetric cholestasis?
High-risk pregnancy; consultant-led care
Close monitoring
- Monitor LFTs weekly
- Foetal surveillance (serial growth scans, doppler USS)
Reduction of pruritis
- Antihistamines (diphenhydramine)
- Ursodeoxycholic acid (UDCA)
- Avoid tight clothing, topical antihistamine lotions, etc.
Delivery:
- IOL at 37wks (to reduce risk of a late stillbirth and maternal morbidity); earlier if foetal distress
- Deliver in labour ward with continuous CTG
- Corticosteroids for women <34wks (in case premature delivery occurs)
- 6-week follow-up to ensure LFTs return to normal
What are the complications of obstetric cholestasis?
Complications:
- Stillbirth (esp after 37wks gestation) – 2%
- Preterm labour (due to direct effects of bile salts on uterine muscle)
- Vitamin K deficiency and clotting abnormalities (liver dysfunction depletes vit K)
- Maternal morbidity (due to constant itching and sleep deprivation)
What is the prognosis of obstetric cholestasis?
Resolves after delivery but tends to recurs in subsequent pregnancies (90%)
What is varicella zoster infection in pregnancy?
Primary infection with VZV during pregnancy
What is the aetiology of varicella zoster infection in pregnancy?
Varicella zoster (HHV3) is a DNA virus responsible for:
- Chickenpox (aka varicella) –> primary infection
- Shingles (aka herpes zoster) –> reactivation (virus becomes latent in cranial nerves and dorsal root ganglia)
Transmitted by droplet spread and direct personal contact; vertical transmission
- Risk of vertical transmission is highest if primary infection occurs at <20wks or within 5 days of delivery
Incubation period is 14 days; infectious from 48hrs before rash until vesicles have crusted (usually 5 days)
Non-immune pregnant women are vulnerable to severe infection
What are the symptoms of varicella zoster infection in pregnancy?
- Primary infection:
- Fever, malaise
- Pruritic maculopapular rash –> becomes vesicular and crusts before healing
- Associated with pneumonia, hepatitis, encephalitis
What are the Ix for ?varicella zoster infection in pregnancy?
- Antenatal screening is not routine, but women are asked if they have had chickenpox at booking
-
Primary infection is usually a clinical diagnosis
- If diagnosis is in doubt or severe infection: PCR of skin lesions or CSF (confirms diagnosis)
-
VZV IgM/IgG serology
- To determine immunity status in women who have been exposed and have unknown immune status
-
Serial USS
- For all women who develop primary varicella in pregnancy, to screen for foetal consequences
What is the Mx for a woman who has been exposed to varicella zoster infection during pregnancy?
Maternal suspected varicella contact:
- Clarify significance of contact (significant if face-to-face or in same room for >15mins)
- Determine immune status
- Previous history of chickenpox –> assume immunity, no action needed
- Uncertain/no history of chickenpox –>VZV IgG serology
- If IgG is present –> immune, no action needed
- If not immune:
- Give varicella zoster immunoglobulin (VZIG) if <10d since exposure
- Advise the woman that she is potentially infectious from 8-28d after contact
- Discuss postpartum varicella vaccination
- Seek medical help if rash develops
What is the Mx for a woman who has confirmed varicella zoster infection during pregnancy?
Maternal chickenpox:
- Avoid contact with other pregnant women and neonates until lesions have crusted over
- Consider hospital admission if >20wks or signs of severe infection (pneumonia, neurological signs)
- Advise woman to attend hospital immediately if symptoms worsen
- Acyclovir:
- For patients presenting <24hrs since rash onset and >20wks gestation
- Consider if <20wks gestation
- IV if any signs of severe infection
- For patients presenting <24hrs since rash onset and >20wks gestation
- Refer to foetal medicine specialist –> serial USS; counselling
- Delivery:
- Avoid until 7d after rash onset (to allow antibody transfer to reduce risk of newborn infection)
- Give VZIG if delivery occurs within 5-7d, or if mother developed varicella within 5d after birth
- Infection at <28wks gestation:
- Inform woman of 1% risk of foetal varicella syndrome
- May consider amniocentesis to detect VZV DNA
What are the maternal complications of varicella zoster infection during pregnancy?
