obs and gynae Flashcards
Who needs pre-pregnancy counselling
diabetes epilepsy cardiac, renal, rheum, inflam bowel haematological disorder alcohol/drugs and mental health
When can pregnancy test be done and what detect
Do anytime after 1st day of missed period, detects betaHCG
Dating USS - why and when
11-14 weeks
crown-rump length - gestational age
detect multiple pregnancies
Measure nuchal translucency for Down syndrome
Pregnancy investigations
FBC ABO and rhesus +ve (anti D at 28w) infection - syphilis, hep b, HIV MSU Downs syndrome Consent for mid T 18-20w
When to do repeated growth scans
prev small for gestational age at birth
diabetes
pre-eclampsia
If Symphysial fundal height is inaccurate such as in high BMI
Obstetric history
Age, gestation, gravidarum and parity presenting complaint PMH PSH - back, abdominal Drug Hx Social Hx Family Hx
past obstetric history
- type of delivery
- antenatal, intrapartum and postnatal complications
- VTE
- birth weight
- live/ nnd
- where? if other hospital get notes
new onset hypertension and proteinuria
- severe headache, visual disturbance, epigastric pain, sudden increase in oedema
Pre - eclampsia
3 stages of labour
1st - onset to full dilation
2nd - full dilation to delivery
3rd - delivery of baby to expulsion of placenta and membranes
what presentations cannot be delivered vaginally
brow and shoulder
how to monitor baby’s heart rate in high risk pregnancy
CTG or fetal scalp electrode
in low risk do intermittent auscultation
Indications for operative delivery and what devices used
use ventouse forceps, neville-barnes forceps, kiellands forceps (rotational)
delay in 1st or 2nd stage
suspected fatal distress
breech - may need forceps to deliver after coming head
multiple pregnancies
severe fatal growth restriction
maternal conditions (HIV, ITP, pre-eclampsia or eclampsia)
pain relief in labour
TENS Parenteral narcotics Epidural Remifentanil PCA Entonox
what is given to women in 3rd stage of pregnancy to reduce blood loss
syntocinon 10 units IM
causes of post partum haemorrhage
Tone - uterine atony
Tissue - retained products of conception
Trauma
cloTTing
in hosp - atonic uterus, retained placenta
delayed - infection or retained placental tissue
benefits and cons of breast feeding
mother
- free
- educed risk of breast/ ovarian ca
- uses 500 calories a day
- mother baby bond
- delays periods
baby
- availability
- temperature
- less diarrhoea, constipation, vomiting
- fewer chest/ ear infections
- less likely to develop eczema
- less likely to develop obesity/ type 2 diabetes
Cons Volume of milk intake unknown Less flexible Low levels of vitamin K and vitamin D Transmission of CMV, Hep C and HIV Transmission of drugs
Causes of delayed menarche
Imperforate hymen
Vaginal agenesis - abdo pain/ swelling, bulging/blue membrane at end of vagina
testicular feminisation, androgen insensitivity
Causes of delayed puberty
Central
- pituitary surgery/ irradiation
- Kallman syndrome
- eating disorder, excessive exercise
Gonadal
- Kleinfelters or Turners
- hx of irradiation of testes
- chemotherapy
- AI ovary disease
Causes of abnormal uterine bleeding
heavy, intermenstrual, post coital, post menopausal
P - polyp A - adenomyosis L - leiomyoma M - malignancy and hyperplasia C - coagulopathy O - ovulatory dysfunction E - endometrial I - iatrogenic N - not yet classified
Heavy regular periods, pressure symptoms, abdominal swelling, pain uncommon
Fibroids - can cause recurrent miscarriage
Fibroids
- More common in pre menopausal, nulliparous
- degenerate in pregnancy
Many asymptomatic, may present with menorrhagia, Abdominal swelling, Pelvic pain, Dyspareunia, Dysmenorrhoea, Urinary/bowel symptoms
Can cause severe acute pain if outgrow blood supply in pregnancy or if undergo torsion
On exam: palpable abdo mass, enlarged/firm/irregular/ non-tender uterus, signs of anaemia due to menorrhagia
Investigations:
- pelvic exam and gynae hx
- AtoE if large blood loss
- Trans vaginal US first line
- hysteroscopy may be helpful
- FBC - anaemia
- Do MRI if clinically unsure, for operative planning
- If intramucosal or ?cancer hysteroscopy with biopsy
Management
- Treat any anaemia with ferrous sulphate
- treat menorrhagia with hormonal first: IUS, COCP, POP
- NSAID, Tranexamic acid can be given as adjunct
- If symptoms not improve refer to secondary care for GnRH analogues
- if menorrhagia not controlled, significant pain, reduced fertility or mass effect sx consider surgery
Surgical options
- transcervical resection of fibroid (if submucosal)
- myomectomy (only effective treatment for large fibroids affecting fertility), hysterectomy
- uterine artery embolisation
First appointment, when and what covered
Booking appointment at 8-12 w
Hx and risk assessment
Estimation of due date (40w from 1st day of last period)
Book dating scan
Investigations
- height and weight
- blood pressure
- urine dip
- blood (anaemia)
- infection screen
- downs screening blood tests
- group and save
- haemolytic disorders and rhesus d
consent for dating scan at 8-14w and mid trimester scan at 18-20
give info on classes, nutrition, exercise, maternity benefits, breast feeding etc.
Normal problems in pregnancy
- Varicose veins
- Carpal tunnel
- N+V
- Backpain
- Braxton hicks (false labour pains)
- Oedema
- Reflux
- Skin changes
Hypertension in pregnancy - types, risk and management
For existing hypertension - Stop ACEi and thiazide like diuretics - switch to CCB or BB
Gestational hypertension:
- After 20 weeks
- SBP >140 or increased by >30
- DBP >90 or increased by >15
- If >140/90 before 32w - BP + urine 2x a week
- If >150/100 - BP + urine 2x a week, start on labetalol, do FBC, LFT, U+E
- If >160/110 - Admit, IV labetalol, BP 4x daily, Urine 1x daily, CTG, blood.
For mild and moderate do US at 34 weeks and umbilical artery doppler
Pre-eclampsia
- above plus addition of protein in urine and oedema or end organ damage/ placental dysfunction
Pre-existing
- > 140/90 prior to 20w
- aim to keep below 150/100 or 140/90 if end organ dmg
- stop ACE/ARB, switch to labetalol/ nifedipine/ methyldopa
- additional US at 28-30 and 32-34w
- regular checking for proteinuria
Risks:
- Maternal: placental abruption, CVA, and DIC
- Foetal: IUGR, prematurity, miscarriage and stillbirth
If at increased risk of pre-eclampsia take 150mg aspirin OD from 12th week
If refractory severe BP then consider induction at 37w
Management of menorrhagia
Ask
Duration of bleeding, and how often is it heavy (heavy flow is indicated by the passage of clots and the simultaneous use of tampons and towels)
Symptoms of anaemia
Symptoms of clotting disorder e.g. bruising, bleeding gums
Sudden change in blood loss, intermenstrual and post-coital bleeding
Local pressure effects and pain
1st line - IUS
2nd line - tranexamic acid, mefanamic acid or COCP
3rd line - progestogens or oral norethisterone
In secondary care trail GnRH agonist for 3-4 months
Surgery - endometrial ablation, hysterectomy, uterine artery embolism
Types of miscarriage and management
Most common cause - chromosomal abnormalities
Investigate recurrent miscarriages if >3 in a row
- antiphospholipid syndrome - anti-cardiolipin
Is a miscarriage if loss of pregnancy before 24 weeks
Threatened - PV bleeding but baby alive, closed cervix
Inevitable - baby alive or dead, more blood, open cervix, pain common
Missed - cervix closed, often no blood or pain, baby dead (no heart beat)
Incomplete - cervix open, some products of conception remaining, PV blood, pain - remove with sponge forceps
Complete - Cervix closed, bleeding/ pain settled, empty uterus
Investigations
- speculum and pelvic exam
- TVUS to identify heartbeat/ foetal pole, if not there repeat in 7-14d, if still not present = miscarriage
- serial hcg to see if cont pregnancy, >63 rise ongoing pregnancy = ectopic, >50 fall failed pregnancy = miscarriage
- progesterone - confirm failed pregnancy if low
- if bleeding heavily go to hosp for FBC, U&E, crossmatch, GC&S, coag, rhesus d
Treatment:
If threatened, mother wants pregnancy start on progesterone 400mg BD if bleeding and had previous miscarriage - reduces rate of miscarriage
1st line: expectant (trialed for 7-14 days for missed/ incomplete) - do if stable, bleeding light - let occur naturally, take 2-8 week, repeat pregnancy test at 3w to check for retained products
For incomplete/ missed: medical
- < 12w - give PV or PO misoprostol, pain relief and anti-emetic as needed,
- > 12w give PO mifepristone + PV misoprostol
- repeat pregnancy test in 3w - speeds up process
Surgical - Do if haemorrhage, unstable, persistent bleeding/pain, trophoblastic disease, infection
- manual vacuum aspiration under LA or surgical curettage under GA, less pain and blood loss, give anti-D
- Psychosocial wellbeing
Common side effects of pregnancy