Maternal complications:
- Pneumonia (10%), hepatitis, encephalitis, meningitis
- Delivery during viraemic period has high risk of thrombocytopenia and DIC
What are the foetal complications of varicella zoster infection during pregnancy?
Foetal complications:
-
Varicella infection of the newborn:
- Highest risk if maternal infection occurs 5 days before or after delivery (can occur within 4wks) – when foetus is unprotected by maternal antibodies and viral load is high
- Transmission can be transplacental, vaginal or from direct contact after birth
- Infants born in high-risk period should receive VZIG, be closely monitored, and receive acyclovir if any symptoms develop
- Mortality 30%
-
Foetal varicella syndrome:
- Occurs in 1% pregnancies infected by VZV before 20wks gestation
- Caused by subsequent reactivation of VZV in utero as herpes zoster
- Presents with skin scarring in a dermatomal distribution, ophthalmic lesions, limb hypoplasia and neurological abnormalities (incl. microcephaly)
What is cytomegalovirus infection in pregnancy?
Primary or recurrent infection with CMV in pregnancy
What is the aetiology of cytomegalovirus infection in pregnancy?
- CMV is a member of the Herpesvirus family (HHV5) DNA virus
- Transmitted via respiratory droplet transmission/personal contact; can be transmitted vertically via placenta and via blood products
- CMV establishes latency (in lymphocytes) and can become reactivated (like other Herpes viruses)
- Reactivation occurs intermittently, with shedding in the genital, urinary or respiratory tract
- Primary infection is more likely to cause congenital CMV (40%) than reactivation (1%)
- Primary infection in 1st trimester gives highest risk
- High prevalence of seropositive women means reactivation accounts for 30-50% of congenital infection
What is the epidemiology of cytomegalovirus infection in pregnancy?
- Most common virus transmitted to foetus during pregnancy
- 60% women are seropositive for CMV before pregnancy; 1% become infected during pregnancy
What are the symptoms of cytomegalovirus infection in pregnancy?
- Primary maternal CMV infection is usually asymptomatic
- May cause flu-like illness (fever, malaise)
What are the Ix for ?cytomegalovirus in pregnancy?
- Pregnant women are not screened; there is no vaccine
-
Viral serology for CMV-specific IgM and IgG
- Positive if IgG in a previously negative mother, or IgM and low IgG avidity (<30%)
- Investigations in foetus/infant:
-
Amniocentesis/foetal blood sampling and PCR if foetal infection is suspected
- Must be done after 21wks because functioning kidneys are required for virus to be excreted into amniotic fluid; at least 6wks after maternal infection
-
Serial USS for features of congenital CMV
- Diagnosis is often suspected after abnormalities are seen on USS
- Microcephaly, IUGR, hepatosplenomegaly, ventriculomegaly, hydrops
-
Neonatal brain USS if congenital infection
- audiological/ophthalmic/developmental routine screening
-
Amniocentesis/foetal blood sampling and PCR if foetal infection is suspected
What is the Mx of cytomegalovirus infection in pregnancy?
Referral to foetal medicine specialist (if confirmed CMV during pregnancy)
Maternal infection:
- No treatment needed
- Avoid anti-CMV drugs (ganciclovir, foscarnet) –> teratogenic
If foetal infection is confirmed (by amniocentesis):
- Offer TOP
- Serial USS to look for congenital CMV
What is the main complication of cytomegalovirus infection in pregnancy?
Congenital cytomegalovirus:
- 40% primary CMV infections in pregnancy are transmitted to foetus
- In infected infants, 90% have no features of CMV, 5% have clinical features at birth, 5% develop features later in life
- Highest risk of congenital CMV is
- Complications:
- Miscarriage/stillbirth, IUGR
- Microcephaly, poor tone/abnormal head lag, sensorineural hearing loss, blindness (chorioretinitis), hepatosplenomegaly, thrombocytopenic purpura
- Babies born without symptoms may develop sequalae later (2yrs): hearing loss, developmental delay, visual impairment
- High mortality in symptomatic newborns (DIC, hepatic dysfunction, bacterial superinfection)
What is rubella infection in pregnancy?
Infection with rubella virus in pregnancy; aka German measles
What is the aetiology of rubella virus infection in pregnancy?