Headaches, vomiting, constipation and heartburn due to progesterone, swelling, carpal tunnel, tiredness, increased frequency of urination due to pressure effects, breast tenderness, foetal movements, backache, symphysis pubis dysfunction and pain, varicose veins, vaginal discharge, haemorrhoids in 3rd trimester
Supplements to take during pregnancy
normal - 400mcg folic acid from preconception to 12w
high risk - 5mg folic acid from preconception to 12w
vit D 400 IU OD throughout
Avoid excessive vit A
Those at risk of pre-eclampsia take aspirin from 12w onwards
When to offer first anti D treatment if rhesus negative
two doses of anti-D immunoglobulin of at least 500 IU at 28 and 34 weeks or as a large single dose of 1500 IU at 28 weeks’ gestation
Why SFH might be low
- Wrong dates
- Oligohydraminos
- IUGR, SGA
- Presenting part deep in the pelvis
- Abnormal lie of the fetus
When to stop contraception after menopause
2 years of amenorrhoea if <50, 1 year if >50
pre-eclampsia
Differentials
- UTI
- HTN in pregnany
- nephritic disease
Complications = IUGR, still birth, preterm birth, HELLP/ DIC
Occurs after 20w
Raised BP >140/90 plus either proteinuria >0.3g/24hr/ 2+ / ACR >8, protein creatinine ratio (PCR) > 30, maternal organ dysfunction or uteroplacental dysfunction
severe if BP >160/110
<34w = early onset
>34w = late onset
Present with
headache, visual disturbance, sudden swelling of hands/feet/face, severe abdo pain and vomiting. Also clonus, foetal distress, altered mental status, hyperreflexia
Investigations
- bedside do BP, urine dipstick + culture, ACR, vitals
- FBC (HELLP - low platelets), U+E, LFT, Coag, urate (indicates worsening disease)
- USS to assess foetal development
- umbilical artery doppler, CTG
- MRI/CT if suspect intracranial haemorrhage
monitoring
mild - bp 4x daily, bloods 2x weekly, US every 2w
mod - same but 3x weekly bloods
severe - bp > 4x daily, 3x weekly bloods, US every 2w
Management
If high risk:
- prevention = 75mg aspirin OD from 12w to birth
- consultant led care
- healthy lifestyle advice
Severe = DBP of at least 110 or SBP of at least 160, and/or symptoms, and/or biochemical and/or haematological impairment
Mild - (140/90 - 150/100) manage conservatively until 34w, give antihypertensive to keep BP <140/90 - Labetalol first line, nifedipine 2nd, methyldopa 3rd. Home BP monitoring every 2 days, bloods every 2w
Severe (>160/110)
- antihypertensives (as above, in very severe consider hydralazine)
- Consider additional corticosteroids
- monitor BP every 15 mins until <160/110 then 4x daily, bloods 3x weekly
- magnesium sulphate if seizure or high risk of seizure (also give prior to delivery)
- fluid restriction to reduce oedema (1ml/kg/hr)
Delivery:
34-36w if high risk - cant control BP, HELLP, O2 < 90%, neuro sx, placental abruption or worrying CTG. Give mg sulphate and corticosteroids
37w if low risk - induce within 24-48 hours
During delivery - constant BP and CTG, consider VTE prophylaxis and in 3rd stage give 5units syntocinon
Post birth: Keep in as risk of eclamptic seizures Monitor bloods at 48-72 hrs Monitor BP every 1-2 days for 2 weeks Do urine dip at 6w Lower antihypertensives to match drop in BP 1st line post pregnancy = enalapril
Hyperemesis Gravidarum
Differentials
Gastroenteritis, pancreatitis, H.pylori infection, Cholecystitis, UTI, DKA, drug induced
Defined as severe N+V in combination with dehydration, electrolyte imbalance, 5% pre-pregnancy weight loss
Usually starts at 4-7w, peak at 9w, gone by 16-20w
Investigations
- Obs, BM, urine dip for ketones, MSU, examine for dehydration
- FBC, U&E (low K+), LFT, amylase, TFT, bone profile, Mg
- US - identify multiple pregnancy or trophoblastic disease
Risk stratify with PUQE-24 - how long felt sick, how many times been sick, how many times dry heaved
- low 3-12 -> outpatient
- med >12 -> ambulatory care
- high (failed amb care, cant keep down liquids, weight loss/ketonuria despite oral therapies, complications) -> inpatient
Management
- outpatient -> oral antiemetics, rehydration, healthy diet
- amb care -> IV antiemetics, IV fluids +K, pabrinex, psychosocial support
- inpatient -> same as amb care + LMWH. severe cases termination
Antiemetic
- 1st line = cyclizine, prochlorperazine, chlorpromazine
- 2nd line = metoclopramide, domperidone
- 3rd line = corticosteroids (IV hydro then oral pred)
Eclampsia presentation and management - here
It is the occurrence of a tonic clonic seizure superimposed on a diagnosis of pre-eclampsia
24 hours post birth most common period for seizure, can be up to 6w
Presents with
- tonic clonic seizure
- Epigastric or RUQ pain
- N+V
- Tea coloured urine due to haemolysis
- Headache, oedema, hyper-reflexia etc
Investigations:
- rule out hellp, DIC with FBC, LFT
- do BM for hypoglycaemia
- do U&E, coag
- check on baby with abdo US and CTG
- rule out neuro if suspected using MRI/CT
Management
- AtoE - lie in left lat, secure airway, IV access
- Mg sulfate - 4g over 5-15mins, then 1g/hr for 24hr. if more fits give 2g bolus. 2nd line diazepam
- control BP - IV labetalol or hydralazine
- reduce oedema with fluid restriction
- monitor obs every 15min, urine 60min, CTG continuous
- deliver once mother stable
Foetal alcohol syndrome - presentation
Presentation
- facial features - small eyeballs, flat groove under nose, thin upper lip, cleft lip/palate, post rotation of ears
- learning disabilities, cognitive impairment, behavioural issues
- IUGR
facial features improve into adulthood but have short stature, microcephaly and learning issues
Combined pill - counselling
What know about types of contraception
What do you already know about the pill
Do you have any concerns about taking the pill
What are you hoping the pill will do for you
There are 3 main types of pill
- monophasic - all same lvl hormone, 21d, 7d break
- phasic - different hormone lvl, have to take in order 21d, 7d break
- everyday pill - 21 normal pill, 7 placebo - take continuously everyday
oestrogen and progesterone
Works to prevent ovulation, thicken cervical mucus, thin endometrium to prevent implantation
99% effective at perfect use, may be less than this if not take at same time every day or miss days
Pros
- can improve acne
- can reduce PMS
- can reduce bleeding/ menorrhagia
- not as strict as POP
- non-invasive
- effective
- can control timings of periods - do up to 3 packs back to back
- reduce ovarian, uterine, colon cancer risk
Cons
- headache, nausea, mood changes, breast tenderness
- breakthrough bleeding in first few months
- need to remember to take each day
- not protect from STI
- increase risk of vte, breast, cervical cancer
- increase risk of cholestasis in PBC, cervical ectropion
Cannot take if
- pregnant
- > 35 and smoke
- BMI > 35
- migraine with aura
- fix of breast cancer
- vte risk factors
Can start at any point during period - if start day 1-5, is effective immediately, if start other times need 7 day barrier
take for 21 days then 7 day break or can take for 3x21 then break
if miss a pill take asap even if means taking 2 in one day. If miss 2 days then need 7 day barrier, if had sex in last 7 days need emergency contraception
if miss 2 pill and >7 left in pack cont then break as normal
if miss 2 pill and <7 then go straight to next pack and dont break
If sick within 2 hours of taking take another if feeling better
If severe diarrhoea >24hrs take pill as though missed one
Epilepsy meds, HIV meds and St Johns wart can reduce the efficacy of the pill
If want to become pregnant stop taking the pill and wait until after their first natural period to begin trying and start folic acid 400mcg, stop smoking
Any Q’s
Give website link/ leaflet
encourage use of condoms
TOP
Can abort up to 24w if
- Reduces risk to M life