- Single-stranded RNA togavirus
- Transmitted by airborne droplets between close contacts; also vertical transmission
- Incubation period 14 days; patients are infectious from 7-30d after infection (from 1wk before to 2wks after rash)
- Gestation at infection determines risk of vertical transmission and development of congenital rubella syndrome
What are the symptoms of rubella infection in pregnancy?
- Maternal rubella:
- Often asymptomatic
- Non-specific symptoms: fever, malaise, headache, coryza, arthralgia, lymphadenopathy
- Maculopapular rash (more common in children)
What are the Ix for ?rubella infection in pregnancy?
-
Antenatal screening is no longer done in UK (from 2016)
- Used to screen for IgM and IgG –> if neither present woman encouraged to seek vaccination post-partum (didn’t help current pregnancy but protected future pregnancies)
-
If maternal infection is suspected:
-
IgM and IgG ELISA
- IgM suggests recent infection; low IgG avidity suggests recent infection/high suggests distant
-
IgM and IgG ELISA
-
If maternal infection is confirmed:
- Amniocentesis/CVS
- Serial USS
- Infant urine/blood –> rubella PCR/IgM
What is the Mx for rubella infection in pregnancy?
Referral to foetal medicine specialist
- For any pregnant woman with known exposure
Maternal infection:
- Symptomatic treatment (e.g. antipyretics, NSAIDs)
- Inform woman she is infective from 7d before symptoms to 4d after
Foetal:
- <12wks: consider TOP (high likelihood of defects)
- 12-20wks: amniocentesis to confirm foetal infection
- Consider TOP if infection is confirmed; serial USS if continuing with pregnancy
- >20wks: no action required
What are the maternal complications of rubella infection in pregnancy?
Maternal complications (uncommon):
- Thrombocytopenia
- Encephalitis
What is the main foetal complication of rubella infection in pregnancy?
Congenital rubella syndrome:
- Increased risk of miscarriage/stillbirth and IUGR
- Classified into ‘present at birth’ and ‘late onset’
-
Present at birth:
- Sensorineural deafness, congenital cardiac abnormalities, ophthalmic defects (cataracts), CNS abnormalities (microcephaly, developmental delay)
-
Late onset:
- DM, thyroiditis, GH abnormalities, behavioural disorders
What is Toxoplasmosis in pregnancy?
Infection with Toxoplasma gondii during (or immediately before) pregnancy
What is the aetiology of toxoplasmosis?
Toxoplasma gondii is a protozoan parasite found in cat faeces, soil or uncooked meat
Transmitted by ingestion of the parasite from undercooked meat or from unwashed hands; also vertical transmission
Parasitaemia occurs within 3wks of infection –> risk to foetus if infected occurs during/just before pregnancy
- Transplacental infection may occur during parasitaemia –> 40% foetuses infected
What is the epidemiology of toxoplasmosis?
1/3 people are infected by toxoplasmosis at some point in their life; congenital toxoplasmosis is rare
What are the symptoms of toxoplasmosis in pregnancy?
- Maternal infection:
- Usually asymptomatic (90%)
- May have non-specific symptoms: lymphadenopathy, fever, malaise, arthralgia
What are the Ix for ?toxoplasmosis in pregnancy ?
- Screening is not routinely done
-
If maternal infection is suspected:
-
IgM and IgG, IgG avidity ELISA
- IgG suggests previous exposure; IgM may suggest acute infection (serial testing must be done to show rising titres – high false-positive rate)
-
IgM and IgG, IgG avidity ELISA
-
Investigations for foetus/infant:
- Amniocentesis/CVS
-
Cord serum/newborn serum: IgM, IgA and IgE
- IgM suggests infection; IgA/E in cord serum are diagnostic of congenital toxoplasmosis
-
Serial USS
- Suspicious USS may be the first suggestion (is suspicious –> do amniocentesis/CVS)
What is the Mx for toxoplasmosis in pregnancy?
Prevention:
- Advise pregnant women to avoid raw/rare meat, avoid handling cats and litter, wear gloves and wash hands when gardening/handling soil
Maternal treatment:
-
Spiramycin (oral, 3wk course, 2-3g/d)
- Reduces the incidence of transplacental infection
- May also use pyrimethamine, sulfadiazine and calcium folinate
- Offer TOP if USS abnormalities
Newborns with congenital toxoplasmosis:
-
Pyrimethamine, sulfadiazine and calcium folinate for 1yr
- Limits CNS and eye damage
What is the main complication of toxoplasmosis in pregnancy?