- Reduces risk M physical or mental health
- Reduces risk to physical or mental health of her existing children
- Baby at risk of being physically or mentally handicapped
Can abort after 24w if
- Risk to the M life
- Risk of grave, permanent injury to M physical/mental health
- Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped
Ix:
- pregnancy test to confirm
- US if suspect ectopic
- STI especially chlamydia
- Contraceptive counselling
- Rhesus status
- VTE risk
- Smear test if not had
Surgical
- antibiotic prophylaxis with 1g metro then 100mg doxy BD for 7d
- Anti D, LMWH if needed
- up to 14 w - vacuum aspiration LA or GA
- after 14-24w - dilation and evacuation with forceps, sedation or GA
Medical
- Anti-D only if after 10w
- NSAID pain relief if needed
- use pads nor tampon for blood
- <9w - 200mg PO mifepristone then 800mcg buccal/lingual/vaginal misoprostol after 24-48hrs
- 9-24w - 200mg PO mifepristone then 800mcg buccal/lingual/vaginal misoprostol after 36-48hrs, additional 400mcg misoprostol can be given up to 4x
sx: headache, nausea, sweating, diarrhoea, pain, cramp
Advise to re-perform pregnancy test after 4w - if still positive may be incomplete TOP or persistent trophoblastic pregnancy
Gestational diabetes - diagnosis, monitoring, management and complications
Any level of glucose intolerance with first onset in gestation
Often asymptomatic may have polyuria, polydipsia, fatigue
Diagnosis:
Fasting > 5.6
Two-hour 75g OGTT > 7.8
Also do HbA1c at time of diagnosis to identify if pre-existing diabetes
Management
Monitoring
- Fetal growth scan every 4w from 28-36w
- Also check amniotic fluid volume
Complications
- macrosomia
- preterm
- organomegaly, polycythemia
- Polyhydramnios
- neonatal hypoglycaemia
- NRDS
Management
- 1st line lifestyle + monitor BMs
- 2nd line metformin if lifestyle not effective within 1-2w
- 3rd line or if >7 fasting or 6-6.9 with complication - Insulin basal + bolus. Council for hypo, what to do if not eat/ vomit.
- 4 weekly growth scans
For insulin aim for 5.3 fasting, 7.8 1hr post, 6.4 2hr post
Measure BM pre meal fasting, 1 hr post meal and bedtime
Birth:
- 40+6 - induce or caesarean beyond this
- if type 1 or complications aim 37-38w birth
- During labour monitor BMs hourly, if 2x raised then put on sliding scale
Post birth:
- Monitor babys BMs
- stop all meds
- if macrosomia give prophylactic oxytocin to prevent uterine atony
Do fasting glucose at 6-13 weeks
<6 - lifestlyle
6-6.9 - high risk, preventative measures
>7 - repeat test for diagnosis
Yearly HbA1c
Who to screen for gestational diabetes
Screen at 24-28w
- BMI >30
- Previous macrosomic baby ≥4.5kg or more
- Previous GDM
- First-degree relative with diabetes
- Family origin – S Asian, black and Middle Eastern
Why stop methyl dopa post delivery?
Increases risk of postnatal depression
How to test for pre-eclampsia if background chronic hypertension?
Placental growth factor (PIGF) testing
Anaemia levels in pregnancy
<110g/L at booking
<105g/L in the second and third trimester
<100g/L postpartum
low MCV, MCHC, low ferretin
IDA
Treat with 100-200mg iron daily + increase dietary Vit C
Raised MCV, low serum, low red cell folate
Folate deficiency 400mcg/day from pre-conception for all 5mg/day from pre-conception if high risk o On anticonvulsants o Previous child affected with a neural tube defect o With demonstrated deficiency o With diabetes o With a BMI >30 o With sickle cell disease
Dyspepsia in pregnancy treatment
1st line conservative
2nd alginates and antacids
3rd ranitidine or omeprazole
Obstetric cholestasis
Presents in late 2nd or 3rd trimester with pruritus and excoriation particularly on palms and soles. Have elevated LFTs, bile acids and sometimes bilirubin. May develop pale stools/dark urine/jaundice and RUQ pain.
Increases risk of foetal distress, preterm birth and stillbirth
Investigations:
- bile acid levels
- weekly LFTs - cholestatic picture
- Abdominal US to exclude other causes
- rule out pre-eclampsia
Management
- Ursodeoxycholic acid but no improvement in foetal outcomes
- cholestyramine or rifampicin if refractory
- Vit K if prolonged PT or steatorrhoea
Birth
- if very high bile acid lvls consider birth before 37w due to high risk of stillbirth, induce
- if normal or slightly elevated then deliver between 37-40
VTE in pregnancy - when to give prophylaxis, how to manage DVT/PE
Prophylaxis
- VTE in past not due to major surgery - LMWH
- Consider LMWH if VTE due to major surgery, high risk thrombophilia, comorbidities, surgical procedure, ovarian hyperstimulation
- > 4 RF - prophylaxis from 1st trimester
- 3 RF - prophylaxis from 28w
- <3 - mobilise and avoid dehydration
Investigations
- AtoE
- compression doppler for DVT
- CXR for PE, V/Q mismatch or CTPA if -ve
- FBC, U&E, LFT, Coag
Management
- Massive PE: AtoE, IV unfractionated heparin 5000IU bolus then 1000-2000/hr. monitor APTT from 6hrs post bolus. If repeated consider caval filter. If life/ limb threatening consider surgical embolectomy, thrombolytic therapy
- Non massive PE: 1.5mg/kg OD LMWH (clexane)
- DVT: LMWH, elevate leg, compression stockings, mobilise
- Maintenance: LMWH subcut as outpatient
- Labour: let ward take over, switch to unfractionated heparin. Can induce/ cesarean 12 hr post stopping LMWH prophylactic dose, 24 post therapeutic dose
- Post birth cont. for 6-12 w with LMWH or Warfarin then reassess
best anti epileptics for use in pregnancy/ breastfeeding
carbamazepine and lamotrigine
for breastfeeding can use any apart from barbiturates
how to induce labour
artificially rupture membranes and give syntocinon
Antepartum haemorrhage
= bleeding between 24w and term
minor <50
major 50-1000, no shock
massive >1000 or shock
Investigations
- Obs to look for shock
- bloods to assess blood loss etc. FBC, G&S, crossmatch, LFT, U&Em COAG
- US look for placenta previa/abruption/ vasa praevia (associated with waters breaking = vasa praevia)
- speculum exam to look for external causes of bleeding
- Swabs for infection
- assess foetus with us or ctg
Treatment
- minor, no foetal issues then discharge
- major or some sign of foetal distress admit for 24hrs and monitor - if unstable consider c-section, stable induction
- massive - AtoE, cannula, fluid resus, bloods (G&S, crossmatch), blood products, CTG, escalate. If M/Baby unstable consider caesarean, if stable consider induction. If before 34+6 give steroids. Do active 3rd stage and continuous ctg
For all assess rhesus -ve and give anti d within 72hrs
Vasa praevia presentation and management (triad)
Present with triad of membrane rupture, painless bleeding and foetal bradycardia
Treat with emergency c-section - due to risk of foetal compromise
Painless bleeding from vagina without membrane rupture
Placenta praevia
Placenta praevia classification and management
minor - close to os
major - covering os
investigations
- abdo US, confirm with TVUS
- bloods - FBC, U&E, LFT, G&S, crossmatch
- Maternal obs
- Speculum - look for external causes of bleeding
- CTG once mother stable
- rhesus status
- high vaginal swabs for infection
Present with painless bleeding - fresh red blood
Management
- usually identified at 20w scan. minor repeat at 36w, major at 32
Grade 1 - encroaches on OS but not reach it
Grade 2 - reaches but not cover OS
Grade 3 - partially covers OS
Grade 4 - completely covers OS
AtoE
Resus, wide bore cannula, blood products, fluids
Anti D if needed
If major or massive bleed consider emergency c-section
- steroids if 34-35+6w
CTG once mother stable
Grade 1 - consider vaginal birth
Grade 2 - clinicians assessment
Grade 3/4 - elective cesarian at 38w
Minor
- Scan at 36w. if >2cm from os vaginal, if <2cm then c-section
Major