Congenital toxoplasmosis:
- Highest risk is if infection in 1st trimester
- 10% infections are transmitted; 85% congenital disease if transmitted
- In 3rd trimester, 85% infections are transmitted but only 10% risk of congenital disease
- Increased risk of miscarriage and IUGR
- Often asymptomatic at birth, but 85% develop symptoms
- Symptoms: retinopathy, CNS problems (seizures, learning difficulty), intracerebral calcification
- If severe: microcephaly, ventriculomegaly
What is listeria infection in pregnancy?
Infection with Listeria monocytogenes in pregnancy –> leads to listeriosis
What is the aetiology of listeria infection in pregnancy?
Listeria monocytogenes is a gram-positive facultatively anaerobic bacillus, whose lifecycle involves obligate intracellular replication
- People with reduced cell-mediated immunity, and therefore pregnant women, are most at risk
Infection is by consuming contaminated food –> unpasteurised milk, ripened soft cheese, pate, prawns
- It is not transmitted in hot foods; can multiply at refrigerator temperatures (so transmitted in chilled food)
Vertical transmission can occur (transplacentally or through contaminated birth canal (ascending through cervix))
What are the symptoms of listeria infection in pregnancy?
- Maternal infection:
- 1/3 asymptomatic
- Flu-like illness with fever, general malaise, myalgia, headache, diarrhoea and vomiting
What are the investigations for ?listeria infection in pregnancy?
- Not routinely screened for
- Bloods: FBC (high WCC)
- Blood cultures
- Vaginal, perinatal and amniotic fluid swabs and culture
- For perinatal listeriosis
What is the Mx of listeria infection in pregnancy?
Prevention:
- Advise pregnant women to not eat soft cheese/unpasteurised milk/pate
Treatment of maternal infection:
- IV ampicillin
- Gentamycin added if very severe (but rarely used as teratogenic)
What are the complications of listeria infection in pregnancy?
Complications:
- Maternal meningitis, sepsis, endocarditis
-
Septic abortion/stillbirth (20%)
- Due to chorioamnionitis or transplacental transmission with generalised formation of microabscesses in the embryo (granulomatosis infantiseptica)
- Premature delivery (50%)
- Meconium staining
-
Clinical neonatal Listeria infection (in 75% neonates born to mothers with listeriosis)
- Respiratory distress, sepsis, neurological symptoms
What is the aetiology of parvovirus B virus in pregnancy?
Parvovirus B19 is a single-stranded DNA virus
- Infects erythrocyte progenitor cells –> usually causes a mild, self-limiting infection
- Foetus has decreased RBC survival time (more vulnerable) –> aplastic anaemia
Transmitted by respiratory droplets or blood; vertical transmission (transplacental)
- Transplacental transmission occurs in up to 30% infections; 2nd trimester has highest risk
What is the epidemiology of parvovirus B infection in pregnancy?
- Common (1 in 400 pregnancies); most common in women who work with young children (e.g. teachers)
- 50% women of childbearing age are immune, so 50% are susceptible to infection
What are the symptoms of parvovirus B infection in pregnancy?
- Maternal infection:
- Usually asymptomatic
- Arthralgia (usually proximal interphalangeal joints and knees), malaise
- NB in children: erythema infectiosum (slapped cheek syndrome)
What are the Ix for ?parvovirus B infection in pregnancy?
- Not routinely screened for
- IgM/IgG serology
- IgM may persist for 2-3 months after infection
- FBC and reticulocyte count (for anaemia)
- Foetal investigations:
- Amniocentesis for PCR
- Serial USS (for hydrops)
- Ascites, oedema, pleural effusion, polyhydramnios
- High velocity in MCA on Doppler USS suggests anaemia
What is the Mx of parvovirus B infection in pregnancy?
Referral to foetal medicine specialist for all suspected infection
Maternal:
- Symptomatic therapies (antipyretics, analgesia)
Foetal:
- Serial USS and Doppler assessment (for foetal hydrops)
- Intrauterine blood transfusion considered in hydrops (at tertiary centre)
- 10% risk of intrauterine death if <20wks gestation (can’t transfuse); 1% if >20wks
What are the complications of parvovirus B infection in pregnancy?