- admit to hosp from 34w onwards if had bleed
- US to confirm at 32w
- always do c-section. Aim for 38w or 36-37 if accreta
- no penetrative sex
Types, main risk factors and management of placenta accreta
accreta - just into myometrium
increta - deep into myometrium/ serosa
percreta - through peritoneum
Main risk factors are previous c-section and placenta praevia. Also increasing maternal age, IVF, fibroids
Diagnosis
- trans abdo US
- confirm depth with MRI
- often not know full extent until surgery
Management
- AtoE and resus for any bleeding
- aim for birth at 35-37 weeks via c-section
- Post birth either deal with placenta conservatively and leave to pass with or without UAE, iliac vessel ligation or methotrexate (no evidence). Or perform elective hysterectomy
- if partial loss off placenta after conservative management can consider partial myomectomy
Placental abruption - types, presentation and management
2 types:
Revealed - blood tracks down between membranes and presents as sudden onset painful PV bleeding
Concealed - blood trapped between myometrium and placenta, presents as pain and shock
Uterus tense, hard, tender and painful on exam
Often in labour with contractions
Dark, red blood
Investigations
- clinical diagnosis
- can do TVUS to rule out praevia - normal in abruption
- FBC, U&E, LFT, Kleihauer, clotting, G&S, crossmatch
- speculum and PV
- CTG
- uterine artery doppler
- high vaginal swabs if bleeding minimal
Management
Acute bleed - AtoE, left lateral position, O2, IV access, G&S, crossmatch, resus with bloods or Hartmans, anti D
If foetal distress on CTG - emergency c-section
If no foetal distress and signif bleed <37w keep in for 24hr, do foetal growth scan
As abruption increases risk of pre-term birth give steroids if before 35w
If no foetal distress, >37w - induce labour with artificial membrane break and syntocinon
if foetus dead induce vaginal delivery
How to differentiate between praevia and abruption
Praevia - painless, fresh red, can see on US, no abdo tenderness
Abruption - panful, dark red or no blood, cant see on US, hard woody uterus, very tender
Uterine rupture - presentation and management
Present with sudden onset tearing abdo pain, pain radiating to tip of shoulder, cessation of contractions, vaginal haemorrhage, tachycardia and shock
Do US and CTG (fetal bradycardia)
Manage by resus, uterine repair +/- c-section
May need hysterectomy
When first feel foetal movements, why might be reduced and how to manage
18 weeks onwards, max at 32
Reduced if
- foetal distress (hypoxia)
- obesity
- Posture
- Distraction due to maternal stress
- Oligo and polyhydramnios
- Anterior placenta can reduce foetal movements
- Alcohol and benzos
- Anterior foetal position
- SGA
If past 28w
1st do foetal heartbeat using doppler
- if no heartbeat do immediate US
- if heartbeat do CTG for at least 20 mins to monitor HR
- if still concerned despite normal CTG do US - assess abdo circumference, weight and look for poly/oligohydramnios
Low grade fever, abdo pain and vomiting during pregnancy
Fibroid degeneration
PROM vs P-PROM, their management
- Genetics, infection, early activation of membrane weakening process are the main causes
Differentials
- UTI
- STI
- chorioamnionitis
In premature labour investigate for infection
- to confirm preterm labour do foetal fibronectin
Both are the rupture of of membranes at least 1 hour before onset of labour
PROM - >37w
P-PROM - <37w - preterm labour is before 36+6
Risk factors =
- Smoking (especially < 28 weeks gestation).
- Previous PROM/ pre-term delivery.
- Vaginal bleeding during pregnancy.
- Lower genital tract infection.
- Invasive procedures e.g. amniocentesis.
- Polyhydramnios.
- Multiple pregnancy.
- Cervical insufficiency.
Painless popping sensation following by a gush of fluid
Investigate with speculum, get woman to lie down for 30 mins prior - look for pooling of amniotic fluid. Can ask to cough, might see fluid expelled.