Foetal complications:
- Severe anaemia, hydrops fetalis and intrauterine death
- Aplastic anaemia results in high output cardiac failure and increased hepatic and extrahepatic erythropoiesis –> portal HTN and hypoproteinaemia –> ascites (hydrops)
- Hydrops fetalis: abnormal accumulation of fluid in 2 or more foetal compartments
- If foetus survives the anaemia –> full recovery
- 10% risk intrauterine death if foetus is infected
- Aplastic anaemia results in high output cardiac failure and increased hepatic and extrahepatic erythropoiesis –> portal HTN and hypoproteinaemia –> ascites (hydrops)
What is the aetiology of malaria infection in pregnancy?
Parasite transmitted by female Anopheles mosquito; most severe type is Plasmodium falciparum
Pregnant women have increased risk of malaria, and are more susceptible to severe disease
- Parasites can sequester in the placenta (so may have negative blood films)
- Co-infection with HIV is common in endemic areas –> vertical transmission of both malaria and HIV is more common if the two infections co-exist
What are the symptoms of malaria infection in pregnancy?
- Maternal infection:
- Cyclical spiking pyrexia (often every 48-72hrs)
- Headache, myalgia, anorexia, diarrhoea
- Anaemia; jaundice and renal failure (due to haemolysis)
- Hypoglycaemia
- Altered consciousness, seizures, hypotension (if severe)
What are the Ix for ?malaria infection in pregnancy?
- Thick and thin blood films
- Thick films to identify parasite; thin films to identify species
- Bloods: FBC (anaemia), clotting (may have bleeding complications), U&Es, LFTs, glucose
- Foetal monitoring (CTG, USS)
What is the Mx of malaria infection in pregnancy?
Prevention:
- In endemic areas: insecticide-treated bed nets, preventative treatment during pregnancy
- For travellers:
- Advise they should only go if absolutely necessary
- Insecticide sprays, mosquito nets, appropriate clothing
- Antimalarial drug prophylaxis: expert advice, balance risks of teratogenicity with risk of malaria; chloroquine and mefloquine considered safe for foetus)
Treatment:
- Manage with infectious diseases specialist and obstetrician
- Supportive care (ABCDE)
-
Antimalarials
- Choice is dictated by local sensitivity
- Quinine + clindamycin; IV artesunate if severe
What is the aetiology of HIV infection in pregnancy?
HIV is transmitted through sexual contact, blood and blood products or vertical transmission
- Vertical transmission can occur in utero, intrapartum or through breastfeeding
What is an APGAR score?
Apgar scores:
- Used to assess wellbeing of the baby
- 1min assesses need for resuscitation (or should already have been assessed), 5mins assesses result of resuscitation and prognostic info, 10 and 15mins give prognostic info
- <7 is abnormal
What are the causes of Poor Progress in the 1st Stage of Labour?
What are the causes of Poor Progress in the 2nd Stage of Labour?
What is the antenatal assessment of VTE in pregnancy?
What is the postnatal assessment of VTE in pregnancy?
What is the aetiology of multiple pregnancy?
May be classified according to number of foetuses (twins, triplets, etc.), number of fertilised eggs (zygosity), number of placentae (chorionicity), or number or amniotic cavities (amnionicity)
Multiple pregnancies can be dizygotic (70%) or monozygotic (30%)
-
Dizygotic (non-identical):
- Ovulation and fertilisation of >1 oocyte by different sperm
- Dichorionic diamniotic (DCDA): each foetus has its own placenta and amniotic cavity
- Placentae are always functionally separate but can become fused so appear as one
- Amniotic cavities are always separate; separated by thick 3-layer membrane
- May be the same sex or different sex
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Monozygotic (identical):
- Single ovum is fertilised with subsequent division of the zygote
- The time of splitting determines the type of multiple pregnancy
- DCDA: splitting shortly after fertilisation (3d)
- Can’t determine if they are identical or not in utero, unless different genders
- Monochorionic diamniotic: splitting 4-8d after fertilisation
- Shared placenta; 2 amniotic cavities (but dividing membrane is thin (1 layer))
- Monochorionic monoamniotic: splitting 8-12d after fertilisation
- Shared placenta, shared amniotic cavity
- Conjoined twins: splitting after day 13
- DCDA: splitting shortly after fertilisation (3d)