- do high vaginal swab, temp, FBC/CRP if suspect infection
- Ferning or Nitrazine test - identify if amniotic fluid
- US if doubt
- CTG if foetal distress
Do not do digital vaginal exam as can expedite labour and increase risk of infection
Differentials = urinary incontinence, increased sweat and moisture, vesicovaginal fistula, loss of mucus plug
Management
- most spont start labour in 24-48hrs so admit to hosp
If not:
- <34w - monitor for chorioamnionitis, avoid sex, erythromycin, steroids, expectant management until 34w
- 34-36 - monitor for signs of chorioamnionitis, avoid sexual intercourse, prophylactic erythromycin 250 mg QDS for 10 days, steroids if 34-34+6w, induction of labour
- >36 - induce after 24-48hrs, monitor for signs of chorioamnionitis, clindamycin/penicillin during labour if GBS isolated
Erythromycin prophylaxis
for all between 24- 29+6 give IV mag sulph to prevent cerebral palsy
Steroids given up to 33+6, consider up to 35+6
If chorioamnionitis detected give IV betamethasone, broad spectrum Abx e.g. benpen and deliver baby
Complications - chorioamnionitis, Placental abruption
Umbilical cord prolapse, Neonatal death, oligohydramnios (can cause lung hypoplasia)
How does chorioamnionitis present
Fever, malaise, abdo pain (tender on exam), purulent vaginal discharge, foetal tachycardia
Premature birth - time, ix, what drugs to give, what procedure can be performed
= onset of contractions and cervical changes (effacement/dilation) of cervix before 37w
RF:
- Multiple pregnancy, infections, smoking, previous preterm, diabetes, placental dysfunction
Increases risk of: PDA, NEC, NRDS, IVH, cerebral palsy, infection/ sepsis
Ix
- Make sure both contractions and cervical changes
- Perform PV to examine for dilation and effacement of cervix
- Speculum to look for membrane rupture, can also swab for STI and GBS screen, also perform fibronectin test
- TVUS to assess placenta
- Bloods for rhesus status and infection screen
Management
- Abx cover for GBS
- Steroids if before 35+6 (dexamethasone)
- give tocolysis (nifedipine) for 48hrs to allow steroids to work (only use if membrane intact)
- IV mag sulphate to protect against cerebral palsy if <29+6
- cervical cerclage if 16-34w with dilated cervix and unruptured membrane
Progesterone can be used to prevent preterm birth if prev late miscarriage or preterm or if low risk woman with shirt cervix.
Late birth definition
> 42w - induce at 41w
Why put in left lateral tilt position
Reduces aorto-caval compression
Causes of maternal collapse and how to manage
4H’s
- hypoxia
- hypo/hyperkalaemia
- haemorrhage
- hypothermia
- hypoglycaemia
4T’s
- Thromboembolism
- Toxicity - mg, anaphylaxis, LA
- Tension pneumothorax
- Tamponade
+ in pregnancy - pre-eclampsia, intracranial haemorrhage
Management
A - secure immediately with intubation
B - O2, bag and mask until intubated
C - if no breathing start chest compressions, defibrillate as normal, insert 2x cannulas, adrenaline every 3-5mins
Give fluid, blood products as needed
Treat cause
If no response with 4mins of CPR do emergency c-section whilst continuing resus
mechanism that starts labour
Reduction in progesterone -> increase in prostaglandins -> contractility -> oxytocin release
get mucous plug/ bloody show, uterine contractions and spontaneous rupture of membranes
Phases of labour
1st
- latent - irregular contractions from 0cm dilated to 3/4
- active - regular contractions from 3/4cm to 10cm. aim for 0.5cm/hr in nulliparous, 1cm/hr in multiparous
listen to babies heart for 1min every 15
If delay examine for problem, Amniotomy if not ruptured membranes, do Bishop score to identify obstruction, if none give oxytocin.
2nd
- 10cm dilated to delivery
- Delayed if last >2 hours in nulliparous or >1 in multiparous - consider amniotomy, oxytocin, instrumental or c-section
listen to baby heart every 5min or after each contraction
3rd
- delivery to passage of placenta and membranes
- physiological/ expectant - aim for 1hr
- active (syntocinon IM 10U, pull on cord) - aim for 30min
Pain relief in pregnancy
Massage, relaxation
TENS machines - level can be increased throughout labour - feels like a tingling, numb sensation - have a boost button for extra painful periods
Entonox - not for >24hrs - can feel dizzy or sick - are in full control, can decide to start and stop using at any point
Opiates e.g. pethidine - only in early labour, can make feel sick, drowsy - given anti-emetic at same time
Remifentanil - PCA, need to be on delivery suite with O2 sats and nasal specs
Epidural - PCA, stops pain altogether, started during active 1st stage, topped up every 2hrs. can drop BP so insert cannula. Requires constant foetal monitoring every 30 mins
